Writing and rhetoric, Conditions and diagnosis in recreation, Recreational Therapy and Inclusive recreation

Culturally Competent Health Care for Sex Workers: An Examination of Myths That Stigmatize Sex-Work and Hinder Access to Care

Danielle A. Sawicki1, Brienna N. Meffert1, Kate Read2, Adrienne J. Heinz1,3

1National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Healthcare System

2Black Dot Writing LLC, Veterans Affairs Palo Alto Healthcare System

3Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System

Abstract

Sex workers are individuals who offer sexual services in exchange for compensation (i.e., money,

goods, or other services). Within the United States the full-service sex work (FSSW) industry

generates 14 billion dollars annually there are estimated to be 1-2 million FSSWers, though

experts believe this number to be an underestimate. Many FSSWers face the possibility of

violence, legal involvement, and social stigmatization. As a result, this population experiences

increased risk for mental health disorders. Given these risks and vulnerabilities, FSSWers stand to

benefit from receiving mental health care however a constellation of individual, organizational,

and systemic barriers limit care utilization. Destigmatization of FSSW and offering of culturally

competent mental health care can help empower this traditionally marginalized population. The

objective of the current review is to (1) educate clinicians on sex work and describe the unique

struggles faced by FSSW and vulnerability factors clinicians must consider, (2) address 5 common

myths about FSSW that perpetuate stigma, and (3) advance a research and culturally competent

clinical training agenda that can optimize mental health care engagement and utilization within the

sex work community.

Keywords

sex work; sex workers; prostitution; mental health; stigma; trauma

The sex industry, in varying forms and degrees, has been in existence for centuries. Attitudes

about sex work have evolved based on political and economic climates, predominant

religious beliefs, and law enforcement efforts. The term “sex work” is an umbrella term for

the provision of sexual services or performances by one person for which a second person,

the client or customer, provides money or other markers of economic value (i.e., goods,

services). Sex work refers to prostitutes, escorts, strippers, porn actors, sex phone operators,

or dominatrixes. It should be noted that not all people who participate in these acts identify

as sex workers. In sex work research, there is a long-standing debate about utilizing

Correspondence for this article should be addressed to Dr. Adrienne J. Heinz, 795 Willow Rd. (152-MPD), Menlo Park, CA 94025. [email protected].

U.S. Department of Veterans Affairs Public Access Author manuscript Sex Relation Ther. Author manuscript; available in PMC 2019 March 19.

Published in final edited form as: Sex Relation Ther. 2019 ; 34(3): 355–371. doi:10.1080/14681994.2019.1574970.

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terminology such as “sex work” versus “prostitution.” We use “sex work” here to emphasize

the labor aspect of commercial sex and find it to be a less pejorative and gendered term. It is

important to distinguish between sex workers who do and do not have in-person contact with

clients, as individuals who meet with clients in-person face more legal and safety risks. For

this article, the term full-service sex worker (FSSW), refers specifically to individuals who

provide in-person sex services. The Center for Disease Control (CDC; 2016) defines FSSW

as:

“Escorts; people who work in massage parlors, brothels, and the adult film

industry; exotic dancers; state-regulated prostitutes (in Nevada); and men, women,

and transgender persons who participate in survival sex, i.e., trading sex to meet

basic needs of daily life. For any of the above, sex can be consensual or

nonconsensual.”

This definition is fallacious, as anything that is not consensual is not part of what has been

agreed upon in terms of services and labor, therefore it enters into the realm of assault. Like

other forms of work or labor, FSSW involves choice and consent among those involved. As

of 2017, 72% of adolescents and 65% of adults reported high levels of trust in the CDC

(Kowitt, Schmidt, Hannan, & Goldstein, 2017). The conflation of assault and FSSW in a

trusted government organization highlights the need for a deeper understanding of

consensual FSSW as it has significant implications for policy and practice.

The FSSW trade in the United States generates about $14 billion annually (Havoscope,

2013). A 2012 report by Fondation Scelles indicated that there were an estimated 40-42

million FSSWers in the world, 1-2 million of which were in the U.S. Importantly, little is

known about the actual size of this population, as most studies of FSSW rely on samples of

convenience, typically recruiting in jails, clinics that treat sexually transmitted infections,

and opioid use disorder treatment programs, and many individuals may elect to not disclose

their work status for fear of stigma. FSSW is criminalized in the U.S. and most countries,

and as such, registries of FSSWers are not available.

Many studies conflate sex trafficking and FSSW, which renders it more difficult to estimate

the prevalence of either group. Sex trafficking is a human rights violation involving threat or

the use of force, abduction, deception, or other forms of coercion to exploit individuals. This

may include forced labor, sexual exploitation, slavery, and more. FSSW, in contrast, is a

consensual transaction between adults, where the act of selling or buying sexual services is

not a violation of human rights. It is important to note that many FSSWers believe that these

two points of nonconsensual and consensual FSSW are more of a continuum of free choice

rather than a dichotomy. FSSW itself is not a form of sexual violence, but FSSWers are

especially vulnerable to sexual and intimate partner violence.

Objectives

The objective of the current review is to (1) provide education on the unique struggles faced

by FSSWers and vulnerability factors clinicians must consider, (2) address 5 common myths

about FSSW that perpetuate stigma, and (3) advance a research and culturally competent

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clinical training agenda that can help optimize mental health care engagement and utilization

within the sex work community.

Unique Struggles of FSSW and Clinical Considerations

FSSW, Violence, and Trauma Exposure

Violence against FSSWers is pervasive and represents a significant public health concern.

Conflation of sexual violence with FSSW can increase violence against FSSWers by

perpetuating stigma (Lowman, 2000) and this is because stigma can alienate FSSWers from

social services (UNAIDS, 2014). Previous studies have noted a robust positive relationship

between anti-sex work rhetoric, which characterizes outdoor workers as a nuisance or threat

to public order, and an increase in violence against sex workers (Lowman, 2000).

Criminalization and policing, population movement and mobility, work environments,

broader economic conditions and gender inequality are also correlated with increased

violence against FSSWers (Deering et al., 2014). Additionally, prior research has shown that

adolescents who are homeless (Shannon, 2009), individuals who has previously been

arrested for FSSW (Cohan et al., 2006), migrant FSSW (Reed, Gupta, Biradavolu, &

Blankenship, 2012), FSSW who use drugs (Wirtz, Peryshkina, Mogilniy, Beyrer, & Decker,

2015), and outdoor (i.e., street-based) FSSWers (Weitzer, 2009) were at especially high risk

of violence.

The magnitude of violence experienced by this population is profound and one in five police

reports of sexual assault from an urban, U.S. emergency room were filed by FSSWers

(Mont, 2008). In Phoenix, Arizona 37% of FSSWers diversion program participants report

being raped by a client, and 7.1% report being raped by a pimp (Schepel, 2011). In Miami,

Florida, 34% of outdoor FSSWers had reported violent encounters with clients in the past 90

days of being interviewed (Surratt, 2011). In New York, 46% of indoor FSSWers (i.e.,

individuals who work in hotels, brothels, homes, or other indoor areas) reported being forced

to do something by a client that they did not want to do (Thukral, 2005), and over 80% of

outdoor FSSWers experienced violence (Urban Justice Center, 2003).

Exposure to institutionalized violence and discrimination.—FSSWers are

especially vulnerable to police violence, and there are several documented cases of this

throughout the United States. Police officers have been documented to threaten victims with

arrest or stage an arrest and sexually assault victims. Seventeen percent of FSSWers

interviewed in a New York study reported sexual harassment and abuse, including rape, by

police (Urban Justice Center, 2003). In a Chicago study, 24% of outdoor FSSWers who had

been raped identified a police officer as the perpetrator (Raphael & Shapiro, 2002).

Frequently FSSWers are not protected by rape shield laws. Although New York and Ohio

explicitly exclude FSSW to be used as character evidence against rape victims, judges in

states without explicit exclusion of FSSW often allow for FSSW to be brought up in order to

invalidate assault charges. FSSWers may also be arrested when they report violence,

including trafficking, to the police because, even though the FSSWers are victims of

violence, they are still criminalized. Additionally, FSSWers receive more victim blame and

less empathy after experiencing a sexual assault in comparison to the general population

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(Sprankle, Bloomquist, Butcher, Gleason, & Schaefer, 2018). Accordingly, many FSSWers

are unlikely to trust or engage with public safety systems as these very systems have failed

to keep them or their colleagues safe, and have even done further harm.

Unaddressed Mental Health Needs and Barriers to Care Engagement

The pervasive violence against FSSWers creates an increased risk of mental health

conditions. Prior research demonstrates that posttraumatic stress disorder (PTSD) is

especially common after traumatic events involving physical and sexual violence (Liu et al.,

2017). In addition to physical and sexual violence, FSSWers are also at greater risk to use

and experience problems with substances than in the general population (Burnette et al.,

2008; Nuttbrock, Rosenblum, Magura, Villano, & Wallace, 2004). The use of substances to

cope with violence and discrimination may explain the higher rate of substance use

problems in FSSW. Indeed, prior substance use research shows that using substances to cope

with negative affect is the best predictor of having or developing a problem (Martens et al.,

2008). In turn, substance use poses a risk for other health problems as well, such as HIV and

other sexually transmitted infections (Hwang, Ross, Zack, Bull, Rickman, & Holleman,

2003). Importantly though, there has been far more clinical attention paid to sexually

transmitted infections (STIs) among FSSWers than to their mental health struggles.

Indeed, there is a dearth of research focused on the mental health of FSSWers (Rössler et al.,

2010). Extant studies have offered important first steps but have tended to only focus on

single conditions like PTSD, depression, or drug use. These prior works did not use

diagnostic criteria, dealt exclusively with selected work settings like outdoor FSSWers, or

were predominantly concerned with violence by customers towards FSSWers (Rössler et al.,

2010). A 2001 study found that 59% of the 193 interviewed FSSWers reported they needed

therapeutic or emotional support from others on the street and 57% said they needed

professional counselling (Valera, 2001). Additionally, a 2010 study of FSSWers observed

higher rates of mental illnesses than seen in the general public, such as PTSD (13%), anxiety

(33.7 %) and major depression (24.4%) (Rössler et al., 2010). In contrast, an estimated

3.6%, 19.1%, and 6.7% of American adults experience clinical PTSD, generalized anxiety

disorder, or depression in 2017 (National Institute of Mental Health, 2018). FSSWers are

therefore at a much greater risk for mental health conditions but often experience barriers to

seeking treatment, such as lack of access to health insurance and general distrust of medical

professionals due to sigma, work invalidation, and potential misogyny (Noyes, 2013; Varga

& Kalash KaFae Magenta Fire, 2018).

Given this constellation of challenges, it is critical that FSSWers have access to competent

and culturally sensitive mental health care to help empower them, and to reduce their risk of

victimization and engagement in risky behaviors. For clinicians to provide culturally

competent care to FSSWers, it is critical to understand why FSSW is stigmatized and how

that stigma perpetuates social inequities.

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Myths That Stigmatize FSSW

1. FSSW Should Be Criminalized

There are several government models for regulating FSSW including criminalization, partial

criminalization, legalization, and decriminalization (see Basil, 2015; Mac, 2016). Currently,

the majority of countries, such as the U.S., operate under a partial or fully criminalized

model of FSSW. In the U.S., other than Nevada, FSSW is illegal. Importantly, in the U.S.,

sex workers that do not engage in physical intercourse (i.e., escorts, strippers, sex phone

operators, dominatrixes) are not subjected to the same penalties that FSSWers face, but still

face regulations that can result in criminal charges. Legalization and decriminalization

models are now seen in countries like Germany, the Netherlands, and New Zealand.

Legalization.—Legalization in other countries commonly means that FSSW is regulated

with laws regarding where, when, and how FSSW may take place. Importantly, legalization

still criminalizes those FSSWers who cannot or will not fulfil various bureaucratic

responsibilities. For example, in Nevada, FSSW that occurs in a sanctioned brothel is legal

while all other forms of FSSW are outlawed. Businesses and individuals involved in FSSW

face regulations and licensing procedures that other businesses do not. FSSWers must

register with the police department as a brothel worker and face restricted mobility,

stipulated working conditions, mandated testing for gonorrhoea, chlamydia, HIV and

syphilis, and more (see NAC 441A.777 to 441A.815). These regulations also

disproportionately affect FSSWers who are already marginalized, like people who use

substances or who are undocumented.

Decriminalization.—In contrast to legalized models of FSSW, decriminalization means

that the criminal penalties attributed to an act are no longer in effect and that the same laws

that regulate other businesses regulate FSSW. Unlike legalization, a decriminalized system

does not have special laws aimed solely at FSSW or sex work-related activity. This

particular model is practiced in New Zealand. In 2003, New Zealand passed the Prostitution

Reform Act (PRA) which acknowledged that FSSW is service work and allows FSSWers to

operate under the same employment and legal rights accorded to any other occupational

group.

A common argument against legalizing or decriminalizing FSSW assert that in places where

the work is legalized or tolerated, there is a greater demand for human trafficking victims

and human trafficking investigations are hampered (U.S. Department of State, Bureau of

Public Affairs, 2004). Furthermore, many believe that the presence of FSSW increases crime

and violence (e.g., drug dealing, assaults and robberies) and that the practice creates higher

levels of vulnerability, exploitation, and coercion that contribute to trafficking (Coté, 2008;

U.S. Department of the Interior, 2017). Opposingly, Law (1999) argues that

decriminalization of FSSW facilitates regulation that reduces exploitation of FSSWers. For

instance, by enabling FSSWers to make complaints without fear of prosecution, abuse and

trafficking can be more easily exposed and tracked (Law, 1999). Others who support the

decriminalization of FSSW focus on the negative consequences of criminalization and

stigmatization on the life and working conditions of FSSWers. They conclude that

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decriminalization is necessary to improve these negative consequences and conditions (e.g.,

Brock, 1998; Delacoste & Alexander, 1998; Ditmore, 2010; Canadian HIV/AIDS Legal

Network, 2005), especially because evidence suggests that the issue of trafficking has been

grossly exaggerated (Harcourt & Donovan, 2005; Hubbard, Matthews, & Scoular, 2008;

Davidson, 2006; Weitzer, 2007). The conflation of consensual FSSW and human trafficking

causes imprecise estimation of trafficking victim rates and increases the likelihood of

exaggeration (Tyldum & Brunovskis, 2005).

Recent policy changes in the U.S. include the Stop Enabling Sex Traffickers Act (SESTA)

and Allow States and Victims to Fight Online Sex Trafficking Act (FOSTA). These policies

seek to stop the assistance, facilitation, or support for sex trafficking by making website

providers liable for any usage of their platforms that facilitates sex trafficking, knowingly or

unknowingly. The bills conflate FSSW and sex trafficking by targeting websites that

promote FSSW without differentiating between consensual FSSW and trafficking. This in

turn, harms both FSSWers and trafficking victims. Research in New Zealand demonstrates

that prior to decriminalization, the FSSW industry showed an industry vulnerable to

exploitation, coercion, and violence (Plumridge, 2001; Plumridge & Abel, 2000; Plumridge

& Abel, 2001). With new policies such as FOSTA-SESTA, it may become harder for

trafficking victims to be identified as they will be pushed offline and further underground

(Fischer, 2018; Zheng, 2010) and can directly impact the lives of FSSWers (Agustín, 2010;

Desyllas, 2007; Doezema, 1998; Katsulis, 2009; Katsulis, Weinkauf, & Frank, 2010).

Furthermore, since FOSTA-SESTA fails to differentiate between FSSW and trafficking,

websites used by FSSWers to protect themselves, such as blacklists (i.e., lists of clients who

have historically been violent, pushed boundaries, stolen from FSSWers, or refused to pay)

have been removed.

Many FSSWers believe legalization would destigmatize their work and make it safer (Read,

2013). However, some acknowledge that legalization simply makes the government their

“pimp” and question the impact of future employment prospects in “straight jobs” if their

name is located in a FSSW database. Decriminalizing FSSW seems to have more support

within the FSSW community as it makes arresting FSSWers a low-priority among law

enforcement and allows the trade to continue with little to no government interference

(Read, 2013). Detractors feel this does not offer enough protections for workers, but

supporters feel it offers them the freedom and anonymity that they desire when operating in

such a highly stigmatized profession.

2. FSSW Cannot Be A Feminist Choice

The vast majority of FSSW discourse (i.e., how it is written and/or spoken about) is steeped

in a long, complex, and highly gendered historical context. Historically, FSSW discourse

established “prostitution” as a female occupation in service to male clientele. This had led,

in part, to classifying female FSSWers as vectors of disease, erasing male and transgender

FSSWers all together, stigmatizing and criminalizing FSSW throughout many parts of the

world, and establishing that FSSW simply cannot be a feminist choice. These pervasive

stereotypes still influence contemporary ideas about FSSW and have emotional and material

consequences for all FSSWers.

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It should be noted that there are various types of feminism, including (though not limited to)

radical, liberal, socialist, marxist, and cultural feminism. These forms of feminism examine

gender through a male/female binary. The two foundational feminisms are “radical” and

“liberal” and they work in direct opposition to each other’s ideologies in many ways.

Radical and liberal feminist discourse has dominated discussions around FSSW, but a new

era of intersectional feminism has introduced a new lens through which to see FSSW.

Radical feminism (also referred to as “second wave feminism”) was cutting-edge feminist

theory in the 1960s and 1970s that gained momentum in the 1980s. It is best described as the

philosophy that men have systematically oppressed women in myriad ways, from bras to sex

trafficking, and that women-only spaces and organizations were necessary to negate this

subjugation. Radical feminists wanted to eliminate male supremacy and were frequently

referred to as “man-haters.” The radical feminist discourse aligns well with the traditional

gendered discourse around FSSW that women are perpetual victims of male domination,

which aligns with our gendered history where women are assumed to be weak and victims,

while men were assumed to be empowered and perpetrators.

Liberal feminism (also referred to as “third wave feminism”) arguably began with the

suffrage movement and is the philosophy that women are equal to men and can maintain

equality through their personal actions and choices. More recently, liberal feminism has

pushed back against the radical feminist narrative by suggesting that women have agency

and therefore can choose FSSW as an occupation and that choosing FSSW can be

empowering, as long as the worker and the client are consenting adults.

Much of the feminist debate around FSSW revolves around the question of whether FSSW

constitutes a form of involuntary sexual objectification [radical feminist perspective] or

voluntary sexual labor [liberal feminist perspective] (Read, 2013). Both the radical and

liberal feminist FSSW discourses are problematic as they are predicated on a male/female

gender binary that constructs the female as the sexual service provider and the male as the

client.

More recently, intersectional feminism has come to the forefront (Crenshaw, 1989) which

points to the inherent racism and classism in other, former feminist movements that have

been traditionally led by privileged, white women and argues that not all women have the

same discriminatory experiences. For example, while white women may experience gender

discrimination, women of color experience gender discrimination compounded by racial

discrimination. The Combahee River Collective, a group of Black feminists, wrote a

manifesto that has been cited as one of the earliest expressions of intersectionality. They

argued, “We […] find it difficult to separate race from class from sex oppression because in

our lives they are most often experienced simultaneously” (Combahee River Collective,

1977/1995, p. 234). Intersectional feminism has opened the feminist conversation to include

class, race, sexual orientation, gender, age, and dis/ability. This is important because it

highlights different experiences within specific categories (i.e., “women” can be women of

color, transwomen, women of various ages and abilities) and appreciates the complexity

within their experiences. This idea then translates to a more layered understanding of various

experiences and occupations, including FSSW. Increased focus on communities that

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experience marginalization based on membership of multiple categories (ex: race, class,

gender, sexual identity) is therefore necessary (Cole, 2009).

Using intersectional feminism as an analytical framework, some scholars have aimed to push

the liberal feminist perspective forward by addressing male and transgender FSSWers

acknowledging that vulnerability and harm co-exist with autonomy and agency in FSSW.

FSSW, like most work, is not a homogenous experience. Recent scholarship discusses

FSSW as a choice for women, men, and the trans community. Smith and Laing (2012)

summarize the literature as having “done much to expose and challenge the entrenched

polarities--such as those between oppression and liberation, violence and pleasure, and

victimhood and agency--that have long underpinned political and philosophical debates

surrounding the sale and purchase of sex” (p.517). FSSW is complex and the people

performing the work have widely varying degrees of satisfaction with it, just as those in

other professions might.

FSSW: A Feminist Choice.—So, how can FSSW be feminist? Simply put, choosing

FSSW establishes a person’s ability to make a choice about their own body, which is at the

heart of all feminist movements. Choosing FSSW establishes that all people have agency

and the right to choose whatever occupation they want. To be clear, even the idea of

“choice” is complicated. For example, a single dad may have to choose between working 60

hours at a call center, making minimum wage and barely seeing his children all week or

choosing FSSW where he will make the same amount of money working only 10 hours per

week, having a flexible schedule and see his children. Detractors argue that FSSW is

exploitive to the (female) body and puts (female) FSSWers in harm’s way. Arguably, many

physically demanding occupations have similar stakes (firefighters, professional football

players), yet there is no stigma around those predominantly male occupations. In part, this is

born out of the anti-feminist notion that men are somehow more capable of making

decisions about their bodies than women. An important aspect to note about FSSW, as with

any work, is that sometimes providers like their job, sometimes they hate it, sometimes they

do it as a last resort, sometimes they do it because it is enjoyable, and everything in between.

What sets FSSW apart from other forms of work is that it is criminalized and highly

stigmatized and this has material consequences for the worker.

3. All FSSWers Are Equally Impacted By Stigma

Comprehensive literature reviews and reports from government agencies conclude that

stigma exerts multiple negative effects on social status, psychological well-being, and

physical health (e.g., Major & O’Brien, 2005; U.S. Department of Health and Human

Services, 1999; Williams, Neighbors, & Jackson, 2003). Members of stigmatized groups are

discriminated against in the housing market, workplace, educational settings, healthcare, and

the criminal justice system (Crandall & Eshleman, 2003; Sidanius & Pratto, 1999). In the

case of FSSW, this identity is often concealed because of stigma. A concealed stigmatized

identity, although kept hidden from others, carries with it social devaluation (Crocker, Major,

& Steele, 1998).

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When clinically assessing a FSSWer’s risk for negative outcomes related to stigma, it is

paramount to appreciate the ways in which race, class, gender, and sexual identity can affect

an individual’s experience. A middle-class white outdoor cisgender female worker will be at

lower risk than an outdoor black transwoman or a lower income Latinx immigrant worker. In

comparison to the general population, FSSWers are overall at higher risk for violence, stress,

low self-esteem, depression, suicide, substance use, disease, malnutrition, family

estrangement, police harassment and profiling, stress from intimate partners, and job

insecurity (Varga & Kalash KaFae Magenta Fire, 2018). Much of this can be tied into the

stigma FSSWers face within society “in the wild” and what happens when marginalized

identities intersect.

FSSWers face different levels of discrimination both from their own community and society

as a whole due to whorephobia. Whorephobia is defined by professionals in the sex work

industry as “the fear or hate of sex workers” although, along with other forms of oppression,

it can be applied on a structural basis. The term whorephobia is used to denote forms of

hatred, disgust, discrimination, violence, aggressive behavior or negative attitudes directed at

individuals who are engaged in sex work. Whorephobia operates in several contexts,

resulting in excessive forms of violence, institutional discrimination, criminalization and all

other negative and hostile environments that target sex workers. Whorephobia, also tends to

hold the most consequences for women. In the majority of languages, the most common

sexist insults are “whore” or “slut,” which makes women want to distance themselves from

the stigma associated with those words, and from those who incarnate it. It is believed that

the ‘whore stigma’ is a way to control women and to limit their autonomy – whether it is

economic, sexual, professional, or simply freedom of movement. Women and men are

brought up to think of sex workers as “bad women”. It prevents women from copying and

taking advantage of the freedoms sex workers fight for, like the occupation of nocturnal and

public spaces, or how to impose a sexual contract in which conditions have to be negotiated

and respected. The stigma that FSSWers carry with them can, at its worst, be fatally

dangerous as they are 18 times more likely to be murdered compared to the rest of the

population (Potterat et al., 2004).

An additional form of marginalization FSSWers face due to whorephobia is based within the

‘whorearchy’. The whorearchy is arranged according to intimacy of contact with clients as

well as intersections of other marginalized identities. The more marginalized and closer in

contact one is to a client, the closer they are to the bottom of the whorearchy (Bosch, 2016).

That puts outdoor FSSWers at the bottom. They are often looked down upon by indoor

FSSWers, who find clients online or via other third parties. Indoor FSSWers are looked

down upon by strippers and escorts who only perform sex fantasies for clients but do not

include full service contact. At the top sit sex workers who have no direct contact with

clients, such as cam girls (i.e web-camera) and phone-sex operators. This means that the

lower an individual is in the whorearchy, the more stigma they face both from internal

community and society more broadly. Survival FSSWers, who are often outdoor workers,

carry a far greater risk of developing depression, psychiatric hospitalization, and workers are

4.5 times more likely to attempt suicide (Anklesaria & Gentile, 2012).

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Unfortunately, male and transgender FSSWers have been historically underrepresented in

discussions of sex work, and to date there is still very little research on this sub-population

that does not have a medical agenda. Specially, contemporary research on male FSSWers

typically has focused on men and HIV transmission or male sex workers and HIV/AIDS.

Yet, with little qualitative data analysis to contextualize the quantitative medical data

collected, it is difficult to gather an accurate depiction of the everyday lived realities of male

and transgender FSSWers. This dearth of knowledge is problematic as of the estimated

40-42 million FSSWers in the global economy, 8-8.42 million are cisgender men, meaning

that about 1 in 5 of FSSWers are cisgender men (Minichiello & Scott, 2017).

4. All Sex Workers Experienced Childhood Trauma

Research findings are mixed regarding whether FSSWers are more apt to have traumatic

pasts in comparison to the general population. An extensive body of literature argues that

working in the sex industry is the result of negative experiences in early stages of the life

course (i.e., childhood, adolescence, and emerging adulthood). According to the oppression

paradigm, a paradigm that assumes that FSSW is an “expression of patriarchal gender

relations and male domination” (Weitzer, 2012, p. 10), childhood sexual abuse and other

sources of trauma are common early life contributors to FSSW (Simons & Whitbeck, 1991;

Stoltz et al., 2007; Wilson & Widom, 2010). A smaller set of studies argues that people’s

current economic opportunities, needs, and other situational adult factors better explains

their involvement in FSSW. Yet, most research on FSSW has used data gathered from small

samples and assumed, but has not demonstrated, that their needs and motives are different

from people employed elsewhere.

On average, a greater proportion of people employed in the sex industry had many of the

early life course experiences—from childhood poverty and abuse, to homelessness—that the

oppression paradigm cites as contributing factors to sex work (McCarthy, Benoit, & Jansson,

2014). However, the data also indicated that, compared to people who worked in other

service/care jobs, a greater proportion of those involved in FSSW had lower levels of human

capital and less education and, on average, had worked in fewer occupations (McCarthy,

Benoit, & Jansson, 2014). People employed in the sex industry were also less likely to have

an income-earning partner. Thus, there was some evidence of the factors highlighted by the

empowerment perspective; namely, that experiences in adulthood, as well as in earlier life

course stages, contributed to working in the industry (McCarthy, Benoit, & Jansson, 2014).

There is a risk of the intersection of childhood trauma and active trauma with this population

that creates the possibility of re-traumatization or repetition compulsion (i.e., the mind’s

tendency to repeat traumatic events in order to deal with them or change a previous

narrative) (Varga & Kalash KaFae Magenta Fire, 2018) that should be considered.

Additionally, previous research shows that childhood sexual trauma can be associated with

hypersexuality, more sexual curiosity, and exploration compared to individuals who had not

experienced childhood sexual trauma (Draucker et al., 2011). This data may support the

conclusion that early sexual trauma impacted a FSSWers choice to become a FSSWer.

Importantly, neither of these points invalidate a worker’s choice to do FSSW or the agency

the individual holds.

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Still, many individuals and clinicians within society believe that FSSWers need to be ‘saved’

from their work, especially if they come from abusive pasts. This concept is known as the

“savior complex” and this term has most often been employed in terms of white savior

complex when discussing persons of color and voluntourism (i.e., volunteer tourism). Savior

complex can happen in any community where an individual has more privilege than the

individual or community they are trying to serve. Given this power imbalance, it is

paramount to mindfully listen to marginalized voices and what the individual wants for

themselves.

5. FSSW Is Not Real Work

Different forms of FSSW (i.e., indoor versus outdoor, independent versus agency) involve

different forms of labor and risk. An indoor, independent FSSWer is often responsible for

creating their own media, marketing, websites, social media management, email

communications with clients, as well as screening clients to ensure safety. This process is

comparable to what an entrepreneur may go through when building their own business.

When with an agency, the individual FSSWer is generally not responsible for these

activities. Outdoor FSSWers are at highest risk, as they lack the online resources and

protection barriers that have become available in more recent years, such as blacklists.

Outdoor FSSWers, often ‘freestyle’ looking to meet potential clients either in bars, hotels, or

on the streets, which involves a different form of labor in comparison to independent indoor

and agency workers. Overall working hours, schedule stability, and the number of clients

seen can vary greatly depending on gender, socioeconomic status, and type of FSSW being

done. When looking at online advertisements for indoor independent FSSW, income varies

greatly, but many have one or two-hour minimums. Regardless of what type of work is being

done all FSSWers often perform both physical and emotional labor, the process by which

workers are expected to manage their feelings in accordance with organizationally defined

rules and guidelines. (Hochschild, 1983). Emotional labor may be listening to a client vent

about career, interpersonal, or psychological struggles. It can also look like offering support

or friendship to a client who is feeling upset. It has been said that individuals need to

perform similar emotional labor to therapists in this way (Varga & Kalash KaFae Magenta

Fire, 2018). It is crucial to note that because of how much labor, both emotional and

physical, FSSWers perform, self-care and recovery time is essential.

While some believe that all FSSWers only do this work because it is their only option for

survival, it is not the case for all. To place the entire community under this blanket

assumption further perpetuates the narrative that FSSWers have no agency and that this work

is not real work. In fact, the skills required to be a successful FSSWer can often be

transferred into other fields such as marketing, customer service, project management, and

office jobs such as legal or executive assistants. FSSWers may feel that their work gives

them the freedom to set their own schedules, have higher wages, and choose how to run their

own entrepreneurial business. These points are especially important to those who are

differently-abled or neurodivergent as the freedom FSSW provides them may be essential to

their well-being. Neurodivergent refers to neurodiversity, this movement neutralizes the

stigma that has traditionally been accorded to autism, ADHD, and other neurodevelopmental

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conditions. Many scholars extend the definition to include mental health differences. To this

portion of the community, FSSW can very well be a choice made out of personal preference.

Future directions for research and culturally competent clinical training for

serving sex workers

Future directions for research

This current review explores unique struggles faced by the sex work and FSSW community

and summarizes the literature to debunk myths that perpetuate stigma and harm towards the

community. These myths addressed include (1) that FSSW should be criminalized, (2) that

sex work is incompatible with feminism, (3) sex workers uniformly face the same level of

stigma, (4) sex workers gravitate to sex work due to childhood abuse, and (5) that sex work

isn’t real work.

Despite the burgeoning research on the mental health needs of FSSWers, there are many

shortcomings that must be addressed in order to better inform policy and best-practices for

culturally competent care. Specifically, there is little quantitative data to characterize the

different vulnerabilities sex workers face, and the preponderance of the literature reviewed

does not put the voices of sex workers first. That is, samples of convenience from drug

treatment or incarceration settings do not necessarily represent the experiences of all sex

workers. Further, given that FSSW is highly stigmatized as well as criminalized, researchers

need to determine how to overcome barriers to finding members of the community who are

willing to participate in research as they may perceive engagement with researchers to be

unsafe. More research is also required to explore the marginalization of sex workers from all

branches of the sex work force and to include representation of male, non-binary, trans, and

LGBTQA sex workers and not just cisgender women. Finally, thorough evaluation of the

costs, impacts, and outcomes of policies that regulate sex-trafficking (and sex work

indirectly), is sorely needed to determine whether such legislation yields the desired public

health and safety effects.

Consideration of multiple identifiers of marginalized populations will better enable

researchers to form a contextualized understanding of FSSWers experiences. This is

important because a focus on race, for example, without consideration of other category

memberships (e.e., sexuality, social-economic status, able-bodiedness) does not account for

the complexities or the layers of stigmas and vulnerabilities a person may hold if they have

multiple marginalized identities (Weber & Parra-Medina, 2003). Such attention to potential

nuances of intersecting marginalized identities is critical because failure to attend to how

social categories depend on one another for meaning renders knowledge of any one category

incomplete (Cole, 2009).

Clinical Recommendations

FSSWers face a multitude of barriers when it comes to accessing care, from stigma to

violence to criminalization. Due to fear of these barriers (i.e.,being stigmatized, violence, or

arrest) FSSWers often do not feel safe going to mental health clinicians. As a result of these

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barriers, FSSWers face higher rates of mental health struggles. As clinicians it is important

to recognize the needs and challenges of this community in order to better serve them.

Mental health providers can take several steps to offer culturally competent care. First, they

can remain client-centered even if their own values may not align with those of the client. It

is recommended that clinicians seek out consultation for any potential internal bias towards

or against sex work (Varga & Kalash KaFae Magenta Fire, 2018). Clinicians can also

employ trauma-informed care as FSSWers may have delayed reaction time to process trauma

due to stigma and shame. Third, clinicians can utilize a harm reduction approach in therapy

(Varga & Kalash KaFae Magenta Fire, 2018), such as removing barriers to entry for sex

workers seeking services and “meet them where they are” as well as focusing on the impact

of behaviors in a non-judgmental setting without discounting an individual’s agency. It can

also be beneficial to connect sex workers to bad date lists, resources where needles are

exchanged and/or supplies are provided (condoms, lubricant, clothes), and resources where

sex workers can find community and social support.

Developing culturally competent trainings—Provision of organizationally supported

mentorship by and consultation among mental health professionals will also function to

better serve the FSSW community. For instance, clinical trainings about the specific needs of

sex workers as well as working to move through biases can be offered to the mental health

community, such as graduate students and medical students as part of the curriculum, and to

first responders who may be in situations where they will need to provide care to sex

workers (ex: police and paramedics). A current successful training model is offered by

clinicians from St. James Infirmary, the nation’s only peer based occupational health and

safety clinic for sex workers. St. James Infirmary’s model focuses on teaching clinicians

about sex workers and ways in which they can support the community and approach issues

with clients in a culturally competent way.

Exploring other forms of information outside of academic research would also be beneficial

in trainings. At the moment, the very limited amount of research done on FSSWers does not

provide a comprehensive view of the needs of FSSWers. Additionally, most clinically-

relevant information that captures the voices of sex workers and describes their needs and

experiences is not captured within academic research products.

Current Resources—There are several nonprofits that focus on sex workers advocacy,

agency, and well being. Among them include St. James Infirmary and Sex Workers Outreach

Project (SWOP), The Sex Worker Project at Urban Justice Center, Helping Individual

Prostitutes Survive (HIPS), and Desiree Alliance. There are organizations that offer

community resources to connect sex workers as well as places to learn more about the sex

work community.

To summarize, it is critical to consider the individual, community, societal, and policy

factors that sex workers face when seeking treatment. As a community that faces

vulnerability to violence, stigmatization, and criminalization, access to culturally competent

mental health care is vital and a matter of public health.

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ACKNOWLEDGEMENT

The authors would like to thank Corrie Varga for assistance in manuscript preparation.

Preparation of this report was supported in part by a VA Rehabilitation Research and Development Career Development Award – 2 (1IK2RX001492-01A1) granted to Heinz. The expressed views do not necessarily represent those of the Department of Veterans Affairs.

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