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The behavioral health field has a long history of working with people involved in sexwork. They are usually women, and increasingly transgender. In the minds of many clinicians, involvement in sexwork or prostitution is seen as a hallmark sign of behavioral health disturbance, typically associated with severe substance use disorders, and people using sex as a way to obtain drugs. Today, amidst a nationwide campaign about human trafficking, many therapists grow concerned that a patient involved in sexwork has been subjected to human trafficking.
Both of these concerns may sometimes be valid, and therapists must carefully assess whether an individual is reporting symptoms of severe substance use disorder, or shows signs that their involvement in sexwork has been nonconsensual or exploitative. However, research with sexwork has predominantly focused on HIV exposure issues, often linked to the high risk-factor of intravenous drug use. Investigation of various risk factors for sexwork, such as drugs, mental health problems, or economic/social vulnerability, have not found consistent or replicated indicators.
Increasingly, individuals consensually involved in various aspects of sexwork are seeking mental health support, and experiencing stigma, assumptions, and judgment from their clinicians. Sexwork itself has become a much broader field than was conceived previously. Today, sexworkers can include individuals engaged in sex for money, escorting, women offering the “girlfriend experience,” women working in legal brothels, exotic dancers, and performers in porn. Porn performers have also become a much wider group than previous, as it now includes not only individuals working in the traditional “adult film” industry, but also performers who work and create in the ethical/independent/feminist/queer porn industries, as well as the growing field of independent and semi-independent online performers. The ability to create independent pornographic material, and market it directly to consumers, using online tools, has led to the creation of many semi-amateur porn performers, whose studios are their own bedrooms, in quiet neighborhoods of small town America. Further, the rise of “camming” and performers who use webcams to live-stream sexual performances to a paying audience scattered across the world, has greatly increased the chances that therapists across the country may encounter a sexworking patient who does not fit the traditional therapist’s idea of what a sexworker is.
“Therapists already show so much bias for my sexual preferences, being nonmonogamous and non hetero, that I don’t feel comfortable telling them about my sexwork, which has even more stigma attached to it.”
In a recent sad tragedy, an adult film performer, August Ames, was lost to suicide. After her death, news coverage revealed that she had a history of both mental health problems, and struggles accessing affirmative, supportive care. Ames reported that “she had difficult experiences with therapists because they would dismiss her the instant they learned of her profession…I would get in contact with some people and then I would feel badly because they’d be like ‘what’s your profession and I’d be like ‘oh, I’m in the adult industry’ and then I’d feel like they’re like ‘oh, that’s the whole reason that you are the way you are’ and then I’d get turned off.”
Ames had a history of sexual abuse, but in contrast to many therapist’s assumptions, research with adult film performers had no greater history of sexual abuse, compared to women in a general population. In this study, adult film actresses reported greater sexual interest and enjoyment, more sexual experience, earlier sexual experiences, and greater history of drug use. These findings support the notion that people who gravitate towards performing in porn may tend to be higher in sensation-seeking tendencies, something that is also seen in consumers of porn, and people engaged in alternative sexual practices and relationships. However, this study concerned performers in the traditional adult film industry, and may not allow us to infer much about the growing semi-pro amateurs, or webcamming. Nevertheless, it poses a powerful challenge to a therapist’s assumption that a sexworker is intrinsically a “damaged” person who needs help.
“Sexworkers don’t need their therapist to ‘rescue’ them.” Ronete Cohen is a London-based psychotherapist who has worked extensively with sexworkers. She tells me that she sees many patients who have been shamed, stigmatized and even harmed by former therapists who decided that their mission with these patients was to “cure” the sexwork. “The goal of therapy (or even condition for therapy) shouldn't be leaving sex work *unless it is the client's goal*.” Cohen described that many of these women come to her struggling to enjoy their sexuality (even outside of sexwork), due to so much pressure that has identified their sexuality as an unhealthy force.
Because sexworkers are often part of an underground industry, they may have mistrust and concern about their lives and activities being exposed. As a result, they often simply don’t disclose their activities or work to therapists, or don’t access mental health treatment at all. “I've had folks say it's easy to find help where I live as the work is legal. But it's not easy. Perhaps easier but it's never easy. Society hates us and biases run deep. Therapists, psychologists and doctors are just people and are sometimes more judgey.”
Often, sexworkers are in economic situations where they don’t have access to health insurance, and may be seeking services that are free or subsidized. “One of the main (and few) places to access free counseling & health care for marginalized folks was very anti sex work on an organization level – they kicked our SW rights group out in the most unprofessional way, so it felt unsafe to go there, which was very limiting.”
Luckily, it’s NOT always so negative. There are good behavioral health clinicians out there, whose patients experience them as supportive, affirmative and nonjudgmental:
“I’m extremely fortunate to have a shrink who supports my career in adult work. She and I make a point to keep a close watch on triggers and my sleep schedule when traveling”
"I've always been out to all my medical people, and I've never had any problems other than the occasional easily-corrected ignorant idea.” (Maggie McNeil)
So, how can therapists help, when working with a sexworker who has consensually and independently chosen sex as a profession? From the mouths of the experts, here are some tips:
“A therapist has to not pathologize the act of doing sex work or insinuate that it is the cause/source of ones problems. Let’s be real, sexwork is great for some and not great for others. But addressing the deeper issues going on will allow the sex worker to come to that place for themself - if the sexwork *IS* a problem, helping that person build self-esteem, confidence, etc., would allow them to make that analysis for themselves instead of having the framework “sex work is bad” put onto them.”
“The ability to discuss sexwork related problems and even question why one is doing the work is important but can only happen in a space that’s safe. If I talk about a bad scene, I might need to have the therapist help me work on my communication skills, how I handle myself in social situations, maybe need to stand up for myself more - OR *maybe* I need to quit porn altogether (hypothetically) but jumping to the conclusion that the porn is the problem is premature and only one of several possible options. If another patient described being upset at their job at the bank, the therapist wouldn’t instinctively jump to the conclusion that their job is automatically unhealthy and they should quit, right?” (Kelsey Obsession PhD.)
"Essentially, I would come away from a session feeling as If we had touched on my personality from a holistic viewpoint, that I had been given the space to exist as such, and that there was genuine curiosity in me as a whole. Not just the sexwork or sex behavior, but support and care in my genuine sense of well-being." (Mistress Eva)
The Adult Performer Advocacy Center (APAC) set forth expectations for professionals who wanted to be on their referral list for performers. “It was a way to guide performers towards sex positive professionals who will respect their choice to be a sex worker and respect their boundaries,” described porn performer and advocate Chanel Preston. In order to obtain approval, APAC asked the professionals to agree to the following:
• I see adult performance as a valid form of employment.
• I am aware of and willing to learn more about the unique nature of the adult industry from performers.
• I acknowledge that sexuality is diverse and that no one view or social norm can encompass what constitutes healthy sexuality.
• I will respect the choice of each individual to be an adult performer and not try to “save” the individual from sex work.
• I understand that sex workers are as entitled to privacy and their boundaries as any other client.
In March, 2018, a conference in London, hosted by LGBT+ mental health agency Pink Therapy, is focused on this issue. The trainings address the intersection of mental health and sexuality professionals, with the goal of developing greater skills in the mental health industry to understand and support the needs of sexworkers. “We're aiming to improve mental health support for people who sell sex in various roles within the 'sex industry' who have quite frequently received appalling treatment from therapists.”
Quotes contained herein, unless attributed, are from sexworkers who generously contributed their experiences and insights.
