Women, mental health and the impacts of the ‘sex industry'
Access to mental health care is fundamental for anyone who needs it, and poor mental health can prevent people from living a full and rich life and make it harder to maintain even the most basic needs, like food and shelter. For women who sell or exchange sex, reaching out to mental health support can come with huge hurdles, which are often compounded by the stigma they often face and the lack of understanding of their experiences.
In this article, we explore some of the ways in which selling and exchanging sex can impact on women’s mental health, the barriers that prevent them from engaging with mental health support, and the ways in which workers in any service (whether focused on mental health or not) can support the mental wellbeing of women.
The ‘sex industry’ and mental health – the impacts
The links between mental health and selling or exchanging sex are not straight-forward. For some women mental health issues can be a pathway into exchanging and selling sex, for some the impact on their mental health is not fully seen until they have stopped selling or exchanging sex and for others the coping strategies used can impact long term on their mental wellbeing.
Crucially, women are not a homogeneous group and so they can be involved in different aspects of the ‘sex industry’ – from exchanging sexual images online on subscription platforms to having direct contact sexual activity or appearing in pornographic films. The sexual activities exchanged and the settings where this happens can involve different risks and impact on women’s mental health in a range of ways.
Recent research suggests that mental health problems such as depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal thoughts and attempts are highly prevalent among women who sell or exchange sex. Indeed, according to Rossler et al, the effect of a single year of selling or exchanging sex is likely to have the same impact on mental health as an entire life of experiences prior to any involvement.
There are also external factors that can mean women carry difficult life experiences that can impact on their mental health. For instance, poverty and depravation are well known determinants of poorer mental health and they are often the reasons why women decide to start selling or exchanging sex. Likewise, a high number of women are pressured or coerced into selling sex by a partner or a pimp, situations which are often accompanied by actual threats of violence. This coercion is also connected to a wider cycle of traumatic experiences such as domestic abuse and abuse during childhood, both of which can have negative implications for mental health.
Whilst the links between child abuse and selling or exchanging sex are unclear, high numbers of adult women have experienced abuse. For example, a 2012 study found that almost three quarters of the women interviewed had experienced physical, sexual and verbal violence during childhood which compounded feelings of worthlessness. In Scotland, almost a quarter of 150 women involved in prostitution supported by the Encompass Network disclosed childhood abuse.
It is clear that women can carry a series of unmet mental health needs, and these can be exacerbated by their experiences in the ‘sex industry.’ Yet, as we will explore later in this article, the fear of judgment and stigma means women may feel there are few or no opportunities to disclose their situation, discuss their mental health and improve or maintain their mental wellbeing.
Some issues affecting the mental health of women who sell or exchange sex
Like anyone, women can experience a range of mental health issues due to a variety of circumstances and factors in their lives. However, some of these factors can be directly related to their involvement in selling or exchanging sex, and we highlight some of them in this section.
It is important to clarify that the issues mentioned below are only some examples and not a comprehensive list, nor are they necessarily the experience of every woman who sells or exchanges sex. Yet, they do offer some understanding of the complexity of women’s mental health needs when they have been involved in the 'sex industry.'
Stigma
Stigma is one of the key issues that women who sell or exchange sex identify as having significant impact on their mental health. Stigma comes from societal attitudes and misconceptions and can mean women face judgement and discrimination as well as negative labels and stereotypes because of their involvement. Women often feel “othered” and derogatory terms can be used against them to undermine and discredit their experiences.
Studies have shown that women can internalise negative beliefs of themselves with ongoing pressure to hide their involvement in selling sex, meaning they have to constantly assess and make decisions as to whom they disclose that part of their lives to.
Social isolation
Related to the above, maintaining secrecy or selective disclosure can come with its own psychological and social burdens. Women can feel that they cannot discuss their day to day situations freely, and thus may prefer to compartmentalise that part of their lives. As a result, women report high levels of social isolation with fears of losing their anonymity, being “doxxed” or being “outed.” Katie, a participant from the Inside Outside project shared the following experience:
In this article, we explore some of the ways in which selling and exchanging sex can impact on women’s mental health, the barriers that prevent them from engaging with mental health support, and the ways in which workers in any service (whether focused on mental health or not) can support the mental wellbeing of women.
The ‘sex industry’ and mental health – the impacts
The links between mental health and selling or exchanging sex are not straight-forward. For some women mental health issues can be a pathway into exchanging and selling sex, for some the impact on their mental health is not fully seen until they have stopped selling or exchanging sex and for others the coping strategies used can impact long term on their mental wellbeing.
Crucially, women are not a homogeneous group and so they can be involved in different aspects of the ‘sex industry’ – from exchanging sexual images online on subscription platforms to having direct contact sexual activity or appearing in pornographic films. The sexual activities exchanged and the settings where this happens can involve different risks and impact on women’s mental health in a range of ways.
Recent research suggests that mental health problems such as depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal thoughts and attempts are highly prevalent among women who sell or exchange sex. Indeed, according to Rossler et al, the effect of a single year of selling or exchanging sex is likely to have the same impact on mental health as an entire life of experiences prior to any involvement.
There are also external factors that can mean women carry difficult life experiences that can impact on their mental health. For instance, poverty and depravation are well known determinants of poorer mental health and they are often the reasons why women decide to start selling or exchanging sex. Likewise, a high number of women are pressured or coerced into selling sex by a partner or a pimp, situations which are often accompanied by actual threats of violence. This coercion is also connected to a wider cycle of traumatic experiences such as domestic abuse and abuse during childhood, both of which can have negative implications for mental health.
Whilst the links between child abuse and selling or exchanging sex are unclear, high numbers of adult women have experienced abuse. For example, a 2012 study found that almost three quarters of the women interviewed had experienced physical, sexual and verbal violence during childhood which compounded feelings of worthlessness. In Scotland, almost a quarter of 150 women involved in prostitution supported by the Encompass Network disclosed childhood abuse.
It is clear that women can carry a series of unmet mental health needs, and these can be exacerbated by their experiences in the ‘sex industry.’ Yet, as we will explore later in this article, the fear of judgment and stigma means women may feel there are few or no opportunities to disclose their situation, discuss their mental health and improve or maintain their mental wellbeing.
Some issues affecting the mental health of women who sell or exchange sex
Like anyone, women can experience a range of mental health issues due to a variety of circumstances and factors in their lives. However, some of these factors can be directly related to their involvement in selling or exchanging sex, and we highlight some of them in this section.
It is important to clarify that the issues mentioned below are only some examples and not a comprehensive list, nor are they necessarily the experience of every woman who sells or exchanges sex. Yet, they do offer some understanding of the complexity of women’s mental health needs when they have been involved in the 'sex industry.'
Stigma
Stigma is one of the key issues that women who sell or exchange sex identify as having significant impact on their mental health. Stigma comes from societal attitudes and misconceptions and can mean women face judgement and discrimination as well as negative labels and stereotypes because of their involvement. Women often feel “othered” and derogatory terms can be used against them to undermine and discredit their experiences.
Studies have shown that women can internalise negative beliefs of themselves with ongoing pressure to hide their involvement in selling sex, meaning they have to constantly assess and make decisions as to whom they disclose that part of their lives to.
Social isolation
Related to the above, maintaining secrecy or selective disclosure can come with its own psychological and social burdens. Women can feel that they cannot discuss their day to day situations freely, and thus may prefer to compartmentalise that part of their lives. As a result, women report high levels of social isolation with fears of losing their anonymity, being “doxxed” or being “outed.” Katie, a participant from the Inside Outside project shared the following experience:
“I was carrying a heavy load but I made that choice. I had no support around. I told no-one, no family and no friends. My family would be distraught, so disappointed. No way I told them. Even now I still wouldn't tell. It's basically like living two lives. You have your work life and your family, friends, partners think you do something else. You have to keep up this fake act. Something could have happened at work and they would have no idea why you were so upset. They wouldn't understand and you can't come out and tell them. No. You just wouldn't. There was times that you want to like, just scream and tell them. Then maybe they would understand why you are, like, you are.”
In addition to finding it harder to access services, feeling that they cannot discuss their lives freely can directly impact on women’s personal and social relationships, limiting their ability to build authentic connections with others. Studies have also pointed out that some women struggle to separate selling sex from sex for pleasure. And a recent study found that the majority of the women interviewed believed that their involvement in selling or exchanging sex affected their romantic relationships in mainly negative ways.
Lost sense of self
For some women, their involvement in the ‘sex industry’ can change their perception of themselves. Women use various strategies to protect their sense of self, mainly through drawing boundaries and limits – this can include separating the selling of sex from their rest of their lives, which in turn can involve ‘blocking out’ or ‘dissociating’ when they are with punters. Sara-Jane told the following story in the Inside Outside project:
Lost sense of self
For some women, their involvement in the ‘sex industry’ can change their perception of themselves. Women use various strategies to protect their sense of self, mainly through drawing boundaries and limits – this can include separating the selling of sex from their rest of their lives, which in turn can involve ‘blocking out’ or ‘dissociating’ when they are with punters. Sara-Jane told the following story in the Inside Outside project:
“I can't remember anything about that first night. Nothing about that first punter. I blocked it all out. Totally blocked it out. I went home and scrubbed myself completely. I think I was in the shower for about two hours but then a few weeks later I did it again and once you'd done it the first time and money was in your hand, the option's there."
These protective strategies can be limited as boundaries can be compromised or overridden by other individuals or situations in their lives. For example, a participant in a Scottish Government report on prostitution evidenced the challenges women face to keep boundaries:
“Within prostitution, there's this thing about pleasing personalities, and I've found boundaries extremely difficult, like I didn't have the right to say no, to anyone."
Additionally, women have highlighted that selling or exchanging sex can harm or diminish their self-worth and increase feelings of shame. In a study, women selling sex on the streets reported low self-esteem and body confidence, often linked to their appearance and which included dental damage, or damage and scarring to their bodies caused by physical assault.
Likewise, women are faced with a specific standard of beauty within the ‘sex industry’ which can further exacerbate issues with self-esteem and body image, including modifying their bodies, routines and habits in order to meet unattainable standards and meet the expectations of paying punters/clients within a competitive industry. This was evident during the pandemic, when women moved to online platforms to sell sex and many of them reported the pressures of getting punters/clients’ attention in already saturated platforms.
Violence and trauma
As we have briefly mentioned at the start, trauma can be an overarching experience for women who sell or exchange sex. We will be publishing an article addressing trauma later in the year. However, our previous Safety article describes the impact of high levels of violence and repeated episodes of rape and assault.
Women can have traumatic experiences in a range of situations outside of their involvement in selling or exchanging sex. We have already highlighted that they may be survivors of childhood sexual abuse or domestic abuse. Women involved are also often subjected to violence from punters, pimps, traffickers, partners, but also from the general public due to the prevalence of stigma against women selling sex.
Not only that, but women involved experience the stress of living in a constant state of alarm, with the fear and anxiety that they could experience violence. The high prevalence of abuse against women and particularly against women selling or exchanging sex means a constant state of vigilance, adding to the mental health burden that they might already be experiencing. It can also add to victim-blaming that women frequently feel when they have been assaulted.
What prevents women from getting mental health support
The path to getting mental health care can present a series of barriers for women who sell or exchange sex such as not feeling comfortable disclosing involvement to health professionals. As a woman supported by CLiCK explained:
Likewise, women are faced with a specific standard of beauty within the ‘sex industry’ which can further exacerbate issues with self-esteem and body image, including modifying their bodies, routines and habits in order to meet unattainable standards and meet the expectations of paying punters/clients within a competitive industry. This was evident during the pandemic, when women moved to online platforms to sell sex and many of them reported the pressures of getting punters/clients’ attention in already saturated platforms.
Violence and trauma
As we have briefly mentioned at the start, trauma can be an overarching experience for women who sell or exchange sex. We will be publishing an article addressing trauma later in the year. However, our previous Safety article describes the impact of high levels of violence and repeated episodes of rape and assault.
Women can have traumatic experiences in a range of situations outside of their involvement in selling or exchanging sex. We have already highlighted that they may be survivors of childhood sexual abuse or domestic abuse. Women involved are also often subjected to violence from punters, pimps, traffickers, partners, but also from the general public due to the prevalence of stigma against women selling sex.
Not only that, but women involved experience the stress of living in a constant state of alarm, with the fear and anxiety that they could experience violence. The high prevalence of abuse against women and particularly against women selling or exchanging sex means a constant state of vigilance, adding to the mental health burden that they might already be experiencing. It can also add to victim-blaming that women frequently feel when they have been assaulted.
What prevents women from getting mental health support
The path to getting mental health care can present a series of barriers for women who sell or exchange sex such as not feeling comfortable disclosing involvement to health professionals. As a woman supported by CLiCK explained:
“I’ve never actually admitted to any of the services about the sex work, it’s only yourselves [CLiCK Scotland] that knows about the sex work. I’ve never disclosed it to any other agency or my GP.”
Women’s isolation and fear of losing anonymity can prevent them from accessing services and instead they may feel they have to manage their own mental health through self-care and occasional access to mental health services. For women who do manage to engage with support, it can be difficult to continue when their needs are not met or there is a lack of understanding of their experiences.
Below are some of the key barriers that women have highlighted:
Mishandling of disclosures
A key concern for women is feeling safe and able to disclose their involvement in selling or exchanging sex and what happens with that disclosure. Often services do not routinely ask about women’s involvement which can make women feel hesitant about opening up. On the other hand, women can have a lack of trust in services and fear that their disclosure could be shared inappropriately and bring negative consequences for them.
Overfocus on or dismissal of women’s involvement
For women who do disclose, there is a sense that services can overfocus on their experience and see it as the one and only cause of all their mental health issues. On the other hand, for some women there can be a complete dismissal of their experiences (for example, when services or professionals do not ask about it).
Both refusing to address women’s experiences of selling/exchanging sex at all and the inability to see beyond women’s involvement can negatively affect the care women receive for both their physical and mental health. In both cases women can feel judged, unheard and ignored, which can result in their mental health worsening and/or complete disengagement from support services.
It is vital that professionals have the confidence to ask about women’s involvement while also seeing women as complete persons whose lives span beyond their involvement in the 'sex industry.'
Conditioning the mental health support
Imposing conditions on access to mental health support can be hugely detrimental to women’s mental wellbeing. For example, asking women to stop substance misusing or stop selling/exchanging sex in order to gain access to a mental health worker, telling women they should only attend if their mental health deteriorates (such as if they are suicidal or showing visible signs that they are not coping), requiring women to have a formal mental health diagnosis – all of these can make women feel that they must manage their mental health without support.
Similarly, denying women support because they present as ‘too difficult’ or ‘challenging’ and they ‘do not meet’ the expectation of a person who is ‘struggling’ can leave women with a negative experience of a service and a reluctance to engage. Flexibility is also essential, as is avoiding penalties for missing appointments. Services must meet women where they are.
Mental health diagnoses
Medical diagnosis can pose a barrier for women who need access to mental health support when therapy and other forms of support are only accessible if there is a formal diagnosis. In fact, a recent report on female survivors of sexual violence found that women will deliberately accept a mental health diagnosis in order to access support, even if they did not believe they have a disorder.
Regardless of whether or not someone has a mental health diagnosis, everybody can experience the positive and healing effects of compassionate, safe and empowering support. Rather than diagnosing mental health disorders, support services should focus on ensuring a trauma-informed approach is used when supporting individuals.
Immigration status
For women who have insecure immigration status or No Recourse to Public Funds, the requirement that they would have to pay for any treatment is a major barrier to accessing the support they need. There are limited situations where this is waived, such as when women have been trafficked and agree to be involved in the National Referral Mechanism or have been compulsory admitted due to a mental health condition.
Lack of tailored support
Finally, there are currently very limited options in terms of tailored mental health support for women who sell or exchange sex. Such tailored support would include well-trained professionals with a good understanding of the experiences of women involved, provide support in a non-judgmental way, free of charge and with flexibility so the women can meet at the times and in the way that works for them.
Whilst there have been some counselling services piloted for women selling or exchanging sex, there are limited organisations that currently offer this type of support. As a counsellor who participated in the CLiCK Counselling Pilot during the pandemic explained:
Below are some of the key barriers that women have highlighted:
Mishandling of disclosures
A key concern for women is feeling safe and able to disclose their involvement in selling or exchanging sex and what happens with that disclosure. Often services do not routinely ask about women’s involvement which can make women feel hesitant about opening up. On the other hand, women can have a lack of trust in services and fear that their disclosure could be shared inappropriately and bring negative consequences for them.
Overfocus on or dismissal of women’s involvement
For women who do disclose, there is a sense that services can overfocus on their experience and see it as the one and only cause of all their mental health issues. On the other hand, for some women there can be a complete dismissal of their experiences (for example, when services or professionals do not ask about it).
Both refusing to address women’s experiences of selling/exchanging sex at all and the inability to see beyond women’s involvement can negatively affect the care women receive for both their physical and mental health. In both cases women can feel judged, unheard and ignored, which can result in their mental health worsening and/or complete disengagement from support services.
It is vital that professionals have the confidence to ask about women’s involvement while also seeing women as complete persons whose lives span beyond their involvement in the 'sex industry.'
Conditioning the mental health support
Imposing conditions on access to mental health support can be hugely detrimental to women’s mental wellbeing. For example, asking women to stop substance misusing or stop selling/exchanging sex in order to gain access to a mental health worker, telling women they should only attend if their mental health deteriorates (such as if they are suicidal or showing visible signs that they are not coping), requiring women to have a formal mental health diagnosis – all of these can make women feel that they must manage their mental health without support.
Similarly, denying women support because they present as ‘too difficult’ or ‘challenging’ and they ‘do not meet’ the expectation of a person who is ‘struggling’ can leave women with a negative experience of a service and a reluctance to engage. Flexibility is also essential, as is avoiding penalties for missing appointments. Services must meet women where they are.
Mental health diagnoses
Medical diagnosis can pose a barrier for women who need access to mental health support when therapy and other forms of support are only accessible if there is a formal diagnosis. In fact, a recent report on female survivors of sexual violence found that women will deliberately accept a mental health diagnosis in order to access support, even if they did not believe they have a disorder.
Regardless of whether or not someone has a mental health diagnosis, everybody can experience the positive and healing effects of compassionate, safe and empowering support. Rather than diagnosing mental health disorders, support services should focus on ensuring a trauma-informed approach is used when supporting individuals.
Immigration status
For women who have insecure immigration status or No Recourse to Public Funds, the requirement that they would have to pay for any treatment is a major barrier to accessing the support they need. There are limited situations where this is waived, such as when women have been trafficked and agree to be involved in the National Referral Mechanism or have been compulsory admitted due to a mental health condition.
Lack of tailored support
Finally, there are currently very limited options in terms of tailored mental health support for women who sell or exchange sex. Such tailored support would include well-trained professionals with a good understanding of the experiences of women involved, provide support in a non-judgmental way, free of charge and with flexibility so the women can meet at the times and in the way that works for them.
Whilst there have been some counselling services piloted for women selling or exchanging sex, there are limited organisations that currently offer this type of support. As a counsellor who participated in the CLiCK Counselling Pilot during the pandemic explained:
“Counselling should be everybody’s right and readily available certainly where adversity and trauma is involved. We know women who work within this huge industry are subject to this and as such its vital that counselling is in place as a right – to meet them, hear them and help support them with the transition to a safer life."
At the same time, it is important to recognise that all services – no matter the sector or specialism – have a role in supporting and maintaining the mental wellbeing of women who sell or exchange sex, to check in on women and to guide them to the support they need.
Read our practice points to find our practical things you can do to improve how you respond to women's mental health needs.
Read our practice points to find our practical things you can do to improve how you respond to women's mental health needs.
