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Sex work has been seen as a problem: a threat to public health, public order, decency, the formal economy, the integrity of borders, and women's rights. 1 Responses range from repression, especially of sex workers, to liberalisation and decriminalisation. Most policy debates share the premise that the sex industry is harmful to participants; its workers are considered to be socially excluded and vulnerable. This belief underpins recent policy changes in the United Kingdom. 2, 3 One key part of government proposals is to emphasise "exiting" strategies-mechanisms for helping people leave the industry and become reintegrated into society.
Unfortunately there is little evidence to support such policies. While the short term impact of sex work on health has been studied extensively in recent decades, 4- 6 prompted by concerns about the risks of HIV, little is known about the longer term impact. In common with others, we have conducted short term studies and found that sex workers in the United Kingdom face increased risks of HIV and other sexually transmitted diseases and blood borne viruses. 7 In addition to infection risks, some studies have identified psychological morbidity as a common outcome in the short term. 8 Few long term studies have been conducted since sex work is widely considered a transient occupation and long term follow up problematic. We have previously reported findings from the first period of a cohort study with a follow up for a median of 18 months. 7 We identified an increased mortality rate, a finding echoed in work from the United States. 9 In this paper, we report from this unique cohort study on the longer term impact of sex work on women's health and careers, exploring the career path of women both within and outside the sex industry.
METHODS
We established a cohort of sex workers in London between 1986 and 1993. Detailed methods, baseline findings, and initial follow up data have been reported elsewhere. 7, 10, 11 Briefly, from 1985 to the end of 1991, women working in the sex industry were enrolled in a cohort study based in an inner London genitourinary medicine department, where a special clinical and outreach service, the Praed Street Project, was developed for sex workers. 12, 13 Women were eligible for the...