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

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.

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 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 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 (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.

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 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.

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 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).

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).

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.

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 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 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.