Selling sex, inequality and the risk of early death
It is well-known that commercial sexual exploitation (CSE) can negatively affect multiple aspects of women’s health and, in some cases, these impacts can directly or indirectly lead to women’s early deaths.
To understand the complex connections between CSE and women’s premature deaths, we spoke with Professor Sarah Johnsen, Chair in Homelessness and Inclusion Health at the University of Edinburgh, and specialising in homelessness, substance use, and health inequalities. In our conversation, Sarah reflected on how these issues can contribute to and exacerbate women’s commercial sexual exploitation, and how this gendered experience can in turn significantly affect women's health.
To understand the complex connections between CSE and women’s premature deaths, we spoke with Professor Sarah Johnsen, Chair in Homelessness and Inclusion Health at the University of Edinburgh, and specialising in homelessness, substance use, and health inequalities. In our conversation, Sarah reflected on how these issues can contribute to and exacerbate women’s commercial sexual exploitation, and how this gendered experience can in turn significantly affect women's health.
How has commercial sexual exploitation featured in your research?
My recent work has explored the intersections between homelessness, substance use, and involvement with the criminal justice system. CSE has featured in various guises within that work. The studies indicate, quite compellingly, that many women affected by these issues enter into unwanted intimate relationships or exchange sex to access shelter, drugs, or both.
For context, many women will go to great lengths to avoid sleeping rough due to the dangers and discomfort associated with it. When they do end up sleeping outdoors, it is often hidden away or in the company of a male partner. Additionally, many women avoid mixed-sex hostels because of the presence of men and the generally volatile environment. There are very few alternatives available if there are no women-only hostels nearby or if they have been excluded from the women-only facilities.
Temporary accommodation such as bed-and-breakfast (B&B) hotels can also pose significant risks. Many women have reported unsettling experiences, such as individuals knocking on their doors demanding drugs or money, or otherwise harassing them, often sexually. I’ve also heard accounts of unscrupulous B&B proprietors demanding sexual favours in exchange for necessities like toilet paper.
These situations lead some women to view exchanging sex for accommodation as the least bad option among other very poor alternatives. In conversations with these women, they often say they are staying with a friend. However, when you look deeper, it often becomes clear that they have entered a relationship primarily to gain access to shelter. Many of these women "sofa surf," which means they move between the homes of friends, relatives, or acquaintances for extended periods. During this time, they can be particularly vulnerable to sexual harassment or even assault.
Exchanging sex for drugs is also fairly common, raising concerns about power imbalances. In some cases, men exploit a woman's addiction to exert control over her. This situation is particularly acute when women rely on men to inject them. Additionally, some women depend on men to obtain clean needles from needle exchange programs. They may do this to avoid alerting social workers or other services about a relapse, fearing that it could jeopardise access to their children.
Some women engage in street-based sex work primarily to fund substance use. They don't feel proud about it or wish to continue; they view it as a less harmful option compared to other alternatives, such as shoplifting or begging.
For context, many women will go to great lengths to avoid sleeping rough due to the dangers and discomfort associated with it. When they do end up sleeping outdoors, it is often hidden away or in the company of a male partner. Additionally, many women avoid mixed-sex hostels because of the presence of men and the generally volatile environment. There are very few alternatives available if there are no women-only hostels nearby or if they have been excluded from the women-only facilities.
Temporary accommodation such as bed-and-breakfast (B&B) hotels can also pose significant risks. Many women have reported unsettling experiences, such as individuals knocking on their doors demanding drugs or money, or otherwise harassing them, often sexually. I’ve also heard accounts of unscrupulous B&B proprietors demanding sexual favours in exchange for necessities like toilet paper.
These situations lead some women to view exchanging sex for accommodation as the least bad option among other very poor alternatives. In conversations with these women, they often say they are staying with a friend. However, when you look deeper, it often becomes clear that they have entered a relationship primarily to gain access to shelter. Many of these women "sofa surf," which means they move between the homes of friends, relatives, or acquaintances for extended periods. During this time, they can be particularly vulnerable to sexual harassment or even assault.
Exchanging sex for drugs is also fairly common, raising concerns about power imbalances. In some cases, men exploit a woman's addiction to exert control over her. This situation is particularly acute when women rely on men to inject them. Additionally, some women depend on men to obtain clean needles from needle exchange programs. They may do this to avoid alerting social workers or other services about a relapse, fearing that it could jeopardise access to their children.
Some women engage in street-based sex work primarily to fund substance use. They don't feel proud about it or wish to continue; they view it as a less harmful option compared to other alternatives, such as shoplifting or begging.
What are the potential links between commercial sexual exploitation and women’s early deaths?
My research isn’t able to show how strong any direct link between CSE and early mortality is. However, in line with other studies, my findings indicate that women in CSE are at significantly greater risk of harm. Some of these harms may contribute to premature death.
Women impacted by substance use, homelessness, and involvement in the criminal justice system often suffer from poor health. They are over-represented in drug-related death statistics. The level of violence they are exposed to is alarmingly high.
I recall a particularly horrifying story shared by a woman who was gang-raped while selling sex. We interviewed her when she was in rehabilitation. She said, "I have to succeed in my treatment because I might not survive the next time something like this happens." She was acutely aware of the danger she faced. I also remember speaking with a staff member at a women's hostel who shared that many of the women she worked with, particularly those involved in CSE, described how normalised rape was in their experiences. They often accepted it as an "occupational hazard."
Overall, women who sell or exchange sex are vulnerable to physical and psychological harm in various forms. While their connections to early mortality may be indirect, those harms are very, very real.
Women impacted by substance use, homelessness, and involvement in the criminal justice system often suffer from poor health. They are over-represented in drug-related death statistics. The level of violence they are exposed to is alarmingly high.
I recall a particularly horrifying story shared by a woman who was gang-raped while selling sex. We interviewed her when she was in rehabilitation. She said, "I have to succeed in my treatment because I might not survive the next time something like this happens." She was acutely aware of the danger she faced. I also remember speaking with a staff member at a women's hostel who shared that many of the women she worked with, particularly those involved in CSE, described how normalised rape was in their experiences. They often accepted it as an "occupational hazard."
Overall, women who sell or exchange sex are vulnerable to physical and psychological harm in various forms. While their connections to early mortality may be indirect, those harms are very, very real.
What actions can individual workers and support services take to improve health outcomes for women?
My main request is for individuals to seek out training in trauma-informed and gender-sensitive support. Many are unaware of the challenges faced by women involved in CSE and those who have experienced homelessness. Unfortunately, training that conveys the realities women encounter in this context is not as accessible as it should be. We must call for more - and hopefully, it will lead to greater availability of relevant training and resources.
It is also important to advocate for the increased availability of approaches that research has demonstrated to be effective. My research highlights several key factors that have positively impacted women facing severe and multiple disadvantage, including those involved in CSE. These factors include maximising choice regarding accommodation and treatment options. It is important not to adopt a one-size-fits-all approach; instead, we should offer women some degree of choice. Additionally, we should minimise access and eligibility thresholds, avoiding excessive criteria related to engagement.
Other strategies include ''sticky'' support even if women have disengaged from services for any reason. Ideally, this continuity should involve consistent workers who can build lasting relationships with the women. We should also promote outreach by bringing services directly to women. It is essential to provide long-term support that remains with women long after periods of crisis. Many support systems are crisis-focused, and once a situation stabilises, the support is often withdrawn. However, life is full of ups and downs, and for women facing severe multiple disadvantages, support needs to be accessible in the longer term.
We also need to challenge the attitudes and systems that stigmatise women for self-medicating with illicit substances when they are denied treatment for mental health issues. We need to stop punishing women for relapsing, as relapse is a recognised stage in the recovery process. We should not judge women who find themselves in another abusive relationship, especially since many of them continue to be targets for predatory men long after their homelessness has been resolved.
Finally, we need to acknowledge the significant demands placed on women. For many, what is often referred to as recovery is in reality a journey of discovery—discovering self-worth, identity, purpose, trust, and much more.
It is also important to advocate for the increased availability of approaches that research has demonstrated to be effective. My research highlights several key factors that have positively impacted women facing severe and multiple disadvantage, including those involved in CSE. These factors include maximising choice regarding accommodation and treatment options. It is important not to adopt a one-size-fits-all approach; instead, we should offer women some degree of choice. Additionally, we should minimise access and eligibility thresholds, avoiding excessive criteria related to engagement.
Other strategies include ''sticky'' support even if women have disengaged from services for any reason. Ideally, this continuity should involve consistent workers who can build lasting relationships with the women. We should also promote outreach by bringing services directly to women. It is essential to provide long-term support that remains with women long after periods of crisis. Many support systems are crisis-focused, and once a situation stabilises, the support is often withdrawn. However, life is full of ups and downs, and for women facing severe multiple disadvantages, support needs to be accessible in the longer term.
We also need to challenge the attitudes and systems that stigmatise women for self-medicating with illicit substances when they are denied treatment for mental health issues. We need to stop punishing women for relapsing, as relapse is a recognised stage in the recovery process. We should not judge women who find themselves in another abusive relationship, especially since many of them continue to be targets for predatory men long after their homelessness has been resolved.
Finally, we need to acknowledge the significant demands placed on women. For many, what is often referred to as recovery is in reality a journey of discovery—discovering self-worth, identity, purpose, trust, and much more.
