Uneducated or lacking education – having no other job options
Sex work and sex workers are met with a lot of prejudice and stereotypes. Facing stigma has very real impacts on sex workers’ lives and work – including on our ability to implement safety measures when we work, to secure and keep housing, and to access appropriate and relevant health care services, among other things. Negative stereotypes about us, coupled with criminal laws that isolate us, promote the social exclusion of sex workers. Health professionals can learn a lot from sex workers about our needs and our experiences of health care services when it comes to offering inclusive health care.
About the author: Stella, l’amie de Maimie
Stella, l’amie de Maimie is a non-profit organization run by and for sex workers, incorporated in 1995. We are the only community group in Montreal created and run by and for sex workers and our goal is to improve working and living conditions for sex workers. We work specifically with female sex workers and women who are trans. Stella works from a framework of empowerment and autonomy, which means that all of our actions and work promote the central role of sex workers, individually or collectively, when it comes to speaking to the diversity of our experiences and to the design of programs and policies. While we deliver frontline services, we also focus on public education. www.chezstella.org
Join the Conversation
This section includes information that can help health care providers ensure that they are providing appropriate, relevant and non-judgmental services to sex workers (and, by extension, a diversity of patients). As health care professionals, you can do a lot to ensure that we can benefit from prejudice-free health and social services, something that has a real impact on our ability to maintain good health and access the resources and supports we need to do so. You can take action to oppose stigmatization in your environment and make better-informed interventions to properly address our needs. Sex workers, like other people, want openness and support and health care services that are truly responsive to our realities, needs and experiences.
Someone you know may be a sex worker. Approach everyone you know with non-judgment and openness.
What is sex work?
Some of us identify as sex workers, some of us don’t, some of us are very open about our work, some of us are not. People may or may not always disclose their work to health care providers but how you talk about sexuality, sexual activity or sex work does make a difference in how we can relate to the people caring for us and if we can trust them with important information about our lives and our health. We define sex work as the exchange of sexual services for goods or money. All of us define this as income generating and some of us define it as an occupation.
What sex work is not: The conflation of sex work and human trafficking, sexual exploitation and how it impacts what services are available!
Over the last decade, there has been an increase in the conflation of human trafficking, sexual exploitation and sex work. This has had negative consequences for sex workers, as well as put migrant and racialized sex workers at significant risk.
There is a vast body of research that documents the factors contributing to the violence experienced by people in the sex industry. One of the main contributors to the risks we face in our work and in our lives has been identified over and over again as the criminalization of sex work. To address that violence, which often comes from the state (violence from the police is often reported as one of the main challenges faced by people in the sex trade), sex workers everywhere are pushing for approaches that focus on human and labour rights, on the decriminalization of our work and our lives, on empowerment, on harm reduction, and on a holistic approach to people’s complex circumstances and needs.
Policies and programs that claim to address human trafficking and sexual exploitation and are anti-sex work do not provide useful service delivery to sex workers. They are often tied to law enforcement efforts, and offer a very limited array of services. For example, it may impose certain directions for service provision that encourage “exit” rather than empowerment approaches that meet people where we are at. It may fund other professionals to be trained on ‘ways to identify and report people they suspect are victims of human trafficking’ which can lead to police being notified when in fact we are not victims of human trafficking or exploitation. These approaches do not contribute to efforts to create safer working conditions for sex workers, including developing visible and safety-equipped work spaces, open distribution of safer sex supplies and information in our workplaces, and funding for harm reduction services in our communities and programming that helps us network and share information. It can and has led to the deportation of migrant sex workers here in Canada. This continues to jeopardizes people’s access to important services.
What to keep in mind
Sex workers are the experts of our own lives. Health care providers (like all service providers) should not impose their interpretation on people’s experiences. So it is up to us to define a situation as being exploitative, and to choose amongst different kinds of services and resources. Let us identify the pressing issues in our lives, what needs we want you to help us address, what could facilitate the transition out of an exploitative situation, or what pressing matters we want to discuss that may have little to do with sex work. To read over someone’s understanding of their experiences reflects the stereotype that they are incapable of operating in their own interests. It is crucial to meet people where they are at and not override what we are telling you about our own lives.
For more information on sex work: ‘Sex Work: 14 Answers to Your Questions’
This booklet is intended for social services and health professionals, police officers and community workers, as well as people from the media, the justice system or the government. Its purpose is to shed light on some preconceived ideas about sex work and to suggest a few ways to improve services offered to people in the sex industry. Available in English, French and Spanish
Sex workers are often imagined to be:
Coming from abusive or dysfunctional families
Suffering from mental illnesses and/or having substance abuse issues
Lacking networks of supportive people that include family members and intimate relationships
Out of control
Victims without agency
Immoral, hyper-sexualized, etc.
Criminals, home wreckers, troublemakers, etc.
Under other people’s control, in abusive or exploitative relationships, pimped, etc.
Unable to act in their own best interest
Dirty, diseased, etc.
What is the impact of these stereotypes?
Feeling like we don’t matter, like our work doesn’t matter or, alternatively, that it is the only thing that matters about us.
Being treated like we are criminals / like we can’t be good parents and/or good partners / like we are victims who don’t know what’s best for us / like we are generally suspect and untrustworthy, etc.
Being viewed through the lens of stereotypes can have profound implications, for example, having our health care providers consider our work alone as a risk factor that warrants the involvement of Child Protection Services or the police, putting our families at risk. It can also mean being mistreated and belittled or being treated like we deserve the violence we face when we report it. It can look like being denied services or being outed.
All of these missteps can lead to a profound mistrust in the health care system and disconnect us from essential services.
Low self-esteem due to the lack of respect and recognition we get from others (as opposed to low self-esteem because of our work), having to live double lives, being confronted to stigmatic assumptions and derogatory language regularly.
Feeling different and isolated.
Inadequate services and restricted access to health care, to police protection, to social safety nets, to resources in our communities and to support generally, with all of the consequences it can have on our health and well being.
Facing significant barriers to harm reduction services and what facilitates implementing safety measures when we work, including when it comes to our sexual heath.
Being criminalized, stigmatized and marginalized. This can lead to us being stuck in cycles of incarceration and reincarceration. It can lead to losing our housing, support networks, family ties, etc.
Sex Worker Positive Health Care
Barriers to health services for sex workers
There are very few sex-work-positive health professionals.
Stigma around sex work means that we are often mistreated in health care settings, which can deter people from accessing health care services in the first place or from coming back for follow-up. It also gets in the way of preventative care. There is a lot of mistrust that can get in the way of good relationships with health care providers.
The criminalization of our work can prevent us from being able to talk about our work and our needs openly or to seek the kind of support and care we need.
The criminalization of our work also means that we fear being outed, having our confidentiality breached and our information shared.
What do sex workers need from health professionals?
Access without discrimination
To be recognized as autonomous beings
To get the care we need and to participate fully in our communities
To be listened to without judgment and to be taken seriously
To have our fundamental rights recognized and protected
To have the violence and coercion that we experience taken seriously and not assumed to be a part of our work in the sex industry. Alternatively, to have our own interpretation of our experiences respected. If we do not identify a situation as being coercive or abusive, as warranting the involvement of law enforcement or social workers, it has to be taken seriously too
To have our lives as a whole be considered when our health is in question. That not all issues be boiled down to the work we do
Tips and tricks for health professionals
*Information from The Toolbox: What Works for Sex Workers
When providing services to a sex worker, avoid focusing on the work they perform. Recognize that sex workers have physical, emotional, social and psychological health needs. Take a global approach in addressing their concerns—do not assume that all their health concerns are related to their work.
Be conscious of your own values, prejudices, attitudes and behaviour, and then seek to understand the motivation behind them. If your values interfere with meeting the individual’s needs, refer them to someone else
Be mindful of making your workplace sex worker friendly. Be aware of systemic barriers to sex workers accessing your services. Such things as hours of operation, attitude of staff, language used, and location can all contribute to making a space or service unwelcoming or inaccessible for workers in the industry.
Create a resource bank in your organization that will address sex workers’ specific needs.
Be aware of sex work/worker stereotypes. For example, do not assume that sex workers have low self-esteem, want to exit the industry, are poor parents or are drug addicts.
Recognize sex workers’ expertise; sex workers are safer sex professionals and know how to protect themselves physically and sexually at work.
When doing a sexual history intake, remember to ask open ended questions or inquire about personal relationships rather than focusing on work relations if one of your patients has disclosed their involvement in the sex industry. Indeed, while sex workers may practice safer sex consistently with their clients, personal relationships are where individuals may expose themselves to risks.
Validate and focus on the individual’s needs and expectations: reassure them and consider them, above all, as a person like any other.
Inform the individual of health care services available, and do so in a nonjudgmental way. Don’t make assumptions about what is needed, make sure they are interested in the services you are referring them to.
Be mindful about your motives when you seek out information from someone who has disclosed their work to you. Avoid asking invasive questions about their work in the sex industry, their clients, what their work entails, what services they offer, what motivates them to do the work they do, etc. simply because you are curious. If you are asking some more personal questions, do explain why you need that information. Make sure you discuss someone’s personal circumstances and/or sexual issues in a sensitive and ethical way, like you would with any other patients.
Be especially vigilant in guarding the confidential information provided by sex workers. Remember: unlike most other workers, sex workers’ labour is criminalized, making it imperative to respect the professional codes of conduct to which you are bound.
Remember that the occupational health and safety needs of sex workers are not restricted to sexual health; there is a range of work-related physical health concerns and vulnerabilities, which vary according to sex industry sector.
Support the fight against the stigmatization of sex workers. Speak up when you hear colleagues make disparaging remarks, out someone, treat someone badly, etc.
Once, during a hospital visit, I received the results of an HIV test I had done during a previous visit with a different doctor. I wasn’t consulted on that information being shared but I still ended up getting the result kind of out of nowhere. When the doctor told me I had HIV, she did it without any consideration, as if it was obvious that being a sex worker meant I had HIV. She left without a referral, without any hint of where to get support, without a kind word. At that time, I thought I was “sentenced to death”, I knew little more than that so I did not take care of myself for a long time. I could have gone on to develop AIDS if I had not kicked myself into gear later on.
I had a casual sex partner who called me and told me he had tested positive for Chlamydia. Obviously, I needed to go get tested for it too, no problem, no big deal. So I go to this clinic and they do contact tracing, which is how Public Health works, which means that they want to trace my boyfriend. The nurse asks me all sorts of questions that I find irrelevant, like his eye color, his height, etc. So I am answering her questions and then she gets to this one: ‘Is he a sex worker?’ and she giggles, says ‘Obviously, he’s not a sex worker’ and checks ‘No’ for me. If I gave him Chlamydia, does it make a difference if he’s a client, a boyfriend or a sex worker? If you’re gonna ask me that question, do it properly and not in such a judgmental way! Why did she assume that my boyfriend is not a sex worker? Because I’m a dude, I look rich and like I’m ‘on the ball’? Because for her, sex workers crawl out of alleys with puss dripping out of their dicks? That’s judgmental! I am not ashamed of my work, so if Iwas asked directly ‘Do you engage in sex work?’ and if I felt like the question was relevant, I would tell them. But they ask so many stupid, irrelevant questions without taking into account any evidence-based research and information that most of the time; I will just skip the question.
I don’t disclose all the time. Some people, you can tell, are going to lecture you on safe sex and talk to you like you’re stupid, as if you don’t practice safe sex already. You can assure them that you always use condoms and they look at you, like, ‘Yeah right’. So at times, I just don’t disclose. For example, I had one nurse once who was kind of brisk, less friendly, after I told her I was a sex worker.
Test Yourself: What’s your relationship status?
You are a doctor and you work in a medical clinic. A woman comes to you for a matter of sexual health. Her vulva feel irritated and painful and she is concerned about a possible infection, so she consults you. In response to questions, she said she realized, after a painful vaginal intercourse that she had forgotten to remove the contraceptive sponge she was using the day before. When you ask her if she has a regular partner, she chooses to speak frankly about her situation and tells you that she is a sex worker.
What is your spontaneous reaction?
Your response should be neutral. Sex work is a job like any other
What do you know of the sexual practices of sex workers and the means they use to protect themselves in terms of STIs and contraception?
Sex workers report higher rates of condom use and of safer sex practices generally. If needed, do you have resources that are sex positive and sex worker positive that can be handed out? What about safer sex tools if someone needs them?
In terms of knowing how to act during the appointment, how will you work with this patient?
Sex workers deserve consideration and respect like any other patient. Reassure the person that the information she share is confidential. Respond to the needs identified by the person, not what you assume a sex worker needs.
In terms of expertise, what are you recommending in a case like this?
The person is concerned about a possible infection so that is what needs to be focused on. Make sure she knows that she can come and see you if she has any sexual health concerns, that you can offer her regular testing, have the information she needs.
You are emergency nurse of a large hospital. A woman in her twenties who looks very nervous and frightened walks up to you. You are trying to assess the situation and the reason why she came to the hospital. She fears she has been infected with HIV, but her answers are vague and she seems hesitant to share more. Suddenly, she starts crying and tells you she was sexually assaulted the night before by someone who posed as a client. You are the first person she is telling.
How will you reassure this person?
Like for any other patient who needs support after a sexual assault, you listen to her account of what happened and offer the appropriate follow-ups, information and supports without judgment about her work and/or how she is framing her experience (i.e. This is not “part of the job” or “to be expected”). You offer to accompany her if she wants to press charges.
What will be your response plan in the short and medium term?
Like for any other patient in this situation, you reassure the patient and listen. You ensure that the patient has the support of the hospital and is being offered the necessary resources and tests. Make sure you are referring her to the appropriate services in her community, including organizations that work specifically with sex workers if there are any. Be mindful of confidentiality.
Will you encourage this woman to make a complaint to the police? If so, are there other community resources that can also help him?
Involving the police can have implications for people whose labour is criminalized. Follow her lead. Offer her support if she wishes to complain. See to refer her to an organization that can support her during the process.
You work as a nurse in sexual heath center that offers STI testing. A young woman under twenty-five years, wearing lots of make-up and revealing clothes, is sitting in the waiting room. Two of your colleagues, a nurse and a doctor, joke about her outfit, saying how she clearly is a ‘hooker’, and make derogatory remarks without her hearing or noticing. You are about to invite her in and test her for STIs.
What will be your attitude towards her?
You are respectful and compassionate, just like with any other patient.
Generally speaking, how should you and your colleagues welcome sex workers when they access your services?
You treat sex workers, like any other patients, with professionalism, empathy and respect. You make sure to ensure their confidentiality.
Do you plan on addressing your colleagues’ behavior and remarks?
It is important to interrupt this stigmatizing behaviour. There are many ways to go about it (directly or not, in group settings or privately, alerting supervisors or not, etc.) but make sure to point out that all patients deserve respect and that assumptions get in the way of providing good care. Make sure that it is a message that is transmitted to the entire team.
Check it out: Stella’s Medical Clinic: Good models of health services for sex workers
Stella hosts a medical clinic that is staffed by health care providers from Quebec Health. They offer health care services on site that can be accessed anonymously. Many people who are disengaged from mainstream health care services because of having been singled out, stigmatized, mistreated or criminalized get their only medical care from our clinic.
Important frontline services are offered like tending to injuries, facilitating STBBI testing and access to treatment, referrals, etc. The services are based on a harm reduction approach and premised on meeting people where they are at.
Good models of health services for sex workers may include:
No health card requirement — services are available to undocumented sex workers or people who do not have ID.
Holding the clinic in a location that is safe and familiar: this is much less intimidating for sex workers who may have felt alienated, judged or mistreated when accessing healthcare in other settings.
Professionals who are sensitized to sex workers’ realities and who offer their services in a non-judgmental way.
Sex Workers’ Health Rights are Inextricable from Our Human Rights
It is important for medical professionals to understand the impact that criminal laws have on the health and safety of sex workers. Sex workers’ health rights cannot be achieved without safety and that cannot happen without a decriminalized working environment.
International experts recognize the overwhelming body of evidence demonstrating that the criminalization of sex work harms sex workers and pushes people into unsafe situations and jeopardizes access to crucial resources and safety measures.
Decriminalization saves lives!
Some of these organizations include the World Health Organization, UNAIDS, the International Labour Organization, the Global Commission on HIV and the Law, Human Rights Watch, and Amnesty International.
Their position papers can be found here:
Stella resources to offer sex workers
Stella favours empowerment of sex workers, which means that we share knowledge about sex work practices, laws and policies that impact us, health and safety information and available resources. Below are some guides and documents created by and for sex workers that are useful to have on hand for patients.
The Dope Guide
The Dope Guide covers the various drugs that are on the market, and suggests ways to reduce the risks that come with using them. The guide also provides crucial information if you want to avoid getting pregnant, or if you want to give birth to a healthy baby and keep custody of it once it’s born. It also contains information about the law and on your rights with regard to dope. And lastly, you’ll find information that may be helpful if you decide to make changes to your drug use or quit entirely.
With the support of Stella, the Art of Striptease was created by and for women who work in the sex trade as dancers. The Art of Striptease contains loads of information for women who practice the art of nude dancing. The subjects covered include dancing in private, placement agencies, lap dancing (contact dancing), health, etc. This advice, most of it provided by dancers, is meant to help you take control of your life, your work and your working environment. In the winter of 2011, the Quebec Court of Appeals judged that contact dancing is illegal and punishable (for dancers) with a criminal charge of “being found in a bawdy house”. To our knowledge, no arrest have been made in the city of Montreal since this judgement. We are waiting to see how (and if) this new decision will be applied (or not) in Montreal. Email email@example.com for a copy
The XXX Guide deals with different aspects of your work and offers suggestions and references for living and working with dignity in a healthy and safe environment. It addresses numerous subjects: negotiating a contract or services, safer sex, relations with clients, the law, your rights, managing stress and dealing with society’s institutions. The contents focus mainly on the reality of female prostitutes who have male clients. If you work at another job in the sex trade, or you are transsexual or transvestite, you will still find that it contains lots of important information. This advice does not attempt to influence you to commit illegal acts or acts that could harm your health. The guide is meant to help you take control of your life, your work and your working environment.
This guide is addressed to you, a regular client or one that is preparing for your first visit with a sex worker. We wanted to respond to your questions to demystify our work so that you can have a better understanding of our limits and who we are. We have included information on the types of services offered by sex workers. By knowing what you want, it will be easier for you to express your needs and to negotiate an agreement with a sex worker.
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