Written by: Jess Kimball
In all parts of healthcare, there can be judgment found between provider and patient, but this seems to be even more evident with patients who choose to disclose their profession as a sex worker. This judgment, in return, leads to fewer sex workers using contraceptives and seeking care for an STI. Some sex workers believe that this is all part of the job and make that sacrifice to earn the income they feel they need to support their life or need to support their families.
A sex worker is defined as someone whose work involves sexually explicit behavior. Commonly we think of prostitution, but this also includes those in the pornography industry or even erotic dancers and “strippers”. March 3rd is the International Sex Workers Rights Day where marches are held worldwide campaigning for the rights of sex workers. The goal is to have sex work decriminalized and end the stigma. Prostitution is illegal in the United States, except for a few counties in Nevada.
Stigma against sex workers has led many sex workers to feel uncomfortable seeking medical care. Even when sex workers experience a crime like being raped, they choose not to seek care.
Many sex workers describe an inability to properly explain themselves to health providers because the provider will create a story in their head about who the patient is and what the patient says can not sway the idea the provider created. A sex worker who contracted an STD prior to sex work may struggle to prove that to the provider, the provider will assume they are embarrassed and lying and decide that STD was caused by the patient’s occupation. Many sex workers are homeless, hungry, and susceptible to extreme violence due to their occupation and the stigma around it.
There is a definite lack of support and resources given to those who choose or are forced, into the sex worker occupation. The ones who are not forced into it, but instead have chosen this career as an empowered decision are angered by the idea that all sex workers are abused women forced into the work. Many people, of all genders, actively choose to go into the sex industry because they want to, not because they had to.
Accessing Care
Quick Facts:
STD testing is often done on sex workers without their knowledge or consent.
One in four sex workers are denied care because of their occupation and more than 60% fear and distrust healthcare providers.
People all over the world need access to reproductive care, but sex workers are one of the most desperate groups of people because their work is centered around reproductive health. Sex workers need contraception to prevent pregnancy and to prevent STIs. This means they need condoms and another, more reliable form of contraception. They need access to healthcare where they can disclose their occupation in order to request the birth control option that is best suitable for them. Every sexually active female over age 21 needs a routine PAP smear, but many sex workers will not receive one if they do not have a provider to see. They will also forego STI testing or may receive testing without their consent if they see a provider for a separate issue and disclose their occupation.
The stigma around sex work has caused homelessness and a lack of reliable transportation for many, leaving them without a means to even get to healthcare practice. Community-based clinics could solve this issue. Planned Parenthood provides nonjudgemental support to all people. Planned Parenthoods are strategically located near bus stops and train stations to make access to care easier, but in southern states Planned Parenthoods are much further apart, making care still hard for sex workers to seek out.
St. James Infirmary in San Fransisco started a clinic for sex workers. The clinic was “Born from a need to protect sex workers’ rights” and was “Founded from a government collaboration with two nonprofits, the clinic is run by the founders and allies of sex workers’ rights groups”. The care provided in these clinics is not just physical. The support from providers and lack of judgment leaves patients feeling mentally supported and helps to improve their mental health too. There is less fear and more trust.
STI Rates in Sex Workers.
Sex workers are 30 times more likely to be HIV positive than the general population. Some sex workers engage in unprotected sex because police officers may use condoms as evidence when prosecuting sex workers. The rates of STIs are from 5 to 60 times higher among sex workers than in general populations.
These rates of sexually transmitted infection and disease contribute to the push for free distribution of condoms in community health clinics and other businesses. The World Health Organization says “While less is known about the prevalence or incidence of other STIs and viral hepatitis infections among sex workers, increased rates have been documented in different contexts around the globe.”
Contraception Use
35% of sex workers report an unmet need for contraceptives. A link has been found between client violence and the likelihood of female sex workers using contraceptives. When violence was present sex workers were more likely to take control of the contraception use. Sex workers reporting interpersonal violence had over twice the odds of reporting woman-controlled contraceptive methods. Despite many sex workers worldwide not using condoms to avoid prosecution, they were the most common form of contraception among sex workers in North America.
Pregnancy in Sex Workers.
Pregnancy in sex workers affects their work in many ways. Whether the pregnancy is intended and leads to time off work or the pregnancy is unintended and lead to an abortion or birth that takes the parent away from their work but leaves them feeling unsupported.
Many who fall pregnant unexpectedly choose abortion because they fear the loss of income. Many sex workers who experience an abortion use good contraception practices afterwards because they fear another painful abortion.
Many sex workers choose to plan a pregnancy, about 36% with a partner, 53% with their clients (casual or regular), and the remaining 7% from casual sex with nonclients. Some chose to plan a pregnancy with a client because of their personal desire to be a mother, some wanted to solidify a relationship with their client, some to gain secure attention from a client, and others did so as a way to leave sex work altogether.
Many sex workers who have a pregnancy during their career will use the pregnancy to their advantage, while others may step away from the work out of fear that they will contract an STI or experience a form of violence detrimental to their baby’s health. The ones who choose to keep working will provide services such as breastfeeding to clients.
While much work needs to be done for providers to better support sex workers, increased documentation of STIs in sex workers could mean that care is improving and patients are more comfortable disclosing their occupation and seeking care than they were prior.
What Clinicians Should Do
As clinicians, it is important to recognize the needs and challenges of this community in order to better serve them. Those barriers include but are not limited to; fear of being stigmatized, violence, arrest, etc.
Mental health providers should aim to stay client-centered even when a client’s choice does not align with their beliefs. The development of culturally competent training for providers is important in order to keep providers informed with up-to-date information and help remove subconscious and conscious bias from providers. Many resources currently exist, although there is a need for more; more conversations on the trainings that exist, more trainings, and more conversation to normalize sex work.
A Need for More Research
More research is needed to form an understanding of why sex workers often do not use contraception and its connection to bias from providers, but based on the research that is available there is clear evidence of poor treatment from healthcare workers to sex workers. There is a need for education in the medical field on offering unbiased, nonjudgemental support to sex workers. The answer to the problem is an increase in community health clinics and an increase in education for providers on how to offer nonjudgemental care. This increase would help meet the goal of culturally competent care, reduced STI and STD rates, and reduced rates of unintended pregnancy. Sex workers deserve healthcare just as anyone else does.
At Global Foundation for Girls (GFG), we are active thought partners, serving global communities of reproductive persons in order to advance and support the advocacy movement. We lead webinars and trainings for providers including doulas, social workers, childbirth educators, reproductive practitioners, and more! To learn more about our upcoming trainings click here!
Jess Kimball, AS, CLC, Certified Birth and Postpartum Doula, PMH-C, Certified Infant Sleep Coach