Sex workers are returning to work and require enhanced support in the face of COVID-19: results from a longitudinal analysis of online sex work activity and a’content analysis of safer sex work guidelines

Sex workers confront unique challenges in the face of COVID-19. Data from an international sex work website popular with cisgender men and transgender men and women suggest that, after a period of physical distancing, many sex workers are returning to in-person work: from May to August 2020, active sex work profiles increased 9.4% (P < 0.001) and newly created profiles increased by 35.6% (P < 0.001). Analysis of sex work and COVID-19 guidelines published by five community-based organisations found that they focused on altering sexual practices, enhancing hygiene and pivoting to virtual work. To capitalise on these guidelines, funding and research for implementation and evaluation are needed to support COVID-19 risk reduction strategies for sex workers. Additional keywords: community health, community interventions, male sex work, risk reduction. Received 21 July 2020, accepted 5 August 2020, published online 25 August 2020 Earlier this year, Platt et al. advocated that ‘sex workers must not be forgotten in the COVID-19 response’. The physically intimate nature of sex work makes physical distancing difficult for those who rely on it as a source of income, and there is mounting evidence that sex workers face unique transmission risks, mental health needs and socioeconomic challenges relative to COVID-19 that have largely been ignored by health organisations and governments. However, sex workers have a long history of taking responsibility for public and their individual health within a model of risk reduction, especially relative to HIV, which in the COVID19 context may provide an important avenue for intervention. To better understand how COVID-19 is affecting sex workers, since the start of the pandemic our team has closely monitored the experiences of diverse sex work communities. As part of this effort, we have studied trends on an international sex work website popular with cisgender male and transgender male and female sex workers, finding that from January to May 2020 (the pandemic’s earliest months) online sex work activity decreased dramatically. However, results from a more recent analysis make it clear that such trends have started to reverse. From May to August 2020, the number of active online profiles maintained by sex workers increased by 9.4% from 6661 to 7285 (inter-rate ratio (IRR) 1.03, 95% confidence interval (CI) 1.02–1.04, P < 0.001); deactivated profiles decreased by 33.0%, from 2311 to 1548 (IRR 0.71, 95% CI 0.70–0.73, P < 0.001); and newly created profiles increased by 35.6%, from 326 to 422 (IRR 1.10, 95% CI 1.06–1.15, P < 0.001). Visits to sex work profiles, an important marker of client interest, during this period increased by 55.1% (from a mean of 72.1 to 111.8 visits per profile per day; F = 273.1, b = 0.11, P < 0.001; Fig. 1). The results of our updated analysis suggest that after a period of social distancing and self-isolation, cisgender male CSIRO PUBLISHING Sexual Health, 2020, 17, 384–386 Letter https://doi.org/10.1071/SH20128 Journal compilation CSIRO 2020 Open Access CC BY www.publish.csiro.au/journals/sh and transgender male and female sex workers, like other populations of sex workers and those in other industries, may be returning to in-person work. Although there is evidence that some sex workers have implemented COVID19 risk reduction strategies of their own design (e.g. enhanced client screening protocols), the extent to which these are being taken up or how effectively they reduce risk remains unclear. Research to clarify what effective ‘safer sex’ looks like in the context of COVID-19 is sorely needed. Promisingly, some community-based and peer-led sex worker organisations have produced COVID-19 safety guidelines. To better understand these, in July 2020 we conducted a content analysis using a convenience sample of five English-language guidelines identified through online keyword searches and consultation with sex work community members. Sampled guidelines focused on COVID-19 risk reduction strategies for sex workers, with common recommendations included limiting in-person work, assessing their own and their clients’ symptoms, enhancing hygiene practices (e.g. hand washing before and after handling money) and altering sexual practices (e.g. limit face-to-face sex acts; Table 1). Guidelines occasionally provided resources around mental health and financial aid (e.g. accessing crowd-sourced schemes, applying for government support) and often advised sex workers to offer virtual services (although it has been reported that virtual sex work can have unique safety risks). The guidelines we reviewed did not target any particular sex work subpopulation (e.g. men, women) and instead seemed to be written for a ‘general’ sex work audience, including three guidelines that provided advice for sex work clients and allies. Guidelines such as these are important resources for sex workers but, to access their full potential, research and funding are needed to support dissemination (and evaluation) of community-led outreach and education. Further, drawing upon the long history of HIV and sexually transmissible infection (STI) prevention, distribution of COVID-19 protective equipment (e.g. gloves, face masks or shields) and culturally competent COVID-19 testing and care are vital missing pieces in the current sex work response. Researchers, community leaders and public health officials must come together to ensure that sex workers returning to and continuing in-person work are properly supported to manage individual and public health in this new COVID-19 era. Conflicts of interest The authors have no conflicts of interest to declare. Before COVID-19 COVID-19 Stage 1 COVID-19 Stage 2 10000

Earlier this year, Platt et al. advocated that 'sex workers must not be forgotten in the COVID-19 response'. 1 The physically intimate nature of sex work makes physical distancing difficult for those who rely on it as a source of income, and there is mounting evidence that sex workers face unique transmission risks, mental health needs and socioeconomic challenges relative to COVID-19 that have largely been ignored by health organisations and governments. [2][3][4] However, sex workers have a long history of taking responsibility for public and their individual health within a model of risk reduction, especially relative to HIV, 5 which in the COVID-19 context may provide an important avenue for intervention.
To better understand how COVID-19 is affecting sex workers, since the start of the pandemic our team has closely monitored the experiences of diverse sex work communities. As part of this effort, we have studied trends on an international sex work website popular with cisgender male and transgender male and female sex workers, finding that from January to May 2020 (the pandemic's earliest months) online sex work activity decreased dramatically. 6 However, results from a more recent analysis make it clear that such trends have started to reverse.
The results of our updated analysis suggest that after a period of social distancing and self-isolation, cisgender male and transgender male and female sex workers, like other populations of sex workers and those in other industries, may be returning to in-person work. Although there is evidence that some sex workers have implemented COVID-19 risk reduction strategies of their own design (e.g. enhanced client screening protocols), 6 the extent to which these are being taken up or how effectively they reduce risk remains unclear. Research to clarify what effective 'safer sex' looks like in the context of COVID-19 is sorely needed.
Promisingly, some community-based and peer-led sex worker organisations have produced COVID-19 safety guidelines. To better understand these, in July 2020 we conducted a content analysis 7 using a convenience sample of five English-language guidelines identified through online keyword searches and consultation with sex work community members. [8][9][10][11][12] Sampled guidelines focused on COVID-19 risk reduction strategies for sex workers, with common recommendations included limiting in-person work, assessing their own and their clients' symptoms, enhancing hygiene practices (e.g. hand washing before and after handling money) and altering sexual practices (e.g. limit face-to-face sex acts; Table 1).
Guidelines occasionally provided resources around mental health and financial aid (e.g. accessing crowd-sourced schemes, applying for government support) and often advised sex workers to offer virtual services (although it has been reported that virtual sex work can have unique safety risks 13 ). The guidelines we reviewed did not target any particular sex work subpopulation (e.g. men, women) and instead seemed to be written for a 'general' sex work audience, including three guidelines 8,10,12 that provided advice for sex work clients and allies.
Guidelines such as these are important resources for sex workers but, to access their full potential, research and funding are needed to support dissemination (and evaluation) of community-led outreach and education. Further, drawing upon the long history of HIV and sexually transmissible infection (STI) prevention, distribution of COVID-19 protective equipment (e.g. gloves, face masks or shields) and culturally competent COVID-19 testing and care are vital missing pieces in the current sex work response. Researchers, community leaders and public health officials must come together to ensure that sex workers returning to and continuing in-person work are properly supported to manage individual and public health in this new COVID-19 era.

Conflicts of interest
The authors have no conflicts of interest to declare.  1. Number of active, inactive and newly created sex worker profiles and profile visits by month on a large, English-language international male sex work website before the COVID-19 pandemic (September 2019-January 2020), during the early months of the COVID-19 pandemic (Stage 1: January to May 2020) and during a period of relaxed physical distancing in many countries (Stage 2: May to August 2020). Note, due to a technical error, data were not extracted for February 2020. In addition, analyses of data from before COVID-19 and during Stage 1 have been published previously. 6 Sex workers and COVID-19 Sexual Health 385