Abstract
Purpose:
Sex work is a common form of work among young trans women (YTW).
Methods:
Using an occupational health frame, we measured associations between demographics, sex work, and vocational outcomes in 18-month visit data from the SHINE study (n=263, San Francisco).
Results:
Overall, 41.8% reported lifetime sex work, primarily escorting/paid sex. Motivations included “better pay” and “can't get a job due to gender discrimination.” Occupational injuries included anxiety (53.6%) and depression (50%), with significantly higher relative risk for YTW doing multiple types of sex work. Criminalization experiences (i.e., incarceration, arrests, and police interaction) were common.
Conclusion:
Results echo calls for sex worker-affirming mental health care for YTW.
Keywords: occupational health, sex work, transgender women, youth and adolescents
Introduction
Sex work (i.e., exchange of sexual services, performances, or products for material compensation) is a common form of work among trans women, who report lifetime engagement across international studies ranging from 24% to 75%.1 Despite its complexities and myriad benefits and risks, most sex work research focuses on exposure to violence and human immunodeficiency virus (HIV).2 This myopic focus may be justified given sex-working trans women face elevated rates of HIV/sexually transmitted infections (STIs), depression, and substance use.3
In the National Transgender Discrimination Survey, sex-working participants were two to three times as likely to use substances to cope with gender-based mistreatment and more likely to have a disability.4 Globally, sex-working trans women face violence, particularly when perceived as transgender.5 Sex work also has benefits for trans women who face employment discrimination and systemic minority stress in formal economies.6 Its advantages range from financial (i.e., funding transitions) and vocational (e.g., job availability, easy entry,7 and self-determined hours) support to psychological well-being (i.e., gender affirmation, affection, and community connectedness).8
Young trans women (YTW) have higher rates of sex work than adults (50.4–67%),9,10 with understudied implications.10 Indeed, few studies have captured occupational aspects of sex work for YTW beyond HIV risk and violence. Most sex work research examines “full-service” work or exchange of sex acts for money and/or basic needs. The present study outlines work-related health, with a broad focus on diverse types of sex work and cumulative occupational risk exposures.
This inquiry is important given sex-working trans women tend to be quite knowledgeable about HIV/STI prevention and, instead, call for attention to issues, including depression, post-traumatic stress disorder, stigma, and decriminalization/legal support.11 Similarly, few studies detail nuances of sex work (and work-related health) beyond “full-service” sex work.12
Sex work occurs both in person and online: in-person jobs include stripping; modeling; porn acting; bondage, discipline, sadism, and masochism [BDSM]; massaging; and paid sex acts (e.g., escorting, brothel work, and street-based work).13 Online sex work includes webcam, phone sex, corporate pornography, and independently created erotic content for subscription-based (e.g., OnlyFans) or pay-per-video (e.g., ManyVids) websites.14 A literature review of studies referencing commercial sex work published during the period 1996–2004 found at least 25 types of sex work.15
Meanwhile, amid the ongoing coronavirus disease 2019 (COVID-19) pandemic, sex worker-serving community organizations have suggested adopting virtual sex work.12 As such, it is critical to move beyond HIV in our framing of occupational implications of sex work, including understanding the impact of engaging in multiple types of sex work.
A crucial target of inquiry and intervention may be occupational stigma—stigma attributed to sex work—which has been linked to poor health care access16 and social isolation.17 Few studies address diverse sex work types or explore relationships between cumulative occupational risks and related exposures to mental and physical health outcomes for YTW. Furthermore, much work on occupational stigma among sex workers either groups trans women with sex workers of other genders or does not include trans women at all.16–18
This exploratory study describes nuances of sex work by measuring multiple work types and associated health/vocational outcomes among a community sample of YTW. Data were analyzed using an occupational health frame5,19 to contextualize motivations for sex work, types of erotic labor performed, occupational injuries and stigma, and opportunities for harm reduction. We also captured police contact and experiences of incarceration, important given that myriad organizations (e.g., Amnesty International and World Health Organization) call for sex work decriminalization to advance public health, racial justice, and human rights.20 Results may inform future interventions to support YTW pursuing or considering sex work to maximize benefits, satisfaction, and survival.
Methods
Sample and procedures
We analyzed 18-month data from SHINE, the first cohort study of YTW in the San Francisco Bay Area (2013–2015) characterizing HIV risk and resilience. The Institutional Review Board (IRB) at University of California, San Francisco (UCSF), approved study procedures (#12-08875), described extensively elsewhere.21 Informed written consent was obtained from all study participants. For participants under age 18, a waiver of parental consent was granted by the UCSF IRB as part of IRB approval for the study.
We used respondent-driven sampling, enrolling an initial group of participants who referred eligible peers, with iterative additional referrals from their social networks (full-sample N=300 YTW).21 Participants completed in-person interviewer-administered surveys at multiple time points. Present analyses are restricted to 18-month survey data (n=263), capturing history of sex work (yes/no) and, if endorsed (n=110), outcomes of interest.
Measures
First, we captured sociodemographic information for the full 18-month sample (n=263, Table 1): age; gender identity; race/ethnicity; lifetime incarceration; recent arrest; recent incarceration; insurance status; and monthly income. Second, we characterized sex work among the sex-working subgroup (n=110, Tables 2 and 3): types of sex work; motivation; occupational stigma; occupational mental health injuries/conditions; occupational physical health injuries/conditions; and care accessed for most recent occupational injury/condition. See Table 2 for response options to each aforementioned measure.
Table 1.
Sample Demographics, Overall and by Engagement in the Sex Industry, in the SHINE Study, San Francisco Bay Area
| Overall |
Ever worked in the sex industry |
Bivariable Poisson regression models comparing the prevalence of characteristics by engagement in the sex industry |
|||
|---|---|---|---|---|---|
| N (%) | N (%) | PR | 95% CI | p | |
| Total | 263 (100.00) | 110 (41.83) | — | ||
| Demographics | |||||
| Age, years | |||||
| 16–18 | 19 (7.22) | 4 (3.64) | Ref. | ||
| 19–21 | 69 (26.24) | 27 (10.27) | 1.86 | (0.74–4.67) | 0.19 |
| 22–24 | 135 (51.33) | 61 (23.19) | 2.16 | (0.89–5.28) | 0.09 |
| 25–26 | 40 (15.21) | 18 (6.84) | 2.14 | (0.84–5.46) | 0.11 |
| Gender identity | |||||
| Female or woman | 99 (37.64) | 40 (15.21) | Ref. | ||
| Trans female or trans woman | 113 (42.97) | 53 (20.15) | 1.16 | (0.85–1.58) | 0.35 |
| Genderqueer/genderfluid | 28 (10.65) | 8 (3.04) | 0.71 | (0.38–1.33) | 0.28 |
| Other | 23 (8.75) | 9 (3.42) | 1.01 | (0.58–1.77) | 0.97 |
| Race | |||||
| White, non-Hispanic/Latina | 97 (36.88) | 41 (37.27) | Ref. | ||
| Hispanic/Latina | 81 (30.80) | 33 (12.55) | 1.11 | (0.72–1.72) | 0.64 |
| Black, non-Hispanic/Latina | 32 (12.17) | 15 (5.70) | 0.28 | (0.07–1.05) | 0.06 |
| Asian, non-Hispanic/Latina | 17 (6.46) | 2 (0.76) | 1.30 | (0.82–2.06) | 0.26 |
| Multiple, non-Hispanic/Latina | 20 (7.60) | 11 (4.18) | 1.18 | (0.69–2.04) | 0.55 |
| Other, non-Hispanic/Latina | 16 (6.08) | 8 (3.04) | 0.98 | (0.69–1.39) | 0.89 |
| Incarceration and policing | |||||
| Ever incarcerated | 21 (7.98) | 15 (5.70) | 2.11 | (1.49–2.97) | <0.01 |
| Arrested/picked up by police, past 6 months | 22 (8.37) | 17 (6.46) | 2.00 | (1.51–2.64) | <0.01 |
| Incarcerated/spent time in jail or prison, past 6 months | 6 (2.28) | 7 (2.66) | 0.69 | (0.43–1.13) | 0.14 |
| Health care access | |||||
| Insured | 220 (83.65) | 91 (82.73) | Ref. | ||
| Uninsured | 37 (14.07) | 16 (6.08) | 0.96 | (0.64–1.44) | 0.85 |
| Income | |||||
| 0–$500 | 103 (39.16) | 34 (12.93) | Ref. | ||
| $501–$1000 | 62 (23.57) | 29 (11.03) | 1.40 | (0.96–2.06) | 0.08 |
| $1001–$1500 | 38 (14.45) | 20 (7.60) | 1.58 | (1.05–2.38) | 0.03 |
| $1501–$2000 | 20 (7.60) | 7 (2.66) | 1.05 | (0.54–2.03) | 0.89 |
| $2001–$3000 | 22 (8.37) | 14 (5.32) | 1.91 | (1.26–2.90) | <0.01 |
| >$3000 | 17 (6.46) | 6 (2.28) | 1.06 | (0.53–2.13) | 0.87 |
CI, confidence interval; PR, prevalence ratio.
Table 2.
Types of Sex Work and Occupational Stigma and Injuries or Conditions Among Young Trans Women Who Have Ever Worked in the Sex Industry
| Ever worked in the sex industry |
|
|---|---|
| N (%) | |
| Total | 110 (100.00) |
| Types of sex work, ever | |
| Escort/paid sex | 95 (86.36) |
| Modeling, video, or webcam | 60 (54.55) |
| BDSM/fetish | 44 (40.00) |
| Stripping | 37 (33.64) |
| Types of sex work, past 6 months | |
| Escort/paid sex | 64 (58.18) |
| Modeling, video, or webcam | 31 (28.18) |
| BDSM/fetish | 26 (23.64) |
| Stripping | 18 (16.36) |
| Reasons for paid sex, past 6 months (n=64) | |
| Better pay than other jobs I could get | 34 (53.13) |
| Other | 19 (29.69) |
| Can't get a job due to gender discrimination | 18 (28.13) |
| Survival sex | 16 (25.00) |
| Meet gender-related goals faster | 15 (23.44) |
| Like doing sex work | 15 (23.44) |
| Can't manage formal job obligations | 12 (18.75) |
| Like being in the community of sex workers | 11 (17.19) |
| Have no desire to get a formal job | 7 (10.94) |
| Pressure from friends to do sex work | 5 (7.81) |
| Occupational stigma | |
| Ever hid sex work from family or main partner | 76 (69.09) |
| Ever hid sex work from friends or home community | 63 (57.27) |
| Occupational mental health injuries or conditions, ever | |
| Anxiety | 59 (53.64) |
| Depression | 55 (50.00) |
| Other mental health condition | 17 (15.45) |
| Occupational physical health injuries or conditions, ever | |
| Anal tearing | 24 (21.82) |
| Pain (jaw/face) | 22 (20.00) |
| Pain (neck/back) | 22 (20.00) |
| Pain (knee/foot) | 15 (13.64) |
| Pain (shoulder/arm/hand) | 13 (11.82) |
| Other pain/bodily injury | 13 (11.82) |
| Pain (hip) | 9 (8.18) |
| Other | 7 (6.36) |
| Vaginal tearing | 3 (2.73) |
| Care accessed for most recent occupational injury/condition | |
| Medical provider | 16 (14.55) |
| Told medical provider that injury/condition resulted from sex work (n=16) | 12 (75.00) |
| Mental health provider | 14 (12.73) |
| Told mental health provider that injury/condition resulted from sex work (n=14) | 12 (85.71) |
| Holistic provider | 4 (3.64) |
| Told holistic provider that injury/condition resulted from sex work (n=4) | 1 (25.00) |
BDSM, bondage, discipline, sadism, and masochism.
Table 3.
Relationships Between Types of Sex Work, Occupational Stigma, and Injuries or Conditions Among Young Trans Women Who Have Ever Worked in the Sex Industry (n=110)
| Multinomial logistic regression comparing two types of sex work (n=30) with one type of sex work (n=33) |
Multinomial logistic regression comparing three types of sex work (n=44) with one type of sex work (n=33) |
|||||
|---|---|---|---|---|---|---|
| RRR | 95% CI | p | RRR | 95% CI | p | |
| Occupational stigma | ||||||
| Never hid sex work from family, main partner, friends, or home community | Ref. | Ref. | ||||
| Ever hid sex work from family or main partner | 2.10 | (0.50–8.74) | 0.31 | 0.87 | (0.20–3.74) | 0.86 |
| Ever hid sex work from friends or home community | 0.0a | (0.0–0.0)a | 0.0a | 1.63 | (0.28–9.33) | 0.58 |
| Both | 2.10 | (0.61–7.18) | 0.24 | 2.27 | (0.76–6.82) | 0.14 |
| Occupational mental health injuries or conditions, ever | ||||||
| Neither anxiety nor depression | Ref. | Ref | ||||
| Anxiety | 1.67 | (0.30–9.36) | 0.56 | 1.67 | (0.33–8.33) | 0.53 |
| Depression | 1.00 | (0.13–7.54) | 1.00 | 1.60 | (0.29–8.82) | 0.59 |
| Both | 6.25 | (1.39–28.16) | 0.02 | 7.67 | (1.88–31.33) | <0.01 |
| Occupational physical health injuries or conditions, ever | ||||||
| None | Ref. | Ref | ||||
| One physical health injury or condition | 1.40 | (0.40–4.86) | 0.60 | 1.09 | (0.33–3.56) | 0.89 |
| Two physical health injuries or conditions | 0.23 | (0.03–2.17) | 0.20 | 0.32 | (0.06–1.77) | 0.19 |
| Three physical health injuries or conditions | 9.80 | (1.08–89.13) | 0.04 | 11.45 | (1.35–96.93) | 0.03 |
This model does not converge due to small cell sizes.
RRR, relative risk ratio.
Analyses
First, we analyzed frequencies of sample demographics, overall for the full sample (n=263), and then used bivariate Poisson regression models to compare the prevalence of characteristics by engagement in sex work (Table 1). Second, we analyzed types of sex work (lifetime or recent), occupational stigma, occupational mental/physical health injuries or conditions, and care accessed among our subgroup of sex-working YTW (n=110, Table 2).
Finally, we ran bivariate, multinomial logistic regression models to Poisson regression models to compare the prevalence of characteristics by level of engagement in the sex industry, comparing differences in outcomes for YTW who did two types of sex work (vs. one) and three types of sex work (vs. one) (Table 3). Analyses were conducted using Stata 14 software (StataCorp LP, College Station, TX, USA).
Results
Of 300 participants enrolled in SHINE, 263 (87.7%) completed 18-month assessments. Most were 22–24 years old (n=135, 51.33%) and identified as trans women (n=113, 42.97%) or women (n=99, 37.64%). Most identified as white (n=97, 36.88%), Hispanic/Latina (n=81, 30.80%), or black or African American (n=32, 12.17%). Twenty-one participants (7.98%) reported lifetime incarceration; the majority of these 21 had done sex work (prevalence ratio [PR]=2.11, 95% confidence interval [CI]=1.49–2.97, p<0.01).
Participants were significantly more likely to report recent arrest/picked up by police (n=22, 8.37%) if they also reported history of sex work (PR=2.00, 95% CI=1.51–2.64, p<0.01). In the full 18-month sample, most earned <$1001 monthly. Compared with those with incomes between 0 and $500, participants with incomes of $1001–$1500 (PR=1.58, 95% CI=1.05–2.38, p=0.03) or $2001–$3000 (PR=1.91, 95% CI=1.26–2.90, p<0.01) were more likely to have done sex work (Table 1).
Among sex-working YTW (110/263=41.83%), escort/paid sex was the most common type of sex work (95/110=86.36% lifetime participation and 64/110=58.18% recent participation), then modeling/video/webcam, BDSM/fetish, and stripping (in descending order). Among YTW who did sex work in the past 6 months, the most commonly reported reasons were better pay (34/64=53.13%), other (19/64=29.69%), can't get a job due to gender discrimination (18/64=28.13%), survival sex (16/64=25%), and either meet gender-related goals faster or like doing sex work (each 15/64=23.44%).
Most sex-working YTW had occupational stigma, including hiding sex work from family or main partner (76/110=69.09%) or friends or home community (63/110=57.27%). About half reported work-related anxiety (59/110=53.64%) or depression (55/110=50%). The most commonly reported physical injuries related to sex work were anal tearing (24/110=21.82%), jaw/face pain (22/64=20.00%), and neck/back pain (22/64=20.00%). Sixteen participants accessed medical care for recent occupational injury/condition(s); 14 accessed mental health care; and 4 saw a holistic provider. Among those who saw a medical/mental health provider, most told their providers that the injury/condition resulted from sex work (Table 2).
Next, we ran bivariate, multinomial logistic regression models to identify associations between number of types of sex work ever engaged in (i.e., 1, 2, 3, or more) and occupational characteristics (Table 3). Risk for anxiety and depression increased significantly for YTW who had engaged in two types of sex work when compared with one (relative risk ratio [RRR]=6.25, 95% CI=1.39–28.16, p=0.02) and also three types of sex work compared with one (RRR=7.67, 95% CI=1.88–31.33, p<0.01). Risk for three physical health injuries or conditions significantly increased for YTW who engaged in two types of sex work (RRR=9.80, 95% CI=1.08–89.13, p=0.04) and, again, three types of sex work (RRR=11.45, 95% CI=1.35–96.93, p=0.03) versus 1.
Discussion
Sex work was common (41.83%) in our sample of YTW, with paid sex being the most common type. This represents a critical opportunity for harm reduction given the elevated risks of full-service sex work relative to other types, as well as high rates of lifetime incarceration and recent arrest for sex-working YTW. These results provide further evidence that YTW are frequently criminalized for sex work: a process rendering trans women at increased risk of housing instability, hate crimes, incarceration, and HIV.22
YTW began sex work for many reasons, reflecting varied and diverse efforts to survive and pursue gender affirmation despite economic, health care, and housing discrimination. Among recently sex-working YTW, the primary reason was better pay. Despite this motivation, renting an apartment remained out of reach for most of our sample. At the time of our survey, monthly full-time income at minimum wage in San Francisco was $1370.23 While non-sex-working YTW reported somewhat higher incomes overall, 93.54% of our sample made <$3000 monthly.
In the face of unaffordable housing, YTW may engage in sex work because it often pays more per hour, perhaps enabling them to work fewer hours and engage in meaningful pursuits beyond work. Recent qualitative data, for example, suggest that working in porn enables performers to escape long hours, boredom, limited advancement opportunities, and stagnating wages endemic to formal sector “straight jobs.” Sex work may thus provide greater autonomy, flexibility, and dignity24 despite economic vulnerabilities, including lack of health care and unemployment benefits.25
The third most common reason for sex work was “can't get a job due to gender discrimination.” Sex work is a common path following employment discrimination and may also affirm YTW's gender26 despite reported pressure to perform narrow fetishized trans-femininity.21,27 A quarter of our sample with recent sex work reported survival as a motivator, consistent with studies suggesting that sex work may be a last resort for YTW navigating intersecting racial, gender, disability, class, and age discrimination.4
Survival sex work may be the best choice for YTW facing family rejection or abuse in the child welfare/shelter system.28 We thus need to improve structural conditions to reduce work-related harm in formal and sex-related economies. Until then, YTW need support in the difficult processes of negotiating boundaries with clients and bolstering bodily self-determination.9
The next most common reason, “meet gender-related goals faster,” revealed potential nuances of barriers to gender-affirming care. Most participants were insured, and Medi-Cal and private insurance in California covered medical gender affirmation. However, barriers clearly persisted, compelling YTW to need fast income and/or to pay out of pocket. Finally, many YTW “like doing sex work.” Despite stigma and criminalization, it can be a pleasurable meaningful job.
A key aim of our study was to capture sex workers' vocational concerns beyond HIV, STIs, and violence. The most common complaints were depression (53.64%) and anxiety (50%), suggesting that sex worker-affirming mental health care is vital for YTW. Health care access trends reveal high insurance coverage (with insignificant differences by sex work history), yet low utilization. Of note, among sex-working YTW who accessed medical/mental health care, most disclosed that their concern resulted from sex work.
Last, YTW who engaged in multiple types of sex work had increased adverse outcomes, including work-related depression and anxiety, and physical injury. This could be explained in multiple ways. First, openness to multiple types of sex work may stem from financial need and thus decreased negotiating power with clients and/or police. Second, doing multiple types of sex work may simply be exhausting, reducing recovery time after intense physical and emotional labor.21 Third, adverse experiences may motivate YTW to diversify their work to avoid specific mental/physical health demands of particular types of labor.
This finding may be evidence of cumulative risk, where engaging in multiple types of sex work may be associated with adverse mental health and physical injury among sex-working YTW. Indeed, a recent study highlights the cumulative nature of minority stress leading to suicide risk among sexual and gender minority youth.29 Similar internalizing processes may occur for sex-working YTW in this study, whereby engaging in multiple types of sex work confers cumulative risk for minority stressors. Future exploration of the intersectional phenomenology of cumulative risk among sex-working YTW is needed.
This study is not without limitations. Measures were included at a later time point in a longitudinal study of HIV risk and resilience. As such, we cannot make causal claims about associations between sex work experience and aforementioned outcomes. During implementation, we found that our current instrument needed to reflect the diversity of trans women's lived experiences in the sex industry.
Although we were able to respond to the need for collection of nuanced measures, our cross-sectional findings are exploratory. Yet, they indicate a need to center the diversity of sex work among YTW in future longitudinal studies. Our exploratory analyses offer potential for generating future hypotheses, reworking existing theories, or generating new theories about sex work among diverse groups of YTW.
Our results may evidence the need for additional research to identify specific occupational health factors contributing to high rates of sex work-related anxiety and depression. Potential clinical implications may include provider training in sex worker-affirming assessment and care, including work to prevent anxiety/depression and other injuries among YTW doing multiple types of sex work.
However, microlevel interventions are limited in their ability to meaningfully improve the health of sex-working YTW without macrolevel structural interventions: sex work decriminalization, affordable housing, livable wages/benefits, and expanded access to gender-affirming care.22
Conclusions
Our study describes work experiences, mental health, stigma, and access to occupational health care among YTW performing erotic labor. Notably, we name unmet economic, housing, and health care needs; criminalization; and transphobic discrimination as structural factors shaping entry into work. We identify cumulative work-related risks and benefits of different types of sex work and suggest that sex worker-affirming mental health care be central to outreach with YTW.
To address limitations, we suggest that clinicians, health care institutions, advocates, and policymakers measure and mitigate unmet clinical and structural needs to support the health of YTW.
Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Acknowledgments
The authors would like to thank all participants in the SHINE study, the resilient trans and gender-expansive communities in the San Francisco Bay Area, and the staff and participants of the St. James Infirmary.
Abbreviations Used
- BDSM
bondage, discipline, sadism, and masochism
- CI
confidence interval
- COVID-19
coronavirus disease 2019
- HIV
human immunodeficiency virus
- PR
prevalence ratio
- RRR
relative risk ratio
- STI
sexually transmitted infection
- YTW
young trans women
Authors' Contributions
All authors contributed to the interpretation of data and revising the manuscript for important intellectual content.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This study was funded by the National Institute of Mental Health (R01MH095598). This study's funding source had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.
Cite this article as: Fisher MR, Turner C, McFarland W, Breslow AS, Wilson EC, Arayasirikul S (2023) Through a different lens: occupational health of sex-working young trans women, Transgender Health 8:2, 200–206, DOI: 10.1089/trgh.2021.0109.
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