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Try out PMC Labs and tell us what you think. Learn More. Sex workers are individuals who offer sexual services in exchange for compensation i. Within the United States the full-service sex work FSSW industry generates 14 billion dollars annually there are estimated to be million FSSWers, though experts believe this 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. 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. 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 FSSWrefers specifically to individuals who provide in-person sex services. 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. The conflation of assault and FSSW in a trusted government organization highlights the need for a deeper understanding of consensual FSSW as it has ificant implications for policy and practice.

A report by Fondation Scelles indicated that there were an estimated million FSSWers in the world, million of which were in the U. 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.

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.

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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. 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.

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

Additionally, prior research has shown that adolescents who are homeless Shannon,individuals who has ly been arrested for FSSW Cohan et al. The magnitude of violence experienced by this population is profound and one in five police reports of sexual assault from an urban, U. 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. Frequently FSSWers are not protected by rape shield laws.

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. 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.

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. 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.

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. Importantly though, there has been far more clinical attention paid to sexually transmitted infections STIs among FSSWers than to their mental health struggles. Extant studies have offered important first steps but have tended to only focus on single conditions like PTSD, depression, or drug use.

In contrast, an estimated 3. 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.

There are several government models for regulating FSSW including criminalization, partial criminalization, legalization, and decriminalization see Basil, ; Mac, Currently, the majority of countries, such as the U. In the U. Importantly, in the U. Legalization and decriminalization models are now seen in countries like Germany, the Netherlands, and New Zealand. Importantly, legalization still criminalizes those FSSWers who cannot or will not fulfil various bureaucratic responsibilities.

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 A.

These regulations also disproportionately affect FSSWers who are already marginalized, like people who use substances or who are undocumented. 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. 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.

Department of State, Bureau of Public Affairs, Furthermore, many believe that the presence of FSSW increases crime and violence e. Department of the Interior, For instance, by enabling FSSWers to make complaints without fear of prosecution, abuse and trafficking can be more easily exposed and tracked Law, 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. Recent policy changes in the U. 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.

This in turn, harms both FSSWers and trafficking victims. 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.

The vast majority of FSSW discourse i. It should be noted that there are various types of feminism, including though not limited to radical, liberal, socialist, marxist, and cultural feminism. 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.

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. 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, More recently, intersectional feminism has come to the forefront Crenshaw, 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.

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This is important because it highlights different experiences within specific i. 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 ex: race, class, gender, sexual identity is therefore necessary Cole, 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.

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FSSW, like most work, is not a homogenous experience. Recent scholarship discusses FSSW as a choice for women, men, and the trans community. FSSW is complex and the people performing the work have widely varying degrees of satisfaction with it, just as those in other professions might. So, how can FSSW be feminist? Choosing FSSW establishes that all people have agency and the right to choose whatever occupation they want.

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. Arguably, many physically demanding occupations have similar stakes firefighters, professional football playersyet 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.

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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. 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.

In the case of FSSW, this identity is often concealed because of stigma. 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. FSSWers face different levels of discrimination both from their own community and society as a whole due to whorephobia. 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. 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.

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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, 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.

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Indoor FSSWers are looked down upon by strippers and escorts who only perform sex fantasies for clients but do not include full service contact.

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