Society demonstrates the ways in which public identity and the politics of disgust are internalized and externalized through criminal legal, biomedical, and public health institutions.
Importantly, this does not merely happen by chance but is part of an interactive, cyclical social process that dehumanizes sex workers, PWUD, and PLHIV and construes them as something outside of humans deserving rights. While this social process ultimately stigmatizes and hurts everyone, it is not applied to all sex workers, PWUD, nor PLHIV equally. It is anti-Black, anti-poor, anti-trans, anti-immigrant, anti-women, anti-queer, anti-sex work, and anti-HIV, among multiple other systems of oppression.
“And, let's be real, one of the greatest drivers of HIV is poverty, is racial injustice…A few years ago, what they used to call school to prison pipeline. Someone's mentioned this to me, they said we now have a clinic to prison pipeline.” - Venita
As Venita demonstrated above, the criminalization of HIV is a racial justice issue that expands upon the already existing relationship between policing and public health. It does not affect the full range of PLHIV equally but rather targets PLHIV based on race, class, and legal status, among many other things. Drawing upon the lived experiences of sex workers, PWUD, and PLHIV attempting to access non-stigmatized care, I attempt to outline the “clinic to prison pipeline” in a way that demonstrates its multiple moving pieces. The accounts that follow demonstrate the lived experiences of those who have been forced to move through the public health and criminal legal systems while stigmatized under the different yet overlapping public identities of sex workers, PLHIV, and PWUD. They exemplify how society–including medical providers– perceive and treat sex workers, PLHIV, and PWUD at the intersections of race, gender, and class. They also reveal the paradox of accessing care while stigmatized and criminalized– public health and biomedical structures are, in many ways, environments of risk for incarceration. In doing so, it demonstrates the ways in which criminal legal, biomedical, and public health systems are both products and reproducers of systemic racism, transphobia, misogyny, classism, and xenophobia.
Barriers to Care– The Culture of the Clinic
Public health and biomedical professionals are not removed from but are rather conditioned by the racist, sexist, transphobic, xenophobic, classist, and homophobic society that is the United States. Consequently, public health and biomedical professionals bring implicit biases to the clinic with them. Medical discourse perpetuates stereotypes of sex workers, PWUD, and PLHIV, often blaming the individual by conceptualizing ‘risk’ only through the lens of individual behavior. Rather than looking to critical race theory or the multiple intersecting systems of oppression that shape patients’ lives, public health and biomedical discourse sees sex workers, PWUD, and PLHIV almost exclusively through ‘risk’, personal responsibility, and blame. In doing so, the culture of the clinic and ‘care’ represents a model in which the individual patient is so grossly misunderstood and mistreated that the culture of the clinic is a barrier to care. PLHIV, for example, are immediately subjugated to increased surveillance, regulatory controls, and punishment via carceral pathways after receiving a reactive test:
“Upon diagnosis, and usually before, depending on like what your cultural background, and race background, and religious background is, but upon diagnosis, all of a sudden, your sexuality and your desires and pleasure don't matter anymore. And how dare you even think about receiving pleasure or using your body in any other way, except to either produce a child... I can only speak for my experience, or to be a source of pleasure for someone else, but I am not allowed to experience pleasure.” – Kamaria
The logic that PLHIV, sex workers, and PWUD are ‘unruly’ and are in need of surveillance and regulatory controls is further elucidated in the carceral logics of the clinic, which are apparent to the people they subjugate but appear to be commonsensical to health workers:
“I just think clinic, where these folks really have this idea of who we are, and because they might run into people who are dealing with so many other things that are homeless, mental health, all this stuff. They have this concept of who we are. That we can't control our own lives or manage our own health. And so, I've worked for a federally qualified health center for four years. And so happened to be in rooms where case managers and others might've been speaking and was just pissed off. Every now and then I'd have to say, "whoa, y'all do realize I'm one of those people". They are othered where there's frustration about "I told them to do this and then they did this", like we're petulant children or something. And I won't say that's everybody, there are some, but this case manager system that's supposed to be empowering, I think, in a lot of cases, is disempowering. I think there is this perception about who we are, and that we just need to take more responsibility for our lives, and all that stuff.” –Venita
Yet, these logics are contradictory to the lived experiences of these groups of people as they ignore the ways in which sex workers living with HIV who use drugs, for example, have come to self-regulate and monitor themselves, both to avoid transmission and arrest. Reflecting on research such as undetectable= untransmissible (U=U) and the ways in which she was treated by the public health and criminal legal systems, Tiffany explains:
“It impacts me now because we know U equals U. So I guess that's what makes me, my labs go back 18 years of my viral load actually maintaining undetectable. So I get very angry knowing that during that entire time that I was falling through that chaos. That, you know, I did take my meds even if I had to take my meds on nothing but cocaine in my body. In a way I always thought I was, you know, went and got the condom.”– Tiffany
In all of This is especially exacerbated by the lack of representation of sex workers, PWUD, and PLHIV in health care positions:
“People living with HIV are looked upon as people who need help instead of looked upon as people who can help. And that's where we have to change the whole culture, and that even relates to how we deal with sex work. We can't think of people who do sex work as being less than, and it's respectable work and it all goes back to women having the control over their body and what they want to do with their body, as well as people living with HIV. We know that The Denver Principles laid this out in 1983 and we're still fighting for the same thing, to participate in boards, and we condemn attempts to label us as a victim, in turn which implies defeat, and we are only occasionally patients, in turn which applies passivity, and depending upon the health care of others.”– Bryan
The culture of care is so stigmatizing and dehumanizing for sex workers, PWUD, and PLHIV– who are all stigmatized and criminalized in overlapping yet different ways– that some avoid services that they need to access out of fear of how they will be treated. One collaborator, for example, worked with a sex worker who was so scared of how she would be treated by workers at the clinic that she decided not to access available post-exposure prophylaxis despite being nervous that she had been exposed to HIV. This was in Florida in an area where services were free and transportation could readily be provided, demonstrating why free or low-cost services alone cannot meet the full needs of sex workers and the need for funding to develop additional sex worker-led organizations such as St. James Infirmary.
The fear of being stigmatized or treated unfairly by health care providers is not unique to this woman– many sex workers do not disclose their work status to their doctor because of the intense stigma and discrimination they experience afterward (Underhill et al 2015; Benoit et al 2019). This also showed up in an online webinar promoting HIV modernization where two sex workers who had lived experience with the criminalization of HIV had to describe their experiences with health care professionals in a room filled with them. The health care professionals described their role in ‘HIV care linkage’ in a way that contradicted the lived experiences of collaborators and their clients. For example, health care providers tend to think of themselves as on the same ‘care team’ as PLHIV. Yet, collaborators in focus groups collectively described their experiences with health care professionals as overwhelmingly stigmatizing and inadequate:
“You know, I mean now my maturity, now where I am today, looking back at that, I kind of wonder. Because I think anybody of sound mind, especially with a doctorate degree in that kind of medicine, should have seen how messed up I was. I mean, we're talking, god at 19, I had the mind of probably the 13 or 14 year old processing, any kind of rational. I just wonder why a call, you know, out of state or somewhere. It can be somewhere to get help instead of letting walk out the door, knowing that I was 75 pounds and my fingers ate up because of chore boy and crack pipes, that you didn't help that. I guess that's what bothers me. No doctor could have not seen that. And so that's what bothers me. It's fine that you treated HIV and you've got me in and prescribed my pill, but isn't there more to it? Nutrition. Do I have a safe place to live? Like I said, I was like 75. I didn't weigh more than 80 pounds through my entire twenties. They called me Skeletor. Like I was that sickly skinny from being so drugged out all the time.” – Tiffany
There was a consensus that these experiences were all too familiar with the culture of clinics. Several people described experiences hearing a public health or care provider openly talking about sex workers, PWUD, and PLHIV in horrible ways, dehumanizing them in the process of receiving care. This treatment was especially bad for Black women, who are often imagined to be ‘potential’ sex workers and painted as ‘hypersexual’, resulting in a range of ‘medical mishaps’ such as misdiagnoses and ill prepared deliveries (Bridges 2016*), but also a slew of mundane experiences in which health providers treated Black women differently because they imagined that they could be a sex worker. One health clinic, for example, repeatedly reminded a Black cisgender woman living with HIV who distributed condoms at events that she could be pulled over by police who might perceive her to be a sex worker because of the number of condoms she had with her. Albeit a microaggression, this behavior of repeatedly reminding her of the real danger of driving while Black, especially when being potentially perceived as a sex worker by police if pulled over, and the threat of criminalization in FL. Moreover, reproductive injustice becomes visible in public health and biomedical spaces in which Black women are always already imagined to be a sex worker or otherwise ‘hyper-sexual’. Doctors at the oldest public hospital in NYC, for example, said that they screened Black women for STIs more frequently than their white counterparts because they believed that they could be a ‘prostitute’ (Bridges 2016). These stereotypes ultimately worsen health outcomes for Black women, both in the lack of culturally competent care but also through ‘medical mishaps’ fueled by these logics. Black women with endometriosis, for example, have been consistently misdiagnosed with PIV, which is caused by an STI (Bridges 2016). Trans and gender non-conforming individuals were subjugated to increased stigma because of doctors’ refusals to use their pronouns or otherwise provide gender-affirming care, making culturally competent care even less accessible:
“As we're talking about black women being sexualized, we see in the political climate that there's always this constant responsibility and blame on women and the reproductive justice, and the productive health... even more so that's trying to be criminalized. So even if you are in this scope of different types of sex, where should you happen to conceive a child in that process of trying to make ends meet or doing whatever you're doing, but you don't want the baby then now you're criminalized on top of the act of sex work... And then also around reproductive equity, how that is not specific to cisgendered women, reproductive equity is across the board. It's not just about family planning, it's about your organs and how a doctor treats you when you go into a medical appointment and to not dead name you and all that jazz. So I just wanted that lifted.” – Kamaria
Ignorance
The culture of the clinic, both literal and figuratively speaking in reference to public health as a practice and discipline, is not critical and is pre-occupied with issues most collaborators found irrelevant to the lived experiences of sex workers, PLHIV, and PWUD. The ill-informed and overly simplistic recommendations public health experts make such as ‘condom use’ and disclosure often ignore the realities of condom negotiation and disclosure wherein many women have been beaten and even killed.
The culture of the clinic and public health as a discipline also seem to ignore or be ignorant of the ways in which they actively put sex workers, PLHIV, and PWUD in harm’s way by involving the police or CPS or otherwise placing individuals at risk of legal liability. Most collaborators, for example, described most health care providers and public health professionals as generally unaware of anti-HIV laws. Yet, they still tokenized PLHIV, especially Black women, by asking them to ‘share their story’ as a ‘cautionary tale’ at a largely ineffective event reaching people for only moments with often naïve understandings of the realities of condom negotiation and disclosure. Here, the ‘storyteller’ was actively put in a situation in which she could become legally liable to criminal HIV exposure by notifying others of her status and thus giving them a tool for potential retaliation, which is not an uncommon experience. Story telling has become increasingly used in HIV movement discourse which has come to search for individuals born with HIV who are exceptions to the idea of receiving a reactive test after engaging in ‘immoral’ behavior.
Taken together, public health professionals were either unaware of anti-HIV laws or did not fully consider the precarious situations they place PLHIV in. The fact that they had not considered the emotional labor they were asking for exemplifies the types of interactions public health and care providers generally have with the Black people they tokenize yet do not fairly compensate. This process becomes clearer when we consider what each party walks away with after a public health study: (1) a grant, award, or salary raise or (2) accessing services that should be freely accessible and a small gift card. Black trans women were acutely aware of the power dynamics that health care providers and public health professionals so often refuse to acknowledge. This practice translates to smaller scale harm reduction projects wherein white cis led programs have relied on the unpaid physical and emotional labor of Black trans and gender non-conforming (TGNC) people for community outreach, ultimately using Black TGNC for to expand programming.
Large amounts of HIV funding have gone to waste as testing is disincentivized in criminalized contexts as being tested could result in being criminally liable under ‘HIV exposure’ laws, which is especially problematic for those who engaged in street-based survival sex work who cannot afford to leave the sex industry. Rather than funneling money into largely ineffective public health and policing strategies, HIV funding could be better spent if directed to the numerous grassroots peers to peer organizations designed by and for sex workers, PWUD, and PLHIV at the intersections of race, gender, and class. This includes but is not limited to organizations led by and for Black trans women, trans women of color, im/migrants, and other populations who are over-exploited by the police state.
Supporting Systems of Surveillance– Public Health & Policing
Public health operates from carceral logics and, in many ways, acts as an extension of the criminal legal system. This becomes increasingly obvious in the overlapping surveillance systems the two create and share with one another. Many public health professionals have proposed collaborating or working with police in surveillance systems. Public health professionals have also often created maps lighting up ‘hotspots’ with higher prevalence of COVID-19, drug use, overdoses, visible sex workers, and HIV. These are often drawn without consent from the individuals they transformed into data points and ‘hotspots’ that were shared with or accessible to police. These ‘hotspots’ are often in communities of color due to structural and systemic inequities and are used as policing maps, increasing the surveillance and policing of Black and brown communities (Policing COVID pandemic). Public health departments also use similar surveillance practices as police, entering communities they often times don’t belong to:
“I do remember the Health Department trying to hunt me down ...and I remember there was a big orange letter taped to the door looking for me...Just sheer harassment. And, at that point, all the dealers that were selling, and everyone was like, Hey, why is the Health Department looking for you? And, it'd kind of gotten to be really dangerous.” – Tiffany
Public health approaches clearly overlap with the carceral logics and systems of surveillance that police ordinarily use, thus demonstrating how public health departments can operate as an extension of the criminal legal system. The irony here is that the steps they took to ‘protect’ ‘public health’ jeopardized the safety of a trafficking victim who had already been arrested and incarcerated several times for ‘aggravated prostitution’ while further perpetuating the cycle of stigma and incarceration. Despite being a trafficking survivor, police had profiled and harassed Tiffany similarly to other known sex workers, which included but was not limited to forcibly taking her photo to be kept in a police surveillance van in TN:
“They stand in you in the back of their cruiser and they take a Polaroid picture of you and add it to their binder. So that's the first step of being profiled. So once they see any new girl out there walking, it doesn't matter. You could be just walking to the store, they will stop you. They will photograph you with a Polaroid and you go in the binder of their truck. And that way all officers pull it out on those study and then they see you. If they see you a second time, and then it starts building from there. So you're automatically profiled. Unless you can dodge a cop car, under covers every single time. It just takes one time to be seen as a female. And your photos being taken.” – Tiffany
Tiffany was later set up by police and arrested after refusing to engage with undercover police officers. Despite ignoring and walking away from police, she was later arrested and charged as it was simply the police’s word against hers to the DA. Other collaborators had described their experiences being arrested as “entrapment” by the police. Unfortunately, this is not an uncommon policing practice. Police often exploit their power to arrest anyone perceived to be a sex worker for mundane reasons. This included but was not limited to harassing people for directions or a ride and then immediately arresting them after they reluctantly agreed. This process
Jail
States with mandatory testing such as TN forcibly tests sex workers in jail, publicly announce the results in court and then subsequently charge sex workers and trafficking victims alike who receive a reactive test with a Class C felony, forcing them to register as ‘violent’ sex offenders, a lifetime status ordinarily reserved for pedophiles disqualifying them from housing, jobs, and education. TN did successfully repeal one aspect of this law, allowing trafficking victims to appeal the charges. One trafficking victim successfully appealed one ‘aggravated prostitution’ charge but was told she would have to repeal each individual charge until she could be taken off the sex offender registry.
Health care and access to medication in jails is disorganized and chaotic, resulting in people losing access to life saving medicine including but not limited to PLHIV and TGNC people being denied ARTs and hormone replacement medications. PLHIV have been forced to wait in jail for months while prosecutors and judges took recesses to learn about HIV transmission. In Tennessee, PLHIV and trans women in TN who have been forced to wait for months on end in jail or were given the wrong medication for hormone replacement, anti-retroviral treatment (ART), and other-life saving medications. A Black cis bisexual man living with HIV, for example, was denied medication for an entire month and forced to wait in jail for nearly 3 months before a trial after being arrested for HIV exposure out of retaliation from two ex-lovers who he disclosed and did not transmit to. This becomes even more problematic during COVID-19 when it is impossible to social distance in jail.
Sex workers living with HIV in jail in TX were treated as something outside of a human as they were forced to perform additional labor simply because they were living with HIV:
“I went to jail. Even then that didn't really do anything, because I also went to treatment. And when they found out I was HIV positive, I was also shamed while I was there, because I found out I was HIV positive during treatment. And somebody had... Literally, this is what happened. Somebody had their period and left bled on the toilet, and out of all 60 women they made me go clean it. Why? I said, that blood ain’t mine. No, because I was HIV positive. You see what I'm getting at?” - Michelle
Prison
Sex workers, PWUD, and PLHIV alike experienced the dehumanization accompanied with incarceration, which was especially problematic for PLHIV whose were isolated in the “HIV tank”, outing them to allegedly for the sake of access to care. Not unlike those in jail, PLHIV in prison were given the wrong ART medication that did not work for their bodies. PLHIV in prison were also fired from jobs after their employer learned of their status, losing any opportunity to generate income while incarcerated.
Re-entry
“The sex offender registration in Tennessee has nothing to do with health. I can't go to playgrounds. I can't live near daycares. I can't, I have a young child. I can't participate in those school activities. I've never met her teachers. I can't do Halloween. And it's heartbreaking because there's what 163 women's lives here in Tennessee that are just torn apart from families and education and housing. No jobs. Just living on the registry in general. It's just, it's a nightmare. I can't get away from my abuser. I can't move nowhere. He'll always find me. So that's been another thing, you know, through the years, I actually had somebody I could not get away no matter where I went. It did not matter. There's no protection of that. You're on the registry. So I stayed in the same relationship and same cycle for so many years. It's never ending. Or so it can feel that way.” –Tiffany
For sex workers who have been forced to register as a violent sex offender in states such as TN, re-entering a society in which you cannot legally be near children and are no longer eligible for public housing, education, or employment opportunities creates an endless cycle of incarceration. For trafficking victims and survivors of domestic abuse, the sex offender registry means never escaping their abusers. Sex workers living with HIV who have re-entered society after incarceration have been harassed by police who have shown up to their jobs to forcibly tell them that they cannot work in food service while living with HIV. Police have also shown up to women’s churches to threaten them with arrest if they did not out themselves to their pastors:
Taken together, the clinic to prison pipeline exemplifies the ways in which public health and biomedical structures act as an extension of the criminal legal system who ultimately work together to demarcate the bodies of sex workers, PLHIV, and PWUD for death at the intersections of race, gender, and class. The shared experiences of sex workers, PLHIV, and PWUD in clinical settings demonstrates the enormous gap in biomedical and public health institutions, largely in their exclusion of these groups and devaluation of lived experience. Holistic care is not possible in criminalized contexts.
Lydia Babcock, (She/Her) MA, MPH, is a Project Consultant at Collaborative Action Consulting and a graduate of University of Memphis. She conducted research around the criminalization of HIV in 2020 in Tennessee, Florida and Texas and wrote a series of posts from the results of that research that we will be releasing over the next few weeks.
"The purpose of this report is to make clear the ways in which the assumptions that sex workers, are both ‘public health threat’ and ‘criminal’ has become common sense to the public. To do so, it examines the logics behind the idea that sex work is always related to HIV and/or drug use and that sex workers, people living with HIV (PLHIV), and people who use drugs (PWUD) are always the same people. Moreover, it hopes to shed light on the ways in which this narrative has been used as a political tool to both (1) justify the state-sanctioned killings of sex workers, PLHIV, and PWUD and (2) employ a variety of strategies (surveillance, policing, incarceration) to rework the social killings of sex workers, PLHIV, and PWUD as a ‘necessary’ social process. Importantly, the intent here is not to insinuate that any one individual cannot have intersecting experiences with sex work, HIV, and/or drug use. This would not only be inaccurate but also harmful as some project collaborators have experienced increased violence because of this intersectionality. Rather, it is to examine the ways in which the different yet overlapping public identities of sex workers, PLHIV, and PWUD have been created and used as a political tool to ultimately prevent the sex worker rights, HIV, and harm reduction movements from working together toward more structural, systemic change." -Lydia Babcock
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