Current sexual health issues for women involved in the 'sex industry'

Sexual wellbeing is a key concern for women who sell or exchange sex, and an area of support that services must be mindful of and proactive about. In this bulletin, Alison Scott, a consultant gynaecologist and founder of WISHES clinic (a unique woman’s only sexual health service in Edinburgh) shares some of the sexual health issues women involved in the ‘sex industry’ have been presenting with and considerations to keep in mind when supporting them.
 
Current risks
There appears to be a recent trend of more men requesting unprotected intercourse, which increases the risk of women being infected with Chlamydia, gonorrhea, hepatitis, syphilis and/or HIV. While we are seeing fewer cases of HIV, the rates of syphilis infection are the highest they have been for years, and gonorrhea is also much more prevalent. All these infections have the potential for long-term health problems, and it is really important that women have regular screening so that any treatment could be started as soon as possible. Women should also be fully vaccinated against hepatitis B to avoid this infection.
 
HIV and transmission prevention
Whilst the risk of HIV transmission from heterosexual men to women is low, it is higher in bisexual men and in those who are having sex with people from overseas. PrEP (Pre-Exposure Prophylaxis) can be used to avoid HIV transmission during condomless sex and can be discussed at sexual health clinics. It is really important to remember that the risk of HIV infection is much lower than the risk of other infections. Overall, it is important that women are empowered to set boundaries and prioritise their health by insisting on condom use. It will help protect against all infections.
 
Sexual health screenings
Women we see at WISHES usually attend for sexual health screening. This involves swabs from the mouth, vagina and anus which most women take themselves. Having regular cervical screening is also very important as most cervical cancer is caused by Human Papilloma Virus (HPV) which is sexually transmitted. HPV vaccination is available to school age young people and protects against this infection.
 
Hygiene routines
Bacterial vaginosis which causes vaginal discharge, and an unpleasant odour seems to be more common in women involved in selling or exchanging sex. We believe this is due to washing more frequently (after each client) which removes many of the healthy bacteria that keeps the pH of the vagina normal. Douching the vagina should be avoided and water only should be used. No soaps or shower gel – and absolutely no feminine washing products which only aggravate the situation. More information can be found here.
 
Contraception and periods
Women also require contraception to avoid unintended pregnancies with clients. Some want different methods with clients and partners, and we can discuss this. Whilst condoms are contraceptive and also vital to try to reduce the chances of infection, they can fail. Emergency contraception tablets are available, and women can keep these at home or receive them from pharmacies for free. Copper coils can also be used as emergency contraception.
 
Irregular bleeding can be a problem with some methods of contraception and is an issue for those who are involved in transactional sex. Vaginal sponges are NOT recommended due to risks of toxic shock syndrome and other infections. Clinics can discuss methods of contraception which stop bleeding or can provide diaphragms which will hold the menstrual blood at the top of the vagina and which men are not aware of during sex.
 
When supporting women who sell or exchange sex, what do workers need to be aware of?
Disclosure of involvement in transactional sex can be a huge anxiety for people as they worry about judgement and consequences. We are lucky in the WISHES service that everyone is presumed to be involved – unless otherwise stated – but to disclose in different situations can be very stressful. Helpful response includes the following:

• Reacting calmly and acknowledging the importance of women’s safety and health.
• Checking if safety measures are in place and supporting safety planning. This is imperative due to the high number of assaults taking place.
  ​Safety planning may include letting someone know where the woman is, arranging codes or signals after a certain amount of time, and having a plan of how to get help. Ideally having another adult close by, which can reduce the risk of violence. Phone trackers are also helpful. Additionally, using National Ugly Mugs website to check history of punter violence, non-payment and other issues. Rape alarms which are relatively cheap to buy are good to have on a keyring or close by – they cause a lot of noise and can disorientate clients.
•  Sharing knowledge of health facilities for testing, treatment and contraception.
• Asking what women’s plans for the future are. Exploring what they did previously for work or how they started selling sex can give ideas as to whether they wish to continue or are looking for support to exit. It is important to remember that exiting is a long process and requires specialist support.
• Acknowledging that reporting assaults is not easy; however, the police should be supportive regardless of the circumstances in which the assault took place.
• Checking for any safeguarding issues such as child protection or vulnerable adults.