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GUJHS. 2013 May; Vol. 7, No. 1: 4-9. Download PDF of this article
Allyson M. Noyes
Department of International Health, Georgetown University, Washington D.C.
This study sought to understand the needs of sex workers (i.e. individuals that trade sexual services primarily for money, though drugs or other goods may be exchanged). This aim was therefore two-fold: to understand the life cycle of “the prostitute” and to identify the social determinants of health and barriers to wellness for an individual working on the street, both while working and transitioning away from sex work. Forty-three women (33 cis-female i.e. biologically female and 10 trans-female i.e. biologically male but identifying as a woman) were interviewed, all of whom identified as sex workers and whose ages ranged from mid-twenties to late-fifties. Five qualitative focus groups took place at the HIPS office (Helping Individual Prostitutes Survive), a harm reduction nonprofit in Washington DC. Interviews were then transcribed and coded. Individuals expressed a need for counseling and a supportive community on the streets and during transition. The evidence form this study demonstrated that there is a great need for non-judgmental health services for this population.
Despite being cited as the world’s oldest profession, prostitution remains a hotly contested moral, health and political issue. Because it remains highly stigmatized and misunderstood, sex workers are a highly neglected population. Reaching marginalized populations, like sex workers, can help improve the understanding of the nature of urban American health and the barriers that still exist. Much research on sex work focuses too narrowly on sex itself in relation to health rather than the socio-economic context of the working environment. This research seeks to understand the reality of the sex worker experience and the social determinants of health that influence wellness and barriers to treatment.
In a 2001 study, 33% of respondents replied affirmatively to the statement “do you have any physical health problems?” Though STDs were mentioned, generalized health problems, such as diabetes, asthma and bronchitis were also cited (Valera, 2001). This study also found that 59% of respondents needed support from others on the street and 57% reported needing counseling. Research has found mental health illnesses at higher rates than the general public, such as PTSD (42%), anxiety (29%) and depression (46%); an estimated 10% of American adults report depression (Rossler, 2010; Valera, 2001; CDC, 2010). Sex workers are therefore at a much greater risk for mental health illnesses but often experience barriers to seeking treatment, as demonstrated by the 57% who reported needing counseling. This study seeks to understand these barriers and present potential alternatives.
Drug and alcohol use has also been found to be more prevalent in sex workers than in the general population (Valera, 2010). One study found that 85% of interviewees were affected by substance dependency (Urban Justice Center, 2003). Drug addiction poses a risk for other health problems as well, such as HIV infection or general health problems due to lack of hygiene (Murphy, 2010). Homelessness and other socio-economic factors pose a barrier to reaching drug-addicted populations. Creating structural solutions to reach these populations can help combat HIV and STI infection as well as improving health outcomes among sex workers.
Violence against sex workers is a third significant public health concern. One study found that 8% of respondents had suffered a serious injury, such as a knife or gunshot wound (Farley, 2000). Another study reported that of those working primary on the street, 50% had experienced some sort of violence in the past six months (Church, 2001). In New York City, it was found that 80% of sex workers experienced violence or threats while working (Urban Justice Center, 2003) while Jackson (2009) found that 80% reported being threatened by a weapon and 50% had a history of rape. Preventing gender-based violence is a WHO health priority in working environments, including sex work and increasing research suggest support groups to address this issue (WHO, 2010).
Despite the riskiness and violence of their work, Rossler (2010) found that 40% of women enjoy their work and Valera (2001) found that 95% entered the work voluntarily. This dissonance has been unexplored in research and this study seeks to allow sex workers to identify their needs and the barriers to attaining these needs. The intention of this research is to examine the extent to which a sex worker is actually concerned about wellness and the external factors that influence health.
Materials and Methods
This study used qualitative focus groups to understand the experience of the sex worker. The researcher obtained approval from the Georgetown University Institutional Review Board (IRB) and support from HIPS (Helping Individual Prostitutes Survive), a local non-profit harm reduction organization, to conduct focus groups. Funding was provided by a grant through the Raines Fellowship. The researcher first met with staff from HIPS to develop a recruiting plan. HIPS employs several peer educators—former and current sex workers—who lead support groups, answer phones and provide general administrative support. The researcher used the following criteria to recruit participants: (1) identify as cis-female (biologically female) or trans-female (biologically male but self-identifies as a woman) (2) be older than 18 (3) be able to give verbal consent in English (4) currently or formerly identify as a voluntary sex worker (i.e. engaging in transactional sex, not involved in forced sex work) (5) work primarily or exclusively on the streets.
The first focus group employed a convenience sampling method comprised of HIPS peer educators. These peer educators served as “seeds” to recruit other sex workers to the study. This sample provided a diverse group of sex workers and represented different ages, neighborhoods, working styles and gender identify. The recruitment method was based on well-established sampling for hidden populations, respondent-driven sampling (RDS) (Heckthorn, 1997). Each individual was given a $20 gift card at the end of the hour-long focus group as well as three uniquely marked business cards with the researcher’s cell phone number, used exclusively for this study. These women were then instructed to distribute the business cards to other sex workers. If one of their recruits came to a subsequent focus group, the recruiters would be given an additional $5 for each person recruited (up to 3 people). Additionally, a convenience sample was taken at a nearby HIV/AIDS center called The Women’s Collective. Business cards were distributed at this location and individuals were screened according to the inclusion criteria. Five focus groups took place, each of which lasted about an hour. The researcher transcribed focus groups verbatim.
Based in Grounded Theory developed by Glaser & Strauss, the analysis was not seeking to confirm a pre-existing hypothesis. Rather, the researcher developed themes and concepts that arose from the data (Dowling, 2007). Once the interviews were transcribed, the researcher employed a method of open coding in which pertinent quotes and reactions were highlighted for later stages of analysis (Rubin & Rubin, 2005). The researcher used Scrivner, a word processing organization program, to develop codes and create a reflexive coding matrix (Scott, 2008). As these themes were revised and altered, a central phenomenon arose that revealed trends in the data. The researcher refined themes into three central concepts. After developing these thematic hypotheses, the researcher tested the hypotheses against the data.
A total of forty-three women were interviewed, including ten transgendered women and thirty-three cis-gendered women. Slightly less than half (44%, n=19) still worked as sex workers while the other half had not worked for a year or longer. Ages ranged from 24 to 58. Through the five semi-structured focus groups, three central themes arose that seemed to follow a similar pattern: before prostitution (entering prostitution), life while working (“the lifestyle”) and life after working on the streets (“I’m just trying to learn me today”).
The women interviewed cited family life, the influence of peers and going to parties as the main channels of entering prostitution. One woman mentioned the “cluttered households, hand-me-down clothes, too small portions” that drove her to the streets. Family involvement in prostitution, gambling and other unregulated economies also influenced these women. Another woman mentioned: “My father hustled all his life. My uncles was hustlers. My cousins was hustlers. My father was a pimp. So. That was a lifestyle for me. I grew up as a baby around this type of lifestyle. You know. Card games, you know. Parties.”
For others, an older friend, cousin or sister may introduce the young girl to the lifestyle. During adolescence (usually between 14 and 16 years old), the women mentioned they were intrigued by those around them who had money, material goods and glamour. Usually, the foray into prostitution began as going to parties and trying drugs; one woman explains “there’s always somebody. Thas gon’ give you a sample of somethin’…and that taste just make yo mouth water. Then hit it and you off to tha races.” Many women admitted that their personality was such that this type of life attracted them; one woman said that working on the street “excited [her]. You know how curiosity just gets you?”
All of the woman mentioned “the lifestyle”, a term that includes the exchange of sex for goods but also refers to the culture that surrounds this activity. For trans women, this lifestyle is much more about community and inclusion; “…it really wasn’t about the money. I went out there because the transgender women. The trans women we could have our hair and our glamour. And the trickin’ came after that.” Cis-women reported more competition on the streets and many women reported that they would “pimp another girl.” Other women mentioned “tricking the trick,” meaning they would rob the johns (men buying sex) or that “[you] don’t have to go out there and have sex to have a trick; you can talk a person out they money.”
Part of this lifestyle is partying and drugs. For some women, life and “the lifestyle” revolved around drugs; for others, the drug use was part of life on the streets rather than the end goal. Working styles differed in slight but important ways depending on the individual’s mentality towards drugs and drug use. Addiction took many different forms. Some mentioned addiction to drugs, but a much more common addiction was being “addicted to the lifestyle.” One woman mentioned that “a typical night be fun” but she “wouldn’t direct a dog in that direction.”
Violence seemed to be fairly accepted as part of their life. While episodes of violence startled the women, it rarely, if ever, stopped them from making a living on the streets. Another woman described getting shot and said “After that. You would think I would hang it up, but it went on another ten years after that still tricked for more years after that. The addiction. The money.” In response to violence, women believed they “did it to [them]self” or that “what goes around comes around” if they previously had robbed or injured a john or dealer. A few mentioned positive police interaction but the majority of women did not see the police as a viable resource. One woman mentioned: “I got raped by three guys. And I went to the police and the police looked their ass the fuck up. Know what I’m saying? So. Every time I got raped, I never went to the police because they made me feel this fuckin’ small.”
“I’m just trying to learn myself today”
As mentioned, many of the women have transitioned away from sex work. For many of these women, their decision to leave sex work stemmed from aging, being “burned out” and the emotional and physical baggage that accompanies this life. Few cited a dramatic event that prompted them to leave the lifestyle; rather, the transition took place gradually and remains an on-going process. Many reiterated that “behavior will take you back” and for those who tried to stop using drugs but continued to be a part of “the lifestyle” often relapsed. Overall, those who maintained sobriety mentioned religion, specifically “God” or “Jesus” as primary influences. They often indirectly mentioned the 12-steps of Alcoholics Anonymous or Narcotics Anonymous and said that “the amount of years don’t add up to nothing if you don’t stay in the room.”
A few mentioned diagnosed psychological disorders like depression, multiple personality disorder and bipolar disorder, and those who cited these diagnosed cases were more likely to mention that they would “run” from their problems or not discuss daily concerns with anyone. However, others mentioned that they didn’t feel comfortable talking about their sex work with therapists or psychologists for fear of being prescribed more medication or being sent to a mental institution.
When asked about legalization, women overwhelmingly agreed that legalization would make their jobs safer. They mentioned brothels, apartment complexes and security for those working as prostitutes. They also agreed that “it shouldn’t be in no one’s neighborhoods” and if prostitution was legal, you couldn’t “prostitute on the street.” If it were legal, one woman said that she would “dive right back in.” There was also a consensus that those working as prostitutes should be tested every six months and that there should be a registration so the police have their names and know they are “registered sex workers.”
The demographics of the participants limited the conclusions that can be drawn from this research since many of the women were slightly older (~35 years old) than the average age of a woman working on the street. Many of those interviewed are in the process of transitioning away from sex work or have left sex work in some capacity. Recruiting younger sex workers (those under 30) provided a significant challenge to the research. The researcher suggests several reasons for this difficulty: (1) many of the older women claimed that younger women are pimped (most notably cis-female) and therefore have less autonomy; (2) younger women typically make the most money and therefore are less inclined to be enticed by a $20 gift card; (3) younger adults in general seem to be less self-reflective than people in later stages of life.
The goal of the research was to assess the concerns of sex workers throughout their life from a holistic health perspective and to understand the social determinants of health of this population. Throughout the interviews, physical health such as STDs, unwanted pregnancy and other concerns incurred through sex were not explicitly mentioned. Treatment remains a barrier to this population and distrust of medical professionals poses a challenge for future interventions. The risky environment and stress of the profession seem the greatest concerns. Thus, future interventions should focus on mental and emotional health and coping mechanisms as sex workers transition away from life on the streets.
In terms of childhood and abuse, the women seemed to identify a larger culture of neglect in the home rather than events that specifically drove them to the streets. Like any other economic phenomenon, both push and pull factors draw someone to the streets. Push factors, like neglect, abuse, poverty, and a troubled childhood drive an individual to the streets and pull factors, like the glamour, attention and fast money keep someone there. Many of the women articulated a link between childhood abuse and neglect and current mental health illnesses. It seems that a by-product of growing up in a low-income family in which family members are involved in hustling (prostitution or otherwise) lends itself to abuse in childhood. Understanding the context in which sex workers grew up helps explain the attitudes towards their work and how this influences risk and self-care.
Addiction, in all its forms, serves as a powerful force to stay on the street. For some of the women who cited financial motivators—like drug addiction, paying bills, large households—sex work is their livelihood and competition for work therefore plays a much larger role in their working style. It seems that the stronger the addiction to whatever “substance,” the greater risk the individual will be willing to take to fuel the addiction. This is a more nuanced understanding of addiction and motivation that can be applied to helping individuals identify risky behavior and subsequently minimize this risk. Understanding working motivation can help health professionals tailor their approach to counseling and implementing health promotion programs.
When individuals mentioned transitioning away from “the lifestyle,” this process seemed to follow a natural aging progression rather than a singular event. Many women voiced a cognitive dissonance about prostitution and their life. On the one hand, they enjoyed the lifestyle while on the other, they wanted to “get out.” For many of the women, sex work is a mark of a greater lifestyle choice rather than the focus of their life. Youth are naturally more inclined to feel invincible and seek out situations and individuals who foster this carefree attitude. As individuals age the reality of responsibility and fatigue of this lifestyle settles in and “the lifestyle” becomes less appealing. A large part of adolescence and early adulthood involves experimentation, curiosity and risk that test an individual’s limits and personal goals. In any culture, aging implies moving from the recklessness of youth and accepting external responsibility. There is a need for more productive outlets for low-income teenagers to create both a sense of opportunity and options outside of working on the streets.
Individuals with a strong support network often felt more confident in their choices and expressed a relief in discussing daily concerns. Individuals who claimed to “bottle up” emotions were more likely to be report undiagnosed anxiety or depression. Stress throughout their life affected the degree of addiction and coping mechanisms. When asked who they would go to if they had a bad day, the two most common responses were religiously affiliated (“God,” “Jesus,” “my pastor”) or drugs and alcohol. This dichotomy sums up the challenge of leaving “the lifestyle”—on the one hand, these women are working hard to change their behavior by taking healthy steps but external forces, like addiction, draw them back into life on the streets. As mentioned, women often blamed themselves for acts of violence which is an attitude that can be detrimental to self-esteem. These notions should be addressed in therapy and counseling.
Future interventions should focus on sex worker support groups. This study highlighted the need for mental health services in these communities and the importance of providing non-judgmental care for women in non-traditional environments. Women involved in other support groups mentioned that they felt uncomfortable talking candidly about the specifics of sex work for fear of judgment. Sex worker specific support groups can give these women an outlet for previous and current challenges. These groups should focus on identifying working motivation and creating community. As mentioned, sex workers may take on a greater level of risk based on their motivation for working and by identifying this motivation, the individual could mitigate risk on their own terms using the tools that are available to them. This study hopes to de-sensationalize prostitution and highlight the external factors that influence wellness.
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