What should trauma-informed support look like for women who sell or exchange sex?
Women involved in selling or exchanging sex often have multiple and intertwined traumatic experiences, some of which we explored in our safety and mental health insights articles.
These can be linked to their involvement in the ‘sex industry’ –physical and sexual violence, the impact of unwanted sexual contact, a constant fear of threat of violence, people finding out about their involvement or from the impact of coping mechanisms; from experiencing other forms of male violence –such as childhood sexual abuse, domestic abuse, neglect; and from everyday life experiences –poverty, having children removed from their care, homelessness.
Although not all women who sell or exchange sex will carry traumatic experiences, recent research has suggested that mental health problems such as depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal thoughts and attempts are highly prevalent among women involved. According to the Encompass Snapshot, more than half of the women involved in selling or exchanging sex supported during a week in 2021 showed these mental health issues, with some displaying trauma symptoms.
Looking at this context, there is no doubt that women need support services that understand how trauma can play out and continue to be re-lived when they have been involved in the sex trade.
Over the last two decades, trauma-informed practice (TIP) has gained significant traction across support services in Scotland. It is an approach that acknowledges that trauma does not happen in isolation – relationships and communities play a central role in how trauma develops and impacts a person’s life, as well as on the healing process.
As the US Substance Abuse and Mental Health Services Administration puts it: “how a community responds to individual trauma sets the foundation for the impact of the traumatic event, experience, and effect. Communities that provide a context of understanding and self-determination may facilitate the healing and recovery process for the individual. Alternatively, communities that avoid, overlook, or misunderstand the impact of trauma may often be re-traumatising and interfere with the healing process.”
It is these community responses — more specifically, responses from support services— and their impact on women selling or exchanging sex that we will explore in this article.
The elements of trauma-informed practice
The ‘Transforming Psychological Trauma: A Knowledge and Skills Framework for the Scottish Workforce’ states that trauma is “everyone’s business.” It explains that trauma often occurs in interpersonal relationships, which can impact on people’s ability to form healthy relationships. It further identifies the risk of re-victimisation as unsafe relationships can compound previous trauma.
Before considering what a trauma-informed approach to supporting women who sell or exchange sex would look like, we must understand that trauma-informed responses are guided by five key principles:
Crucially, these principles of TIP should be applied to all aspects of an organisation or services: physical environments, engagement with service users, staff wellbeing, leadership, and organisational policies and procedures. And while we want to emphasise that none of these areas should be neglected, below we focus only on direct work with women.
Trauma-informed practice and women who sell or exchange sex
Recently, the Scottish Government commissioned a report titled The experiences of people who sell or exchange sex and their interaction with support services, which explicitly acknowledged that support provided to women must be trauma-informed. Unfortunately, it also revealed that more women have had negative than positive experiences with services, and so it describes the key things that women involved in the sex trade need from services in order to feel supported and have their needs met.
Below we draw from the findings, the voices of women who participated in the report and the key principles of TIP to explore the specific things that women involved in selling or exchanging sex need from trauma-informed support.
Safety
Recognising the prevalence of fear in women’s lives
The testimonies of women who participated in the report highlight just how important it is for workers to understand women’s safety concerns and to address the related impacts on their daily lives. For example, one woman said:
“You're constantly in fight or flight. . . Loads of people get killed in this [sex] industry and you know that but you take that risk because of the money, but you still know in the back of your mind all the time that if somebody walks through your door, they could potentially be the person that's going to murder you.”
Psychological safety
Societal stigma is a significant barrier to women’s engagement with services. A psychologically safe environment requires workers to be aware of the cultural blame and judgment directed at women. On the one hand, this means being non-judgemental about women’s involvement in the ‘sex industry’ and other related stigmatised behaviours such as substance use. On the other, it requires avoiding pitying women or treating them as ‘helpless victims.’
Creating emotional safety is about validating women’s experiences and not creating an arbitrary hierarchy of abuse. For example, this story of a woman who approached a domestic abuse charity shows how judging women on how they present to a service can negatively affect the woman’s self-perception and ability to cope:
“When I went to go see [the organisation], I was looked upon as, ‘You're fine. You don’t have a lot of problems,' I wasn't getting beaten up on a daily basis by my husband, I was okay. . . They actually made me feel like I was being like somebody who was like a drama queen. . . Meanwhile they don’t understand what I was going through. . . I was so alone in the world not really knowing how the hell am I going to fix all of this.”
Environmental safety
Elements of physical safety include a calm and clean space, secure and private access to the building, and disability access. Women also appreciated the opportunity to meet in alternative locations.
The ability to choose a female worker is also a distinct component of safety. Due to traumatic experiences involving men, some women found it difficult to establish a relationship with male workers.
Group work
Women talked about wishing to get involved in more group work, as it offered a way to get peer support and get involved in different activities. However, women also highlighted some concerns that should always be considered when designing group activities. For instance, some women were triggered by hearing the experiences of others or felt manipulated by fellow members. One participant shared how exploitative dynamics played out in a support group:
“It just triggered all my insecurities. . . Everything played out in that [therapy] group, and there was only me and two women who did the whole course, the whole 6 months, and I was getting a bit used by one of the women, to help her move flat, and just different things she asked of me, and I wasn't able to say no. Because, 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.”
The above calls for careful facilitation of a group, setting clear boundaries, and creating opportunities for members to safely express any concerns with the facilitator.
Trust
Confidentiality
One of the concerns women raised was the implications of information about their involvement in selling/exchanging sex being potentially shared among services. They were worried that services may form a negative perception of them and that this information could be used against them, such as removing their children or gaining a criminal record.
Some women, for example, expressed a deep distrust in the police, which becomes a barrier if they ever wish to report a crime:
“If I was raped by a client, it would be very tricky to go to the police because I wouldn’t want to tell them I was [selling sex] ... so you can’t give them all the information for your own safety. Like that’s how it should be viewed not like you’re breaking the law and bad things happen to you.”
Consistency
Women appreciated a consistent response from services, which included getting the same level of reassurance when disclosing their involvement and having one support worker. For women, consistency also meant being able to continue receiving support even if they had periods where they disengaged from support:
“[Service] never gave up on me even when I wasn't attending appointments or speaking with my worker when she called. They took time with me and let me go at my pace I didn't feel pressured I felt supported.”
Fulfilling promises
Women insisted that it was important for workers to manage expectations and honour their commitments. One woman described how broken promises left her feeling worse:
“They were promising me things that never happened. There is no point in promising things - like that my house was going to get sorted - because I will get my hopes up and then feel gutted when they don't happen and end up even worse than I was before.”
Another participant referred to the power imbalance that resulted from unfulfilled promises:
‘They [workers] are unreliable, they say they will do things but don't but if I don't do things then it's the end of the world. They aren't really interested, they just want things done to say that it's done, they're not interested in you or things that have happened. They do one job and you're supposed to be grateful.’
Choice
Accurate information about services
Women can only make informed choices if they have the right information, and the starting point is knowing what support is available. This requires organisations to properly communicate the remit of their service and targeted client group. As one woman put it, it would be useful to specify there is support for people involved in all different aspects of the ‘sex industry’:
“Better advertising of the range of behaviours that could constitute the sale of sex. I was involved in sugar dating so when it all went wrong for me I did not really know that I would be entitled to any support or help.”
Accessibility
Women are more likely to reach out for support when a service considers different access needs. As an example, for non-English speakers, availability of interpretation services can determine whether they approach a service. Similarly, assisting women with childcare and removing physical barriers for disabled people can encourage women to seek support.
Accessibility can also be improved when services offer different ways to get support. While many women may prefer to see a worker face-to-face, using alternative means of communication —telephone, text, email, chat, video calling— can be beneficial, particularly where it gives women the chance to engage anonymously.
One woman shared her experience of using an online app to access sexual health services:
“Just typing it out is probably easier as well than being on the phone sometimes. The first time you go, you’re going to feel stressed and worried about, ‘Oh, look at me. I'm here because I have this.’. . . A phone-call, as well, can be quite daunting. I feel like you can take a step back and think.”
Service flexibility
This includes allowing people to engage and re-engage as and when they are able; offering drop-ins rather than fixed appointments; having services available outwith traditional 9-5 hours; having short waiting times to access services where possible, and when this isn’t possible, considering how workers will maintain contact with women in the meantime; and having an accessible location, close to public transport.
Collaboration
Multi-agency collaboration
In addition to person-centred, women-led service provision, external partnership work is equally crucial, especially given that on average, women selling or exchanging sex seek support for seven different needs. A timely and effective referral process is necessary for women to get proper support. Aside from emotional support, it should also address practical support aspects, such as provision of toiletries, condoms and lube, sexual health testing, food parcels, and literacy support.
Joint work can also prevent women from having to repeat their story multiple times. As one woman said:
“…you’re working with one service and then you’re getting directed to another, and then sometimes information isn’t getting passed on, you’re having to go through everything again. And that’s not down to, well, it is down to the services, it should be working alongside each other.”
Opportunities for peer support
Peer support can be a powerful and validating experience for women. Indeed, some of the women who participated in the research project found it particularly helpful to work with other women or to be supported by workers with lived experience of selling or exchanging sex. In the words of one participant:
“Just knowing what it's like, how it happens and not having to try and imagine it, and just understanding how it happens is a lot easier than someone trying to make it up.”
Creating such spaces is important and should be done in a way that, as mentioned before, is conscious of boundary setting and potentially unhealthy dynamics. At the same time, if you don't have lived experience, having an awareness and being confident in raising the issue and working with the women is equally important.
Empowerment
Restoring self-agency
In order to move forward, it is vital for women to recognise their strengths and have hope. As the testimony below shows, practitioners can help women to re-establish a relationship with their strengths and create hope:
“My case management worker has made me realise I am much more capable of things than I ever believed I was.”
Person-centred approach
It is important for women to feel that their support is led by their needs and not dependant on particular conditions. The report also advocated for individually tailored support within clearly defined broader remit of services such as support to exit or harm reduction.
Similarly, women were critical of services that excessively focused on their involvement in selling or exchanging sex and instead they felt there should be opportunities to focus on the present and consider the future:
“[My worker] wasn’t interested in what I had done in my past, she was interested in how she could help me move on, and how she can support me.”
Women also expressed the importance of workers not only focusing on their involvement in selling or exchanging sex and in recognising their wider needs. One woman said:
“[My worker] is a real person and we can speak about things that aren't just about support, like a normal conversation.”
Trauma-informed practice is a beneficial and necessary approach to supporting anyone who is looking for support. Yet, what the voices and experiences of women we have shared here show is that, while the values and principles underpinning TIP are universal, putting them in practice always requires considering the specific context and the individuality of each woman.
These can be linked to their involvement in the ‘sex industry’ –physical and sexual violence, the impact of unwanted sexual contact, a constant fear of threat of violence, people finding out about their involvement or from the impact of coping mechanisms; from experiencing other forms of male violence –such as childhood sexual abuse, domestic abuse, neglect; and from everyday life experiences –poverty, having children removed from their care, homelessness.
Although not all women who sell or exchange sex will carry traumatic experiences, recent research has suggested that mental health problems such as depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal thoughts and attempts are highly prevalent among women involved. According to the Encompass Snapshot, more than half of the women involved in selling or exchanging sex supported during a week in 2021 showed these mental health issues, with some displaying trauma symptoms.
Looking at this context, there is no doubt that women need support services that understand how trauma can play out and continue to be re-lived when they have been involved in the sex trade.
Over the last two decades, trauma-informed practice (TIP) has gained significant traction across support services in Scotland. It is an approach that acknowledges that trauma does not happen in isolation – relationships and communities play a central role in how trauma develops and impacts a person’s life, as well as on the healing process.
As the US Substance Abuse and Mental Health Services Administration puts it: “how a community responds to individual trauma sets the foundation for the impact of the traumatic event, experience, and effect. Communities that provide a context of understanding and self-determination may facilitate the healing and recovery process for the individual. Alternatively, communities that avoid, overlook, or misunderstand the impact of trauma may often be re-traumatising and interfere with the healing process.”
It is these community responses — more specifically, responses from support services— and their impact on women selling or exchanging sex that we will explore in this article.
The elements of trauma-informed practice
The ‘Transforming Psychological Trauma: A Knowledge and Skills Framework for the Scottish Workforce’ states that trauma is “everyone’s business.” It explains that trauma often occurs in interpersonal relationships, which can impact on people’s ability to form healthy relationships. It further identifies the risk of re-victimisation as unsafe relationships can compound previous trauma.
Before considering what a trauma-informed approach to supporting women who sell or exchange sex would look like, we must understand that trauma-informed responses are guided by five key principles:
- Safety: in the context of service provision, safety is facilitated by creating a warm and welcoming physical environment and maintaining respectful, predictable and non-judgemental interactions with individuals.
- Choice: individuals are asked about their preferences in service delivery; they are encouraged to identify alternatives and make informed decisions.
- Trust: service parameters, policies and procedures are clearly communicated to service users to avoid misunderstandings. Workers fulfil their promises.
- Collaboration: relational power asymmetries are avoided and inter-agency collaboration that would help to meet the needs of service users is actively sought.
- Empowerment: a strengths-based approach is promoted, which reframes symptoms as adaptations and highlights individual resilience.
Crucially, these principles of TIP should be applied to all aspects of an organisation or services: physical environments, engagement with service users, staff wellbeing, leadership, and organisational policies and procedures. And while we want to emphasise that none of these areas should be neglected, below we focus only on direct work with women.
Trauma-informed practice and women who sell or exchange sex
Recently, the Scottish Government commissioned a report titled The experiences of people who sell or exchange sex and their interaction with support services, which explicitly acknowledged that support provided to women must be trauma-informed. Unfortunately, it also revealed that more women have had negative than positive experiences with services, and so it describes the key things that women involved in the sex trade need from services in order to feel supported and have their needs met.
Below we draw from the findings, the voices of women who participated in the report and the key principles of TIP to explore the specific things that women involved in selling or exchanging sex need from trauma-informed support.
Safety
Recognising the prevalence of fear in women’s lives
The testimonies of women who participated in the report highlight just how important it is for workers to understand women’s safety concerns and to address the related impacts on their daily lives. For example, one woman said:
“You're constantly in fight or flight. . . Loads of people get killed in this [sex] industry and you know that but you take that risk because of the money, but you still know in the back of your mind all the time that if somebody walks through your door, they could potentially be the person that's going to murder you.”
Psychological safety
Societal stigma is a significant barrier to women’s engagement with services. A psychologically safe environment requires workers to be aware of the cultural blame and judgment directed at women. On the one hand, this means being non-judgemental about women’s involvement in the ‘sex industry’ and other related stigmatised behaviours such as substance use. On the other, it requires avoiding pitying women or treating them as ‘helpless victims.’
Creating emotional safety is about validating women’s experiences and not creating an arbitrary hierarchy of abuse. For example, this story of a woman who approached a domestic abuse charity shows how judging women on how they present to a service can negatively affect the woman’s self-perception and ability to cope:
“When I went to go see [the organisation], I was looked upon as, ‘You're fine. You don’t have a lot of problems,' I wasn't getting beaten up on a daily basis by my husband, I was okay. . . They actually made me feel like I was being like somebody who was like a drama queen. . . Meanwhile they don’t understand what I was going through. . . I was so alone in the world not really knowing how the hell am I going to fix all of this.”
Environmental safety
Elements of physical safety include a calm and clean space, secure and private access to the building, and disability access. Women also appreciated the opportunity to meet in alternative locations.
The ability to choose a female worker is also a distinct component of safety. Due to traumatic experiences involving men, some women found it difficult to establish a relationship with male workers.
Group work
Women talked about wishing to get involved in more group work, as it offered a way to get peer support and get involved in different activities. However, women also highlighted some concerns that should always be considered when designing group activities. For instance, some women were triggered by hearing the experiences of others or felt manipulated by fellow members. One participant shared how exploitative dynamics played out in a support group:
“It just triggered all my insecurities. . . Everything played out in that [therapy] group, and there was only me and two women who did the whole course, the whole 6 months, and I was getting a bit used by one of the women, to help her move flat, and just different things she asked of me, and I wasn't able to say no. Because, 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.”
The above calls for careful facilitation of a group, setting clear boundaries, and creating opportunities for members to safely express any concerns with the facilitator.
Trust
Confidentiality
One of the concerns women raised was the implications of information about their involvement in selling/exchanging sex being potentially shared among services. They were worried that services may form a negative perception of them and that this information could be used against them, such as removing their children or gaining a criminal record.
Some women, for example, expressed a deep distrust in the police, which becomes a barrier if they ever wish to report a crime:
“If I was raped by a client, it would be very tricky to go to the police because I wouldn’t want to tell them I was [selling sex] ... so you can’t give them all the information for your own safety. Like that’s how it should be viewed not like you’re breaking the law and bad things happen to you.”
Consistency
Women appreciated a consistent response from services, which included getting the same level of reassurance when disclosing their involvement and having one support worker. For women, consistency also meant being able to continue receiving support even if they had periods where they disengaged from support:
“[Service] never gave up on me even when I wasn't attending appointments or speaking with my worker when she called. They took time with me and let me go at my pace I didn't feel pressured I felt supported.”
Fulfilling promises
Women insisted that it was important for workers to manage expectations and honour their commitments. One woman described how broken promises left her feeling worse:
“They were promising me things that never happened. There is no point in promising things - like that my house was going to get sorted - because I will get my hopes up and then feel gutted when they don't happen and end up even worse than I was before.”
Another participant referred to the power imbalance that resulted from unfulfilled promises:
‘They [workers] are unreliable, they say they will do things but don't but if I don't do things then it's the end of the world. They aren't really interested, they just want things done to say that it's done, they're not interested in you or things that have happened. They do one job and you're supposed to be grateful.’
Choice
Accurate information about services
Women can only make informed choices if they have the right information, and the starting point is knowing what support is available. This requires organisations to properly communicate the remit of their service and targeted client group. As one woman put it, it would be useful to specify there is support for people involved in all different aspects of the ‘sex industry’:
“Better advertising of the range of behaviours that could constitute the sale of sex. I was involved in sugar dating so when it all went wrong for me I did not really know that I would be entitled to any support or help.”
Accessibility
Women are more likely to reach out for support when a service considers different access needs. As an example, for non-English speakers, availability of interpretation services can determine whether they approach a service. Similarly, assisting women with childcare and removing physical barriers for disabled people can encourage women to seek support.
Accessibility can also be improved when services offer different ways to get support. While many women may prefer to see a worker face-to-face, using alternative means of communication —telephone, text, email, chat, video calling— can be beneficial, particularly where it gives women the chance to engage anonymously.
One woman shared her experience of using an online app to access sexual health services:
“Just typing it out is probably easier as well than being on the phone sometimes. The first time you go, you’re going to feel stressed and worried about, ‘Oh, look at me. I'm here because I have this.’. . . A phone-call, as well, can be quite daunting. I feel like you can take a step back and think.”
Service flexibility
This includes allowing people to engage and re-engage as and when they are able; offering drop-ins rather than fixed appointments; having services available outwith traditional 9-5 hours; having short waiting times to access services where possible, and when this isn’t possible, considering how workers will maintain contact with women in the meantime; and having an accessible location, close to public transport.
Collaboration
Multi-agency collaboration
In addition to person-centred, women-led service provision, external partnership work is equally crucial, especially given that on average, women selling or exchanging sex seek support for seven different needs. A timely and effective referral process is necessary for women to get proper support. Aside from emotional support, it should also address practical support aspects, such as provision of toiletries, condoms and lube, sexual health testing, food parcels, and literacy support.
Joint work can also prevent women from having to repeat their story multiple times. As one woman said:
“…you’re working with one service and then you’re getting directed to another, and then sometimes information isn’t getting passed on, you’re having to go through everything again. And that’s not down to, well, it is down to the services, it should be working alongside each other.”
Opportunities for peer support
Peer support can be a powerful and validating experience for women. Indeed, some of the women who participated in the research project found it particularly helpful to work with other women or to be supported by workers with lived experience of selling or exchanging sex. In the words of one participant:
“Just knowing what it's like, how it happens and not having to try and imagine it, and just understanding how it happens is a lot easier than someone trying to make it up.”
Creating such spaces is important and should be done in a way that, as mentioned before, is conscious of boundary setting and potentially unhealthy dynamics. At the same time, if you don't have lived experience, having an awareness and being confident in raising the issue and working with the women is equally important.
Empowerment
Restoring self-agency
In order to move forward, it is vital for women to recognise their strengths and have hope. As the testimony below shows, practitioners can help women to re-establish a relationship with their strengths and create hope:
“My case management worker has made me realise I am much more capable of things than I ever believed I was.”
Person-centred approach
It is important for women to feel that their support is led by their needs and not dependant on particular conditions. The report also advocated for individually tailored support within clearly defined broader remit of services such as support to exit or harm reduction.
Similarly, women were critical of services that excessively focused on their involvement in selling or exchanging sex and instead they felt there should be opportunities to focus on the present and consider the future:
“[My worker] wasn’t interested in what I had done in my past, she was interested in how she could help me move on, and how she can support me.”
Women also expressed the importance of workers not only focusing on their involvement in selling or exchanging sex and in recognising their wider needs. One woman said:
“[My worker] is a real person and we can speak about things that aren't just about support, like a normal conversation.”
Trauma-informed practice is a beneficial and necessary approach to supporting anyone who is looking for support. Yet, what the voices and experiences of women we have shared here show is that, while the values and principles underpinning TIP are universal, putting them in practice always requires considering the specific context and the individuality of each woman.
