In 2003 the Prostitution Reform Act (PRA) was passed in New Zealand which decriminalised all activities associated with sex work. Prior to this, although sex work itself was not criminalised, all activities associated with it were.It is useful to examine whether decriminalisation has changed the way sex workers interact with health care professionals. There have been many commentators writing in the context of criminalised sex work environments who have reported on the distrust sex workers have towards health care workers.1-5Much of this distrust arises out of sex workers' fears of judgemental and discriminatory attitudes. There is a perceived threat posed by visiting doctors, psychologists and other health professionals4and it has been noted that sex workers prefer non-medical healthcare providers because of perceptions that doctors would not be accepting of their profession.1When sex workers do not reveal their occupation to their doctors, it makes it difficult for the doctors to provide appropriate care and support.A study carried out in Christchurch in 1999 prior to decriminalisation found that only 12 of the 302 sex worker respondents did not go for sexual health checks.3 General practitioners (GPs) were the most commonly used medical provider for sex workers accessing sexual health services. Of the 251 (83%) women who reported having their own GP, 135 (54%) reported going to that GP for sexual health checks. However, only 84 (62%) of these 135 workers disclosed that they were sex workers to their GP.This paper examines whether there have been changes in utilisation of health services since decriminalisation and whether sex workers are any more likely to disclose their occupation to health service providers.Methods The research was conducted by public health researchers from the University of Otago, Christchurch, in partnership with the New Zealand Prostitutes' Collective (NZPC). Ethics approval was obtained from the Multi-region Health and Disability Ethics Committee. The study was carried out in Auckland, Wellington and Christchurch as well as two smaller regional cities: Nelson and Napier. Between June 2006 and January 2007, a questionnaire was administered by NZPC staff, trained in interviewing techniques, to a sample of sex workers in the five cities. Although random sampling was not carried out, care was taken to represent the diversity of the industry within the final sample by conducting an estimation of the number of private (people working for themselves and not giving a portion of their money to others), managed (people working in brothels and escort agencies under a system of management) and street-based sex workers, including the gender distribution within each sector, across the five locations of the study.6 Participants were sampled purposively within the sectors and locations of the study and street-based, small city, male and transgender workers were over-sampled because of smaller numbers in these populations. The final sample achieved was 772, which represents 32% of the estimated sex worker population across those areas. Questionnaire data were analysed using SAS 9.1. In-depth interviews were carried out with 58 sex workers in the five locations of the research between August 2006 and April 2007. The diversity of the industry was also reflected in this sample. The interviews utilised a semi-structured interview guide and were conducted by NZPC outreach workers who had been trained by us in interviewing techniques. All interviews were digitally recorded and transcribed to word accuracy. Thematic analysis was undertaken. Transcripts were read and re-read, and datasets were developed by cutting and pasting relevant quotations by participants around a range of subject areas. Each data-set was analysed, identifying themes or patterned responses or meaning. Names of all participants have been changed to protect their identity. Results Most sex workers in this study stressed their social responsibility in ensuring that they did have regular sexual health checks. I tend to do my STD and blood tests at the NZPC just ‘cos I like catching up with the people and coming in to see, you know, the nurse and saying ‘hi'. You know, because it's just a comfortable environment to be in. The people don't judge you and that sort of thing. Ever since I've been sexually active, I've always made sure I've had regular tests, STD and blood tests. Obviously since I started working I make sure I get it every 3 months. (Sheila, Managed, Female) Health-wise, I go and have a check-up once a month at, you know, at the doctor's and I have all tests and all that. You know, I mean especially if a condom has broke, you know, so I mean I certainly look after myself, because, you know, I value my life and my health. (Joan, Street, Female) Few survey participants reported that they did not go for sexual health check-ups, with managed workers the least likely of all participants to report this (see Table 1). Most participants indicated that they accessed their GP for their general health needs (91.8%) as well as their sexual health needs (41.3%). A local Sexual Health Centre was the second most utilised facility for sexual health check-ups with one-quarter of participants indicating that this was their preferred option, particularly for managed and private sex workers. The third most utilised service for sexual health check-ups was NZPC with 15.5% of the survey participants indicating that they attended this service on the days that either a sexual health doctor or nurse was running a clinic (see Table 1). There was, however, a significant difference between numbers of people attending NZPC services for their sexual health needs in the different cities. Sex workers in the smaller centres do not have the option of attending a NZPC clinic. In Auckland, 11.7% of participants reported accessing NZPC for sexual health check-ups, 13.9% in Christchurch and 36.0% in Wellington (χ² 54.6, 2df, p<0.0001). Clinics are held at NZPC offices for three hours once a week in Christchurch and Auckland, and twice a week in Wellington. The fact that sex workers in Wellington had 6 hours a week, as opposed to 3 hours in the other big cities, to access these services could explain the difference in attendance. Many participants in in-depth interviews did access NZPC for their sexual health check-ups and these participants were clear that they found the services less judgemental than that provided by other health professionals, they were more comfortable talking over intimate issues and there was a greater level of trust. Jack: My GP is not aware of the fact that I work. I deal with (X) here at NZPC, and any issues surrounding, or around my sexuality, my sex work, she deals with those, and that's actually really good. It makes it a lot easier because the two, it's almost like I've compartmentalised my life. My GP has all of my history, you know, from right from zero to whenever to now. And (X), I trust her on a different level with my information, so yeah. Interviewer So it comes down to a level of trust in having that information? Jack Yeah, absolutely, and I trust her more than I do my GP. I trust my GP will look after my health, but I trust (X), because of her, that's there, she's in the environment, you know, of looking after people that are sexually active, sexual health and those sort of things, so. (Jack, Private Male) Two-thirds (64.9%) of survey participants reported that they accessed NZPC's drop-in service: street-based and private sector workers were significantly more likely to report this than participants in the managed sector. During in-depth interviews, some street-based workers gave accounts of how NZPC were vital in ensuring their sexual health through their provision of condoms at a subsidised rate. Some indicated that without that service they might not personally go and buy condoms. I mean if it wasn't for them, you know, I couldn't really basically - well I wouldn't actually go out and buy the condoms. It's not something I do, you know, go out and purchase condoms just, you know, even though it's for my safety. Yet it's comfortable to go to the NZPC or the condom ladies to basically give them to you, because it's normal and it's just like much better and you feel comfortable taking condoms off them. And it's not in a store where they'll have to, you know, say, you know, “Can I have a price check on such and such condoms,” you know. (Terri, Street, Transgender) Other participants valued the information they received from NZPC about bad clients, what to expect when they were new to the job as well as information on their rights. I'm aware that we do have rights, and that's what NZPC helps a lot, ‘cos if it wasn't for NZPC and the YCD ones, yeah, none of us would be here now, because, you know, if it wasn't for them being able to take time out of their own personal time, sit down, have a chat with us. They get a nurse around – we've got our own, you know, nurse that helps us with everything. Like makes sure we're clean, does our tests and everything, you know. If it wasn't for these people, we'd be all, we'd probably all be 6 feet under. (Joyce, Street and Private, Female) I went in there (NZPC) before I started working, and they gave me a whole lot of information about what the, what my rights were. And yeah, so they sort of told me what was expected in the room and what wasn't. You know, what you're allowed to ask for more money was, or you know, for and that sort of thing. (Jenny, Managed, Female) The majority of survey participants reported having their own GP (see Table 1). However, only half of the participants who reported having a GP indicated that they told him/her that they were sex workers. Street-based workers were the most likely sector to report their occupation to their GPs with managed workers the least likely. Some of the participants in in-depth interviews said they informed their doctor of their occupation. They ensured that by disclosing this information that they were seen as being responsible and getting comprehensive check-ups. I'm totally open with health professionals. It's like I'm speaking with you, they can ask me something and I'm totally honest with them. You know, what's the point in going to a doctor if you're not going to be real with them. They can't possibly do anything for you if you're not honest, you know. (Paul, Street, Male) Because I'm quite an open talkative person, doctors and Family Planning, you think like they, they're not allowed to say anything, and it's better if they know, ‘cos then they can help you out. Whereas if they don't know, they just think I'm just having sex with a boyfriend or, you know, or a couple of guys, and not knowing the full extent of it, and they don't, they can't understand me. (Debbie, Managed, Female) However, there were many participants who did not see the need to disclose their occupation to their doctor. Obviously I haven't mentioned to them that I'm a sex worker. I don't really see the need. You know, it's not, it doesn't seem to be an issue. (Lorraine, Private, Female) I think because of my prescription, and I just think that maybe he would stop my prescription if he knew I was back out working. Yeah. He used to be my methadone doctor when I was on methadone. And then I've given him quite a bit of bullshit in the past, so, you know, I just, yeah, there's just some things your doctor doesn't need to know. (Joan, Street, Female) The stigma attached to sex work prevented many from disclosing their occupation and this has implications for the sexual health of sex workers. There were fears of negative reactions and judgementalism. Yes, see, I think it just depends on the medical worker. Most medical workers who've been working for a certain amount of time, they are sweet with it, you know, ‘cos they've heard everything, they've seen everything, and they don't mind. I find it's usually like religious nurses that I've come across and they're like, “Oh, oh, you do that, do you?” And I'm just, “Well fuck, you know, what do you want me to tell you? Yes, I do that, yes, I'm a very happy person, don't try to commit suicide on a weekly basis,” you know. And it's usually the same stigma of it and it's just, it's a fucking joke, especially in this day and age, but you can't change some people. (Vicky, Managed, Female) Another concern for many participants was that their GP was not only their doctor but was also the family GP. If they did not disclose their occupation to their family, they perceived a danger in disclosing to somebody like a GP who had a relationship with their family. In some cases, the GP had known them since childhood and disclosing to him/her held risk for altering the relationship. It's too close to home and the fact that my mum and my brother and myself and my daughters are all with the same doctor, I feel he sees us as this nice family unit, and I'm certainly not going to break it. (Ann, Managed, Female) Yeah, ‘cos it's quite like changed now ‘cos like some of them don't think it's really good for you to work when you've got children, ‘cos they're thinking of the children, hey. I understand where they're coming from, like they're thinking more of the children. But as long as they know that the children's been taken care of, you know, and the reason why you're doing it is to survive, you know, and you're a solo mother, then it's, you know, it should be pretty much all right. But no. (Toni, Street, Female) Discussion The majority of sex workers in this study were accomplished in practising safe sex in their working lives7, but it is important to explore whether they managed other areas of their sexual health in an equally effective way. There is no provision under the PRA for compulsory periodic sexual health check-ups which are a requirement in many countries, especially those which have legalised sex work.4 It is acknowledged under section 8 of the PRA that medical certificates showing an absence of STIs are only valid at the time of testing and instead there are efforts to promote safer sex cultures within the legislation. Direct comparisons can be drawn between results from the 1999 study of Christchurch female sex workers and results from the 2006/07 survey as identical questions were asked in both surveys. With regards to utilisation of services there has been little change in the intervening period even though sex workers now work in a decriminalised environment. Similar to 1999, most participants positioned themselves as responsible in regularly attending a health service provider to have sexual health check-ups. Only 3.7% of participants reported that they did not have regular sexual health check-ups in 2006/07 compared to 4% reporting this in the 1999 survey.3 There were also no significant differences in services accessed for sexual health needs between 2006/07 and 1999. GPs continue to be the preferred option for sexual health check-ups, followed by sexual health centres and then NZPC. The stigma which continues to be attached to sex work means that many sex workers still do not disclose to health care providers that they are working in the sex industry. The 1999 survey reported that 52% did not disclose their occupation to the GP3 compared to 46% in 2006/07. If sex workers are not disclosing their occupation to their GP they may not be getting the comprehensive check-up they would require. Many participants also do not disclose their occupation to family and friends which means that many are living double lives.8,9 Although the rights that sex workers now have under the PRA has given them some legitimacy and respectability,10,11perceptions of stigmatisation has implications for their emotional8 as well as their sexual health. It is interesting that most participants in the 1999 and 2006/07 surveys attended their GP service for sexual health check-ups when the literature suggests that health services run from sex workers' organisations are more acceptable to sex workers.5,12,13 Sex workers' rights and grassroots organisations have become increasingly important in recent years, offering drop-in as well as community-based outreach options for the delivery of health services, condoms, emergency assistance, advice and health promotion messages to sex workers. Many combine with other agencies to work together to provide a more integrated, holistic service for sex workers.13 In so doing a wide variety of services can be offered, including housing, drug services and treatment, social services, sexual health and various support services. NZPC has been effective in fulfilling this role in New Zealand since 1988. Yet whilst many sex workers in this study reported using the drop-in services NZPC provide, fewer reporting making use of the sexual health clinics held on their premises. It would be beneficial to sex workers if they were able to make better use of NZPC for check-ups as these would be more thorough as disclosure is not an issue. However, clinics are only held on NZPC premises in the three main cities and these clinics do not provide adequate consultation hours. The clinic at NZPC in Wellington opens for twice the length of time each week (six hours) as those in Auckland and Christchurch and has proportionally three times the number of sex workers accessing this service. If consultation hours were increased in all centres, it is likely that a greater proportion of sex workers would utilise this service. Perhaps as time goes on, perceptions of stigma may change and sex workers will feel more confident in disclosing their occupation to their GP. Social perceptions of sex work do not change with a change in legislation. It is possible that it is too early to see any changes in perceived stigmatisation and this needs to be examined further down the track.