Selling sex and women’s sexual health – risks, challenges and reducing harm
Women’s sexual health is so much more than their reproductive organs. It is about having positive sexual relationships and safe sexual experiences, and it is closely linked to women’s overall wellbeing.
Women involved in selling or exchanging sex use complex strategies to protect their health and keep safe when seeing clients – and sexual health is one of their key concerns. Yet, being involved in the ‘sex industry’ presents unique risks and challenges which can hinder women’s ability to manage their sexual health and can impact their wellbeing.
In this article we delve into the sexual health needs of women who sell or exchange sex, and consider these beyond the traditional medical lens. We look at the historical stigma around women’s health and the spread of disease; we then explore women’s strategies to keep healthy and the ways these are often challenged and overridden; and we conclude by reflecting on why all types of services must play a part in supporting women’s sexual health and wellbeing.
A note on historical stigma and women's sexual health
Before looking at the sexual health needs of women selling or exchanging sex, it’s essential to consider the historical context that has led to some of the stigma women still face today.
Historically, concerns around women’s sexual health were about keeping society – and specifically men – free from disease. In past centuries, women who sold or exchanged sex were blamed for the spread of sexually transmitted diseases (STIs) among men. This led to prejudice and women being categorised as ‘vectors of disease,’ a misconception that still lingers today.
Governments developed strategies to tackle the spread of STIs, but in reality these were used to punish women who were seen to be morally “fallen.” This was the case in 19th century Glasgow, when the Lock Hospital was established to treat women with STIs. However, in fact these facilities were used to experiment on women’s bodies, conceal sexual violence and exclude working class women from society. You can read more about Lock Hospital and the women in our blog.
Later, Scotland’s HIV outbreak in the 1980s led to greater awareness and promotion of safer sex practices and prevention. As a result, women involved in the ‘sex industry’ were given access to sexual health check-ups, condoms and testing for STIs and blood borne diseases (BBVs). But, as researchers have pointed out, this approach has led to a narrow focus on mainly preventing, testing, and treating for infections, with less attention paid to other areas of women’s health and wellbeing.
As we the risks and needs women face in terms of their sexual health, we need to keep this historical context in mind so we challenge the misconceptions and stigma that prevent women who sell or exchange sex from having equal access to health.
Some risks and challenges to women's sexual health
Although women selling or exchanging sex do their best to keep themselves safe and healthy, they often speak of difficulties in maintaining boundaries with customers/clients and managing their sexual health. Here we highlight some of the risks that women have flagged up, as well as areas of their sexual health that are often overlooked.
Clients demands and negotiating safe sex
One of the risks women frequently highlight is the challenges in negotiating condom use with clients. An American study of women involved who attended family planning services found that 40% were offered more money to have unprotected sex and 30% reported client condom refusal. Similarly, in a Scottish study of transactional sex, women also described intermittent condom use due to pressures from clients who would, for example, coerce women by saying they were allergic to latex or use violence and force to avoid condom use.
Stealthing – the removal of the condom without consent – was also common in a study of women selling sex who attended a sexual health clinic in Ireland who often recounted ‘condom accidents’ to nurses. Natalia, one of the participants, described her experience of stealthing with a client she had known for years:
“I got [one] guy. I know him long time. I think maybe seven years or eight years… and now he starts trying to take the condom [off]. He did that few times, and I said, ‘Look, you know, if you do that it’s a rape, right?’ … ‘No, I want to take the condom [off], make you pregnant, so then you go to live with me.’ I caught his hand...[he said] ‘Oh, no, just came off’. Come on, that doesn’t come off like that! [I] explain to him, look, that’s a rape if you do that. My concern is a rape.”
In the same clinic, medical staff also mentioned that, to overcome clients’ demands for unprotected sex, some women would offer anal sex without a condom as a way to avoid pregnancy, not realising this did not remove the risk of contracting STIs.
Negotiating safe sex was also an issue some women encountered in their personal relationships. A study exploring the impact of selling sex on women’s personal romantic relationships found that some women preferred having unprotected sex with their partners to create a distinguishing boundary between seeing clients and their personal relationship.
Risk of contracting STIs and other health conditions
While it is essential to move away from unhelpful narratives that associate women involved in the ‘sex industry’ with STIs , it is important to acknowledge that the combination of the demands from clients, having multiple sexual partners, the high rate of sexual violence women face, having sex under the influence of drugs and alcohol, and accidents with condoms mean a higher risk of contracting blood borne viruses (like HIV and Hepatitis), STIs and other conditions.
Studies have pointed out that women who sell sex are twice as likely to have had chlamydia and gonorrhea, and four times as likely to contract syphilis. Moreover, the sexual health clinic in Ireland found that women selling sex experienced multiple sexual health issues; the most common of which were reoccurring, required multiple visits to the clinic and repeat or ongoing treatment.
And even when women were able to use protection during penetrative and oral sex, they described contracting infections in other ways. This was the casa of Luciana, another participant in the Irish study:
“… as I offered full service, I always used protection, but...I never offered kisses to any man because I find kiss very personal ... [and] I never gave them oral without protection, but they gave me...And so I went to the clinic – I came to the clinic so often in the past to ask for medication because always something was going [on], you know, in that area there...because they used to lick my pussy, so I got like bacteria...it was one of the reasons I decided to not have sex, not offer sex anymore, because I said ‘No, I don’t want anybody putting their dongs, their mouth in my vagina anymore’.”
One of the main reasons why some women attend sexual health clinics is due to vaginal discomfort and infections, which clinicians have linked to the excessive use of lubricants or the overcleaning of the genital area, given many women will wash with perfumed soaps after seeing each client.
At the same time, the mental health impacts that come with the worry of having being infected cannot be underestimated. Luciana described the stress and fear she experienced when the condom broke when seeing clients:
“It did happen twice in the past yes [condom accidents]…I got very concerned. Oh my god, scared. And I came straight to the clinic to have the test … if you plan to have sex with somebody without condom, without protection, you do that because you want to…but when you don’t plan [that] and it happens, oh my god, that’s so scary!...It’s so much risky. Imagine if you get something really serious from many of these men? So, your money won’t buy your health.”
Contraception and unwanted pregnancies
The pressures and challenges women face in negotiating safe sex also brings a higher risk of unwanted pregnancies. Studies have also shown there is a higher rate of abortions among women who sell sex compared to the general population.
Many women rely solely on condoms, and some women have expressed difficulties in using other contraceptive methods. In some cases, information about options and how to access them is not as readily available and, when it is, women may feel that these methods do not fit with their lifestyles.
For example, women have reported they stopped using the pill due to the need to take a daily dose, which some found hard to comply with. Elsewhere, women have described missing their monthly contraceptive supply because clinics open at hours that do not match their routine, or skipping a pill if they have taken alcohol or drugs. Younger women in particular can have concerns around hormonal contraceptives because of worries it might lead to weight gain, irregular bleeding and affect the number of clients they can see.
Fertility and pregnancy
A large number of women involved in selling sex plan to have children or are already parents. Some women have started to sell sex or continue to do so in order to provide for their family. However, issues with fertility and care during and after pregnancy are areas often overlooked when thinking of women’s sexual health.
For some women, fertility issues are connected to their fears of contracting an STI, given infections like gonorrhoea and chlamydia have been linked to infertility. Women interviewed at the Irish clinic were often anxious and scared about becoming infertile after testing positive for an STI. Anecdotally, services in Scotland have also mentioned situations where pimps exert control by telling women that contraceptive methods will cause them infertility, which can lead women to decide not to use them.
On the other hand, despite high rates of pregnancy among women involved, there are clear gaps in their access to maternal care. A study in Bristol found that 13% of women interviewed did not receive antenatal care until they were admitted to labour. Yet, women who do attend appointments may not feel able to explain the full extent of their concerns and the risks they may be experiencing for fear of being judged or having their children removed.
At the same time, women often find that they have no choice but to continue selling sex whilst pregnant or shortly after giving birth. In fact, within the ‘sex industry’ there is specific demand for sex with pregnant and breastfeeding women, and clients will often offer more money for this. Pimps, brothel owners and even partners may use pregnancy to further exploit women and pressure them into seeing clients during and after giving birth. Equally, financial worries can mean women decide to continue selling sex while pregnant so they don’t lose their income. For example, Jay, a woman involved in selling sex, described in a blog how she had to managed breastfeeding her child around meetings clients:
“I put my first child on formula despite the fact they clearly weren’t tolerating it because I had to be back to work at three weeks. Faced with having to slow my supply down so I didn’t spray someone who’s not a fetishist or timing my pumping around appointments and sets, risking ruining all my business if I ever started unexpectedly leaking breast milk, saving my one steady source of income won out over giving my child the best nutrition...”
Menstruation and menopause
Awareness about menstrual cycles and menopause is not as widespread as it should be among society in general. For women who sell or exchange sex, there can be specific challenges as they may have to continue seeing clients while dealing with the physical and emotional changes that come with periods and the onset of menopause later in life.
For example, women often have to find strategies to continue selling sex during while menstruating and may recur to introducing sponges or small socks in their vaginas to conceal their periods from clients. Moreover, women who use substances can stop having periods altogether, and these can return unexpectedly when they reduce or stop their substance use, which creates a risk of having an unintended pregnancy.
Menopause, which can appear when women reach their mid-forties, still remains largely underdiscussed. In fact, workers at a housing service in Glasgow anecdotally mentioned that women in their service may notice changes to their bodies without knowing these are linked to menopause. It can be a huge challenge for women to manage periods or the menopause with the selling of sex and other issues they might be dealing with, such as trauma, medical conditions, substance use and poverty.
Boundaries, relationships and intimacy
Many women try to keep a boundary between selling sex and their personal relationships, but some women have found this creates issues and can ultimate affect their romantic and sexual life. In Australia, a study of women who sell sex and their romantic relationships found that 78% of the women interviewed felt that selling sex had a primarily negative effect on their romantic relationships. While some women preferred not to tell their partners about their involvement, which made it hard to build trust and intimacy; others who were open described having to deal with jealousy and mistrust from their partners.
In the same study women discussed coping mechanisms to keep a boundary between clients and their personal relationships. This included using a different persona, having unprotected sex with partners to differentiate having sex with clients, and creating a physical separation between the place where they sell sex and home. However, just as other researchers have pointed out, this dissociation could have a long-term impact on women’s mental health.
In some cases, women took the decision not to enter a relationships, as they felt it was too difficult to keep a boundary. For example, in the Inside Outside podcast, Cassie explained how selling sex changed her willingness to have sexual and romantic relationships:
“I think how [selling sex] changed me is - I'd say that sexually, I am quite frigid in the fact that I don't... I begrudge giving sex free. If someone's paying then I'll do it but if they're not paying then I don't want it. It's like when you over-do something it becomes a chore. It's like if you work in a bar all day and you don't want to then go and sit in a bar after your shift. It's kind of the same thing. So for most of my life it's been really difficult to hold down any kind of relationships with anyone.”
Ability to manage sexual health
So far we have looked at the unique challenges that women face in order to protect their sexual health and wellbeing when involved in selling or exchanging sex. However, one aspect to consider is that women do not always have full control over their health. On the one hand, pimps, controllers, partners and even clients can prevent women from attending sexual health checks, from using contraception, accessing testing, and speaking openly about their health concerns.
On the other, financial pressures can make women delay attending health checks or decide not attend at all. For example, women supported by CLiCK Scotland during the pandemic reported having to offer services they were not entirely comfortable with (such as unprotected sex or riskier sexual activities) in order to make more money. The pandemic context is something to keep in mind as the Cost of Living brings even greater financial pressures onto women and, with that, can reduce their ability to prioritise their health and wellbeing.
The role of services in supporting women's sexual health
We want to conclude by emphasising that any service supporting women in any way has a role in mitigating the risks to women’s health and wellbeing.
Much like with substance use, harm reduction can be a useful tool when it comes to women’s sexual health. Talking about and providing women with information about contraception, STIs and HIV testing and treatment, abortions, period products, routine sexual health checks, among others, so that women can make informed decisions about their health. As the Scottish Drugs Forum recommends, often sharing the most basic information about sexual health can pave the way to address underlying issues such as shame, trauma and abuse.
Shame, stigma and past negative experiences with services can prevent women from disclosing they sell or exchange sex, and make them reluctant to openly discuss their sexual health concerns. This is why services have the duty to challenge the historical stigma and shame that exists around women’s bodies, and have the opportunity to normalise having open conversations about sexual health.
Read our practice points with practical steps you can take to respond to women’s sexual health needs, and check our resources for details of sexual health harm reduction services available to women.
Women involved in selling or exchanging sex use complex strategies to protect their health and keep safe when seeing clients – and sexual health is one of their key concerns. Yet, being involved in the ‘sex industry’ presents unique risks and challenges which can hinder women’s ability to manage their sexual health and can impact their wellbeing.
In this article we delve into the sexual health needs of women who sell or exchange sex, and consider these beyond the traditional medical lens. We look at the historical stigma around women’s health and the spread of disease; we then explore women’s strategies to keep healthy and the ways these are often challenged and overridden; and we conclude by reflecting on why all types of services must play a part in supporting women’s sexual health and wellbeing.
A note on historical stigma and women's sexual health
Before looking at the sexual health needs of women selling or exchanging sex, it’s essential to consider the historical context that has led to some of the stigma women still face today.
Historically, concerns around women’s sexual health were about keeping society – and specifically men – free from disease. In past centuries, women who sold or exchanged sex were blamed for the spread of sexually transmitted diseases (STIs) among men. This led to prejudice and women being categorised as ‘vectors of disease,’ a misconception that still lingers today.
Governments developed strategies to tackle the spread of STIs, but in reality these were used to punish women who were seen to be morally “fallen.” This was the case in 19th century Glasgow, when the Lock Hospital was established to treat women with STIs. However, in fact these facilities were used to experiment on women’s bodies, conceal sexual violence and exclude working class women from society. You can read more about Lock Hospital and the women in our blog.
Later, Scotland’s HIV outbreak in the 1980s led to greater awareness and promotion of safer sex practices and prevention. As a result, women involved in the ‘sex industry’ were given access to sexual health check-ups, condoms and testing for STIs and blood borne diseases (BBVs). But, as researchers have pointed out, this approach has led to a narrow focus on mainly preventing, testing, and treating for infections, with less attention paid to other areas of women’s health and wellbeing.
As we the risks and needs women face in terms of their sexual health, we need to keep this historical context in mind so we challenge the misconceptions and stigma that prevent women who sell or exchange sex from having equal access to health.
Some risks and challenges to women's sexual health
Although women selling or exchanging sex do their best to keep themselves safe and healthy, they often speak of difficulties in maintaining boundaries with customers/clients and managing their sexual health. Here we highlight some of the risks that women have flagged up, as well as areas of their sexual health that are often overlooked.
Clients demands and negotiating safe sex
One of the risks women frequently highlight is the challenges in negotiating condom use with clients. An American study of women involved who attended family planning services found that 40% were offered more money to have unprotected sex and 30% reported client condom refusal. Similarly, in a Scottish study of transactional sex, women also described intermittent condom use due to pressures from clients who would, for example, coerce women by saying they were allergic to latex or use violence and force to avoid condom use.
Stealthing – the removal of the condom without consent – was also common in a study of women selling sex who attended a sexual health clinic in Ireland who often recounted ‘condom accidents’ to nurses. Natalia, one of the participants, described her experience of stealthing with a client she had known for years:
“I got [one] guy. I know him long time. I think maybe seven years or eight years… and now he starts trying to take the condom [off]. He did that few times, and I said, ‘Look, you know, if you do that it’s a rape, right?’ … ‘No, I want to take the condom [off], make you pregnant, so then you go to live with me.’ I caught his hand...[he said] ‘Oh, no, just came off’. Come on, that doesn’t come off like that! [I] explain to him, look, that’s a rape if you do that. My concern is a rape.”
In the same clinic, medical staff also mentioned that, to overcome clients’ demands for unprotected sex, some women would offer anal sex without a condom as a way to avoid pregnancy, not realising this did not remove the risk of contracting STIs.
Negotiating safe sex was also an issue some women encountered in their personal relationships. A study exploring the impact of selling sex on women’s personal romantic relationships found that some women preferred having unprotected sex with their partners to create a distinguishing boundary between seeing clients and their personal relationship.
Risk of contracting STIs and other health conditions
While it is essential to move away from unhelpful narratives that associate women involved in the ‘sex industry’ with STIs , it is important to acknowledge that the combination of the demands from clients, having multiple sexual partners, the high rate of sexual violence women face, having sex under the influence of drugs and alcohol, and accidents with condoms mean a higher risk of contracting blood borne viruses (like HIV and Hepatitis), STIs and other conditions.
Studies have pointed out that women who sell sex are twice as likely to have had chlamydia and gonorrhea, and four times as likely to contract syphilis. Moreover, the sexual health clinic in Ireland found that women selling sex experienced multiple sexual health issues; the most common of which were reoccurring, required multiple visits to the clinic and repeat or ongoing treatment.
And even when women were able to use protection during penetrative and oral sex, they described contracting infections in other ways. This was the casa of Luciana, another participant in the Irish study:
“… as I offered full service, I always used protection, but...I never offered kisses to any man because I find kiss very personal ... [and] I never gave them oral without protection, but they gave me...And so I went to the clinic – I came to the clinic so often in the past to ask for medication because always something was going [on], you know, in that area there...because they used to lick my pussy, so I got like bacteria...it was one of the reasons I decided to not have sex, not offer sex anymore, because I said ‘No, I don’t want anybody putting their dongs, their mouth in my vagina anymore’.”
One of the main reasons why some women attend sexual health clinics is due to vaginal discomfort and infections, which clinicians have linked to the excessive use of lubricants or the overcleaning of the genital area, given many women will wash with perfumed soaps after seeing each client.
At the same time, the mental health impacts that come with the worry of having being infected cannot be underestimated. Luciana described the stress and fear she experienced when the condom broke when seeing clients:
“It did happen twice in the past yes [condom accidents]…I got very concerned. Oh my god, scared. And I came straight to the clinic to have the test … if you plan to have sex with somebody without condom, without protection, you do that because you want to…but when you don’t plan [that] and it happens, oh my god, that’s so scary!...It’s so much risky. Imagine if you get something really serious from many of these men? So, your money won’t buy your health.”
Contraception and unwanted pregnancies
The pressures and challenges women face in negotiating safe sex also brings a higher risk of unwanted pregnancies. Studies have also shown there is a higher rate of abortions among women who sell sex compared to the general population.
Many women rely solely on condoms, and some women have expressed difficulties in using other contraceptive methods. In some cases, information about options and how to access them is not as readily available and, when it is, women may feel that these methods do not fit with their lifestyles.
For example, women have reported they stopped using the pill due to the need to take a daily dose, which some found hard to comply with. Elsewhere, women have described missing their monthly contraceptive supply because clinics open at hours that do not match their routine, or skipping a pill if they have taken alcohol or drugs. Younger women in particular can have concerns around hormonal contraceptives because of worries it might lead to weight gain, irregular bleeding and affect the number of clients they can see.
Fertility and pregnancy
A large number of women involved in selling sex plan to have children or are already parents. Some women have started to sell sex or continue to do so in order to provide for their family. However, issues with fertility and care during and after pregnancy are areas often overlooked when thinking of women’s sexual health.
For some women, fertility issues are connected to their fears of contracting an STI, given infections like gonorrhoea and chlamydia have been linked to infertility. Women interviewed at the Irish clinic were often anxious and scared about becoming infertile after testing positive for an STI. Anecdotally, services in Scotland have also mentioned situations where pimps exert control by telling women that contraceptive methods will cause them infertility, which can lead women to decide not to use them.
On the other hand, despite high rates of pregnancy among women involved, there are clear gaps in their access to maternal care. A study in Bristol found that 13% of women interviewed did not receive antenatal care until they were admitted to labour. Yet, women who do attend appointments may not feel able to explain the full extent of their concerns and the risks they may be experiencing for fear of being judged or having their children removed.
At the same time, women often find that they have no choice but to continue selling sex whilst pregnant or shortly after giving birth. In fact, within the ‘sex industry’ there is specific demand for sex with pregnant and breastfeeding women, and clients will often offer more money for this. Pimps, brothel owners and even partners may use pregnancy to further exploit women and pressure them into seeing clients during and after giving birth. Equally, financial worries can mean women decide to continue selling sex while pregnant so they don’t lose their income. For example, Jay, a woman involved in selling sex, described in a blog how she had to managed breastfeeding her child around meetings clients:
“I put my first child on formula despite the fact they clearly weren’t tolerating it because I had to be back to work at three weeks. Faced with having to slow my supply down so I didn’t spray someone who’s not a fetishist or timing my pumping around appointments and sets, risking ruining all my business if I ever started unexpectedly leaking breast milk, saving my one steady source of income won out over giving my child the best nutrition...”
Menstruation and menopause
Awareness about menstrual cycles and menopause is not as widespread as it should be among society in general. For women who sell or exchange sex, there can be specific challenges as they may have to continue seeing clients while dealing with the physical and emotional changes that come with periods and the onset of menopause later in life.
For example, women often have to find strategies to continue selling sex during while menstruating and may recur to introducing sponges or small socks in their vaginas to conceal their periods from clients. Moreover, women who use substances can stop having periods altogether, and these can return unexpectedly when they reduce or stop their substance use, which creates a risk of having an unintended pregnancy.
Menopause, which can appear when women reach their mid-forties, still remains largely underdiscussed. In fact, workers at a housing service in Glasgow anecdotally mentioned that women in their service may notice changes to their bodies without knowing these are linked to menopause. It can be a huge challenge for women to manage periods or the menopause with the selling of sex and other issues they might be dealing with, such as trauma, medical conditions, substance use and poverty.
Boundaries, relationships and intimacy
Many women try to keep a boundary between selling sex and their personal relationships, but some women have found this creates issues and can ultimate affect their romantic and sexual life. In Australia, a study of women who sell sex and their romantic relationships found that 78% of the women interviewed felt that selling sex had a primarily negative effect on their romantic relationships. While some women preferred not to tell their partners about their involvement, which made it hard to build trust and intimacy; others who were open described having to deal with jealousy and mistrust from their partners.
In the same study women discussed coping mechanisms to keep a boundary between clients and their personal relationships. This included using a different persona, having unprotected sex with partners to differentiate having sex with clients, and creating a physical separation between the place where they sell sex and home. However, just as other researchers have pointed out, this dissociation could have a long-term impact on women’s mental health.
In some cases, women took the decision not to enter a relationships, as they felt it was too difficult to keep a boundary. For example, in the Inside Outside podcast, Cassie explained how selling sex changed her willingness to have sexual and romantic relationships:
“I think how [selling sex] changed me is - I'd say that sexually, I am quite frigid in the fact that I don't... I begrudge giving sex free. If someone's paying then I'll do it but if they're not paying then I don't want it. It's like when you over-do something it becomes a chore. It's like if you work in a bar all day and you don't want to then go and sit in a bar after your shift. It's kind of the same thing. So for most of my life it's been really difficult to hold down any kind of relationships with anyone.”
Ability to manage sexual health
So far we have looked at the unique challenges that women face in order to protect their sexual health and wellbeing when involved in selling or exchanging sex. However, one aspect to consider is that women do not always have full control over their health. On the one hand, pimps, controllers, partners and even clients can prevent women from attending sexual health checks, from using contraception, accessing testing, and speaking openly about their health concerns.
On the other, financial pressures can make women delay attending health checks or decide not attend at all. For example, women supported by CLiCK Scotland during the pandemic reported having to offer services they were not entirely comfortable with (such as unprotected sex or riskier sexual activities) in order to make more money. The pandemic context is something to keep in mind as the Cost of Living brings even greater financial pressures onto women and, with that, can reduce their ability to prioritise their health and wellbeing.
The role of services in supporting women's sexual health
We want to conclude by emphasising that any service supporting women in any way has a role in mitigating the risks to women’s health and wellbeing.
Much like with substance use, harm reduction can be a useful tool when it comes to women’s sexual health. Talking about and providing women with information about contraception, STIs and HIV testing and treatment, abortions, period products, routine sexual health checks, among others, so that women can make informed decisions about their health. As the Scottish Drugs Forum recommends, often sharing the most basic information about sexual health can pave the way to address underlying issues such as shame, trauma and abuse.
Shame, stigma and past negative experiences with services can prevent women from disclosing they sell or exchange sex, and make them reluctant to openly discuss their sexual health concerns. This is why services have the duty to challenge the historical stigma and shame that exists around women’s bodies, and have the opportunity to normalise having open conversations about sexual health.
Read our practice points with practical steps you can take to respond to women’s sexual health needs, and check our resources for details of sexual health harm reduction services available to women.
