For the oldest profession known to man, sex work remains a contentious career choice for those who engage in it. These days, sex work is more prevalent than ever before in part due to the accessibility of the internet and the minimal costs associated with the software and hardware needed to create content (though as we’ll learn, creating online content is merely one form of sex work). It’s no surprise that in the day and age of recessions and inflation, the prospect of sex work becomes more and more appealing. But what does that have to do with therapy? And what do, we, as therapists, care about sex work at all? In this series of blogs entitled, Equity in the Margins, I will delve into the intricacies of marginalized identities and ways in which we can professionally and competently show up for our clients who often feel relegated to the verges of society.

Understanding Sex Work

Sex work (SW), like many things in life, exists on a spectrum. At one end, we have direct or Full-Service Sex Work (FSSW) that engage in traditional oral and penetrative sex acts that can be mutual. On the other end of the spectrum is indirect sex work that merely “sells” the idea of sex to a consumer but does not necessarily have the sex worker engaging in actual sex (e.g., a Hooters girl or Shots Girl at a club). Due to the ever-changing nature of work in general, many sex workers can flow between the two and engage in several different acts depending upon their level of comfort and compensation.

Check out this chart below by Harcourt and Donovan from their 2005 article, The Many Faces of Sex Work.

It is important to make a distinction here before we continue--work can, and is often, inherently sexual by it's sheer nature of combining people together in close proximity. Consider the work of waitresses who often remark on their attractiveness as a factor in their ability to earn tips. Or the ubiquitous "Male Firefighter" calendars that are used as fundraising for fire departments. Our sexuality does not disappear when we enter into work. So while Sex Work places sexuality at the forefront, it is important to recognize the layers of sexuality that are always present. 

The Conditions for Sex Work

When therapists can better conceptualize how their client's arrived to sex work, they can work to align with their client's goals and avoid unnecessarily pathologizing. 

A helpful way to conceptualize how people come to sex work is through the triple C acronym.

Choice; a person who freely, of their own will and volition, engages in sex work.

Coercion; a person who through fraud, coercion or threat has been forced into sex work (I.E., sex trafficking)

Circumstance; a person who by financial or situational means cannot support themselves otherwise (e.g., minors, immigrants, or folks with minority gender status/expression)

Regardless of how a person has come into sex work it is imperative as mental health professionals that we maintain a professional, open-minded attitude. Sex work is work and a valid, even if not (yet) legal, occupation (full-service sex work is only legal in some areas of Nevada, and it’s legal to sell sex in Maine but illegal to buy sex in Maine. Make that make sense.) Learn more about that here, for those who are curious. 

There is also a distinction to be made between sex work and sex trafficking. Due to the erotophobic nature of the society in which we live, the two are often conflated to be the same phenomenon. While sex trafficking could be conceptualized as a form of sex work (going back to the idea of the 3 Cs, coercion) not all sex work is sex trafficking. Many sex workers will proudly tell you that no one is forcing them to do the work they do. In fact, many find empowerment in usurping traditional ideals attached to gender and commodifying their sexuality in a way that benefits them. While sex trafficking is a real issue in our country, what we’re focusing on in this blog is choice and circumstance-based sex work.

It is also to be noted that for the purpose of this blog, we will be focusing on adult based sex work. While sex work can be an unfortunate product of circumstance for vulnerable adolescents (e.g. homeless, queer, migrant kids), sex work that involves minors is understandably illegal and considered sex trafficking in the eyes of the law.

Potential Harms from Sex Work

Therapists who recognize the risks associated with sex work can show up for their clients in ways that make meaningful connection and impacts on their lives. 

Like any livelihood, sex work comes with the risk of potential occupational hazards. Here are some examples to consider when addressing these specific workplace stressors.

• Higher incidence of trauma and violence

• Legal considerations

• Stigma

When work is relegated to the margins through its legal status it’s easy to see how quickly it can become violent and traumatic. Some sex workers can face unsafe working conditions, hostile clients, and are often reluctant to interact with law enforcement if a crime happens out of fear of being arrested themselves. It’s no wonder that the rate of PTSD among sex workers rivals that of combat veterans (Park et al., 2021). The likelihood of physical and sexual trauma increases for full-service sex workers as they occupy spaces such as motels, clubs, and the streets. This also opens the door for revictimization as many sex workers often have a history of trauma in childhood that transcends into adulthood. This phenomenon only serves to exacerbate mental and physical health issues (Park et al., 2021).

How can I show up for my clients who are sex workers?

Great question! Here are some recommendations I would suggest to any therapist looking to up their 
 Sex Positivity game. 

1. Know your yums and yucks: "Don't yuck my yum" is a prevalent phrase in the Sex Educator/Sex Therapist world and promotes a positive attitude towards sexuality and sexual inclinations. It basically reminds folks that while you may not be into something another might be and as long as they aren't harming themselves or anyone else (nonconsensually at least), it's all good. How can I know myself better and know my yums and yucks? I'd recommend participating in a Sexual Attitude Reassessment (SAR). SAR is a structured group experience that helps participants become more aware of their attitudes and values regarding sexuality. Therapists who know themselves and their sexuality can arrive to session with sex workers with a sense of confidence and acceptance. 
2. Get familiar with trauma: While not all sex workers arrive to session with traumatic histories, research (as stated above) does indicate that trauma may be present. Let's be real--living in late stage capitalism will leave many people traumatized from their work, so sex workers are no different in that regard. Pursue Continuing Education that seeks to educate therapists on trauma, complex trauma, PTSD and polyvictimization. 
3. Embrace multiculturalism: The reality is that sex workers can hold multiple identities--man, woman, cis, trans, gay, hetero, Black, White, disabled, Neurodivergent, etc. Knowing how these identities influence one another allows for a richer understanding of your client's lived experience. Again, I'd recommend pursuing Continuing Education that facilitates exploration into varying identities. Beyond structured classes, I'd also recommend therapists browse social media--platforms across apps have allowed sex workers to speak candidly about their experiences in an effort to de-stigmatize the profession. Nothing is more valuable that real, first hand accounts!
4. Get familiar with laws around sex work and sex in general. This helps understand the climate of not only your state but the country as well. America is infamously sex negative due to our Puritanical roots, but a more insidious legal trend is happening lately with legislation that appears to be sex positive, but actually negatively impacts sex workers and places them at greater risk. The elimination of Back Pages is a good example of this--framed as a way to curb sex trafficking, the FOSTA-SESTA debacle actually disenfranchised sex workers leaving them at risk of physical danger due to their inability to utilize their established internet infrastructure to securely attract clients. 

Being a sex competent, and sex positive therapist is a career-long journey. Research is constantly teaching us new ideas and concepts around sex, sexuality and subsequently sex work. Offering a warm, welcoming environment to a client who may feel the need to hide themselves out of fear of judgement and misunderstanding is one of the best joys of being a therapist. I hope this blog has helped empower you to pursue this journey. Stay connected with KDH Collective to receive alerts about classes related to this subject and more!

Harcourt, C. (2005). The many faces of sex work. Sexually Transmitted Infections, 81(3), 201–206. https://doi.org/10.1136/sti.2004.012468