thesis about sex worker

• USF Research
• USF Libraries

Digital Commons @ USF > Office of Graduate Studies > USF Graduate Theses and Dissertations > USF Tampa Theses and Dissertations > 722

USF Tampa Graduate Theses and Dissertations

The voices of sex workers (prostitutes) and the dilemma of feminist discourse.

Justine L. Kessler , University of South Florida

Graduation Year

Document type, degree granting department.

Women's Studies

Major Professor

Carolyn DiPalma, Ph.D.

Committee Member

Marilyn Myerson, Ph.D.

Sara Crawley, Ph.D.

Trafficking, Migration, Marxist, Postmodern, Radical

The existence of prostitution has been a longtime concern for many societies. It has also been a complicated issue within feminist discourse. Some women choose sex work as a viable economic option while others are forced into prostitution by traffickers and pimps and some are forced into it due to disadvantaged circumstances. The presence of sex work and prostitution is one of the occurrences that accompany a patriarchal capitalist system. Many feminists indeed argue that prostitution is a byproduct of a patriarchal capitalist system. The migration of women for sex work and the trafficking of women into prostitution cannot occur without participation of a dominant more powerful group, and a marginalized less powerful group. Sex work and prostitution are complicated components in an ever increasingly connected world. However, all too often, the belief that a patriarchal capitalist system supports the migration of women for sex work and the trafficking of women into prostitution fails to encompass all the complexities surrounding these occurrences.

The existence of sex work and prostitution involves legal, economic, political, and moral implications that deserve broad theorization. In order to more fully understand the legal, economic, political, and moral implications that contribute to the existence of sex work and prostitution, the voices of women that are involved must be illuminated. While this interview does not yet exist, I argue that only through interviews of women in sex work and prostitution can we fully understand the issue. Illuminating the voices of these women will help to reveal how issues surrounding sex workersí agency and victimization of trafficked women are present and absent within feminist discourse.

This thesis focuses on the differences between women sex workers with agency and women who are victims of trafficking and pimping. It also discusses the migration of women into the sex industry. The discussion of agency and victimization is applied to modern and postmodern feminist theory. Modern feminist theory is useful to an understanding of how sex work and prostitution are oppressive to the women involved and how conditions of agency and victimization are supported and/or negated. Postmodern feminist theory transforms the focus of the discussion from the identity of sex workers and prostitutes as agents and victims to a discussion of these women as subjects. First person interviews by sex workers reveal their subjectivity and supports the argument that what they do is indeed work, and it is viewed as such by the women themselves. Inclusion of the voices of sex workers and prostitutes also reveals the issues and concerns that they experience as employees in sex work and prostitution.

Scholar Commons Citation

Kessler, Justine L., "The Voices of Sex Workers (prostitutes?) and the Dilemma of Feminist Discourse" (2005). USF Tampa Graduate Theses and Dissertations. https://digitalcommons.usf.edu/etd/722

Since February 24, 2011

Included in

American Studies Commons

Advanced Search

• Email Notifications and RSS
• All Collections
• USF Faculty Publications
• Open Access Journals
• Conferences and Events
• Theses and Dissertations
• Textbooks Collection

Useful Links

• USF Office of Graduate Studies
• Rights Information
• SelectedWorks
• Submit Research

Home | About | Help | My Account | Accessibility Statement | Language and Diversity Statements

Privacy Copyright

• Search Menu
• Browse content in Arts and Humanities
• Browse content in Archaeology
• Anglo-Saxon and Medieval Archaeology
• Archaeological Methodology and Techniques
• Archaeology by Region
• Archaeology of Religion
• Archaeology of Trade and Exchange
• Biblical Archaeology
• Contemporary and Public Archaeology
• Environmental Archaeology
• Historical Archaeology
• History and Theory of Archaeology
• Industrial Archaeology
• Landscape Archaeology
• Mortuary Archaeology
• Prehistoric Archaeology
• Underwater Archaeology
• Urban Archaeology
• Zooarchaeology
• Browse content in Architecture
• Architectural Structure and Design
• History of Architecture
• Residential and Domestic Buildings
• Theory of Architecture
• Browse content in Art
• Art Subjects and Themes
• History of Art
• Industrial and Commercial Art
• Theory of Art
• Biographical Studies
• Byzantine Studies
• Browse content in Classical Studies
• Classical History
• Classical Philosophy
• Classical Mythology
• Classical Literature
• Classical Reception
• Classical Art and Architecture
• Classical Oratory and Rhetoric
• Greek and Roman Epigraphy
• Greek and Roman Law
• Greek and Roman Papyrology
• Greek and Roman Archaeology
• Late Antiquity
• Religion in the Ancient World
• Digital Humanities
• Browse content in History
• Colonialism and Imperialism
• Diplomatic History
• Environmental History
• Genealogy, Heraldry, Names, and Honours
• Genocide and Ethnic Cleansing
• Historical Geography
• History by Period
• History of Emotions
• History of Agriculture
• History of Education
• History of Gender and Sexuality
• Industrial History
• Intellectual History
• International History
• Labour History
• Legal and Constitutional History
• Local and Family History
• Maritime History
• Military History
• National Liberation and Post-Colonialism
• Oral History
• Political History
• Public History
• Regional and National History
• Revolutions and Rebellions
• Slavery and Abolition of Slavery
• Social and Cultural History
• Theory, Methods, and Historiography
• Urban History
• World History
• Browse content in Language Teaching and Learning
• Language Learning (Specific Skills)
• Language Teaching Theory and Methods
• Browse content in Linguistics
• Applied Linguistics
• Cognitive Linguistics
• Computational Linguistics
• Forensic Linguistics
• Grammar, Syntax and Morphology
• Historical and Diachronic Linguistics
• History of English
• Language Acquisition
• Language Evolution
• Language Reference
• Language Variation
• Language Families
• Lexicography
• Linguistic Anthropology
• Linguistic Theories
• Linguistic Typology
• Phonetics and Phonology
• Psycholinguistics
• Sociolinguistics
• Translation and Interpretation
• Writing Systems
• Browse content in Literature
• Bibliography
• Children's Literature Studies
• Literary Studies (Asian)
• Literary Studies (European)
• Literary Studies (Eco-criticism)
• Literary Studies (Romanticism)
• Literary Studies (American)
• Literary Studies (Modernism)
• Literary Studies - World
• Literary Studies (1500 to 1800)
• Literary Studies (19th Century)
• Literary Studies (20th Century onwards)
• Literary Studies (African American Literature)
• Literary Studies (British and Irish)
• Literary Studies (Early and Medieval)
• Literary Studies (Fiction, Novelists, and Prose Writers)
• Literary Studies (Gender Studies)
• Literary Studies (Graphic Novels)
• Literary Studies (History of the Book)
• Literary Studies (Plays and Playwrights)
• Literary Studies (Poetry and Poets)
• Literary Studies (Postcolonial Literature)
• Literary Studies (Queer Studies)
• Literary Studies (Science Fiction)
• Literary Studies (Travel Literature)
• Literary Studies (War Literature)
• Literary Studies (Women's Writing)
• Literary Theory and Cultural Studies
• Mythology and Folklore
• Shakespeare Studies and Criticism
• Browse content in Media Studies
• Browse content in Music
• Applied Music
• Dance and Music
• Ethics in Music
• Ethnomusicology
• Gender and Sexuality in Music
• Medicine and Music
• Music Cultures
• Music and Religion
• Music and Media
• Music and Culture
• Music Education and Pedagogy
• Music Theory and Analysis
• Musical Scores, Lyrics, and Libretti
• Musical Structures, Styles, and Techniques
• Musicology and Music History
• Performance Practice and Studies
• Race and Ethnicity in Music
• Sound Studies
• Browse content in Performing Arts
• Browse content in Philosophy
• Aesthetics and Philosophy of Art
• Epistemology
• Feminist Philosophy
• History of Western Philosophy
• Metaphysics
• Moral Philosophy
• Non-Western Philosophy
• Philosophy of Science
• Philosophy of Language
• Philosophy of Mind
• Philosophy of Perception
• Philosophy of Action
• Philosophy of Law
• Philosophy of Religion
• Philosophy of Mathematics and Logic
• Practical Ethics
• Social and Political Philosophy
• Browse content in Religion
• Biblical Studies
• Christianity
• East Asian Religions
• History of Religion
• Judaism and Jewish Studies
• Qumran Studies
• Religion and Education
• Religion and Health
• Religion and Politics
• Religion and Science
• Religion and Law
• Religion and Art, Literature, and Music
• Religious Studies
• Browse content in Society and Culture
• Cookery, Food, and Drink
• Cultural Studies
• Customs and Traditions
• Ethical Issues and Debates
• Hobbies, Games, Arts and Crafts
• Lifestyle, Home, and Garden
• Natural world, Country Life, and Pets
• Popular Beliefs and Controversial Knowledge
• Sports and Outdoor Recreation
• Technology and Society
• Travel and Holiday
• Visual Culture
• Browse content in Law
• Arbitration
• Browse content in Company and Commercial Law
• Commercial Law
• Company Law
• Browse content in Comparative Law
• Systems of Law
• Competition Law
• Browse content in Constitutional and Administrative Law
• Government Powers
• Judicial Review
• Local Government Law
• Military and Defence Law
• Parliamentary and Legislative Practice
• Construction Law
• Contract Law
• Browse content in Criminal Law
• Criminal Procedure
• Criminal Evidence Law
• Sentencing and Punishment
• Employment and Labour Law
• Environment and Energy Law
• Browse content in Financial Law
• Banking Law
• Insolvency Law
• History of Law
• Human Rights and Immigration
• Intellectual Property Law
• Browse content in International Law
• Private International Law and Conflict of Laws
• Public International Law
• IT and Communications Law
• Jurisprudence and Philosophy of Law
• Law and Politics
• Law and Society
• Browse content in Legal System and Practice
• Courts and Procedure
• Legal Skills and Practice
• Primary Sources of Law
• Regulation of Legal Profession
• Medical and Healthcare Law
• Browse content in Policing
• Criminal Investigation and Detection
• Police and Security Services
• Police Procedure and Law
• Police Regional Planning
• Browse content in Property Law
• Personal Property Law
• Study and Revision
• Terrorism and National Security Law
• Browse content in Trusts Law
• Wills and Probate or Succession
• Browse content in Medicine and Health
• Browse content in Allied Health Professions
• Arts Therapies
• Clinical Science
• Dietetics and Nutrition
• Occupational Therapy
• Operating Department Practice
• Physiotherapy
• Radiography
• Speech and Language Therapy
• Browse content in Anaesthetics
• General Anaesthesia
• Neuroanaesthesia
• Browse content in Clinical Medicine
• Acute Medicine
• Cardiovascular Medicine
• Clinical Genetics
• Clinical Pharmacology and Therapeutics
• Dermatology
• Endocrinology and Diabetes
• Gastroenterology
• Genito-urinary Medicine
• Geriatric Medicine
• Infectious Diseases
• Medical Toxicology
• Medical Oncology
• Pain Medicine
• Palliative Medicine
• Rehabilitation Medicine
• Respiratory Medicine and Pulmonology
• Rheumatology
• Sleep Medicine
• Sports and Exercise Medicine
• Clinical Neuroscience
• Community Medical Services
• Critical Care
• Emergency Medicine
• Forensic Medicine
• Haematology
• History of Medicine
• Browse content in Medical Dentistry
• Oral and Maxillofacial Surgery
• Paediatric Dentistry
• Restorative Dentistry and Orthodontics
• Surgical Dentistry
• Browse content in Medical Skills
• Clinical Skills
• Communication Skills
• Nursing Skills
• Surgical Skills
• Medical Ethics
• Medical Statistics and Methodology
• Browse content in Neurology
• Clinical Neurophysiology
• Neuropathology
• Nursing Studies
• Browse content in Obstetrics and Gynaecology
• Gynaecology
• Occupational Medicine
• Ophthalmology
• Otolaryngology (ENT)
• Browse content in Paediatrics
• Neonatology
• Browse content in Pathology
• Chemical Pathology
• Clinical Cytogenetics and Molecular Genetics
• Histopathology
• Medical Microbiology and Virology
• Patient Education and Information
• Browse content in Pharmacology
• Psychopharmacology
• Browse content in Popular Health
• Caring for Others
• Complementary and Alternative Medicine
• Self-help and Personal Development
• Browse content in Preclinical Medicine
• Cell Biology
• Molecular Biology and Genetics
• Reproduction, Growth and Development
• Primary Care
• Professional Development in Medicine
• Browse content in Psychiatry
• Addiction Medicine
• Child and Adolescent Psychiatry
• Forensic Psychiatry
• Learning Disabilities
• Old Age Psychiatry
• Psychotherapy
• Browse content in Public Health and Epidemiology
• Epidemiology
• Public Health
• Browse content in Radiology
• Clinical Radiology
• Interventional Radiology
• Nuclear Medicine
• Radiation Oncology
• Reproductive Medicine
• Browse content in Surgery
• Cardiothoracic Surgery
• Gastro-intestinal and Colorectal Surgery
• General Surgery
• Neurosurgery
• Paediatric Surgery
• Peri-operative Care
• Plastic and Reconstructive Surgery
• Surgical Oncology
• Transplant Surgery
• Trauma and Orthopaedic Surgery
• Vascular Surgery
• Browse content in Science and Mathematics
• Browse content in Biological Sciences
• Aquatic Biology
• Biochemistry
• Bioinformatics and Computational Biology
• Developmental Biology
• Ecology and Conservation
• Evolutionary Biology
• Genetics and Genomics
• Microbiology
• Molecular and Cell Biology
• Natural History
• Plant Sciences and Forestry
• Research Methods in Life Sciences
• Structural Biology
• Systems Biology
• Zoology and Animal Sciences
• Browse content in Chemistry
• Analytical Chemistry
• Computational Chemistry
• Crystallography
• Environmental Chemistry
• Industrial Chemistry
• Inorganic Chemistry
• Materials Chemistry
• Medicinal Chemistry
• Mineralogy and Gems
• Organic Chemistry
• Physical Chemistry
• Polymer Chemistry
• Study and Communication Skills in Chemistry
• Theoretical Chemistry
• Browse content in Computer Science
• Artificial Intelligence
• Computer Architecture and Logic Design
• Game Studies
• Human-Computer Interaction
• Mathematical Theory of Computation
• Programming Languages
• Software Engineering
• Systems Analysis and Design
• Virtual Reality
• Browse content in Computing
• Business Applications
• Computer Security
• Computer Games
• Computer Networking and Communications
• Digital Lifestyle
• Graphical and Digital Media Applications
• Operating Systems
• Browse content in Earth Sciences and Geography
• Atmospheric Sciences
• Environmental Geography
• Geology and the Lithosphere
• Maps and Map-making
• Meteorology and Climatology
• Oceanography and Hydrology
• Palaeontology
• Physical Geography and Topography
• Regional Geography
• Soil Science
• Urban Geography
• Browse content in Engineering and Technology
• Agriculture and Farming
• Biological Engineering
• Civil Engineering, Surveying, and Building
• Electronics and Communications Engineering
• Energy Technology
• Engineering (General)
• Environmental Science, Engineering, and Technology
• History of Engineering and Technology
• Mechanical Engineering and Materials
• Technology of Industrial Chemistry
• Transport Technology and Trades
• Browse content in Environmental Science
• Applied Ecology (Environmental Science)
• Conservation of the Environment (Environmental Science)
• Environmental Sustainability
• Environmentalist Thought and Ideology (Environmental Science)
• Management of Land and Natural Resources (Environmental Science)
• Natural Disasters (Environmental Science)
• Nuclear Issues (Environmental Science)
• Pollution and Threats to the Environment (Environmental Science)
• Social Impact of Environmental Issues (Environmental Science)
• History of Science and Technology
• Browse content in Materials Science
• Ceramics and Glasses
• Composite Materials
• Metals, Alloying, and Corrosion
• Nanotechnology
• Browse content in Mathematics
• Applied Mathematics
• Biomathematics and Statistics
• History of Mathematics
• Mathematical Education
• Mathematical Finance
• Mathematical Analysis
• Numerical and Computational Mathematics
• Probability and Statistics
• Pure Mathematics
• Browse content in Neuroscience
• Cognition and Behavioural Neuroscience
• Development of the Nervous System
• Disorders of the Nervous System
• History of Neuroscience
• Invertebrate Neurobiology
• Molecular and Cellular Systems
• Neuroendocrinology and Autonomic Nervous System
• Neuroscientific Techniques
• Sensory and Motor Systems
• Browse content in Physics
• Astronomy and Astrophysics
• Atomic, Molecular, and Optical Physics
• Biological and Medical Physics
• Classical Mechanics
• Computational Physics
• Condensed Matter Physics
• Electromagnetism, Optics, and Acoustics
• History of Physics
• Mathematical and Statistical Physics
• Measurement Science
• Nuclear Physics
• Particles and Fields
• Plasma Physics
• Quantum Physics
• Relativity and Gravitation
• Semiconductor and Mesoscopic Physics
• Browse content in Psychology
• Affective Sciences
• Clinical Psychology
• Cognitive Psychology
• Cognitive Neuroscience
• Criminal and Forensic Psychology
• Developmental Psychology
• Educational Psychology
• Evolutionary Psychology
• Health Psychology
• History and Systems in Psychology
• Music Psychology
• Neuropsychology
• Organizational Psychology
• Psychological Assessment and Testing
• Psychology of Human-Technology Interaction
• Psychology Professional Development and Training
• Research Methods in Psychology
• Social Psychology
• Browse content in Social Sciences
• Browse content in Anthropology
• Anthropology of Religion
• Human Evolution
• Medical Anthropology
• Physical Anthropology
• Regional Anthropology
• Social and Cultural Anthropology
• Theory and Practice of Anthropology
• Browse content in Business and Management
• Business Strategy
• Business Ethics
• Business History
• Business and Government
• Business and Technology
• Business and the Environment
• Comparative Management
• Corporate Governance
• Corporate Social Responsibility
• Entrepreneurship
• Health Management
• Human Resource Management
• Industrial and Employment Relations
• Industry Studies
• Information and Communication Technologies
• International Business
• Knowledge Management
• Management and Management Techniques
• Operations Management
• Organizational Theory and Behaviour
• Pensions and Pension Management
• Public and Nonprofit Management
• Strategic Management
• Supply Chain Management
• Browse content in Criminology and Criminal Justice
• Criminal Justice
• Criminology
• Forms of Crime
• International and Comparative Criminology
• Youth Violence and Juvenile Justice
• Development Studies
• Browse content in Economics
• Agricultural, Environmental, and Natural Resource Economics
• Asian Economics
• Behavioural Finance
• Behavioural Economics and Neuroeconomics
• Econometrics and Mathematical Economics
• Economic Systems
• Economic History
• Economic Methodology
• Economic Development and Growth
• Financial Markets
• Financial Institutions and Services
• General Economics and Teaching
• Health, Education, and Welfare
• History of Economic Thought
• International Economics
• Labour and Demographic Economics
• Law and Economics
• Macroeconomics and Monetary Economics
• Microeconomics
• Public Economics
• Urban, Rural, and Regional Economics
• Welfare Economics
• Browse content in Education
• Adult Education and Continuous Learning
• Care and Counselling of Students
• Early Childhood and Elementary Education
• Educational Equipment and Technology
• Educational Strategies and Policy
• Higher and Further Education
• Organization and Management of Education
• Philosophy and Theory of Education
• Schools Studies
• Secondary Education
• Teaching of a Specific Subject
• Teaching of Specific Groups and Special Educational Needs
• Teaching Skills and Techniques
• Browse content in Environment
• Applied Ecology (Social Science)
• Climate Change
• Conservation of the Environment (Social Science)
• Environmentalist Thought and Ideology (Social Science)
• Natural Disasters (Environment)
• Social Impact of Environmental Issues (Social Science)
• Browse content in Human Geography
• Cultural Geography
• Economic Geography
• Political Geography
• Browse content in Interdisciplinary Studies
• Communication Studies
• Museums, Libraries, and Information Sciences
• Browse content in Politics
• African Politics
• Asian Politics
• Chinese Politics
• Comparative Politics
• Conflict Politics
• Elections and Electoral Studies
• Environmental Politics
• European Union
• Foreign Policy
• Gender and Politics
• Human Rights and Politics
• Indian Politics
• International Relations
• International Organization (Politics)
• International Political Economy
• Irish Politics
• Latin American Politics
• Middle Eastern Politics
• Political Methodology
• Political Communication
• Political Philosophy
• Political Sociology
• Political Behaviour
• Political Economy
• Political Institutions
• Political Theory
• Politics and Law
• Public Administration
• Public Policy
• Quantitative Political Methodology
• Regional Political Studies
• Russian Politics
• Security Studies
• State and Local Government
• UK Politics
• US Politics
• Browse content in Regional and Area Studies
• African Studies
• Asian Studies
• East Asian Studies
• Japanese Studies
• Latin American Studies
• Middle Eastern Studies
• Native American Studies
• Scottish Studies
• Browse content in Research and Information
• Research Methods
• Browse content in Social Work
• Addictions and Substance Misuse
• Adoption and Fostering
• Care of the Elderly
• Child and Adolescent Social Work
• Couple and Family Social Work
• Developmental and Physical Disabilities Social Work
• Direct Practice and Clinical Social Work
• Emergency Services
• Human Behaviour and the Social Environment
• International and Global Issues in Social Work
• Mental and Behavioural Health
• Social Justice and Human Rights
• Social Policy and Advocacy
• Social Work and Crime and Justice
• Social Work Macro Practice
• Social Work Practice Settings
• Social Work Research and Evidence-based Practice
• Welfare and Benefit Systems
• Browse content in Sociology
• Childhood Studies
• Community Development
• Comparative and Historical Sociology
• Economic Sociology
• Gender and Sexuality
• Gerontology and Ageing
• Health, Illness, and Medicine
• Marriage and the Family
• Migration Studies
• Occupations, Professions, and Work
• Organizations
• Population and Demography
• Race and Ethnicity
• Social Theory
• Social Movements and Social Change
• Social Research and Statistics
• Social Stratification, Inequality, and Mobility
• Sociology of Religion
• Sociology of Education
• Sport and Leisure
• Urban and Rural Studies
• Browse content in Warfare and Defence
• Defence Strategy, Planning, and Research
• Land Forces and Warfare
• Military Administration
• Military Life and Institutions
• Naval Forces and Warfare
• Other Warfare and Defence Issues
• Peace Studies and Conflict Resolution
• Weapons and Equipment

• < Previous chapter
• Next chapter >

26 Sex Work, Gender, and Criminal Justice

Ronald Weitzer is a Professor of Sociology at George Washington University.

• Published: 01 July 2014
• Cite Icon Cite
• Permissions Icon Permissions

This essay examines key dimensions of contemporary sex work as they relate to gender and the legal system. Theoretical perspectives and empirical research on street and indoor prostitution, stripping, and pornography are reviewed. In most places, the law and criminal justice system focus on women working in these sectors, with much less official attention to male and transgender sex workers. Scholarly research on male sex work has expanded in the past two decades but remains but a fraction of the academic literature. The essay concludes with a discussion of two recent, divergent trends in state policies: increased criminalization and legalization.

26.1. Introduction

Sex work involves the exchange of sexual services or erotic performances for material compensation and includes pornography, commercial telephone sex, erotic performances (stripping, webcam), and prostitution. Depending on the society in question, these practices may be legal or illegal. Where legal, they are subject to some type of government regulation, such as restrictions on eligibility and location. Unlike predatory crimes with a clear victim, illegal sex work involving adults generally entails exchanges between willing buyers and sellers, which leads some members of the public to view it with a measure of moral ambivalence or tolerance.

This essay focuses on prostitution—and, to a lesser extent, pornography and stripping—with special attention to issues of gender and criminal justice. In addition, it documents some important international trends in state policy. These trends are not uniform, as criminalization has intensified in some societies just as legalization is being embraced by others ( McCarthy et al. 2012 ; Weitzer 2012 ). Importantly, under both trends it is typically women who are the focus of new legislation and enforcement practices. While the new laws are usually gender-neutral, they are drafted with women in mind: law enforcement (under criminalization) and implementation of regulations (under legalization) is usually directed at female rather than male sex workers. Male clients of female sex workers are targeted in some nations but not in others, while male and transgender sex workers are almost entirely neglected in the law-in-action.

This essay begins with a review of major theoretical perspectives on sex work and then addresses gender issues. It argues that gender is all too often taken for granted in this scholarly work in part because of its focus on female sex workers and male customers and the general neglect of male and transgender sex workers and female customers. Additional research on these latter actors will help clarify both the ways in which sex work is gendered and the ways in which it is experienced similarly irrespective of gender. The essay concludes with a discussion of the legal context in the United States as a point of departure for considering broader international trends in legislation regarding sexual commerce. In doing so, the essay examines research bearing on two trends—increased criminalization and legalization.

26.2. Competing Theories

Three main theoretical perspectives have been applied to sex work. The oppression paradigm holds that prostitution reflects and reinforces patriarchal gender relations. Advocates of this paradigm argue that sex work is harmful both instrumentally and symbolically. Instrumentally, exploitation, subjugation, and violence against women are viewed as inherent in sex work ( Jeffreys 1997 ; Farley 2006 ). Symbolically, the very existence of commercial sex is seen as implying that men have a “patriarchal right of access to women’s bodies”: Men can pay for sex or sexual entertainment from women who otherwise would be unavailable to them, thus perpetuating their subordination ( Pateman 1988 , p. 199). Oppression writers typically use dramatic language to highlight the plight of workers (sexual slavery, prostituted women, survivors) and to emphasize the notion that sex workers are victims of male exploiters and misogynists ( Jeffreys 1997 ; Farley 2006 ). Oppression theorists typically describe only the worst examples of sex work and treat them as representative, and they tend to ignore counterevidence to the paradigm’s main tenets ( Weitzer 2010 ). Female sex workers who claim they have agency or view their work positively are discounted by advocates of this paradigm. Male and transgender sex workers are ignored as well.

The empowerment paradigm is radically different. It focuses on the ways in which sexual services qualify as work, involve human agency, and may be empowering for workers ( Delacoste and Alexander 1987 ; Chapkis 1997 ). Advocates argue that there is nothing inherent in sex work that would prevent it from being organized like any other economic transaction (i.e., for the mutual gain of buyers and sellers alike). Apart from its material rewards, some types of sex work provide greater control over working conditions than many traditional jobs, and this work can enhance workers’ sense of self-worth. However, the positive potential of sex work, from the worker’s perspective, is diluted when it is outlawed, marginalized, and heavily stigmatized.

Few empowerment writers argue that sex work is empowering without qualification; rather they argue that it can be validating under the right circumstances. Writers in this camp highlight benefits and success stories, without claiming that these are typical. For instance, one analyst argues that sex work can be liberating for those who are “fleeing from small-town prejudices, dead-end jobs, dangerous streets, and suffocating families” ( Agustín 2007 , p. 45). A few writers go further and make bold claims that romanticize sex work. Chapkis (1997 , p. 30) describes a “sex radical” version of empowerment wherein sex workers and other sexual outlaws “embrace a vision of sex freed of the constraints of love, commitment, and convention” and present “a potent symbolic challenge to confining notions of proper womanhood and conventional sexuality.” Paglia takes issue with the very notion that commercial sex is an arena of male domination over women:

The feminist analysis of prostitution says that men are using money as power over women. I’d say, yes, that’s all that men have . The money is a confession of weakness. They have to buy women’s attention. It’s not a sign of power; it’s a sign of weakness. (Paglia, quoted in Chapkis 1997 , p. 22)

The empowerment paradigm is particularly salient when the discussion moves from mainstream, heterosexual sex work to alternative genres. Research on gay and transgender sex work highlights the ways in which the work can be identity-affirming for individual workers (and customers) and for these marginalized populations more generally. For example, pornography made by and for women and stripping by female dancers for female audiences can help to replace traditional and heteronormative ideals of sexuality with a woman-centered alternative ( Bakehorn 2010 ; Frank and Carnes 2010 ). Similarly, gay male pornography can help affirm the consumer’s sexual orientation. Thomas (2010 , p. 84) argues that gay pornography is “one of the few venues for seeing gay sexuality presented in a positive light.” Also, it is held in much higher esteem in the gay community than heterosexual pornography is within that population: Gay pornography has “achieved an almost respectable position in gay life” ( Thomas 2010 , p. 83).

Transgender sex workers report that prostitution can provide a haven from societal rejection and may foster a sense of pride in their identity. A Brazilian study of transgender women reports that prostitution provided a “sense of personal worth, self-confidence, and self-esteem” ( Kulick 1998 , p. 136). These transgender women sold sex for emotional and sexual fulfillment as well as income. A recent study ( Cortez, Boer, and Baltieri 2011 ) that compares Brazilian transgendered and male sex workers finds that the former are more successful in creating strong social bonds with other workers and in fostering a shared identity. In focus groups in San Francisco, researchers discovered that “sex work involvement provided many young transgender women of color feelings of community and social support, which they often lacked in their family contexts”; moreover, it gave these workers a “sense of independence and non-reliance on others (i.e., managers, coworkers) who might express discrimination or harassment” ( Sausa, Keatley, and Operario 2007 , p. 772). For these populations, sex work can contribute to a larger identity politics that challenges conventional heterosexual norms and helps to empower otherwise marginalized groups.

Yet both the empowerment and oppression paradigms are deeply flawed. While exploitation and empowerment are certainly present in sex work, neither paradigm reflects its rich diversity and the implications of such variation for the participants. An alternative perspective, the polymorphous paradigm ( Weitzer 2009 , 2010 ), highlights the wide variety of occupational arrangements, power relations, and personal experiences among those involved in sexual commerce. Sex workers differ in their reasons for entry, dependence on third parties, relations with clients, risk of victimization, contacts with the authorities, job satisfaction, public visibility, and impact on the surrounding community. Recognizing such diversity as a starting point, researchers can then identify the determinants of these varying outcomes.

Polymorphism is superior to the other two paradigms because empirical research amply demonstrates the variegated nature of sex work and because this paradigm encompasses everything highlighted in the other two paradigms (see Vanwesenbeeck 2001 ; Harcourt and Donovan 2005 ; Shaver 2005 ; Bradley-Engen 2009 ; Weitzer 2009 ; Attwood 2011 ). Because the oppression and empowerment paradigms are one-dimensional, they are clearly unsuited to the sociological task of identifying the structural conditions responsible for the uneven distribution of key outcomes—such as agency, exploitation, victimization risk, and job satisfaction. The polymorphous prism is well suited to precisely this kind of analysis.

26.3. Gender

In the popular imagination, sex work is perceived through a single-gender lens: Women sell sex or erotic performances, and men are the buyers. When people think of strippers, pornography stars, and prostitutes, they typically think of women. It is true that the mainstream sex industry is highly gendered in this way, and it is important to examine why so much sex work is performed by women. This gender imbalance clearly reflects traditional gender relations (i.e., men’s sexual objectification of women) that some women capitalize on, and the existence of sex for sale provides men with an avenue for reaffirming their masculinity, although this is hardly the only motivation for buying sexual services or erotic performances ( Milrod and Weitzer 2012 ). The gendered character of the sex industry is also evident in its power structure: Many of the owners and managers of sex businesses are men who exercise control over female employees and profit from their labor. Finally, it is likely that many of the women working in the sex industry would not do so if other jobs, paying the same as sex work, were available to them. In each of these ways, it is clear that gender inequality is deeply inscribed in the world of sexual commerce.

But it is also important to recognize that many sex workers are male or transgender. Male prostitutes, pornography actors, and strippers service or perform for women or for other men, and together these men constitute a sizeable proportion of the sex worker population. Yet, far less research has been conducted on them than on their female counterparts. While research on male prostitutes has grown somewhat in recent years ( West 1993 ; Browne and Minichiello 1996 ; Aggleton 1999 ; Uy et al. 2004 ; Smith, Grov, and Seal 2008 ; Logan 2010 ; Walby 2012 ), hardly any research has been conducted on male commercial strippers or pornography actors ( DeMarco 2007 ; Abbott 2010 ).

Even scarcer are studies that systematically compare male and female workers in the same occupational sector, research that can be particularly revealing. For example, a recent study of male and female independent escorts reports greater similarities than differences between them. Both groups placed a high value on working independently, rather than for an agency, and both were committed to condom use with clients. But the women charged much more for their services and also experienced greater stigma than the men, largely because sex work is “more socially acceptable within the gay community” ( Koken, Bimbi, and Parsons 2010 , p. 229).

A unique comparison of male, female, and transgender prostitutes in San Francisco identifies a number of significant differences between the three groups ( Weinberg, Shaver, and Williams 1999 ). The women in the study were more likely than the men or transgenders to have been coerced into prostitution and to have pimps, and the men experienced more sexual satisfaction at work than the female prostitutes, although the three groups reported similar levels of overall job satisfaction. Another study, of 100 street workers, finds that males were the least likely and females the most likely to have experienced assault and rape, while the transgender workers fell in between the other two groups in rates of victimization ( Valera, Sawyer, and Schiraldi 2001 ).

Research on strippers shows that female audiences tend to act more aggressively toward male dancers than is allowed in clubs featuring female dancers before a male audience—social control is more lax when men dance for women—but also that male dancers grapple with the same stigma and objectification as their female counterparts ( Dressel and Petersen 1982 ; Montemurro 2001 ). Men who strip for male audiences experience less stigma but the same challenges in maintaining boundaries vis-à-vis their male patrons ( DeMarco 2007 ).

Sex tourism also differs by gender. A study in the Dominican Republic reports that male prostitutes (known as “beach boys”) felt free to be seen in public (relaxing, partying) with female tourists, whereas female prostitutes used public space solely to solicit men ( Herold, Garcia, and DeMoya 2001 ). The male prostitutes were more likely to form relationships with female tourists over an extended period of time, but the female workers were more dependent on prostitution for their livelihood and felt more stigmatized by the local population. The beach boys often had other jobs, and they and the female tourists defined their relationships not as prostitution but as “romance tourism” ( Sanchez Taylor 2001 ). Yet these relationships have all the hallmarks of sexual commerce, provided that the man receives at least some material compensation (meals, gifts, money, lodging). Similar kinds of relationships, short and long term, have been observed among gay male tourists and local male sex workers in the Caribbean, Thailand, and other places ( Padilla 2007 ).

Much more comparative work of this kind is needed to document the ways in which the gender of the sex worker and of the customer influence both the social organization of sex work and the modal experiences of the participants. At this point, we know that female, male, and transgender sex workers share certain commonalities (e.g., negotiating transactions, managing clients, dealing with risks, coping with stigma), but they also appear to differ to some extent in the meanings they attach to commercial sex and in their modal experiences with clients and third parties. Additional research on male and transgender workers, as well as female clients, will help clarify the ways in which sex work is gendered as well as its more universal dimensions.

Like academic research, public policy and law enforcement largely focus on women in the sex industry, either as offenders or victims. Although most laws are written in a gender-neutral fashion, they are applied to female sex workers much more than to men. Arrests of male prostitutes are a minority of total prostitution arrests, for instance. According to the Federal Bureau of Investigation’s (2010 a )   Uniform Crime Report , males comprised 31 percent of those arrested for prostitution-related crimes in 2010 and 30 percent in 2009, which included solicitation, pimping and procuring, and owning or managing a place where prostitution takes place. Because these figures aggregate all of these activities, the percentages of men arrested for prostitution (i.e., solicitation) per se are not reported. We do know that most of the arrests of prostitutes take place outdoors. Having said that, females are more likely than males to be arrested in indoor locations, such as a massage parlor or a hotel where an escort agrees to meet an undercover officer posing as a client. Because national-level figures are not broken down by type of offense, we do not know either the number or the gender of persons arrested for pimping, procuring, or running a brothel. The conventional wisdom is that most of these third parties are males. Similarly, it is often assumed that the majority of persons involved in sex trafficking are male. An analysis of data from 2008–2010 by the US Bureau of Justice Statistics lends credence to this view: 82 percent of 385 suspected sex traffickers were male ( Banks and Kyckelhahn 2011 , p. 6). But worldwide, women are certainly not absent from the ranks of those who recruit or manage prostitutes, nor do they necessarily treat the individuals under their control better than male managers.

26.4. Victimization

The research literature draws three main conclusions about the risk of victimization. First, male sex workers are less likely than their female counterparts to experience violence while at work or to be controlled by pimps or other third parties ( West 1993 ; Aggleton 1999 ; Weinberg, Shaver, and Williams 1999 ). Second, transgendered workers report more frequent victimization than male sex workers ( Valera et al. 2001 ; Cortez et al. 2011 ); and third, indoor sex workers in developed countries who have not been coerced into prostitution are much less likely than street prostitutes to experience assault, robbery, rape, threats of violence, or murder. Street workers experience more frequent and more severe victimization over time, whereas some indoor providers report never having experienced violence on the job. This was the case for 78 percent of indoor workers in a British study ( Sanders and Campbell 2007 ). Similarly, about two-thirds of a Dutch sample of prostitutes ( Vanwesenbeeck et al. 1995 ) had never experienced physical or sexual violence on the job (most of the remainder had experienced violence infrequently). The Dutch sample included both street and indoor workers, so it is likely that the number experiencing violence would be even lower if the sample was restricted to the indoor population. Studies that directly compare indoor and street prostitutes tend to find substantial differences in victimization rates. A British study of 115 street and 125 indoor prostitutes ( Church et al. 2001 ), for example, asked whether they had ever been robbed (37 versus 10 percent, respectively), beaten (27 versus 1 percent), or raped (22 versus 2 percent) while working. Although random sampling was not possible in these studies, the common finding of significant street-indoor disparities lends credence to the general conclusion that “street workers are significantly more at risk of more violence and more serious violence than indoor workers” ( Plumridge and Abel 2001 , p. 83).

Indoor prostitution tends to be safer for two reasons: (a) It allows for more thorough screening of clients than is possible in street encounters, and (b) third parties may be present and willing to intervene in the event of trouble with a client. Street work involves very brief transactions that give workers little opportunity to assess a prospective client’s temperament. By contrast, indoor workers (whether independent or working for an agency) typically put clients through an elaborate screening process—requiring information about the person’s employer, a home address, social security and phone numbers, a referral from another sex worker, and completion of an online questionnaire. The Internet facilitates this screening, and a client’s responses can be confirmed with an online search and return phone calls. Such personal information helps to weed out both predators and police officers. A study of call girls finds that, as a result of phone screening, these workers develop “a sensitivity to detecting potential danger in the caller’s attitudes, manners, tone of voice, or nature of the conversation” ( Perkins and Lovejoy 2007 , p. 51). People who work for an agency routinely check in with a manager by phone before and after a visit and use code words if they sense trouble. In addition, compared to street customers, a larger proportion of indoor clients are regulars, who tend to be low risk ( Lever and Dolnick 2010 ).

For those who work in group settings—in brothels, massage parlors, saunas, bars, and strip clubs—the presence of managers and colleagues may offer additional safety; their very presence may preempt altercations with a customer, and they can intervene if a customer becomes unruly. Many erotic businesses also have video surveillance and alarm systems. Sex workers who work in bars and clubs have time to screen prospective customers; conversing over drinks allows them to judge the client’s character. Indoor sex work is by no means risk-free, but there is no doubt that it is generally safer than the streets.

26.5. The American Legal Context

In the United States, prostitution policy is largely devolved to the states. Federal law bans interstate transportation of a person for the purpose of prostitution (the 1910 Mann Act), sex trafficking is outlawed under the 2000 Trafficking Victims Protection Act, and minors are banned from pornography under a recordkeeping requirement (the 2257 rule) whereby producers must verify the name and age of everyone depicted in sexually explicit material. Aside from these few national statutes, prostitution law is determined by each state, and decisions regarding pornography (i.e., whether it is legally obscene) are determined at the municipal level, under the doctrine of local “community standards” (there is no national obscenity test in the United States: municipal juries decide whether a work violates local community standards). All states prohibit solicitation for prostitution as well as pimping, procuring, operating a brothel, and running any other business that offers or allows sex for sale. The exception is Nevada, which since 1971 has permitted rural counties to license and regulate brothels. All prostitution is outlawed in Las Vegas and Reno, however, and in the counties where brothels are legal, other types of prostitution are prohibited.

In 2010, 62,668 Americans were arrested for prostitution offenses ( Federal Bureau of Investigation 2010 b ; the figure combines arrests for solicitation of customers; for owning or managing a place where prostitution takes place; and for procuring, pimping, or transporting a person for the purpose of prostitution; however, these statistics do not include figures on arrests of customers). Arrests are sporadic and selective in most cities, but in others they are more sustained and may have the effect of displacing street prostitution to another locale ( Scott 2001 ). Efforts against indoor operations are less common because they typically involve considerable planning and resources. In some departments, vice officers routinely monitor the Internet for the purpose of arresting individual prostitutes or shutting down escort agencies and massage parlors. Other departments prefer to target enforcement at the street trade ( Weitzer 1999 ).

Police agencies that conduct undercover stings sometimes cross the line of propriety. Officers involved in operations targeting massage parlors in Lynnwood, Washington, for example, allowed masseuses to masturbate them prior to making an arrest, while state police officers in Pennsylvania and vice officers in Louisville, Kentucky, and Spotsylvania County, Virginia, received oral sex prior to arresting the masseuses and parlor owners ( Weitzer 2012 ). In these and similar cases, the police claim that masseuses are savvy in detecting vice cops and thus some sexual contact is necessary to affect an arrest ( Almodovar 2010 ). But other police departments have strict policies prohibiting any sexual contact between officers and masseuses and rely instead on a verbal agreement of payment for sex.

Strip clubs are regulated by municipal laws in the United States. Undercover police officers occasionally visit the clubs to determine if anything unlawful is taking place—such as violations of rules regarding attire and physical contact between dancers and patrons. Police also look for signs of prostitution on the premises. A larger issue is the claim, made by officials in many cities, that strip clubs have “adverse secondary effects” on surrounding communities. Among the alleged effects are increased crime and disorderly conduct in the vicinity of a club. Although this claim is frequently made and used as a basis for prohibiting clubs in some jurisdictions, supporting evidence is lacking. Some carefully conducted studies, matching locales with and without strip clubs, report either no difference in crime rates or less reported crime in the strip club areas ( Paul, Shafer, and Linz 2001 ). A study of Charlotte, North Carolina, documents more crime in the immediate vicinity of bars and gas stations than in the area near strip clubs, and in Fort Wayne, Indiana, calls to the police in areas hosting strip clubs were no higher than in matched areas without such clubs ( Linz 2004 ). Looking only at reported sex crimes in a matched-area study of four Ohio cities, Linz, Yao, and Byrne (2007) find that there were no sex crimes near most of the strip clubs; where crimes occurred near clubs, there was a higher incidence in locales with fewer clubs. A study of San Diego, California, reports identical findings for areas with peep shows ( Linz, Paul, and Yao 2006 ). The researchers explain these findings in terms of club owners’ interest in maintaining a lawful business and the special security measures they employ both inside and outside their clubs to preempt problems with patrons and thwart criminal activity outside.

26.6. Recent Trends: Increasing Criminalization

Internationally, there have been two divergent trends in state policies toward sex work over the past two decades: increased criminalization and decriminalization/legalization. Those who champion the oppression paradigm, sketched above, have been in the forefront of an international campaign to outlaw currently legal forms of sex work and to intensify sanctions against already illegal forms. Recall that under the oppression paradigm, all types of sex work are regarded as harmful to the participants and to the larger society. Current efforts to expand criminalization echo earlier attempts, in the 1980s in the United States, to ban pornography ( Vance 1986 ). This effort met with some success during the Reagan administration, as indicated by the Justice Department’s increased prosecution in the late 1980s of pornography distributors accused of peddling obscene materials ( US Department of Justice 1988 ). Under the Clinton administration, prosecutions shifted toward child pornography, but under the subsequent Bush administration, adult pornography was targeted once again. The Obama administration has followed the Clinton model of focusing on child porn, not adult obscenity.

Much of the recent shift toward greater criminalization in the United States (and some other nations) has been driven by antitrafficking policy. Beginning with passage of the Trafficking Victims Protection Act in 2000, the trend has been one of construing all types of sex work through the trafficking prism. The Bush administration (2001–2008) conflated sex trafficking with prostitution in general; some officials even argued that most prostitutes were trafficking victims. Rejecting the idea that legalization might help to reduce abuse, a State Department “fact sheet” claimed that legal prostitution “creates a safe haven for criminals who traffic people into prostitution” ( US Department of State 2004 , p. 2). Subsequently, the Bush administration began to float the idea that many of those who work in pornography and at strip clubs had been trafficked as well.

The Bush administration was heavily influenced by lobbying from prohibitionist activists who subscribe to the oppression paradigm. These activists enjoyed unparalleled access to state officials, testifying at Congressional hearings and networking at private conferences with government officials; government reports privileged their views, citing their work and providing links to their websites; and lucrative grants were awarded to the preeminent prohibitionist groups in the United States ( Chuang 2010 ; Weitzer 2011 ). There was thus a remarkable convergence between the dominant forces in the trafficking movement and the state during the Bush presidency. Over a short period of time, activists’ claims and demands were almost fully institutionalized in government policy and enforcement practices ( Weitzer 2007 , 2011 ). Other groups working against trafficking—those that did not accept the conflation of sex work with trafficking and advocated a more targeted approach—were completely marginalized by state officials ( Soderlund 2005 ; also see Goździak this volume).

A key part of the criminalization trend has been a robust crackdown on the clients of prostitutes. This is known as attacking “the demand.” The targeting of customers is a policy first adopted by Sweden in a 1999 law. The law punishes clients but not prostitutes on the grounds that clients are predators and women are victims who should be rescued rather than prosecuted. The rationale for the new law is described in a government publication:

In Sweden, prostitution is regarded as an aspect of male violence against women and children. It is officially acknowledged as a form of exploitation...which is harmful not only to the individual prostituted woman or child, but also to society at large...Gender equality will remain unattainable as long as men buy, sell, and exploit women and children by prostituting them. ( Ministry of Industry, Employment, and Communications 2004 , p. 1)

These declarations show that the 1999 law was firmly rooted in the oppression paradigm: Male domination is seen as the root cause of prostitution.

Some other nations have followed Sweden’s lead. In 2006 Finland passed a law outlawing the buying of sex from a trafficked person, and in 2009 Norway and Iceland enacted legislation similar to Sweden’s. In the same year, England and Wales passed a bill criminalizing those who buy sex from an individual who has been coerced into prostitution by a third party. The Finnish and British statutes construe the purchase of sex as a strict-liability offense: The client’s knowledge of the prostitute’s circumstances is irrelevant. In each case, advocates of the measures drew inspiration from Sweden, and the Swedish government has trumpeted the law’s success internationally. The available evidence, however, does not show that prostitution has been reduced in Sweden but instead that it has migrated into more clandestine and riskier settings ( Scoular 2004 ; Dodillet and Östergren 2011 ).

Not all anti-prostitution activists favor the Swedish approach; some continue to press for the criminalization and punishment of all parties involved in sex for sale, not just the clients. This is the prevailing approach in the United States, where increased penalties for purchasing sex run parallel to continuing enforcement against the prostitutes themselves. The official targeting of clients is evident in legislation reauthorizing the original 2000 trafficking law. The 2005 reauthorization bill, for instance, allocated $25 million per year for increased prosecution and programs, such as re-educational “john schools,” directed at those who purchase sex.

John schools are day-long seminars for men arrested for soliciting a prostitute. The program involves lectures on the harms of commercial sex, with the goal of preventing reoffending. About forty American cities operate such programs ( Ohtake 2008 ). Almost all of the men who have ended up in john schools were arrested on the street, not indoors. A comparison of men arrested for soliciting a prostitute who attended the city’s john school and men who did not attend the school found no difference in recidivism ( Monto and Garcia 2002 ). About 1 percent of both groups were rearrested for a prostitution offense, suggesting that the arrest itself is the key deterrent. Men arrested in cities without john schools are similarly unlikely to be rearrested for a prostitution offense, a pattern that suggests that the school experience per se does not serve as a significant deterrent ( Weitzer 1999 , pp. 97–98).

26.7. Recent Trends: Decriminalization and Legalization

The second and opposite trend in sex work legislation involves decriminalization and legalization. Several nations have recently decriminalized prostitution and third-party involvement in it (removing these from the criminal law) and legalized sexual commerce (imposing specific regulations on actors and enterprises). The few existing studies of legal prostitution systems indicate that many of the harms often associated with prostitution are at least partly due to its illicit status and may be alleviated when it is decriminalized and regulated by the state. Where it is illegal, prostitution is set apart from legitimate work, actors are marginalized and reluctant to report crimes to the police, and the authorities provide little if any protection.

The legalization and regulation of prostitution in some nations shows that criminalization is not the only option. It may be difficult for residents of nations where prostitution is illegal to imagine circumstances under which it can become normalized, but that is one of the goals of legal liberalization. The ideal situation is described by Overall (1992 , p. 716): “It is imaginable that prostitution could always be practiced...in circumstances of relative safety, security, freedom, hygiene, and personal control.” Most existing legal prostitution systems have registered at least some success in achieving one or more of these goals for at least some categories of sex workers ( Weitzer 2012 ).

Prostitution is legal and regulated by the government in more places than is commonly thought, and in some other places it is tolerated and regulated despite being technically illegal (e.g., Belgium, Thailand). Several Australian states decriminalized or legalized at least one type of prostitution in the 1980s (Victoria), 1990s (Queensland, New South Wales), and 2000s (Northern Territory, Tasmania). These jurisdictions vary in whether third-party involvement is permitted (e.g., running a brothel or escort agency), whether street prostitution or only indoor prostitution is allowed, and in other respects ( Sullivan 2010 ; Weitzer 2012 ). Legalization has also taken place in the Netherlands (in 2000), Germany (in 2002), and New Zealand (in 2003). Regulations vary from place to place, but a common objective is harm reduction—that is, lowering the risk of victimization, improving health, and reducing third-party exploitation. Government regulations dictate the type of prostitution allowed, who is eligible to work in the sex industry, the rights and responsibilities of workers and business owners, methods of licensing and governing businesses, special taxes, health and safety requirements, advertising restrictions, the location of establishments, and periodic inspection of premises. The regulatory apparatus in some contexts is extensive (e.g., Nevada) and compliance can be quite expensive (e.g., exorbitant licensing fees in Queensland). In other places, the controls are much more limited (e.g., Germany, New Zealand).

The available evidence suggests that prostitution, when legalized and regulated by the government, can pay dividends, although this is certainly not guaranteed. Nevada legalized brothel prostitution in 1971 and currently has about thirty such brothels scattered around its rural counties (but not in Las Vegas and Reno). These legal brothels “offer the safest environment available for women to sell consensual sex acts” ( Hausbeck and Brents 2010 , p. 272). Research on other legal prostitution regimes also documents certain benefits, including enhanced health and safety ( Weitzer 2012 ). In Queensland, Australia, for example, a government agency reports, “There is no doubt that licensed brothels provide the safest working environment for sex workers in Queensland...Legal brothels now operating in Queensland provide a sustainable model for a healthy, crime-free, and safe legal licensed brothel industry” and are a “state of the art model for the sex industry in Australia” ( Crime and Misconduct Commission 2004 , pp. 75, 89). In most of these cases, brothels have screening procedures, surveillance, and alarm buttons that reduce the chances of abuse by customers and allow for rapid intervention in case of trouble.

A comparative analysis of legal and illegal prostitutes working in Tijuana, Mexico—where about 1,000 women are licensed to operate legally—identifies several advantages of legal sex work ( Katsulis 2008 ). Legal status, in itself, has a multiplier effect, providing workers with a set of protections as well as a broad sense of empowerment. The legal regime is associated with improved working conditions, job satisfaction, and self-esteem; decreased victimization risk; a “barrier against police harassment”; and a “sense of legitimacy and community” and social capital among the legal workers ( Katsulis 2008 , p. 77). Illegal workers in Tijuana, by contrast, are subject to fines or incarceration and are at higher risk of police harassment and violence; they have less stable support networks; and they are about twice as likely to have been assaulted, robbed, or kidnapped as legal workers. A major evaluation in New Zealand, where prostitution was decriminalized in 2003, reports that more than 90 percent of sex workers interviewed were aware that they had legal and employment rights under the new law ( Prostitution Law Review Committee 2008 ); two-thirds felt that the law gave them more leverage to refuse a client or his requests; and a majority (57 percent) felt that police attitudes had changed for the better since passage of the law. This assessment is confirmed by other research ( Abel, Fitzgerald, and Healy 2010 ) that finds legalization has achieved many of its objectives and that the majority of sex workers are better off than they were under the previous system.

The argument here is not that legalized prostitution is preferable, across the board, to criminalization, but instead that legalization can be superior. What is crucial are the specific kinds of regulations in place and the degree to which they are enforced. Legalizing prostitution is one thing; implementing and enforcing regulations in accordance with a new law is another and has presented serious challenges in many nations postlegalization. Common problems include (a) difficulties getting prostitutes and business owners to comply with the law, (b) eliminating parasitical third parties, (c) preventing the growth of an illegal sector alongside the legal sector, and (d) in some places, unrelenting demands from social forces that seek to tighten restrictions or repeal the law entirely. These and other unforeseen challenges have arisen in most newly legal prostitution systems, taxing policymakers and enforcement agents. There are some exceptions (Nevada, New Zealand) where the aftermath of legalization was relatively smooth, but elsewhere (e.g., Germany, Australia, the Netherlands) the implementation of legal arrangements has been buffeted by unanticipated problems, including the persistence of illegal prostitution parallel to the legal sector—a two-tiered situation that has been difficult to resolve (see Weitzer 2012 ). Such problems are not unique to prostitution postlegalization but apply to other vices as well, as illustrated by the recent challenges (in implementation and oversight) facing the twenty states that now allow medical marijuana in the United States ( Geluardi 2010 ).

Although the laws and regulations in these systems are framed in gender-neutral language, they are either drafted with female sex workers in mind or have been applied largely to them. Male prostitutes and their managers are usually untouched by the new controls. In other words, authorities operating in legal regimes tend to focus on female sex workers just as much as their counterparts in jurisdictions where prostitution is illegal. Women are everywhere the chief concern. Why? Perhaps because women are construed as universally more vulnerable to victimization and as having much less agency than male sex workers—a rather blatant paternalism—regardless of whether prostitution is legal or outlawed. One obvious problem with this orientation is that male sex workers are left both unmonitored and unprotected (see Katsulis 2008 ). They are less susceptible to arrest when prostitution is legal, but this hardly translates into enhanced health, safety, or labor rights for them.

Another issue that arises in deliberations about legalized prostitution is whether sexually oriented businesses should be restricted to a particular locale and prohibited outside it or whether a laissez-faire approach should prevail, where such businesses may locate wherever they please. Some cities have both geographically delimited red-light districts in addition to brothels and clubs in outlying communities. Because these red-light districts are rather visible and sometimes controversial, it is worth discussing them in some detail here. Such zones were studied decades ago by Chicago School researchers, who described vice districts as socially disorganized areas of the city. In his detailed study of Chicago, Reckless (1933 , p. 252) observed “[v]ice resorts concentrated in those tracts of the city which showed the highest rate of community disorganization,” measured by rates of predatory crime, disease, divorce, poverty, and physical decay. These associations continue to be made today and are used to justify zoning ordinances that ban or restrict strip clubs and adult video stores in the United States. But red-light districts are not, as Reckless argued, universally anomic, criminogenic, and socially disorganized. Indeed, the social ecology of such zones differs tremendously from place to place, with some departing considerably from the traditional, marginalized “skid row” image ( Weitzer 2012 , 2013 ).

Some countries where prostitution is legally regulated by the government have restricted visible prostitution to particular geographic areas. For example, several Dutch and Belgian cities and towns have districts whose main attraction is window prostitution; prostitutes sit behind red-lit windows and seek to attract male customers (no male prostitutes work in these districts, but some transgender women do). The physical appearance, social structure, and level of public order in some of these red-light zones clash with conventional stereotypes of such areas ( Weitzer 2012 , 2013 ). Such zones exist in Antwerp and Ghent in Belgium and in Alkmaar, Eindhoven, Haarlem, Groningen, The Hague, and Utrecht in the Netherlands. Based on this author’s field observations in some of these places coupled with descriptions in clients’ online discussion boards, these cities’ red-light districts have the following characteristics: They are located in enclaves away from the town center, making them less obtrusive for persons who wish to avoid the zone; they are single-purpose environments, largely restricted to window prostitution with few if any other businesses in the district; they are limited to pedestrians; the ambience of the zone is fairly tranquil; and the area is clean and lacking in signs of physical disorder or decay. The level of social control is also high: Police patrols are frequent, which sends a symbolic message to visitors, and some of the zones have visible security cameras as well. Antwerp has a mini-police station in the heart of its red-light district (see Weitzer 2013 ).

The existence of these kinds of zones suggests that legal prostitution can manifest itself in an erotic landscape that departs dramatically from conventional stereotypes. At the same time, such areas are by no means preordained in legal prostitution systems. In the same nations hosting the zones described above, there are other red-light districts that come closer to the traditional disorderly vice district model (e.g., Brussels). The key point here, however, is that prostitution, once legal and regulated, can be organized in a manner that is likely to benefit sex workers, clients, and local residents alike.

26.8. Conclusion

Most research on sex work has been conducted in nations where prostitution is outlawed. This means that what we think we know about prostitution may be distorted by the disproportionate research focus on criminalized prostitution. Research that examines sex work under different legal regimes, from criminalization to legalization, is necessary if we are to understand how legal approaches influence the origin, character, and consequences of sex work. In addition, the literature is heavily weighted toward studies of street prostitution and female sex workers. A more balanced and comprehensive picture requires a major shift in research. First, researchers should, when possible, adopt a comparative framework that includes female, male, and transgendered providers. Investigations of this sort are necessary if we are to understand the ways in which gender influences involvement in sex work, its conditions, and its effects. Second, researchers need to further expand the categories of actors studied to include the customers as well as the owners and managers who operate legal and illegal erotic businesses. Regarding customers, there is a growing but still small research literature on prostitutes’ clients but almost no studies of the consumers of pornography in the real world—outside artificial laboratory settings (exceptions include Loftus 2002 and McKee, Albury, and Lumby 2008 ). Third, researchers need a broader lens, not only examining sex work as a deviant or illegal act but also as a form of income-generating labor and the working conditions associated with it.

Some recent research has begun to shatter prevailing generalizations about commercial sex, generalizations that are largely based on studies confined to female street prostitutes. This work highlights significant differences between women who provide sexual services indoors versus the streets and has begun to document ways in which female prostitution both differs from and is similar to male and transgender prostitution. Gender differences have been documented in stripping and pornography as well, differences that shape the experiences of male and female performers as well as their customers ( Dressel and Peterson 1982 ; Montemurro 2001 ; De Marco 2007 ; Abbott 2010 ; Thomas 2010 ). We are also learning that geographical context matters tremendously. Sex work can differ radically from one locale to the next, as some major, recent international studies demonstrate ( Steinfatt 2002 ; Agustín 2007 ; Katsulis 2008 ; Kelly 2008 ; Zheng 2009 ; Abel, Fitzgerald, and Healy 2010 ; Kotiswaran 2011 ; Liu 2011 ; Trotter 2011 ; Chin and Finckenauer 2012 ; Weitzer 2012 ). But much more research is needed to expand and deepen our understanding of sex work and the factors responsible for its polymorphous character around the world.

Abel, Gillian , Lisa Fitzgerald , and Catherine Healy , eds. 2010 . Taking the Crime Out of Sex Work: New Zealand Sex Workers’ Fight for Decriminalization . Bristol, UK: Policy Press.

Google Scholar

Google Preview

Abbott, Sharon.   2010 . “Motivations for Pursuing a Career in Pornography.” In Sex for Sale , edited by Ronald Weitzer . New York: Routledge.

Aggleton, Peter , ed. 1999 . Men Who Sell Sex . Philadelphia: Temple University Press.

Agustín, Laura.   2007 . Sex at the Margins: Migration, Labor, and the Rescue Industry . London: Zed.

Almodovar, Norma Jean.   2010 . “ The Consequences of Arbitrary and Selective Enforcement of Prostitution Laws. ” Wagadu 8:241–57.

Attwood, Feona.   2011 . “ The Paradigm Shift: Pornography Research, Sexualization, and Extreme Images. ” Sociology Compass 5:13–22.

Bakehorn, Jill.   2010 . “Women-made Pornography.” In Sex for Sale , edited by Ronald Weitzer . New York: Routledge.

Banks, Duren , and Tracey Kyckelhahn . 2011 . Characteristics of Suspected Human Trafficking Incidents, 2008–2010 . Washington, DC: Bureau of Justice Statistics.

Bradley-Engen, Mindy.   2009 . Naked Lives: Inside the Worlds of Exotic Dance . Albany, NY: SUNY Press.

Browne, Jan , and Victor Minichiello . 1996 . “ Research Directions in Male Sex Work. ” Journal of Homosexuality 31:29–56.

Chapkis, Wendy.   1997 . Live Sex Acts: Women Performing Erotic Labor . New York: Routledge.

Chin, Ko-lin , and James Finckenauer . 2012 . Selling Sex Overseas . New York: New York University Press.

Chuang, Janie.   2010 . “ Rescuing Trafficking from Ideological Capture: Prostitution Reform and Anti-trafficking Law and Policy. ” University of Pennsylvania Law Review 158:1655–728.

Church, Stephanie , Marion Henderson , Marina Barnard , and Graham Hart . 2001 . “ Violence by Clients towards Female Prostitutes in Different Work Settings. ” British Medical Journal 32:524–26.

Cortez, Fernanda Cestaro Prado , Douglas Pieter Boer , and Danilo Antonio Baltieri . 2011 . “ A Psychosocial Study of Male-to-Female Transgendered and Male Hustler Sex Workers in Sao Paulo, Brazil. ” Archives of Sexual Behavior 40:1223–31.

Crime and Misconduct Commission. 2004 . Regulating Prostitution: An Evaluation of the Prostitution Act 1999, Queensland . Brisbane: Crime and Misconduct Commission.

Delacoste, Frederique , and Priscilla Alexander , eds. 1987 . Sex Work: Writings by Women in the Sex Industry . Pittsburgh, PA: Cleis.

DeMarco, Joseph.   2007 . “ Power and Control in Gay Strip Clubs. ” Journal of Homosexuality 53:111–27.

Dodillet, Susanne , and Petra Östergren . 2011. The Swedish Sex Purchase Act: Claimed Success and Documented Effects . Paper presented at International Workshop on Prostitution, The Hague.

Dressel, Paula , and David Petersen.   1982 . “ Gender Roles, Sexuality, and the Male Strip Show. ” Sociological Focus 15:151–62.

Farley, Melissa.   2006 . “ Prostitution, Trafficking, and Cultural Amnesia: What We Must Not Know in Order to Keep the Business of Sexual Exploitation Running Smoothly. ” Yale Journal of Law and Feminism 18:101–36.

Federal Bureau of Investigation.2010 a . Crime in the United States . Table 37. Washington, DC: Department of Justice. http://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2010/crime-in-the-u.s.-2010/tables/10tbl37.xls

——. 2010 b . Crime in the United States . Washington, DC: Department of Justice.

Frank, Katherine , and Michelle Carnes.   2010 . “Gender and Space in Strip Clubs.” In Sex for Sale , edited by Ronald Weitzer . New York: Routledge.

Geluardi, John.   2010 . Cannabiz: The Explosive Rise of the Medical Marijuana Industry . Sausalito, CA: PoliPoint.

Harcourt, Christine , and Basil Donovan.   2005 . “ The Many Faces of Sex Work. ” Sexually Transmitted Infections 81:201–6.

Hausbeck, Kathryn , and Barbara Brents . 2010 . “Nevada’s Legal Brothels.” In Sex for Sale , edited by Ronald Weitzer . New York: Routledge.

Herold, Edward , Rafael Garcia , and Tony DeMoya . 2001 . “ Female Tourists and Beach Boys: Romance or Sex Tourism? ” Annals of Tourism Research 28:978–97.

Jeffreys, Sheila.   1997 . The Idea of Prostitution . North Melbourne: Spinifex.

Katsulis, Yasmina.   2008 . Sex Work and the City: The Social Geography of Health and Safety in Tijuana, Mexico . Austin: University of Texas Press.

Kelly, Patty.   2008 . Lydia’s Open Door: Inside Mexico’s Most Modern Brothel . Berkeley: University of California Press.

Koken, Juline , David Bimbi , and Jeffrey Parsons . 2010 . “Male and Female Escorts: A Comparative Analysis.” In Sex for Sale , edited by Ronald Weitzer . New York: Routledge.

Kotiswaran, Prabha.   2011 . Dangerous Sex, Invisible Labor: Sex Work and the Law in India . Princeton, NJ: Princeton University Press.

Kulick, Don.   1998 . Travesti: Sex, Gender, and Culture among Brazilian Prostitutes . Chicago: University Chicago Press.

Lever, Janet , and Deane Dolnick . 2010 . “Call Girls and Street Prostitutes: Selling Sex and Intimacy.” In Sex for Sale , edited by Ronald Weitzer . New York: Routledge.

Linz, Daniel.   2004 . “ An Examination of the Assumption that Adult Businesses are Associated with Crime in Surrounding Areas. ” Law and Society Review 38:69–104.

Linz, Daniel , Bryant Paul , and Mike Yao . 2006 . “ Peep Show Establishments, Police Activity, Public Place, and Time: A Study of Secondary Effects in San Diego, California. ” Journal of Sex Research 43:182–93.

Linz, Daniel , Mike Yao , and Sahara Byrne . 2007 . “Testing Supreme Court Assumptions in California v. la Rue : Is There Justification for Prohibiting Sexually Explicit Messages in Establishments that Sell Liquor?” Communication Law Review 7:23–53.

Liu, Min.   2011 . Migration, Prostitution, and Human Trafficking: The Voice of Chinese Women . New Brunswick, NJ: Transaction.

Logan, Trevon.   2010 . “ Personal Characteristics, Sexual Behaviors, and Male Sex Work: A Quantitative Approach. ” American Sociological Review 75:679–704.

Loftus, David.   2002 . Watching Sex . New York: Thunder’s Mouth Press.

McCarthy, Bill , Cecilia Benoit , Mikeal Jansson , and Kat Kolar . 2012 . “ Regulating Sex Work: Heterogeneity in Legal Strategies. ” Annual Review of Law and Social Science 8:255–71.

McKee, Alan , Katherine Albury , and Catherine Lumby . 2008 . The Porn Report . Carlton: Melbourne University Press.

Milrod, Christine , and Ronald Weitzer . 2012 . “ The Intimacy Prism: Emotion Management among the Clients of Escorts. ” Men and Masculinities 15:447–67.

Ministry of Industry, Employment, and Communications. 2004 . Prostitution and Trafficking in Human Beings . Stockholm: Ministry of Industry, Employment, and Communications.

Montemurro, Beth.   2001 . “ Strippers and Screamers: The Emergence of Social Control in a Noninstitutionalized Setting. ” Journal of Contemporary Ethnography 30:275–304.

Monto, Martin , and Steve Garcia . 2002. “Recidivism among the Customers of Street Prostitutes: Do Intervention Programs Help?” Western Criminology Review 3:1–10. http://wcr.sonoma.edu/v3n2/monto.html

Ohtake, Miyoko.   2008 . “ A School for Johns. ” Newsweek (July 24).

Overall, Christine.   1992 . “ What’s Wrong with Prostitution? Evaluating Sex Work. ” Signs 17:705–24.

Padilla, Mark.   2007 . Caribbean Pleasure Industry: Tourism, Sexuality, and AIDS in the Dominican Republic . Chicago: University of Chicago Press.

Pateman, Carole.   1988 . The Sexual Contract . Palo Alto, CA: Stanford University Press.

Paul, Bryant , Bradley Shafer , and Daniel Linz.   2001 . “ Government Regulation of Adult Businesses through Zoning and Anti-nudity Ordinances: Debunking the Legal Myth of Negative Secondary Effects. ” Communication Law and Policy 6:355–92.

Perkins, Roberta , and Frances Lovejoy . 2007 . Call Girls: Private Sex Workers in Australia . Crawley: University of Western Australia Press.

Plumridge, Libby , and Gillian Abel.   2001 . “ A Segmented Sex Industry in New Zealand: Sexual and Personal Safety of Female Sex Workers. ” Australian and New Zealand Journal of Public Health 25:78–83.

Prostitution Law Review Committee. 2008 . Report of the Prostitution Law Review Committee on the Operation of the Prostitution Reform Act 2003 . Wellington, NZ: Ministry of Justice.

Reckless, Walter.   1933 . Vice in Chicago . Chicago: University of Chicago Press.

Sanchez Taylor, Jacqueline.   2001 . “ Dollars Are a Girl’s Best Friend: Female Tourists’ Sexual Behavior in the Caribbean. ” Sociology 34:749–64.

Sanders, Teela , and Rosie Campbell . 2007 . “ Designing out Vulnerability, Building in Respect. ” British Journal of Sociology 58:1–19.

Sausa, Lydia , JoAnne Keatley , and Don Operario . 2007 . “ Perceived Risks and Benefits of Sex Work among Transgender Women of Color in San Francisco. ” Archives of Sexual Behavior 36:768–77.

Scott, Michael.   2001 . Street Prostitution . Washington, DC: US Department of Justice.

Scoular, Jane.   2004 . “ Criminalizing Punters: Evaluating the Swedish Position on Prostitution. ” Journal of Social Welfare and Family Law 26:195–210.

Shaver, Frances.   2005 . “ Sex Work Research: Methodological and Ethical Challenges. ” Journal of Interpersonal Violence 20:296–319.

Smith, Michael , Christian Grov , and David Seal.   2008 . “ Agency-based Male Sex Work. ” Journal of Men’s Studies 16:193–210.

Soderlund, Gretchen.   2005 . “ Running From the Rescuuers: New U.S. Crusades Against Sex Trafficking and the Rhetoric of Abolition. ” NWSA Journal 17:64–87.

Steinfatt, Thomas.   2002 . Working at the Bar: Sex Work and Health Communication in Thailand . Westport, CT: Ablex.

Sullivan, Barbara.   2010 . “ When (Some) Prostitution is Legal: The Impact of Law Reform on Sex Work in Australia. ” Journal of Law and Society 37:85–104.

Thomas, Joe.   2010 . “Gay Male Pornography Since Stonewall.” In Sex for Sale , edited by Ronald Weitzer . New York: Routledge.

Trotter, Henry.   2011 . Sugar Girls and Seamen: A Journey into the World of Dockside Prostitution in South Africa . Athens: Ohio University Press.

US Department of Justice. 1988 . Beyond the Pornography Commission: The U.S. Response . Washington, DC: Government Printing Office.

US Department of State. 2004 . “ The Link between Prostitution and Sex Trafficking. ” Washington, DC: Bureau of Public Affairs.

Uy, Jude , Jeffrey Parsons , David Bimbi , Juline Koken , and Perry Halkitis . 2004 . “ Gay and Bisexual Male Escorts who Advertise on the Internet: Understanding Reasons for and Effects of Involvement in Commercial Sex. ” International Journal of Men’s Health 3:11–26.

Valera, Roberto , Robin Sawyer , and Glenn Schiraldi . 2001 . “ Perceived Health Needs of Inner-city Street Prostitutes. ” American Journal of Health Behavior 25:50–59.

Vance, Carole.   1986 . “ The Meese Commission on the Road. ” The Nation (August 2): 65 :76–82.

Vanwesenbeeck, Ine.   2001 . “ Another Decade of Social Scientific Work on Prostitution. ” Annual Review of Sex Research 12:242–89.

Vanwesenbeeck, Ine , Ron de Graaf , Gertjan van Zessen, CeesStraver , and Jan Visser . 1995 . “ Professional HIV Risk Taking, Levels of Victimization, and Well-being in Female Prostitutes in the Netherlands. ” Archives of Sexual Behavior 24:503–15.

Walby, Kevin.   2012 . Touching Encounters: Sex, Work, and Male-for-Male Internet Escorting . Chicago: University of Chicago Press.

Weinberg, Martin , Frances Shaver , and Colin Williams . 1999 . “ Gendered Sex Work in the San Francisco Tenderloin. ” Archives of Sexual Behavior 28:503–21.

Weitzer, Ronald.   1999 . “ Prostitution Control in America: Rethinking Public Policy. ” Crime , Law , and Social Change 32:83–102.

——. 2007 . “ The Social Construction of Sex Trafficking: Ideology and Institutionalization of a Moral Crusade. ” Politics and Society 35:447–75.

——. 2009 . “ Sociology of Sex Work. ” Annual Review of Sociology 35:213–34.

——. 2010 . “ The Mythology of Prostitution: Advocacy Research and Public Policy. ” Sexuality Research and Social Policy 7:15–29.

——. 2011 . “ Sex Trafficking and the Sex Industry: The Need for Evidence-based Theory and Legislation. ” Journal of Criminal Law and Criminology 101:1337–70.

——. 2012 . Legalizing Prostitution: From Illicit Vice to Lawful Business . New York: New York University Press.

——. 2013 . “ The Social Ecology of Red-Light Districts: A Comparison of Antwerp and Brussels. ” Urban Affairs Review DOI: 10.1080/01419870.2013.790984

West, Donald.   1993 . Male Prostitution . Binghamton, NY: Haworth.

Zheng, Tiantian.   2009 . Red Lights: The Lives of Sex Workers in Postsocialist China . Minneapolis: University of Minnesota Press.

• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Institutional account management
• Rights and permissions
• Get help with access
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Am J Public Health
• v.104(5); May 2014

A Systematic Review of the Correlates of Violence Against Sex Workers

K. N. Deering and K. Shannon conceptualized the study. K. N. Deering, A. Nesbitt, P. Duff, and E. Argento conducted the systematic literature review and compiled data. K. N. Deering wrote the first draft of the article and A. Amin, J. Shoveller, A. Nesbitt, C. García-Moreno, P. Duff, E. Argento, and K. Shannon provided key revisions to the drafted article. K. Shannon oversaw data collection and all other aspects of the study.

We conducted a systematic review in June 2012 (updated September 2013) to examine the prevalence and factors shaping sexual or physical violence against sex workers globally.

We identified 1536 (update = 340) unique articles. We included 28 studies, with 14 more contributing to violence prevalence estimates. Lifetime prevalence of any or combined workplace violence ranged from 45% to 75% and over the past year, 32% to 55%. Growing research links contextual factors with violence against sex workers, alongside known interpersonal and individual risks.

This high burden of violence against sex workers globally and large gaps in epidemiological data support the need for research and structural interventions to better document and respond to the contextual factors shaping this violence. Measurement and methodological innovation, in partnership with sex work communities, are critical.

Frequent reports of incidents of widespread violence against sex workers continue to emerge globally, 1–3 including media reports of abuse, human rights violations, and murder. 4–7 Despite increasing recognition of violence in the general population as a public health and human rights priority by policymakers, researchers, and international bodies, 8–10 violence against sex workers that occurs within and outside the context of sex work is frequently overlooked in international agendas to prevent violence. Although increasing research has explored the prevalence, determinants, and correlates of violence against women, 8,11–14 comparable research specifically among sex workers is lacking. There remains limited review of the magnitude, severity, or type of violence experienced by sex workers globally. This paucity of data on prevalence and incidence of violence against sex workers has been highlighted in a review on the magnitude and scope of violence globally. 15

Negative health effects of intimate partner violence in the general population include poor health overall, physical and sexual injury, and mental health problems including depression, anxiety, and posttraumatic stress disorder. 16–21 Intimate partner violence faced by women in the general population has also been linked to unwanted pregnancy, abortion, and increased risk for HIV and other sexually transmitted infections (STIs), through different direct and indirect mechanisms. 22–26 Victims of violence in early childhood are also more likely to have increased risk for HIV and other STIs. 27 However, the role of violence, both workplace violence and violence by intimate or other nonpaying partners, in influencing negative health outcomes among sex workers, who are highly stigmatized and often criminalized, has received comparably less attention.

The legal status of sex work can be a critical factor in shaping patterns of violence against sex workers. 1,28 In many settings, the criminalized or quasicriminalized nature of sex work means that violence that occurs in the context of sex work (i.e., as a workplace harm and abuse) is not monitored by any formal bodies, with few to no legal protections afforded to sex workers by police and judicial systems. 1,28 Violence against sex workers is often not registered as an offense by the police and in some cases is perpetrated by police. 29,30 Physical and sexual violence, and verbal abuse or threats of abuse from police, can prevent sex workers from reporting violence to the police or accessing other public agencies (e.g., health or social services), exacerbating their trauma and health risks. 1,29,30 These risks include the risk for HIV and other STIs, and in some settings, threats of arrest for possession of condoms as evidence of engaging in sex work can deter sex workers from carrying condoms. 30–32 This can create a climate of tolerance of violence and thereby perpetuate violence against sex workers.

We conducted a systematic review to examine the documented magnitude of violence against sex workers and to review the factors that shape risk for violence against sex workers. In our review we were guided by theoretical frameworks that implicate structural factors in shaping vulnerabilities experienced by vulnerable populations. 33–35 Within the interrelated physical, social, economic, and policy environments, factors operate to create different levels of susceptibility and risk. 33–35 The current review provides an evidence base pertaining to violence against sex workers from which to better inform the development of public health and social interventions to reduce violence and ameliorate its impacts on sex workers.

To conduct this systematic review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, consistent with previous systematic reviews among marginalized populations. 36

Search Strategy and Inclusion Criteria

We undertook a comprehensive review of all major databases between June 22 and 23, 2012 (K. N. D. and A. N.), updated September 9–14, 2013 (E. A. and P. D.). Databases included the Science Citation Index Expanded and Social Sciences Citation Index (via Web of Science), Ovid Medline (1948 to present with daily update), Ovid MEDLINE In-Process and Other Non-Indexed Citations, All Evidence-Based Medicine Review, PAIS, EMBASE, BioMed Central, PubMed, Academic Search Complete, Social Work Abstracts, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO. Search terms included “violence” or “sexual violence” or “physical violence” or “victimization”; and “sex work” or “sex worker” or “sex workers” or “prostitute” or “prostitutes” or “prostitution.” Both authors (K. N. D. and A. N.) searched reference lists of published articles and reviews, and Google Scholar. Articles were limited to those published in English language, but there was no limit on the year in which the study could be published. Details on the search strategy (both the original and the updated searches) are included in Table A (available as a supplement to this article at http://www.ajph.org ).

TABLE 1—

Summary of Included Studies and the Correlates of Violence for Systematic Review in June 2012 (Updated September 2013) to Examine the Prevalence and Factors Shaping Risk of Sexual or Physical Violence Against Sex Workers Globally

Note . AOR = adjusted odds ratio; AUDIT = Alcohol Use Disorders Identification Test; CI = confidence interval; NPP = intimate or other nonpaying partner; OR = odds ratio; PV = physical violence; SV = sexual violence.

We included articles that examined the prevalence and correlates of violence against sex workers (i.e., violence as an outcome) by using quantitative, multivariable methods, published in peer-reviewed journals. We also collected additional quantitative studies captured in the search process that examined the correlates of violence by using either bivariate methods to test statistical significance or no test of statistical significance. The latter studies were not included in the main review results, but we did collect violence prevalence estimates from these studies to combine with violence prevalence estimates from studies identified in the main review, to provide a more comprehensive and representative set of violence prevalence estimates. We excluded gray literature (e.g., government reports), as well as case reports and case series, reviews, editorials, and opinion pieces.

We included studies on individuals who exchanged sexual intercourse for money or other goods as a commercial activity (i.e., sex work); however, we excluded studies that focused exclusively on transactional sex (i.e., which occurs when something, primarily nonmonetary goods, shelter, gifts, services, but could include money, is informally provided in exchange for sexual services, but not within a formal or professional commercial transaction). Sex workers could be self-identified as female, male, or transgender. We included studies that included details on workplace violence (e.g., perpetrated by clients, police, managers, pimps, madams, or other third parties) and intimate and other nonpaying partners (i.e., casual, noncommercial partners). Of interest was physical or sexual violence, or violence measures that included at least 1 of physical or sexual (any or combined violence); although we did not specifically search for emotional or verbal violence, this type of violence was sometimes nested within scales that measure violence.

We read all abstracts to determine their relevance. We read all of the relevant articles in their entirety. Reviewers compared inclusions, and discussed them; in the case of discrepancies, we discussed with another author (K. S.) to reach a consensus. Where necessary, we contacted authors of the articles for additional data. The exclusion process and details on excluded articles are provided in Figure 1 .

Screening flowcharts of how studies were chosen to examine the prevalence and factors shaping risk of sexual or physical violence against sex workers globally, by (a) the original set of studies in June 2012 and (b) the updated set of studies in September 2013.

Data Extraction and Analysis

We extracted relevant information from each study (study design, participant characteristics, sex work environment [i.e., indoor, outdoor], violence outcome) and entered by one author and checked by others. We described the violence outcomes used by researchers to capture violence in each study and then summarized them into a standardized violence outcome for comparison purposes, by the type of violence (i.e., any or combined, physical, sexual), timescale (i.e., ever or lifetime, past year, past 6 months), and perpetrator (i.e., any or combined, workplace, intimate or nonpaying partners).

Table B (available as a supplement to this article at http://www.ajph.org ) provides the specific violence measure used in each specific study as well as the standardized outcome; Table 1 provides only the standardized outcome. The majority of “workplace” violence outcomes related to violence by clients.

The search process is described in Figure 1a (original search) and 1b (updated search) and Table A . Overall, 28 studies 37–64 with quantitative multivariable studies met our inclusion criteria and were included in the primary analysis on correlates of violence ( Table 1 ), with 14 additional studies 37,65–77 contributing violence prevalence estimates only ( Table B ).

Summary of Included Studies

The 41 peer-reviewed articles that met the inclusion criteria for assessing prevalence of violence (including the requirement that the study examine correlates of violence in bivariate or multivariable analysis) covered multiple geographic regions, with 27 from Asia (India, China, Thailand, Bangladesh, Mongolia), 6 from North America (Canada, United States, Mexico), 3 from Central and Western Europe, 2 from Central Africa (Kenya, Ethiopia), and 1 each from the Middle East, Latin America, Russia, and South Africa ( Table B ).

Overall, 27 of the studies included samples of sex workers from multiple sex work environments (e.g., homes, brothels, public places), and 12 included samples of sex workers from a single sex-work environment (6 exclusively street-based; 1 exclusively wine shop–based, where transactions with clients are brokered by wine shop patrons; 5 exclusively indoor-based); and 3 where the sex-work environment was not described. Studies were diverse according to the perpetrator (exclusively client; workplace [e.g., could include any combination of police, clients, other sex workers, the public]; any perpetrator, including nonpaying partners, police, clients, other); the type of violence (any or combined violence [could include any combination of sexual, physical, emotional], sexual violence, physical violence); and the timescale over which women were asked to estimate violent acts occurring (ever or lifetime, past year, past 6 months, past 3 months). Overall, 37 studies were of female sex workers only, with 3 studies of female and transgender (male-to-female) sex workers, and 1 study of transgender sex workers only. There were no studies of male sex workers.

The 41 peer-reviewed articles included 105 estimates of the overall prevalence of various violence measures ( Table B ). Ever or lifetime of any or combined violence by any or combined perpetrators ranged from 41% to 65% (n = 2), with no estimates for the past 6 months or past year ( Figure 2 ). Ever or lifetime of any or combined workplace violence, physical workplace violence, and sexual workplace violence ranged from 45% to 75% (n = 4; any or combined), 19% to 67% (n = 7; physical), and 14% to 54% (n = 9; sexual) and in the past year ranged from 32% to 55% (n = 3), 19% to 44% (n = 4), and 15% to 31% (n = 3), respectively ( Figure 3a ). Ever or lifetime of any or combined violence, physical violence, and sexual violence by intimate or nonpaying partners ranged from 4% to 73% (n = 3; any or combined), 57% (n = 1; physical), and 42% (n = 1; sexual) and in the past year ranged from 22% (n = 1), 15% to 61% (n = 3), and 8% to 19% (n = 3), respectively ( Figure 3b ).

Violence prevalence estimates for all included studies, including violence committed against sex workers by any or combined perpetrators.

Note . All prevalence estimates came from studies that assessed correlates of violence bivariately or multivariably; studies that included only prevalence estimates were not specifically searched for, and thus this set of studies is an underestimate of the total violence prevalence estimates available in the literature.

Violence prevalence estimates for all included studies, including (a) workplace violence committed against sex workers (i.e., violence committed within the context of sex work, such as by police, clients, pimps, madams, etc.) and (b) violence committed against sex workers by an intimate or other nonpaying partner.

Risk Contexts of Violence

In 28 studies, 47 different violence measures were examined as outcomes in multivariable analysis and had a statistically significant relationship with at least 1 covariate ( Table 1 ). Key relationships are summarized under the following 6 themes.

Legal policies and the regulation of sex work.

In 4 studies, multiple measures of policing practices (e.g,. arrest, violence, or coercion) remained independently associated with increased violence against sex workers. Police arrest is a direct measure of enforcement of criminalized laws, whereas police violence and coercion are enabled in settings where some or all aspects of sex work are criminalized. 1,78 Sex workers who had ever been arrested or imprisoned were more likely to have experienced physical violence by clients in Britain, 55 and physical or sexual violence by clients in India. 46 In Canada, previous police violence (physical or sexual), confiscation of drug paraphernalia by police, and enforced police displacement away from main areas were independently associated with experiencing violence by clients and any physical violence. 60 In India, multiple measures of police violence and coercion (police having coercive sexual activity with respondent, police accepting a bribe or gift from respondent, police taking condoms away, police raiding workplace) as well as police arrest were independently associated with increased physical or sexual violence by clients. 48 Of sex workers who experienced sexual violence in the past year in India, 6.6% reported that the main perpetrators were the police 37 ; of the total sample of sex workers in Bangladesh, 6.8% and 18.2% reported sexual violence in the past year by police and political officials, respectively, in 2000, up from 0.7% and 6.3% in 1998. 68

Importantly, 1 study in India examined exposure to a combined structural and community-led intervention, which included developing partnerships with police, police training and sensitization of sex work issues, and educating sex workers of their legal rights, alongside community empowerment. Exposure to the intervention was associated with decreased rates of violence over time by any perpetrator in the past year. 37

Work environments.

Four studies examined the role of work environment (i.e., places of solicitation and servicing clients) in promoting or reducing risk of violence against sex workers, with our review showing the highly heterogeneous and context-specific nature of work environments. In India, sex workers who worked in their homes (vs brothels, lodges, or public places) were less likely to experience sexual violence by clients. 40 In Britain, sex workers who worked outdoors versus indoors had greater than 6 times higher odds of experiencing client violence. 44 In Canada, sex workers who serviced clients in cars or public places (vs indoor settings) were more likely to experience client violence 60 ; in Russia, sex workers in street-based settings were more likely to experience sexual violence by police. 54

Economic constraints and conditions.

Economic constraints or conditions were examined in 4 studies. In China, increased economic pressure on sex workers who came from or were brought from Russia, Vietnam, Thailand, and mainland China was associated with an increase in any violence ever by clients, as measured with a client violence scale. 43 In India, currently being in debt was associated with experiencing physical violence by any perpetrator. 58 Also in India, residential instability (> 5 evictions in the past 5 years) was associated with experiencing both sexual and physical violence by any perpetrator. 57 In Canada, being homeless was associated with experiencing both sexual and physical violence by intimate or nonpaying partners. 60

Gender inequality, power, and social stigmatization of sex work.

Indirect or direct measure of gender inequality (n = 4 studies); individual, relationship, or collective power (n = 4 studies); and social stigma (n = 1 study) were considered as risks or protective factors of violence among sex workers. For example, educational attainment can be constructed as a direct structural marker of marginalization and a lack of opportunities for women. In India, sex workers who were illiterate were more likely to have experienced sexual violence by clients. 40 In China, sex workers with higher education were less likely to have ever experienced violence by clients (measured on a violence scale), and increased sexual health knowledge was positively associated with ever experiencing any or combined workplace violence. 43 In India, having a greater number of people who spoke about family violence was associated with reduced sexual violence by any or combined perpetrators, 51 and in Mexico, sex workers had a higher likelihood of experiencing violence in the past 6 months by an intimate or nonpaying partner if the participant had experienced abuse as a child. 63

Also in India, a stronger sense of power, both individual and collective (and which itself was associated with engagement with HIV programs and community mobilization activities), was associated with reduced physical or sexual violence by “more powerful groups,” 39 and sex workers who were members of a sex worker group or collective experienced significantly less violence than nonmembers. 38 In Mexico, an inverse relationship between average relationship power and violence was also observed, with a higher power score associated with a reduced likelihood of violence. 63 In Canada, client condom refusal was associated with multiple workplace and other violence measures. 60

The effects of structural stigmatization are difficult to measure quantitatively, and we found only 1 study that addressed the association between workplace stigma and violence, albeit indirectly. In India, sex workers who were initiated through a traditional practice of Devadasi were much less likely to experience sexual violence by clients in the past year compared with sex workers who entered the profession for other reasons, even after adjustment for the geographic location of work (rural vs urban) and the home-based nature of Devadasi sex-work environments, which also likely had a protective effect against violence. 40 The Devadasi practice is an ancient religious practice in which girls were dedicated, through marriage, to different deities, after which they perform various temple duties including providing sexual services to priests and patrons of the temples. Today, despite a law banning the practice, it continues, but in a different form. Women who are initiated as Devadasis engage in sex work outside the temple context and this form of sex work is socially and culturally embedded in many communities. 40

Population movement and sexual coercion of women and girls.

A study based in Macau, China (a city with a high level of involvement in the entertainment industry, known as “China’s Las Vegas”), found that both migrant Vietnamese and Thai sex workers were less likely to have ever experienced violence by clients than were migrant mainland Chinese sex workers. 43 In India, sex workers who worked in brothels and were under contract to madams or brothel owners outside their home districts (compared with those who engaged in sex work only in their home districts) were more likely to experience both physical and sexual workplace violence in the past 6 months. 50 Also in India, sex workers who were highly mobile (e.g., worked in 3 or more villages or towns in the past year) were more likely to experience both sexual and physical violence in the past 6 months, by any perpetrator 56 ; however, another study in India examined the complexity of mobility as both a risk and protective factor with multiple measures of mobility (4 or more moves in the past 2 years vs 4 or fewer moves; staying for 1 month or less at the last 2 places vs longer-term mobility; mobility to religious festivals; mobility to places frequented by seasonal male migrant workers) were associated with experiencing physical or sexual violence in the past 6 months, by any perpetrator. 59

In addition to voluntary population movement, a history of trafficking or forced labor was associated with violence against sex workers. In Thailand, sex workers who were forced or coerced into sex work (i.e., defined as “trafficked”) were more likely to have experienced sexual violence at sex work initiation and any violence or mistreatment (general, workplace, past week) compared with women who were not trafficked. 45 In India, sex workers who were forced or coerced into sex work were more likely to experience physical or sexual violence by any perpetrator 49,52 and in the first month of sex work. 62

Interpersonal, individual, and psychosocial associations.

A number of interpersonal factors were associated with experiencing violence (e.g., marital status 42,55 ). Several studies reported associations between partner-level sexual practices and violence: in India, having anal sex with 5 or more casual sexual partners in the past week was associated with sexual violence by any or combined perpetrator 61 ; in Kenya, having more sexual partners was associated with workplace sexual violence 42 ; and in Mexico, having a spouse or steady partner who had sexual intercourse with another partner was associated with any or combined violence by intimate or nonpaying partners. 63 In Russia, being raped by a client was associated with sexual violence in the past year by police. 54 Individual behavior or psychosocial factors were measured in a number of studies. In China, 5 measures used to assess psychosocial distress (i.e., depression, loneliness, and suicidal behavior as well as 2 related to drug use) were associated with ever experiencing violence by clients and intimate or nonpaying partners. 53 In Mongolia, participating in different individual behavioral interventions was associated with reduced physical and sexual violence by intimate or nonpaying partners. 41

Individual alcohol and drug use behaviors of sex workers were associated with elevated rates of violence in multiple settings, with no studies examining drug or alcohol use of violence perpetrators or clients, and only 2 studies examining drug use at the interpersonal level (e.g., concomitant sexual and drug risks in sex-work transactions). In Kenya, binge drinking was associated with sexual violence by clients, 42 and in the United States, injecting heroin and trading sexual intercourse for money or drugs at a crack house were significantly associated with any violence by clients. 47 In Russia both recent injecting and binge drinking were significantly associated with sexual violence by police, 54 and in China sex workers who used alcohol at “risky,” “heavy,” or “hazardous” drinking levels were more likely to have experienced client-perpetrated sexual violence than those who did not (12 total associations), 64 and sex workers who reported general drug use were more likely to ever have experienced violence by clients. 53

Interpersonal factors operated together with drug use to produce higher risk for violence in India: sex workers who had unprotected sexual activity with a nonspousal partner and more than 20 days of alcohol consumption in the past 30 days (vs no unprotected sex and 0 to 9 days of alcohol consumption) and sex workers with 2 or more partners with strong tendency to drink alcohol before sexual activity (vs no partners) had increased probability of sexual violence by any partner. 51 By contrast, sex workers in Britain with higher alcohol use were less likely to experience physical violence by clients. 55 Compared with the large number of studies examining individual drug use behaviors of sex workers, only 1 study examined more upstream contexts of drug use environment. In Canada, sex workers who were unable to access drug treatment had higher risk for physical violence and any violence by clients. 60

This systematic review identified consistent evidence of a high burden of violence against sex workers globally. Despite a substantial human rights and public health concern, there are major gaps in documentation of violence against sex workers in most parts of the world, with the majority of studies from Asia, and only 2 studies from Central Africa. The review reveals a growing body of research demonstrating a link between social, physical, policy, and economic factors, alongside more proximal interpersonal and individual factors (e.g., sexual and drug risk practices, psychosocial factors), and elevated rates of violence against sex workers. Results indicate the need for more methodological innovation (e.g., longitudinal studies, mixed methods, multilevel analyses) in research and intervention design and evaluation, as well as increased measurement rigor, to better document and respond to violence against sex workers.

Key Correlates of Violence Against Sex Workers

Policing practices as enforcement of laws, either lawful (e.g., arrest) or unlawful (e.g., coercion, bribes, violence) are a critical means for measuring how criminalization and regulation of sex work may have a negative impact on risks of violence against sex workers. In our review, there was consistent evidence of an independent link between policing practices (e.g., arrest, violence, coercion) and elevated rates of physical or sexual violence against sex workers. 46,48,55,60 These data support growing evidence-based calls, including World Health Organization and United Nations guidelines and Global Commission on HIV and Law, 8–10 of the critical public health and human rights need to remove criminalized laws targeting sex work (e.g., decriminalization) as a barrier to basic health, safety, and rights to protection of among sex workers.

In addition to legislative changes at national or district levels, structural policy changes through police–sex worker engagement have also been proposed. 8–10 Our review found 1 study showing the success of a combined structural and community-led intervention in a district in southern India (including engagement with police stakeholders, sensitivity training of police, and community empowerment) and associations with reduced violence experienced by sex workers over the year. Although challenges with replication of structural and community-led interventions are well-known, 79 qualitative literature suggests that sex work engagement with police may have had success in other settings in changing the environment within which sex work operates and promoting increased capacity for sex workers to safely engage in sex work and report violence to authorities. 80

In our review, we also found evidence of the role of the work environment in shaping risks for violence among sex workers, with data from 3 countries showing sex workers in street or public-place environments to be at highest risk of violence. Laws that criminalize or regulate sex-work environments (e.g., prohibitions on operating bawdy houses) shape access to indoor work environments for sex workers in many settings globally. 1 Although there is growing literature of the role of supportive indoor sex-work environments (e.g., supportive venue-based policies and practices, enhanced physical access to health services) in promoting condom use, 80–82 our review found no studies examining the more complex and nuanced nature of work environments in promoting or reducing rates of violence among sex workers. In light of important qualitative work from a number of settings, 37,80,83 there is a clear need for epidemiology to better document these structural interventions as they unfold.

Alongside known proximal risks for violence (e.g., drug use, sexual risks with intimate, nonpaying partners), our review also documented a number of more upstream factors as linked to risks of violence against sex workers, including gender and economic inequities, voluntary migration and population movement, and history of trafficking or forced labor, further supporting need for violence prevention at structural and community levels. Of note, although drug use was measured as an individual behavior among sex workers in a number of studies, no studies examined drug use of the perpetrators and few studies considered the interpersonal or partner-level nature of drug use within sex-work environments.

As epidemiology continues to better measure and document both upstream and downstream factors, there is increasing need for multicomponent structural and community-led interventions to address and respond to violence against sex workers. Only 2 studies that examined interventions were documented in this review, suggesting a major scientific gap in evaluating interventions to reduce violence against sex workers. 37,41 Because many programs and interventions happen organically (e.g., sex work–led interventions) or outside the control of science (e.g., policing policy changes), there is a critical need for more methodological innovation in evaluating interventions, in partnership with sex-work communities, including engagement with a range of stakeholders (e.g., police, clients, managers, government). Furthermore, because of the highly context-specific nature within which social, physical, policy, economic, and interpersonal factors are embedded, better dialogue between epidemiology and social sciences is a priority.

Strengths and Limitations

The cross-sectional nature of almost all of the studies available, with most based on convenience samples, limits the strength of the evidence and highlights the need for research that is of higher methodological quality. Cross-sectional studies cannot assess temporality and, thus, causality in the relationship between an explanatory variable or risk factor (e.g., being arrested) and an outcome. Some of the risk factors in the studies assessed would better be viewed as outcomes, or as being in a complex synergistic relationship with the outcome. Longitudinal studies among sex workers are rare, but critically needed to shed light on drivers of violence against sex workers, as has been done in other populations. 24 More work also needs to be done on understanding how to measure structural risk factors for violence that may operate differently on micro and macro levels. In this regard, there is a strong body of social science and qualitative literature as theoretical literature on structural interventions that can be used to help guide epidemiology. 33,79 The majority of associations were simple risk factor–outcome associations, which fail to take into account the complex interrelationships between factors that produce violence (e.g., social stigmatization of sex work, criminalization of sex work).

We identified no studies on perpetrators of violence against sex workers in this review, with all studies focusing on samples of sex workers. This lack of perspective is a substantial limitation to understanding how violence against sex workers can be mitigated and to developing effective prevention that includes both men and women. Increasing calls are being made to include clients, intimate or nonpaying partners, and third parties (e.g., police, managers) of sex workers in research and programming with sex workers, particularly with respect to HIV and other STIs. 84–86

Because we limited the search to English-language studies from North American databases, studies published elsewhere may not be included. As probability-based sampling frames of sex workers are difficult to create, it is likely that the studies we included have limited generalizability across settings. Our review only included peer-reviewed literature of epidemiological studies and excluded other potential sources of data, both peer-reviewed qualitative and social science literature and gray literature. Although such data can be useful, we chose to restrict our review to capture the highest quality peer-reviewed evidence to better inform responses to violence against sex workers. It is possible that we missed some studies that would otherwise have been eligible; this is a limitation faced by all systematic reviews. However, we attempted to address this limitation by having multiple reviewers (who each conducted independent reviews using the same method with which to search and extract data) and by contacting authors of publications to clarify if or how the study should be included and classified.

As our study’s aim was to review the correlates of violence, we did not search for or include studies that included only violence prevalence estimates without assessing correlates (i.e., we only included violence prevalence estimates that came from studies examining correlates of violence with bivariate or multivariable analysis). Thus, the violence prevalence estimates provided in this study cannot be considered a comprehensive collection and are an underestimate of the total violence prevalence estimates available in the literature. Nevertheless, results consistently showed a high prevalence of violence against sex workers in a range of settings.

Few studies examined violence by intimate or other nonpaying partners and thus we were unable to make conclusions related to prevalence or correlates of intimate or other nonpaying partner violence compared with workplace violence. We were limited from making comparisons between female sex workers and transgender or male sex workers, because of the few studies available (3 studies with a sample population that included combined female and transgender; 1 study with a sample of men who have sex with men and transgenders). As gender or sexual identity has been identified as a key factor influencing pathways of violence against sex workers in qualitative studies, 30 the lack of studies on transgender and male sex workers is a key gap in research that should be addressed in future studies. For each correlate, a limited number of studies was available to draw definitive conclusions. Moreover, we could not conduct a meta-analysis because of the range of measures of different risk factors and violence outcomes. A standardized approach to measuring and collecting data to document prevalence and correlates of violence against sex workers would help address these limitations.

Conclusions

This systematic review reveals a high burden of violence against sex workers globally, and documents existing evidence of the social, physical, policy, economic, and interpersonal correlates of violence against sex workers. The review supports increasing evidence-based calls to make violence against sex workers a public health and human rights priority on national and international policy agendas, and the urgent need for structural research and interventions to better document and respond to the contextual factors shaping violence against sex workers. These include structural changes to legal and policy environments (e.g., decriminalization, policing practices), work environments, gender and economic inequities, population movement, and stigma. In this regard, measurement and methodological innovation (e.g., longitudinal, multilevel, and mixed-methods research) and rigor, in partnership with sex-work communities, are critical.

Acknowledgments

Funding for this review was made possible through the German BACKUP Initiative, implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit project grant to the World Health Organization. This work was partially supported by a Canadian Institutes of Health Research Gender, Violence and HIV Team Grant (TVG-115616).

This systematic review was commissioned in part by the Department of Reproductive and Research of the World Health Organization. We thank Ruth Morgan Thomas and Penelope Saunders from the Network of Sex Work Projects for their leadership and support in the project.

Human Participant Protection

No ethical review was needed because this was a review of already published, secondary data.

• Open access
• Published: 14 November 2019

A qualitative study into female sex workers’ experience of stigma in the health care setting in Hong Kong

• Haixia Ma 1 &
• Alice Yuen Loke   ORCID: orcid.org/0000-0002-0676-8139 1  

International Journal for Equity in Health volume  18 , Article number:  175 ( 2019 ) Cite this article

34k Accesses

19 Citations

6 Altmetric

Metrics details

Hong Kong has gained a good reputation for its quality public health care services. However, there is a growing recognition that social stigma is a potential obstacle when female sex workers (FSWs) access health care services. There are a lack of studies focusing on how FSWs experience and cope with stigma when accessing health care services in Hong Kong.

This study aims to explore how FSWs experience stigma and develop coping strategies when accessing health care services in Hong Kong.

This is a qualitative interview study. Staff of non-governmental organizations (NGOs) that serve sex workers in Hong Kong facilitated the process of recruiting the participants. In-depth individual interviews were conducted with 22 FSWs, focusing on their experiences of stigma and coping strategies when accessing health care services. A directed content analysis approach was adopted to analyze the data.

The interview data can be grouped into three themes: experience of stigma in the health care setting; coping with the stigma of sex work; and the call for non-judgmental holistic health care.

This study contributes to an understanding of the experience of stigma and stigma coping strategies of FSWs when accessing health care services in Hong Kon g. stigma remains an important issue for a large proportion of FSWs when they seek timely professional help, openly disclose their sex work identity, and receive comprehensive health care services. The study also highlights the need to address multiple healthcare needs of FSWs beyond STDs. Moreover, the study contributes to increasing awareness of, and respect for, the human right of FSWs to receive non-discriminatory health services.

Introduction

According to the classic definition of stigma provided by Erving Goffman (1963), stigma is “an undesirable or discrediting attribute that an individual possesses, thus reducing that individual’s status in the eyes of society.” (p.3) [ 1 ]. Stigma is a process by which the member of the stigmatized group holds a devalued identity. Female sex workers (FSWs) are stigmatized and marginalized around the world. They are generally not accepted in society and are regarded as criminals, immoral troublemakers, sexual deviants, and vectors or reservoirs of disease [ 2 , 3 ]. Criminalization of sex work could further entrench the social stigma and increase FSWs’ vulnerability to violence [ 4 ].

The conceptualization of stigma and the extensive literature on the stigma of sex workers suggested that FSWs may experience multiple levels of stigma, namely social stigma, structural stigma, and self-stigma [ 5 , 6 , 7 ]. Social stigma is the attitudes and beliefs that the general public hold toward the stigmatized population [ 5 ]. Structural stigma refers to the ways institutions legitimize and perpetuate stigma [ 6 ]. For example, health care providers’ stereotypes about FSWs may result in refusal of treatment, sub-optimal care, humiliation, breach of confidentiality and privacy, and other forms of discrimination [ 8 , 9 ].

At the individual level, self-stigma refers to the stigmatized members may experience, anticipate, and internalize the social stigma and the structural stigma [ 5 ]. The experienced stigma refers to the actual occurrence of prejudice and discrimination experienced by the member of the stigmatized groups. The anticipated stigma refers to the expectations that the members of the stigmatized group may experience stigma if their stigmatized condition has been revealed [ 10 ]. The internalized stigma arises when the individuals who belong to a stigmatized group accept and internalize the society’s negative attitudes [ 5 ]. FSWs may anticipate or experience negative attitudes or rejection at the health care setting and in the community. Those who suffer from self-stigma may have low self-esteem and avoid seeking help [ 11 , 12 ]. To avoid stigma and discrimination in the health care setting, FSWs are more likely than the general population to hide private information and to set boundaries with health care providers when they need to disclose their occupation [ 11 , 12 ].

Hong Kong Special Administrative Region of the People’s Republic of China, is a city with approximately 7.5 million people [ 13 ]. It has been recognized as a leading global financial centre. Also, Hong Kong has a good reputation for its quality, efficiency, accessible, and affordable public health care services. The hospital authority provides public hospitals and related medical services. The Department of Health focuses on disease prevention and health promotion [ 14 ]. The social hygiene clinics under the Department of Health provide free services for skin diseases and sexually transmitted diseases (STDs) for its citizens [ 15 ]. Besides, a number of local non-governmental organizations (NGOs), such as the Action for Reach Out, Ziteng, JJJ Association, also offer free and confidential STDs services and/or gynecology examinations for FSWs. Moreover, people could enjoy personalized services from the private sectors if they are willing to pay for higher health care costs.

The exact number of sex workers in Hong Kong is difficult to estimate since they often work in secrecy. A local NGO for sex workers estimated the number of sex workers might range from 20,000 to 100,000 in 2001 [ 16 ]. Since there has been a dramatic increase in the number of sex workers crossing the border from mainland China into Hong Kong [ 16 , 17 , 18 ], the current number of sex workers may exceed what was estimated around two decades ago. The act of prostitution itself for Hong Kong residents is not illegal, but it is illegal under certain circumstances according to the local law, such as controling sex workers for prostitution, soliciting for immoral purpose in a public area, or living off the earning of a sex worker [ 19 ].

Despite universal health coverage, comprehensive services available at public hospitals, and free sexual and reproductive health care services offered by social hygiene clinics and numerous NGOs in Hong Kong [ 15 ], many FSWs remain reluctant to seek timely treatment [ 20 , 21 , 22 , 23 ]. A survey among 89 FSWs in Hong Kong reported that 55.1% of participants had never taken STDs tests [ 20 ]. Another study among 293 FSWs reported that 43.2% of them used illegal clinics for induced abortion [ 22 ]. A more recent survey among 340 FSWs in 2013 has found that the prevalence of HIV and STD screening test in the previous year was 44.4 and 45.0%, respectively [ 23 ]. Besides, self-medication is not uncommon among FSWs. The prevalence of self-medication estimated from 494 FSWs who had suspected STD symptoms in the previous year was 14.1% [ 24 ].

The factors affecting the uptake of health care services by sex workers have been extensively studied. A synthesis of the relevant literature suggests that multiple barriers, including those at the intrapersonal, interpersonal, institutional, community, and policy levels, could hinder sex workers from accessing health care services. Social stigma has been recognized as a key barrier that is present at different levels [ 7 ].

Although the recognition of the impact of stigma on the access of health care by FSWs has grown, there are a lack of researches focusing on how FSWs experience stigma and cope with it when accessing health care services in Hong Kong. According to the social-cognitive model, the response to self-stigma could either diminish one’s self-esteem and self-efficacy or increase one’s sense of self-empowerment [ 25 , 26 ]. Individuals who accept societal stigma as legitimate may suffer from low self-esteem. While an individual who perceived societal stigma as illegitimate may resist the stigmatized identify and bolster their empowerment [ 25 , 26 ].

This study aims to fill this gap by including the voices of FSWs in an attempt to explore how they experience stigma and develop coping strategies when accessing health care services. It should be noted that this work is not merely focused on the illness related to sex work, but also include other health conditions that require access health care services. The findings of this study could raise awareness among health care professionals of the health risks and health care needs of sex workers, and the obstacles that they encounter when accessing health care services. This will make it possible to develop appropriate intervention programs to allow sex workers and other marginalized populations to receive equal access of health care services in an environment where they feel respected.

A qualitative approach was adopted as this approach emphasized people’s lived experience and suited for health care research and stigma research [ 27 , 28 ]. This approach would allow the researcher to get rich and in-depth information of FSWs stigma experience when accessing health care services. The individual interview was considered best suited to topics that are sensitive in nature and was employed in this study [ 29 ].

Recruitment of participants and study setting

FSWs are a hard-to-reach population. Since local NGOs had established a relationship of trust with FSWs, the potential participants were recruited with the support of NGOs, including the Action for Reach Out (AFRO) and the JJJ Association. These organizations focus on the social inclusion of FSWs and assist them in dealing with health, safety, legal, and human rights issues. They also run outreach teams and are in regular contact with a number of FSWs throughout the city. One of the authors received training from NGOs and worked with them during outreach activities, campaigns, and events related to sex workers’ rights. The long-term relationship between the author and NGOs contributed to the success of recruitment.

After obtaining ethical approval for this study from the Human Subjects Ethics Sub-committee of the Hong Kong Polytechnic University (Reference Number: HSEARS20181122001), potential FSWs were recruited. Non-probability methods, such as convenience and snowball sampling, are often used to recruit hard-to-reach populations [ 30 ]. A combination of convenience and snowball sampling techniques were used to recruit FSWs in this study.

The criteria for inclusion in the study were FSWs who were: 1) over 18 years of age; 2) currently engaged in sex work, defined as having offered to perform at least one sexual service for money within the last 4 weeks; 3) able to speak Cantonese/Putonghua; and 4) able to give informed consent. Excluded from the study were: 1) those unable to speak Cantonese/Putonghua; 2) who had been diagnosed with and were currently undergoing medical or psychological treatment for a serious psychological health problem such as psychosis, bipolar disorder, and/or severe affective disorder; 3) who had self-reported current suicidal ideation and/or attempts; 4) who refused to give their informed consent to participate in the study.

A safe and comfortable environment was essential to ensure the safety for both FSWs and the interviewer. The interview took place at the office of one NGO or at one-woman brothels accompanied by an NGO staff member. Also, due to the sensitive nature of the topic, the “same-gender” interviewing was considered beneficial to build rapport between the researcher and the participants. All the interviews were conducted by a female research student who came from a postgraduate research background and had received qualitative interview training during her master of public health and doctor of philosophy programmes. The research student was a registered nurse, who had experience in providing sexual and reproductive health care services to FSWs at the local NGO, and had gained rich experience in talking with FSWs in a sensitive, open, and non-judgmental manner. Moreover, the research student had received Mental Health First Aid training in Hong Kong, and the skills that she had learnt from the course helped her to assess the mental health of the participants during the interview.

The researcher did not contact FSWs directly. Instead, staff of NGOs contacted potential participants directly via phone calls or during outreach activities, and provided them with the information sheet and the consent form of the study. They described the aims of the study, went through the information sheet, and invited FSWs to participate. Once the potential participant agreed to participate, staff of NGOs confirmed with the research student about the eligibility of the participants, the interview date, time, and venue by email or instant message (i.e., WhatsApp).

Before the interview started, the research student started the conversation casually to establish rapport with the participants. Then, the research student explained the aims of the project and checked potential participants for eligibility. She then invited those who were eligible to participate and obtained their informed consent prior to conducting the interview.

The author would disseminate the results to the participants upon their request. The participants were given options for receiving the research findings from journal papers, seminars, one-on-one meetings, and other social media (i.e. Facebook, Twitter, WeChat, or WhatsApp). Also, the two NGOs would be involved in the dissemination of the findings of the study to FSWs community and healthcare organizations.

Data collection

The semi-structured interview was used, as it is considered as a flexible tool to capture the voice and experience of the participants. This method uses a prepared interview guide, but the open-end and probing questions are flexible to allow the participants to recount their experience and even expand the original questions and responses [ 27 , 31 ].

The semi-structured interview guide was developed by the research student based on a review of the literature and on her previous experience with working and volunteering at an NGO that offers health services to FSWs. The proposed questions were further discussed with a university professor who is an expert in women’s health and a social worker from an NGO. The interview guide covered the following topics: FSWs’ health and service needs, access and experience with health care services, the attitude of health professionals, the disclosure of FSWs’ status in the health care setting, and whether they had any recommendations for better health care services (See Additional file  1 -Interview Guide). In the interviews, the interview questions were only used as a guide; the prompts were used to explore the participants’ concerns in depth.

From December 2018 to February 2019, semi-structured individual interviews were conducted with FSWs in Hong Kong. The number of the participants involved were determined by data saturation when no new data was being found from the participants [ 32 ]. The theoretical saturation was reached when 22 interviews had been completed. The interviews lasted from 42 to 124 min. The interview data were transcribed and briefly analyzed within 1 week after the holding of the interview.

All the participants provided written consent with pseudonyms. Most of the individual interviews were audio-recorded, although five participants refused to be recorded during their interviews, and handwritten notes were taken during those interviews. In addition, communication with a hearing and speech impaired FSW was conducted by writing notes on a computer. Field notes were written down to complement taudio-recordings.

Data analysis

Directed content analysis is adopted when “the existing theory or prior research exists about a phenomenon that is incomplete or would benefit from further description” (p.1281) [ 33 ]. The present study started with the previously developed conceptualization of self-stigma and aimed to explore the experience of stigma of FSWs when accessing health care services. The predetermined coding categories for stigma from the literature were: experienced, anticipated, and internalized stigma. Besides, the classification of coping behaviors has been extensively studied [ 34 , 35 ], it could be divided into two general categories: active coping and passive coping [ 34 ]. Therefore, a directed content analysis was adopted to analyze the interview data and field notes.

First, the transcriptions and field notes were read by two researchers independently without any attempts to conduct coding, to obtain an overall picture of the interview. A meaning unit is the smallest unit that contains aspects related to each other through their content and context (p.106) [ 36 ]. It could be words, phases, or sentences [ 36 , 37 ]. The meaning units related to the participants’ experiences of stigma and coping strategies were identified and highlighted, which included simple and clear phrases and sentences, such as “bad attitudes”, “I feel ashamed of myself”, “I feel stressed on the way to the clinic”, etc. After that, the meaning units were coded with the predetermined coding categories if possible. The data that could not be coded in these categories were coded with other categories and themes by adopting the inductive approach. Examples of meaning units, summarized meaning units, sub-theme and theme are presented in Table  1 . The two researchers discussed the resulting themes until they reached a consensus. Once no new concepts emerged from the data, the researchers re-examined the data and agreed upon a number of higher-order themes. Only after the themes were identified and confirmed were the quotations translated into English by the researchers for use in writing the report. The number at the end of each quote refers to the number assigned to the individual who was interviewed.

In the qualitative study, member checking is considered as a crucial technique to ensure the accuracy, credibility and validity of the results [ 38 , 39 ]. It was performed after the data analysis of the study. All the participants were invited to review the analyzed data and gave comments on the accuracy of the interpretation.

Ethical considerations

The interviews were conducted with caution and with the guidance and support of NGOs. The well-being of FSWs was the central consideration of the study, which was considered as a driver of the design of the study and the reasons for the involvement of NGOs. Staff of NGOs helped to monitor the emotional reactions of FSWs during the interview and provided psychological support to the participants if needed. FSWs were also offered the number of a crisis hotline.

To avoid being identified, the participants were required to sign the informed consent by using pseudonyms. The participants had the rights to accept or refuse audio-recording. If they refuse to be recorded, handwritten notes would be taken by the researcher and staff of NGOs during the interview, and the participants would be asked to comment on the notes after the interview.

Each participant was offered HK$400 (US$1 USD ≈ HK$7.8) as compensation for their time and willingness to share their experiences in seeking health care. To ensure the confidentiality of the participants, they were not required to give their legal name. Participation in this study was voluntary, and numerical identifiers were used to protect the participant’s identity. FSWs’ decision on whether or not to participate in the study would not affect their current or future relationship with NGOs. They would be allowed to withdraw from the study at any time without penalty.

Study population

Study participants were recruited from various settings with the assistance of NGOs. They included those who work in one-woman brothels ( n  = 18), massage parlors ( n  = 3), and those who are involved in compensated dating ( n  = 1). The participants were 30 to 59 years of age. The majority of FSWs were born in mainland China ( n  = 20), one was born in Hong Kong, and another in Vietnam. They had lived in Hong Kong from two to 20 years. Approximately half of them ( n  = 10) had received a primary school education, while the rest had received a middle school education ( n  = 12). All but one of them had had an unsuccessful marriage: two had separated from their spouse and 19 had divorced, with six of them having remarried. All but three participants had children, and 10 had had at least one induced abortion. The majority of them lived in government-subsidized public housing ( n  = 8) or in a rented apartment ( n  = 8), two lived in a private apartment, and four lived and worked in a rented one-woman brothel.

All the participants engaged in the sex industry for money and viewed sex work as a rational choice. The reasons were complex, and many factors were interrelated. The majority of the divorced women ( n  = 15) were confronted with great economic difficulties and viewed sex work as a means of survive, such as the responsibility of raising children, rent house, and live independently. Over half of the participants ( n  = 14) reported a lack of job opportunities. Nine of them complained about the low-paid labor work in the service industry, four reported limited job opportunities due to their health condition, and one could not speak the local language fluently. Besides, three participants needed to pay off the family debt. Only one sex workers worked for buying luxury goods.

The participants had been engaged in sex work for an average of 3.95 years (range 0.5–12 years), and were serving about 2 to 7 clients a day. Their monthly income ranged from HKD$4000 to HKD$100,000 (US$510–$12,800). Five of them had sources of income other than that derived from sex work.

In relation to self-protection in sex work, all except three of the participants used a condom consistently with their clients. However, two of them had had a condom slip off or removed by the client during intercourse, and 14 provided unprotected oral sex. All denied ever having engaged in anal sex.

Health conditions and accessing health care services

The participants engaged in various types of health risk behaviors, such as smoking ( n  = 10), drinking alcohol ( n  = 5), gambling ( n  = 3), being shopaholics ( n  = 2), and using illicit drugs ( n  = 1).

The participants suffered from a range of diseases. STDs were the most frequently reported forms of disease, with urethritis being the most common ( n  = 10), followed by vaginitis ( n  = 5), chlamydia ( n  = 2), syphilis ( n  = 1), hepatitis B ( n  = 1), herpes ( n  = 1), and acute pelvic inflammatory disease ( n  = 1). The participants also suffered from chronic conditions, including hyperthyroidism ( n  = 2), hypoglycemia ( n  = 2), diabetes ( n  = 1), heart disease ( n  = 1), stomach ulcers ( n  = 1), endometrial polyps ( n  = 1), headache ( n  = 1), back pain ( n  = 1), and plantar fasciitis ( n  = 1).

All but two participants had ever sought health services in the past year ( n  = 19). The most common reasons for seeking help were for HIV/STDs tests or treatments ( n  = 15), followed by an annual health check-up ( n  = 6) and for the management of chronic diseases ( n  = 3).

The participants tended to seek health care from NGOs ( n  = 10), followed by social hygiene clinics ( n  = 7) and private doctors ( n =  6). The participants had reservations about seeking health services from public hospitals in Hong Kong. Among those who sought such services, four did so when they returned to mainland China and one when she returned to Vietnam; only three were willing to do so in Hong Kong.

Themes of the study

Theme 1: experience of stigma in the health care setting.

The experience of stigma and discrimination among FSWs who accessed healthcare services varied. We found that 12 out of the 22 participants indicated that they did not experience discrimination from health care providers. Despite the long waiting time at the public health sectors, some commented favorably about the universal coverage of health care services in Hong Kong. In fact, the majority of the participants did not perceive the bad attitude of health care providers as a sign of stigma when seeking treatment. Instead, they perceived all patients were treated equally, or treated with equally bad attitudes.

By contrast, some FSWs had experienced stigmatized attitudes from health care providers when they sought treatment for their STDs. The participants believed that the stereotypes held by health care providers were that women who contracted STDs were sex workers and fallen women. They may experience, anticipate, or internalize stigma when accessing health care services.

Experienced stigma

The participants complained that health care providers, especially those from the public health sector, hold negative and discriminatory attitudes towards them. A participant described her unfortunate experience at a social hygiene clinic.

I visited a social hygiene clinic 3 years ago. The staff there probably suspected that I was a sex worker, because they were rude and spoke to me in harsh reprimanding voices. I felt humiliated. I definitely won’t go there again. (#5)

Anticipated stigma

FSWs believed health care providers held prejudiced attitudes toward sex work and STDs, and would judge them as sinful and diseased. Being worried about and anticipating or having experienced disdain from health care providers, FSWs accentuated their self-stigma when they were forced to access health care services for STDs:

I was so scared and worried about being humiliated when I first sought help for STDs. I wore a mask and big sunglasses when I visited the clinic. As soon as I had completed my medical consultation, I ran away like “a rat scampering in the street.” (#12)

Internalized stigma

The experienced stigma and the anticipated stigma could lead FSWs to internalize the prejudice, manifesting in shame, fear, and low self-esteem. The majority of FSWs felt ashamed of their occupation. They feared that their identity as a sex worker might be revealed in the process of visiting STDs clinics, and were worried about the consequence of being identified as a sex worker, such as gossip and discriminated by health care providers.

I felt ashamed of myself when I visited the social hygiene clinic. A good woman does not need to have the STDs examination. Health care providers must associate me with a sex worker and a dirty woman. They must look down on me. (#5)

FSWs believed the general public, including their “sex customers,” held prejudiced attitudes toward sex work and STDs. They would feel ashamed if they were witnessed visiting the public STDs clinic.

It would be embarrassing to bump into acquaintances at the social hygiene clinics. I won’t seek help from public health services or social hygiene clinics. (#11)

In summary, FSWs acknowledged that the sex trade and STDs were socially despised. They had experienced or anticipated stigma and discrimination in the health care setting. The perceived lack of public acceptance when they sought help at health services clinics for STDs led to a feeling of stress, fear, and shame.

Theme 2. Coping with the stigma of sex work

The participants adopted various strategies to cope with the stigma associated with sex work and STDs in the health care setting. Those who accepted the social stigma of sex work may adopt passive coping strategies, including the concealment of sex worker identity, avoidance of stigmatizing situations, and ignore the stigma. FSWs who resisted the social stigma of sex work may adopt active coping strategies, including selective disclosure of sex worker identity, justification of sex work, and seek out social support. Below is a description of the coping strategies.

Passive coping

Concealment of sex worker identity.

The majority of the participants worried that if they disclosed their sex work they would be inviting moral judgments from health care providers and gossip about their identity, leading to shame and embarrassment as well as possibly impacting the care that they would receive. Thus, the majority would attempt to protect their privacy when seeking health care services. For example:

I will lose face if I disclose my sex worker identity to the health care provider. It is an untold secret. (#1)

Some would lie about their work. For example, one participant commented:

I can be a housewife or a manager in a company. It is not necessary to tell health care workers the truth about my work when seeing a doctor. Even if I get HIV, it does not mean that I necessarily got it from my sex work. Everyone has a chance to become infected. (#13)

Sex work is a taboo in the health care setting, and most of FSWs were aware that health care providers in Hong Kong are not allowed to directly ask them this sensitive question. One FSW described how a doctor asked her about her sexual activities:

Once I went to a clinic for STDs or gynaecological diseases, and I could tell that the doctor there suspected me of engaging in sex work, but he knew that it would be offensive if he asked directly. Instead, he asked me whether or not I use a condom with my partner and whether or not I have a job. (#19)

Avoidance of stigmatizing situations

Some FSWs believed health care providers, especially those from public health sectors, held prejudiced attitudes toward sex work and STDs. To avoid situations that may result in stigma and discrimination, many FSWs preferred to use clinics operated by NGOs, where they could receive both informational and emotional support and enjoyed free condoms and sexual and reproductive health care services. They did not have to worry about disclosing their sex work to NGOs since the service was anonymous.

I would go to the local NGOs for regular STDs tests. Because it is a sex worker-friendly organization, I feel safe and be respected there. (#4)

To avoid being identified as a sex worker, some FSWs would visit a hospital of the neighbouring city or their hometown in mainland China. Moreover, they commented that the service in mainland China was more convenient and comprehensive, and they did not to feel embarrassed since they could avoid talking about STDs.

If I want to get sexual health check-up, I can go to the department of obstetrics and gynaecological of a hospital instead of STDs clinics. No one will associate me with a sex worker there. Also, I could have a full body check-up without mentioning STDs tests. (#7)

Ignore the stigma

Ignore the attitudes of health care providers was considered as an important strategy to buffer against the stress and fear when accessing health care services. Many participants built resilience and had learnt to ignore others’ perception. As one participant explained:

I understand that not everyone accept sex workers. Therefore, I pay more attention to the disease treatment than the attitudes of the health care provider. Their perception of me would not affect my life. (#3)

Active coping

Selective disclosure of sex worker identity.

FSWs would weigh the risks and benefits of revealing their identity. Sometimes, the perceived benefits of revealing the truth to receive appropriate and timely diagnostic tests and medical treatment might trigger the decision to make the disclosure.

We could receive more comprehensive and necessary diagnostic tests and treatments if we disclose our sex work at the social hygiene clinic. Besides blood tests, they also offer a saliva test and a Pap smear test. (#12)

When a serious illness such as HIV is suspected, it is better for us to disclose our sex work because it is important information that will help the doctors and nurses to decide on the diagnostic tests and treatment plan. Only if we tell the truth can we get prompt treatment. (#9)

The participants also commented on the supportive health care environment that empowered them to be open. The participants were confident about the maintenance of confidentiality in the public and private health sectors, and therefore did not see the need to conceal their identity from health care providers.

There was a gradual change in FSWs’ attitudes toward STDs services. Several FSWs admitted that they felt embarrassed and ashamed to have STDs tests when they entered into the sex industry, and were reluctant to reveal their identity to health care providers at the social hygiene clinic. Only after they became acquainted with them and had established mutual trust were they able to disclose their sex work. They observed that the attitudes of health care providers did not change after they disclosed their secret.

The attitude of health care providers in the social hygiene clinic did not change after I disclosed my sex work. The nurse was gentle when she was examining me. She also spoke softly, telling me to “Relax, relax!” (#15)

Justification of sex work

In most circumstances, FSWs resisted the stereotype that sex work were immoral or deviant. They tended to justify sex work as a personal and rational choice, and were not ashamed of engaging in it. They felt that, as divorced women, single mothers, and lacking in education and other skills, they had limited job opportunities and choices. They confided that sex work offers economic benefits, flexible work hours, and allows them to provide their family with the necessities of life. As an FSW commented:

Women engage in sex work for various reasons, many FSWs scarify their pride and dignity for their family. I need to pay for the rent, the tuition fee of my son, and the living expenses. Sex work is the only way for me to make a living and be a responsible mother. Health care providers should not judge me based on the sex work I do. (#20)

Some even suggested that their work could reduce the incidence of rape for the public good. These FSWs justified their sex work as labor they undertook to support their family and felt empowered to disclose their identity to health care providers. For example:

The attitudes of health care providers won’t upset me. I have no other choice, and I am proud that I can make a living for myself. I also think that sex workers have helped to reduce the incidence of rape and the crime rate. (#16)

The participants also emphasized that in Hong Kong, commercial sexual services between two adults was not illegal, and being an FSW was not illegal as long as one serves in a one-woman brothel and was legally resident in Hong Kong. The participants were free from the fear of being arrested even if they disclosed their work.

Seek out social support

Social support played vital role in reducing the fears and stress of FSWs. Many participants were accompanied by peers or staff of NGOs during their visit to doctors. The emotional support and the resilience of peers who against the stigma of sex work helped to reduce their psychological stress. A FSW commented:

My peers gave me great support. They encouraged me to have routine STDs tests and even accompanied me to the hospitals. This makes me feel less stressed when visiting the doctor. (#12)

In summary, the interviewed FSWs adopted various strategies to combat stigma in the health care setting. The majority of FSWs chose to hide their identity due to the fear of stigma. Those who were able to disclose their identity were empowered by their open-minded attitude towards sex work, the perceived benefits of disclosing their identity, and the perception of a supportive health care environment. Sometimes, FSWs would ignore the attitudes of health care providers or seek help from the place where they felt safe and friendly. Some FSWs tended to justify sex work and emphasize their contribution to their family and the society. Moreover, the social support they received allowed them to deal with the stress and fear when accessing health care services.

Theme 3: the call for non-judgmental holistic health care

The majority of the participants believed they would more readily access health care services if the health care team had a good understanding of the sex industry, recognized them as people, and treated them holistically with dignity. Besides sexual health, they desired comprehensive and holistic health care which could take into consideration of their multiple health care needs, such as mental disorders, diabetes, hypoglycemia, insomnia, plantar fasciitis, problem gambling, and other addictions.

“Our comprehensive health care needs should be addressed. For example, my heel is killing me, and I could not walk a long distance. However, I have no idea where to seek help. I wish someone could help me with these problems other than STDs.” (#15)

Multiple health care needs beside STDs

Due to life difficulties/traumas and the stigma associated with sex work and STDs, many participants had developed mental health problems, such as severe stress, anxiety, insomnia, and depression, and some had even attempted suicide. Several participants engaged in various types of addiction to cope with the difficulties of their life and with emotional disorders, including chain smoking, drinking alcohol, binge drinking, shopping, taking drugs, and gambling. All except one did not seek mental health care services. The one person who had visited a mental health care provider was merely told “not to think too much.” She then drank a great deal of alcohol to deal with her depression and sadness.

When I feel sad or unhappy, I will go out with friends and drown my sorrows with alcohol. (#17)

Another FSW who suffered from a gambling addiction described her emotional despair:

I am a gambler! That way I can free myself from thinking of my troubles. But once I lost a huge amount of money in a casino. I hated myself so much and attempted to commit suicide with a knife. Eventually, I called the police for help. (#15)

Expand the scope of services

FSWs with multiple health care needs made a strong call for the provision of non-judgmental holistic care. Some participants highlighted the needs for health care providers to understand the sex industry and their occupational health and safety.

Only if health care providers have a good understanding of the sex industry and our work environment would they understand our occupational risks and be more sensitive to our multiple health care needs. They would also understand our fears, sorrows, and depression beyond those related to the contraction of STDs. (#14)

Further, some FSWs spoke very favorably of the free sexual health services provided by the social hygiene clinic and NGOs, especially the non-judgmental care and outreach services provided by NGOs. However, they also highlighted that services provided by these organizations were not comprehensive enough, and they made a series of recommendation for the expansion of health care services. For example:

Sometimes, I feel depressed. But I never seek help from a health professional because I can neither afford the years-long waiting time at the public health sector nor afford the expenses in the private health sector. Since we have regular STDs screening tests at NGOs or the social hygiene clinic, it would be great if they could offer more supportive services, like psychological counselling or referral to mental health treatment. (#15)

This theme revealed that besides STDs, FSWs had multiple health care needs. They were also at risk of developing mental disorders and addictions as a result of social stigma and life difficulties. STD clinics or NGOs should take a holistic approach that considers multiple health care needs when caring for FSWs.

The study aimed to investigate the experience of stigma in the health care setting and stigma coping strategies among FSWs in Hong Kong. Generally speaking, stigma was not viewed as a concern for some FSWs unless they sought for STDs services from the public STDs clinic. The participants believed that the stereotypes held by health care providers were that women who contracted STDs were sex workers. The finding of this study is consistent with literature showing that, for FSWs, stigma is an important issue when accessing HIV/STDs health care services [ 9 , 40 , 41 ]. Despite the available, accessible, and affordable public health care services in Hong Kong [ 15 ], being a sex worker or having STDs is not socially acceptable and sometimes a significant concern for FSWs when seeking help from health care providers.

The results revealed the flexibility of FSWs in responding to the stigma of sex work and the associated STDs in the health care setting. Their choice of stigma coping strategies varied as a result of the self-perception, the perception of the occupation, the perception of STDs and the severity of the disease, the perceived risks and benefits, the complex interactions with health care providers, and the availability of social supports. This finding provides insights into FSWs’ internal dilemma, on making a decision whether or not to disclose their identity. Consistent with reports in the literature that FSWs rarely reveal their sex worker identity when seeking professional help [ 11 , 42 ], the paradox of coming out as a “sex worker” was considered as most challenging for the majority of FSWs in this study. However, holding back one’s feelings and emotions could lead to stress and subsequent physical health problems [ 43 ]. The burden of internalized stigma and perceived stigma from the public and health professionals could lead to a vicious cycle of internalized stigma, poor self-esteem, and illness.

It was quite encouraging to notice that a few participants were empowered to open themselves up to face the stigma in society. The perceived seriousness of their health condition and the potential benefits of disclosing their identity may cause them to feel a pressing need to respond to their health problems and prompt them to disclose their private information to health care providers. Such disclosure often invited more support from health care providers, such as comprehensive and timely diagnostic tests and treatments, empathetic, respectful, and non-judgmental care, and free resources and services. Meanwhile, findings from this study further indicated that the support in the health care setting facilitated FSWs’ access of health care services and the disclosure of private information. Similar findings have been reported in other countries that the disclosure of sex work could lead to increased social support and vice versa [ 44 ]. Thus, it is crucial to raise the awareness of health care providers that their support could help to end the vicious cycle of stigma and illness among FSWs. The provision of a friendly environment offering non-judgmental health services could help to mitigate the stigma felt by FSWs and encourage them to access the services. The sexual and reproductive health service provided by NGOs was considered to be friendly and sensitive, which facilitates the provision of better services and bolsters the service uptake rate.

In addition, results from the study highlight the need to address multiple health needs of FSWs. Besides STDs, FSWs also need support for other conditions, such as mental illness and addictions. However, they are facing barriers to access specialty care which could have a significant impact on their health. As many of FSWs have regular STDs check-ups, health care providers of STDs clinics and NGOs should be sensitive to the needs of FSWs and offer referral to those who need specialty care. Besides, it is suggested that a multidisciplinary team may be considered to integrate mental health services and addiction with STDs services.

Implications

The stigma of sex work and the associated STDs may influence the experience of health care services among FSWs, especially the experience of STDs services. In order to improve FSWs’ experience of health care, interventions programmes could be conducted at different levels.

At the individual level, interventions are needed to reduce FSWs’ internalized stigma According to the social identity theory [ 45 ], identity management strategies may help members of the stigmatized group cope with stigma, restore their positive social identity, and improve the self-esteem. Regarding various coping strategies FSWs may adopt, researchers are suggested to take into the perspectives of FSWs and find the fit identity management strategy with which FSWs feel comfortable. Also, self-stigma reduction interventions among people with other stigmatized conditions could be used as a reference to develop the intervention to reduce the self-stigma among the sex workers, such as psychoeducation, cognitive restructuring, and narrative intervention [ 46 , 47 ].

At the instructional level, it is crucial to raise health care providers’ awareness of the stigma or subconscious bias toward FSWs. Health care providers and students in the health care professions should participate in sensitivity-training programs. These could focus on increasing their awareness and understanding of the sex industry, increasing their knowledge about the multiple health risks and health care needs of FSWs, and improving their history-taking skills and their ability to encourage FSWs to disclose their health concerns, and instructing them on how to promote a friendly and non-judgmental medical environment. The intergroup contact theory suggested that the intergroup contact under the conditions of equal status, common goals, intergroup cooperation, and institutional support could reduce the bias and improve understanding [ 48 ]. This approach may be used to reduce stigmatized attitudes towards sex workers among health care providers.

Furthermore, communications with FSWs should not be based on the assumption that they were merely vulnerable to contracting HIV/STDs, since this study also revealed that FSWs face other work-related risks beyond STDs, such as mental illness, addictions, and other chronic diseases. Health care providers need to conduct a comprehensive assessment of all clients, using patient-centered care principles.

At the societal level, community empowerment may be used to promote a respectful environment for FSWs. The Sonagachi Project in India achieved success in reducing the social stigma toward sex workers as well as empowering sex workers [ 49 ]. It promoted the human rights, provided condoms and material resources, and created a sense of collective identity among FSWs. The local NGOs in Hong Kong could play an essential role in promoting the recognition and decriminalization of sex work, which, in turn, empower FSWs when accessing health care services. Furthermore, open discussions on the best legal framework for dealing with prostitution and protecting the human rights of prostitutes should be encouraged.

Limitations of the study

The study was conducted among a subgroup of FSWs in Hong Kong (those operating out of one-woman brothels). The findings of this study may not be applicable to other groups of FSWs. A further study should be conducted of other subgroups of FSWs, such as adolescent FSWs, sex trafficked women, migrant FSWs, or FSWs based in other venues.

Second, due to the highly sensitive nature of the topic, the possibility exists that FSWs gave socially desirable responses when describing their health, sexual activities, and health behaviors towards the utilization of health care services.

Although stigma does not affect all FSWs when accessing health care services in the study, it remains an important issue for a significant proportion of FSWs when they seek timely professional help, fully disclose their secret of being involved in sex work, and receive comprehensive health care services. Thus, stigma is still an important aspect to address. The study also contributes to the existing literature on various coping strategies that FSWs adopted in dealing with stigma in the health care setting. Findings from the study also highlight the need for understanding and addressing multiple healthcare needs of FSWs, and NGOs and the social hygiene clinic may consider expand its services to other health concerns beyond STDs. Moreover, it contributes to increasing awareness of, and respect for, the health care needs and human rights of FSWs among health care professionals and students in the health care professions.

Availability of data and materials

The datasets during and / or analysed during the current study available from the corresponding author on reasonable request.

Erving G. Stigma: notes on a spoiled identity. Jenkins: JH & Carpenter; 1963.

Google Scholar  

Durisin EM, Van der Meulen E, Bruckert C. Red Light Labour: Sex Work Regulation, Agency, and Resistance. Vancouver: UBC Press; 2018.

Poutanen MA. Beyond brutal passions: prostitution in early nineteenth-century. Montreal: McGill-Queen’s Press-MQUP; 2015.

Rekart ML. Sex-work harm reduction. Lancet. 2005;366(9503):2123–34.

Article   Google Scholar  

Corrigan PW, Watson AC. Understanding the impact of stigma on people with mental illness. World Psychiatry. 2002;1(1):16.

PubMed   PubMed Central   Google Scholar  

Corrigan PW, Lam C. Challenging the structural discrimination of psychiatric disabilities: lessons learned from the American disability community. Rehabil Educ. 2007;21(1):53-8.

Ma PH, Chan ZC, Loke AY. The socio-ecological model approach to understanding barriers and facilitators to the accessing of health services by sex workers: a systematic review. AIDS Behav. 2017;21(8):2412–38.

Rahmati-Najarkolaei F, Niknami S, Aminshokravi F, Bazargan M, Ahmadi F, Hadjizadeh E, et al. Experiences of stigma in healthcare settings among adults living with HIV in the Islamic Republic of Iran. J Int AIDS Soc. 2010;13(1):27.

Beattie TS, Bhattacharjee P, Suresh M, Isac S, Ramesh B, Moses S. Personal, interpersonal and structural challenges to accessing HIV testing, treatment and care services among female sex workers, men who have sex with men and transgenders in Karnataka state, South India. J Epidemiol Community Health. 2012;66(Suppl 2):ii42–i8.

Stangl AL, Earnshaw VA, Logie CH, van Brakel W, Simbayi LC, Barré I, et al. The health stigma and discrimination framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Med. 2019;17(1):31.

Urada LA, Simmons J. Social and structural constraints on disclosure and informed consent for HIV survey research involving female sex workers and their bar managers in the Philippines. J Empir Res Hum Res Ethics. 2014;9(1):29–40.

Hunt J, Bristowe K, Chidyamatare S, Harding R. ‘They will be afraid to touch you’: LGBTI people and sex workers’ experiences of accessing healthcare in Zimbabwe—an in-depth qualitative study. BMJ Global Health. 2017;2(2):e000168.

Census and Statistics Department. The Government of the Hong Kong Special Administrative Region. Available from: https://www.censtatd.gov.hk/hkstat/sub/so20.jsp . Accessed 11 Nov 2019.

Department of Health. Vision, mission and core values. The Government of the Hong Kong Special Administrative Region Available from: https://www.dh.gov.hk/english/aboutus/aboutus_mv/aboutus_mv.html . Accessed 11 Nov 2019.

Kong X, Yang Y, Gao J, Guan J, Liu Y, Wang R, et al. Overview of the health care system in Hong Kong and its referential significance to mainland China. J Chin Med Assoc. 2015;78(10):569–73.

Ziteng. The sex trade industry in Hong Kong: a call for activism and transformation. 2001. Available from: http://www.ziteng.org.hk/eng/the-sex-trade-industry-in-hong-kong .

Emerton R, Laidler KJ, Petersen CJ. Trafficking of mainland Chinese women into Hong Kong’s sex industry: problems of identification and response. Asia Pac J Hum Rts & L. 2007;8:35.

Cheung N. Accounting for and managing risk in sex work: a study of female sex workers in Hong Kong (Doctoral dissertation, Royal Holloway, University of London); 2012.

Hong Kong Crimes Ordinance. Cap. 200 S147 Soliciting for an immoral purpose. (1990). Available from: https://www.elegislation.gov.hk/hk/cap200 . Accessed 11 Nov 2019.

Wong WC, Gray SA, Ling DC, Holroyd EA. Patterns of health care utilization and health behaviors among street sex workers in Hong Kong. Health Policy. 2006;77(2):140–8.

Lau JT, Tsui H, Ho SP, Wong E, Yang X. Prevalence of psychological problems and relationships with condom use and HIV prevention behaviors among Chinese female sex workers in Hong Kong. AIDS Care. 2010;22(6):659–68.

Lau JT, Mui LW, Tsui H, Wong E, Ho SP. Prevalence of induced abortion and associated factors among Chinese female sex workers in Hong Kong. J Sex Marital Ther. 2007;33(1):19–29.

Wong HT, Lee KC, Chan DP. Community-based sexually transmitted infection screening and increased detection of pharyngeal and urogenital Chlamydia trachomatis and Neisseria gonorrhoeae infections in female sex workers in Hong Kong. Sex Transm Dis. 2015;42(4):185.

Center for Health Protection DoH. HARiS - HIV and AIDS response indicator survey 2015 for female sex worker. Hong Kong: Center for Health Protection, Department of Health; 2016.

Corrigan PW, Watson AC. The paradox of self-stigma and mental illness. Clin Psychol Sci Pract. 2002;9(1):35–53.

Watson AC, River LP. A social-cognitive model of personal responses to stigma; 2005.

Book   Google Scholar  

Al-Busaidi ZQ. Qualitative research and its uses in health care. Sultan Qaboos Univ Med J. 2008;8(1):11.

Weiss MG. Cultural epidemiology: an introduction and overview. Anthropol Med. 2001;8(1):5–29.

Kaplowitz MD, Hoehn JP. Do focus groups and individual interviews reveal the same information for natural resource valuation? Ecol Econ. 2001;36(2):237–47.

Faugier J, Sargeant M. Sampling hard to reach populations. J Adv Nurs. 1997;26(4):790–7.

Article   CAS   Google Scholar  

Mishler EG. Research interviewing. Context and narrative. Cambridge: Harvard University Press;1986.

Francis JJ, Johnston M, Robertson C, Glidewell L, Entwistle V, Eccles MP, et al. What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychol Health. 2010;25(10):1229–45.

Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88.

Brown GK, Nicassio PM. Development of a questionnaire for the assessment of active and passive coping strategies in chronic pain patients. PAIN®. 1987;31(1):53–64.

Folkman S, Lazarus RS. An analysis of coping in a middle-aged community sample. J Health Soc Behav. 1980:219–39.

Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–12.

Mostyn B. The content analysis of qualitative research data, a dynamic approach. The research interview, users and approaches; 1985. p. 115–45.

Lincoln YS. Naturalistic inquiry. In: The Blackwell encyclopedia of sociology; 2007.

Creswell JW, Poth CN. Qualitative inquiry and research design: choosing among five approaches: Sage Publications; 2016.

Scorgie F, Nakato D, Harper E, Richter M, Maseko S, Nare P, et al. ‘We are despised in the hospitals’: sex workers’ experiences of accessing health care in four African countries. Cult Health Sex. 2013;15(4):450–65.

Mtetwa S, Busza J, Chidiya S, Mungofa S, Cowan F. “You are wasting our drugs”: health service barriers to HIV treatment for sex workers in Zimbabwe. BMC Public Health. 2013;13(1):698.

Ndung'u CN. Barriers faced by female sex workers in seeking healthcare at public health facilities in mlolongo ward, athi-river sub-county (Doctoral dissertation, University of Nairobi); 2016.

Paxton S. The paradox of public HIV disclosure. AIDS Care. 2002;14(4):559–67.

Benoit C, Smith M, Jansson M, Magnus S, Maurice R, Flagg J, et al. Canadian sex workers weigh the costs and benefits of disclosing their occupational status to health providers. Sex Res Soc Policy. 2018;16(3):329–41.

Tajfel H, Turner JC, Austin WG, Worchel S. An integrative theory of intergroup conflict. Organizational identity: a reader; 1979. p. 56–65.

Yanos PT, Lucksted A, Drapalski AL, Roe D, Lysaker P. Interventions targeting mental health self-stigma: a review and comparison. Psychiatr Rehabil J. 2015;38(2):171.

Ma PH, Chan ZC, Loke AY. Self-stigma reduction interventions for people living with HIV/AIDS and their families: a systematic review. AIDS Behav. 2018:1–35.

Allport GW, Clark K, Pettigrew T. The nature of prejudice; 1954.

Gangopadhyay DN, Chanda M, Sarkar K, Niyogi SK, Chakraborty S, Saha MK, et al. Evaluation of sexually transmitted diseases/human immunodeficiency virus intervention programs for sex workers in Calcutta, India. Sex Transm Dis. 2005;32(11):680.

Download references

Acknowledgements

We would like to thank the action for reach out and JJJ association in data collection. We would like to thank all the women who participated in this study.

Author information

Authors and affiliations.

School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, GH 525, Hong Kong, China

Haixia Ma & Alice Yuen Loke

You can also search for this author in PubMed   Google Scholar

Contributions

All of the authors planned the study. And the first author (HM) conducted the interview. All the authors contributed to data analysis and drafting the manuscript. Both authors read and approved the final manuscript.

Corresponding author

Correspondence to Alice Yuen Loke .

Ethics declarations

Ethics approval and consent to participate.

Ethical approval for this study was obtained from the Human Subjects Ethics Sub-committee of the Hong Kong Polytechnic University (Reference Number: HSEARS20181122001). Information consent was obtained from all participants prior to their inclusion in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Additional file 1..

Qualitative interview guideline.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

Ma, H., Loke, A.Y. A qualitative study into female sex workers’ experience of stigma in the health care setting in Hong Kong. Int J Equity Health 18 , 175 (2019). https://doi.org/10.1186/s12939-019-1084-1

Download citation

Received : 11 August 2019

Accepted : 01 November 2019

Published : 14 November 2019

DOI : https://doi.org/10.1186/s12939-019-1084-1

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Female sex workers
• Accessing health services

International Journal for Equity in Health

ISSN: 1475-9276

• General enquiries: [email protected]

Advertisement

Sex Work: A Review of Recent Literature

• BOOK REVIEW ESSAY
• Published: 13 February 2009
• Volume 32 , pages 213–220, ( 2009 )

Cite this article

• AnneMarie Cesario 1 &
• Lynn Chancer 2  

746 Accesses

6 Citations

Explore all metrics

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price includes VAT (Russian Federation)

Instant access to the full article PDF.

Rent this article via DeepDyve

Institutional subscriptions

Chancer, L. (1998). Reconcilable differences: Confronting beauty, pornography, and the future of feminism . Berkeley: University of California Press.

Google Scholar  

Further Reading

Baker, T., & Simon, J. (2002). Embracing risk: The changing culture of insurance and responsibility . Chicago: University of Chicago Press.

Beck, U. (1992). Risk society: Towards a new modernity . Thousand Oaks: Sage Publications.

Bourdieu, P. (1984). Distinction: A social critique of the judgment of taste . Cambridge: Harvard University Press.

Garland, D. (2001). The culture of control: Crime and social order in contemporary society . Chicago: University of Chicago Press.

Katz, J. (1988). Seductions of crime: Moral and sensual attractions in doing evil . New York: Basic Books.

Winick, C., & Kinsie, P. M. (1971). The lively commerce: Prostitution in the United States . Chicago: Quadrangle Books.

Download references

Author information

Authors and affiliations.

Department of Sociology, The Graduate Center—City University of New York, 365 Fifth Avenue, New York, NY, 10016, USA

AnneMarie Cesario

Department of Sociology, Hunter College, 695 Park Avenue, New York, NY, 10021, USA

Lynn Chancer

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Lynn Chancer .

Rights and permissions

Reprints and permissions

About this article

Cesario, A., Chancer, L. Sex Work: A Review of Recent Literature. Qual Sociol 32 , 213–220 (2009). https://doi.org/10.1007/s11133-009-9122-8

Download citation

Published : 13 February 2009

Issue Date : June 2009

DOI : https://doi.org/10.1007/s11133-009-9122-8

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Risky Business
• Male Street
• Street Prostitution
• Crime Control Policy
• Pornographic Film
• Find a journal
• Publish with us
• Track your research

Cookies in use

Beyond the stereotypes: a deep dive into sex work.

Sex work. We all see it across tv, in the news, or maybe even on platforms like OnlyFans, but the diverse experiences of those involved in this profession are deeper and more comprehensive than you may know. Dispelling misconceptions, challenging stigmas, and promoting a perspective that recognizes the agency, rights, and well-being of sex workers is how we can ensure that we have a more holistic approach to ending health care disparities.

Navigate The Page:

Sex Work as Survival - Criminalization - Ending HIV - Support

Spectrum of Sex Work

Sex work is the exchange of sexual services for money or something of value (erotic dancing, adult film actors, BDSM workers, etc.). Individuals engage in sex work for a variety of reasons, which could include choice, circumstance, and coercion.

Sex Work As Survival

Sex work is often part of a survival economy. When society makes access to health care, education, food, water, and shelter extremely inaccessible or unaffordable to many people and families across the country, biased political leaders strategically use those barriers and the gaps they create to target marginalized communities or any group they deem as an “other.”

The criminalization of sex work is rooted in stigmatization and a sex shaming culture. Society over-polices and shames sex work under the guise of ‘ keeping the community safe, ’ but all it ultimately does is punish and dehumanize sex workers while perpetuating the existing societal structures that may have coerced or placed people in a circumstance where sex work becomes survival. This practice threatens human rights for vulnerable communities, deprives them of access to essential social, economic, and health systems, and makes it that much harder to end epidemics such as HIV, mpox, and health care disparities.

In addition to the desperation someone may feel in this situation, imagine the added burden for those who are medically dependent, such as individuals who need gender-affirming services and/or whose health and life depends on their adherence to sexual health services such as HIV treatment .

The “Legal” Targeting of Poverty

Social Determinants of Health are disproportionately impacted by current policies and legislation against sex workers. The policies affect historically marginalized identities such as LGBTQ+ communities, and have especially targeted transgender folks. These policies negate the survival economy sex workers are forced into, demonize and dehumanize them, and paint them not as people but “threats.”

Systemic Barriers that Sex Workers Face:

Criminalization:.

Legislation that encourages the policing and criminalization of sex work, such as criminalizing, loitering gives law enforcement a tool to harass and discriminate against communities.

Surveillance:

Institutions such as police departments, state legislatures, and corporate businesses, prioritize funding towards surveillance technologies that are designed specifically to increase the targeting of sex workers. This redirects public blame onto sex workers and diverts attention from the actual systemic problems that drove them there.

Incarceration:

Incarcerated, sex workers have a hard time gaining job and educational opportunities. It can also further debt, or even cause loss of life, especially during imprisonment. Ultimately, incarceration creates a cycle where sex workers lose too much access and opportunity to move from sex work to other careers and educational paths.

Lack of Safety:

Sex workers often operate in unsafe locations to avoid surveillance, debt, incarceration, and other forms of punishment -- increasing the risk of physical harm, hate crimes or even fatal assault.

Public and private entities are legally allowed to deny human rights and health care to people who are incarcerated, which negatively impacts their quality of life.

Difficulty Seeking Justice:

Fearing punishment and mockery, sex workers don’t always feel comfortable coming forward with their stories of abuse or seeking legal justice when attacked.

Shame & Stigma Prevents Ending the HIV Epidemic

Institutional punishment such as incarceration, and discriminatory policies in health care interfere with attempts to solve current health issues—such as the global HIV epidemic and the transmission of STD’s and STI’s across the country—and cause economic hardship and worsened access to health care. This hurts the ability for non-profits and health focused organizations to provide care towards ending the epidemic and dealing with public health crises, which worsens health outcomes for society as a whole.

The simple fact is that we can’t end HIV without providing support to both sex workers and their sexual partners, and the key to that is removing stigma and providing social aid. The prevalence of HIV in sex workers is 12x that of the average population . Our international goal of ending the HIV epidemic involves taking care of sex workers as an important factor in finding success. As Fannie Lou Hamer once said, “nobody’s free until everybody’s free.”

How You Can Support

See sex workers as humans.

Focusing on force, punishment, sex shaming, and excommunication from society instead of on solutions only contributes to the system of poverty and the dehumanization and fatal dangers that many sex workers face—especially, transgender women of color.

Support Decriminalization

HRC supports decriminalization legislation and the push for decriminalization of sex work across the United States. Decriminalizing sex work would allow those engaged to live without stigma, social exclusion, and fear of violence or fear of seeking justice. Removing surveillance, prosecution, and stigma from sex work would be recognizing sex work as work , and would enable society to protect sex workers and help them navigate workplace safety and health concerns. It would also open their access to additional opportunities to improve their well-being

Find Advocacy Opportunities

Below are a list of organizations that help provide life-saving resources and support to sex workers. Our partners may also be a good resource to find local advocacy opportunities in your area.

Urban Justice Center: https://swp.urbanjustice.org/

St. James Infirmary: https://www.stjamesinfirmary.org/

Asian and Migrant Sex Workers and Allies: https://www.redcanarysong.net/

Red Umbrella Fund: Sex Workers Rights: https://www.redumbrellafund.org/

Sex Workers Outreach Project USA: https://swopusa.org/

HIPS: https://www.hips.org/

Liberating LGBTQ+ People: https://www.blackandpink.org/

Read More About STAR: http://nswp.org/timeline/street-transvestite-action-revolutionaries-found-star-house

Decriminalize Sex Work (2020): DECRIMINALIZING SURVIVAL: POLICY PLATFORM AND POLLING ON THE DECRIMINALIZATION OF SEX WORK

Decriminalize Sex Work (DSW), National Nonprofit: https://decriminalizesex.work/why-decriminalization/

The Stroll (2023) - Documentary on HBO detailing the experiences of trans women who were sex workers in Lower Manhattan in the 90s

Learn & Live into Sexual Health:

Learning about sex practices is empowering and important for everyone. Take control of your sexual health by checking out our My Body, My Health initiative to find sexual health resources, services on prevention, testing, treatment options, U=U, sex positivity, local providers, and more!

Embrace Your Sexuality

We're building a generation free of HIV and stigma. Embrace sex positivity with My Body, My Health campaign. Are you in?

Related Resources

HIV & Health Equity, Health & Aging

Is PrEP Right For Me?

HIV & Health Equity, Health & Aging, Sexual Health, Recursos en Español, Reports

Healthy Sex Guide (La Guía de Sexo Más Seguro)

Workplace, Allies

Human Rights Campaign Foundation Overview

Love conquers hate., wear your pride this year..

100% of every HRC merchandise purchase fuels the fight for equality.

Choose a Location

• Connecticut
• District of Columbia
• Massachusetts
• Mississippi
• New Hampshire
• North Carolina
• North Dakota
• Pennsylvania
• Puerto Rico
• Rhode Island
• South Carolina
• South Dakota
• West Virginia

Leaving Site

You are leaving hrc.org.

By clicking "GO" below, you will be directed to a website operated by the Human Rights Campaign Foundation, an independent 501(c)(3) entity.

What It Is Like to Be a Sex Worker And whether we should approve.

Jeannette Cooperman

Editor’s note: Tracy’s surname is a pseudonym, as are her relatives’ first names.

It is the oldest profession, I say. No, someone reminds me, hunting is the oldest profession. Exactly. But if the quarry is willing, is the hunt ethical? I cannot decide. Does a woman have the right to sell her body freely and legally? Models do. Lady Gaga sells her vocal cords. LeBron James sells his height. In a world that tells us to forge a personal brand and sell ourselves, surely a woman skilled in the art of physical pleasure ought to be able to use that talent to make a living?

Those appalled by that proposition say the act is too intimate. What innocence I have left wants to agree. But all told, I suspect such a transaction is less intimate than a hopeful first date or a thorough physical exam. Certainly, it is less intimate than writing a memoir. And with criminal penalties lifted, sex work would be cleaner and safer.

I want to approve. It seems cooler, more modern and relaxed. But like abortion, this issue renders me a hypocrite: I say yes for everybody else and breathe relief that it never had to be me. There but for the grace.

Feminist scholars, it turns out, are as ambivalent as I am. Though there are plenty of trans and male sex workers, this is still a predominantly female industry, and the practice does seem to perpetuate the objectification of women. It also excuses and accommodates just about anything men do to gratify their ostensibly overwhelming sexual desires. The transaction erases the need for respect, deference, consideration, permission.

Those appalled by that proposition [of sex work] say the act is too intimate. What innocence I have left wants to agree.

I turn back and forth in the wind. Finally, I ask Tracy Shellington, a former sex worker, if she will talk to me. She is wary at first, not sure of my purpose. Nor am I. Is it prurience? Curiosity? Female solidarity? I have no agenda, I explain; I just want to know what her experience was like.

“Wow,” she says, sounding relieved but a little daunted. “It’s a lot. I did it for a long, long, long time.”

We start at the beginning.

“Silent all these years.”

Tracy’s friends walk a few paces ahead in a bubble of intimacy, whispering about her. Finally, they turn and announce rather grandly that she can come with them if she likes. There is this house on the next street where an old guy pays them to look at dirty pictures and touch him.

Relief floods her— you, too? Her uncle Billy started making her do that when she was five. He would pick her up to come play with his daughter, and Tracy would pray the whole car ride that maybe this time they really would get to play house with Ginny’s little toy kitchen. Instead, he would hurry upstairs, and in half a minute she would see him standing at the top of the steps buck naked. Sometimes she and Ginny both had to touch him. Sometimes just her. It lasted till she was nine—that was the year her aunt divorced him.

Now, though, she is much older. Fifth grade. And at least this guy is gonna pay them. “Sure,” she says brightly. “I’m in.”

They troop down to the man’s basement, him a little slower because he is missing the lower half of his leg. She tries not to stare at the waist belt that somehow holds the prosthetic calf in place. The basement goes dark, and the movie projector crackles. Naked bodies writhe on a sheet tacked to the wall. Then comes storytime: He flips through big picture books explaining what the kids are doing to each other. Afterward, he lies down and has the girls take turns touching him.

This part, Tracy is used to. The new part is that he kisses her down there. “You feel that, nasty girl?”

Weeks go by. He owes them a fortune , more than a hundred dollars! The other two girls are on free lunch and Tracy, whose mom works, is on reduced lunch. So she and her friend’s bold little sister, Deb—who has no idea what really goes on at that house—decide to go get the money.

The police officers question Tracy separately. They know , she is sure of it, so she lets the story tumble out. When they drive her home and come inside with her, she wants to die.

Nobody is home. Bored, they start ringing doorbells, then Deb sasses an irate neighbor and he calls the cops. “He owes us money!” Deb says, indignant. When the cops ask why, she shrugs and says, “We do the dishes?”

Her mom drops into a chair, crying.

“Would you like to prosecute?” one of the officers asks.

“You bet I would!”

At the station, a bland lady takes down the details. “Where did you think he was going to get all this money?” she asks. “Did he ever give you any money? Did you notice what his furniture was like?” Maybe she is trying to warn Tracy, smarten her up. But the questions only make it feel even more shameful, like she is lying.

The girls have told the police where everything is—the books, the movie reels, all the pictures, even the huge one inside his closet. Peering outside the interview room, Tracy sees officers carrying box after box down the hall.

Tracy’s father grew up in an alcoholic home and became a drugstore cowboy, robbing pharmacies for a fix. “I didn’t exactly feel like he didn’t love us,” she will say later. “He just got put away somewhere in my head where, if I see him, great, if I don’t, great.” Her grandpa taught her all the important stuff anyway—how to tie her shoes, how to ride a bike….

Unlike her mother, exhausted and martyred, and her grandmother, a proper Southern lady, Grandpa never tells Tracy to sssshhhh . He is sweet—and, she will realize years later, drunk most of the time. Out in the garage, they sit side by side listening to Jack Buck announce the Cardinals game, and Grandpa sips the “cough syrup” he hides out there, winking that this is their little secret, so Grandma will not worry about him being sick.

Tracy’s mom works days at a utility company, nights at the tavern around the corner, where the fringe benefits are free booze and the guys she brings home afterward. Come morning, she forces herself awake at sunrise and takes three buses to work. “You kids quiet down,” she is always saying, and Tracy, wide-eyed and sensitive as a fawn, understands that she is a burden.

An auto mechanic woos Tracy’s mother to Minnesota. There, he beats her and ogles Tracy’s sister. One day, the girls come home to a locked door, curtains drawn, and the new boyfriend upstairs (with, it turns out, a wealthy older man). In a white-hot rage, their mother packs them up, calls her employer in St. Louis to get her job back, and rents a U-haul.

“Forget this ,” Tracy thinks. “ My turn.” She has been used by men, and she has watched her mother be used by men, and she has picked up their little secrets, what they want and like. Now she is fifteen, with a brand-new hot figure, and she intends to play them.

She waitresses at the Lucky Dog Saloon on Broadway and drinks on the East Side, or in a little sundress on the Admiral cruise ship. When a nice guy asks her out and she says no, it feels like a Wonder Woman superpower. Invincible, she starts working the street for cash. The “girlfriend experience” pays better, but you have to dress up and smile, giggle at their jokes, let them touch you all sorts of ways, and it takes forever . She wants to be done, grab the cash, go get high. For a sex worker, she decides, faster is better.

She has been used by men, and she has watched her mother be used by men, and she has picked up their little secrets, what they want and like. Now she is fifteen, with a brand-new hot figure, and she intends to play them.

Her first pimp, Corky, sells her crack cocaine. The first time she shoots it into a vein, the euphoria takes her prisoner. In time, the track marks make it harder to work; guys will not pay as much if you are that messed up. Another worker hides the abscesses on her legs with gartered fishnet stockings.

“Get beaten for it

Drugged for it

Paid for it

Make a life of it.”

—Cassandra Troyan in Freedom & Prostitution

The stroll moves. First it is on Washington Avenue, then on Cherokee, and when that gets too hot, it shifts over to Chippewa. The strategy is to work the side streets: The tricks have to circle the block, but the cops keep their eyes trained on the main drag.

Because her mom lives on one of those side streets, Shellington has to make sure to quit before sunrise. The tricks are like vampires anyway—sunlight makes them nervous. One winter night, the sky looks like smudged charcoal, and the air is icy. What time is it? she wonders, suddenly nervous. Nights are long in winter—fewer people are out, and the whole process is slower and more cumbersome, all those heavy clothes. She walks east and sees a cop, so she ducks down a side street, and a customer spots her.

“I saw you the other day,” her mom says casually the next time they are together. “I was waiting for my bus, and I seen you get in a car, and I kept waiting for the car to go by.” She meets her daughter’s eyes. “I wondered all the way to work if that would be the last car you would ever get in.”

Another day, Shellington’s mom hands her a note and says, her voice harsh with distress, “Would you please call this guy back so he stops calling me?” Shellington has given her mom’s number to a few longtime customers—the ones she needs to keep close, because they will put a little cash on her account the next time she lands in prison. “If I hear another trick say how he just wishes you’d get off the drugs,” her mother exclaims. “It takes everything I have not to say, ‘Keep your hands off my daughter. You know damn well if she did all those things you wish she’d do, she wouldn’t be with you.’”

By now, a cop can bring Shellington in just for walking —this is called a demonstration charge—because she has a prostitution charge on her record. They do street sweeps, too, four or five guys on their walkie-talkies, and load up the paddy wagon. Some nights, social work students from Washington University wait for the women at central booking. After taking a quick survey about condom use and violence, they offer tips, like keeping a condom tucked inside your cheek or using certain defense tactics. Shellington is startled by their kindness—and what seals it is when they hand out jumbo-sized Snickers bars. Coming off the streets and off the dope, that candy bar tastes like filet mignon.

After one arrest, Shellington, now twenty-seven, tells the correctional officer she started drinking hard at fifteen.

“You don’t look old enough to drink now ,” the woman exclaims. “How on earth did you manage to order alcohol at fifteen?”

Some nights, social work students from Washington University wait for the women at central booking. After taking a quick survey about condom use and violence, they offer tips, like keeping a condom tucked inside your cheek or using certain defense tactics.

“My mother was the bartender,” Shellington tosses back, hurt that the woman does not believe her.

The look on the correctional officer’s face stings, but only for a second. She has no room left for more shame.

She is thirty-one, biding her time in an honors center, and her mom is visiting. They watch a tv crime show about somebody being molested. At the commercial break, Shellington’s mom blurts, “Why didn’t you ever tell me Billy was molesting you?”

Shellington freezes like she is nine again. “ What ?” she says, like, “ What on earth are you talking about?” Her mom looks confused, tries to ask again. Ginny, it turns out, is in therapy now. After the divorce, Billy married a woman with two daughters, and she kicked him out fast. “I bet he was molesting them, too,” Shellington’s mom says.

“Sure,” Shellington agrees. They watch the rest of the show in silence.

Another worker nicknames her “Payday,” teasing that “Tracy makes them think they are fucking kings. And then they file Chapter 13 in the morning.” She knows how to make men want her. And despite the risks, she finds sex work comfortable. There is camaraderie on the street. Roles are well-defined; everybody obeys a common code. In the larger world, she has not experienced that.

The ease can blow up fast, though. A urine test after yet another arrest indicates that she is pregnant, and she winds up in the workhouse with no prenatal care and a full-blown heroin habit. Her mother has just been diagnosed with cancer. Her child will be a ‘trick baby,’ a term she wants to spit on.

As soon as she gives birth, she is shackled to the bed again. She will have twenty-four hours with her son before the Mennonites pick him up. She nurses him for the first time, then tentatively rubs his back, and he burps. Anxious, she looks over at the correctional officer, who has kids of his own. “Sounded like a good one to me!” he reassures her. Relieved, she holds the baby close, cooing to him and patting his soft skin. He dozes. When his eyelids flutter open, he nestles at her breast. By the time someone comes to take him away, they have found their rhythm.

“Lay me down, pretend I’m real I’ll give you all the love I’m paid to feel.”

—from the song “I Can’t Go Home Again”

“John-shaming”—publishing names to discourage anyone from buying sex—seldom lasts long. In 1979, New York City mayor Ed Koch tried reading the names aloud on the radio. The John Hour lasted less than two minutes—and only aired once.

Shellington hates the practice anyway: “They’ll just want to go somewhere darker, more deserted.” Or they will stop reporting possible cases of trafficking. Right now, one of the best sources for law enforcement is the guys who call in, saying, “I’d swear she was only fifteen” or “She didn’t speak English, and she seemed scared.”

“You don’t want to hurt the families,” argued one man, adding that besides, going to a prostitute was “natural.” Who was the victim?

When police in Kennebunk, Maine, released a long list of prominent citizens charged with patronizing a prostitute, a wiseguy printed up T-shirts that read, “I’m not on the list. Are you?” Many were, and they were steaming mad at the violation of privacy. “You don’t want to hurt the families,” argued one man, adding that besides, going to a prostitute was “natural.” Who was the victim?

Because this supposedly victimless crime has to be conducted in dark alleys and cul de sacs, sex workers are easily hurt, cheated, exploited by their pimps, shamed by polite society, killed without consequence. Criminologist Steven Egger includes sex workers in his list of the “less-dead,” people whose deaths or disappearances are barely noticed. Shellington tells me she did time with a woman who “barely got away from a serial killer. They didn’t believe her ’cause she was a hooker. Down the line, he killed three or four people. My friend Erin was picked up and taken to some abandoned building and held there for a few days. She ended up figuring out who the guy was, but they ignored her because she was a prostitute. That guy went on and killed more people, too. Sam threw herself off I-44 to escape somebody she thought was going to kill her. Sandy, they found in a wooden box off I-70.”

The man parks under an I-55 overpass and takes off all her clothes—but does not even unzip his pants. He stretches Shellington’s body across the front seat, and she feels his hand tighten around one of her ankles, and her heartbeat turns staccato. Hiding any reaction, she coos, “Oh, baby!” and stretches her arm back languidly, thinking I’m only gonna have this one chance. Bringing the other leg up, she throws the door open, flips herself out backwards, and takes off running. She sees she is trapped—running straight toward a fence—so she launches herself over the barbed wire and up the hill and now she is standing stark naked on the shoulder of I-55. She thinks of Sandy, her soft body crammed in that wooden box. Then she looks back and sees the guy climbing the hill.

A cab pulls alongside her, and a man in a business suit beckons her into the back seat, asks where she would like to be dropped off, and hands her his jacket to cover herself. Nobody says much; it is quiet and calm— like he is an angel or something, she thinks.

Criminologist Steven Egger includes sex workers in his list of the “less-dead,” people whose deaths or disappearances are barely noticed.

Now she tries even harder to stay away from the dark edges of the city, especially the riverfront, where the nervous ones always want to head. One guy scares her so badly, she pulls out strands of her hair, strewing her DNA all over his car.

I force myself to imagine it: A car jerks to a stop. The window rolls down. A face, hard to see in the dark; a voice, rough or scared. You hop in, they speed off—it all has to happen so fast, too fast to assess weirdness or danger, even if you could. And then you are locked into the car—

“And you start thinking, Something’s wrong. This guy’s not right, ” Shellington says. “But you can’t freak out; you’ve got to play it cool, so they don’t know you know. If somebody’s got an icepick above your head, you’re thinking, If I make him come, is that when he’s going to start stabbing me? Or if I don’t, is that when he’ll start?

This job she dove into because she wanted control has left her vulnerable in almost every way.

“If they want to know if prostitutes are positive, they should test the Vice cops.”

—Margo St. James

Would decriminalizing sex work ease some of the danger and exploitation? Shellington shrugs. “I mean, some of it. But there would still be the underbelly.” She says she is sure there are women who freely choose this work as a profession, who were never abused or made to hate themselves, whose bodies are not whiplashed by drug cravings. “I just haven’t met them.”

Yet in a Dutch survey , sex workers cited the hours (convenient for single mothers or graduate students), autonomy, flexibility, and income. Quite a few said they enjoyed the work.

This is why I cannot decide what to think about sex work: It exists in such radically different forms, hinged to class and circumstances. I have no trouble smiling at (and envying) the skill and sensuality of a courtesan with spirited self-confidence and a thorough understanding of human nature. Even after two decades of a good marriage, I sometimes feel clumsy in bed, uncertain in technique. Imagine knowing exactly how to seduce in any situation—how to amuse, arouse, drain away tension or sadness; when to retreat into mystery; when to be bold.

I watch young cam girls who have the resources and tech savvy to pull off touch-free, virtual sex work. More power to them. They are taking revenge for centuries of objectification by flipping it: If this is all I am to you, then pay for it. A century earlier, they would have been expected to use the same wiles to marry a man with money—and cast out if they chose a bohemian poet instead.

In the Seventies, Margo St. James, a self-described prostitute and feminist activist, hosted the glitzy Hooker’s Ball in San Francisco. She used the proceeds to fund a nonprofit called COYOTE, Call Off Your Old Tired Ethics. In 1976, COYOTE filed a lawsuit against Rhode Island, questioning how much power the state should have to control the sexual activity of its citizens and pointing up the asymmetry in enforcement, with female sex workers arrested far more often than male customers.

The Swedish model reverses the equation, arresting the customers and not the workers. But that, opponents say, just drives demand underground.

So what do we do? Laws against prostitution work about as well as Prohibition did. What about legalizing it completely, as counties have in Nevada? Sex workers there like the additional health screenings and safety but hate all the barriers to entry (no prior convictions allowed) and the loss of autonomy and earning power. With legalization, it is not the customers but the state and the business owners that hold the power.

This February, Amsterdam announced that it was closing the tourist-bait brothel windows in its Red Light District and setting up an “erotic center” in the suburbs. Nearly all sex workers opposed the move, saying they would lose business and pointing out that the visibility of working in a window kept them safer. One study found far lower rates of rape, other forms of violence, and stalking for sex workers in windows than for those using a club, the client’s residence, their own residence, or a private house set up for that purpose.

When Rhode Island accidentally decriminalized prostitution in 2003, courtesy of a legal loophole, rapes against women decreased by thirty percent. The state restored criminal penalties in 2009. In 2008, the statewide total of reported rapes (which are probably a fraction of the total) was 276; ten years later, when prostitution was again a punishable crime, the total was 379.

Dr. Heather Berg, assistant professor of women, gender, and sexuality studies at Washington University, says “it’s just obvious to me that decriminalization is the only sensible solution. Policing has been a source of violence and compounded risk. Prisons are full of sexual violence. And managers and pimps like criminalization because it’s job security for them.”

Though erasing criminal penalties would not end sex work, Berg thinks “the conditions would absolutely be better. The fastest way to make sure no one is forced into sex work is not piling on laws and regulations but making sure housing, food, and health care are provided.”

They are taking revenge for centuries of objectification by flipping it: If this is all I am to you, then pay for it.

Even well-intended laws can get in the way. Frances Steele, a Wash.U. alum who is now a project coordinator for Decriminalize Sex Work, points out that in many states, possession of a condom counts as evidence in a prostitution charge—a serious disincentive for safe sex. When sex workers band together for safety’s sake, with one person managing or driving them to appointments, that person can be arrested for human trafficking. A 2019 study showed that online sex work sites had decreased the female homicide rate by seventeen percent, but now those sites have been censored, making it impossible to screen clients or compare notes with other sex workers online. Shutting down Craig’s List to thwart the trafficking of minors was a popular political move, Steele says, but “there was coded language online that law enforcement could tap into, and now they’ve actually lost a lot of leads.”

New Zealand decriminalized consensual sex work back in 2003 and saw a significant decrease in trafficking. Sixty-four percent of sex workers found it easier to refuse clients. Fifty-seven percent said police attitudes toward sex workers improved.

Those who call loudest for criminalization are often middle- and upper-class White women, Berg says, “who have a lot at stake in maintaining the nuclear family and preserving the idea that sex is special and private and should be free.” I am not sure what I have at stake, but I do prefer sex that is not transactional—or strung across the workplace like a tripwire. Many of the sex workers Berg interviewed had grown frustrated by all the unpaid objectification: “A woman who worked at Applebee’s got really sick of having to flirt with customers when, if she danced at a strip club down the street, she could make ten times more.”

Any kind of work can objectify; part of what is so explosive about sex work is that it lays that bare.

By the time I talk to Asha Malhotra, I am convinced we need to decriminalize sex work.

“Absolutely not,” she snaps. “It will just give people more of a reason to run girls. It gives them a green light, and it removes our voice.” Her dark eyes hold mine. “Feminists who believe we have equal rights have never been in a position where you have none to begin with.”

Trafficked at seventeen, Malhotra later started a nonprofit called Break Every Chain. She believes that decriminalization, like pornography, will only perpetuate the violence and misogyny written into our culture. Even cam girls do damage, she says, changing how men think about women and about sex.

When Rhode Island accidentally decriminalized prostitution in 2003, courtesy of a legal loophole, rapes against women decreased by thirty percent.

She tells me more of her story, how she was working at a strip club and struggling with substance abuse when she was “picked out” by a man who ran women the way smugglers used to run bootleg whiskey. “They use anything that can separate you from reality and let them manipulate you,” she says: bringing you drugs, pretending to love you, noticing that your beliefs waver, that you feel abandoned by your family, that your heart is broken.

At first she was desperate not just for the money but for the attention, the glamour, the escape. “That fantasy dropped away fast,” she says. “It became rape for profit. I’ve been beaten; I’ve had a gun in my mouth.” When a friend came into the strip club and saw her bruises, he gave her $100 and told her to get on a Greyhound bus. She wound up in St. Louis and never went back.

“The men were just bodies moving on me. Bits of color. They didn’t matter none. Sometimes I just felt like a needle in a jukebox. I just fell on that groove and rode in awhile. Then I’d pick the dust off and drop again.”

—Colum McCann in Let the Great World Spin

We talk a lot about men objectifying women, but to survive sex work, you have to detach. With the exception of a few affectionate regulars, clients are a blur of egos and body parts, all demanding to be sated.

I would like to think I could cut my mind loose, let it drift to a tropical island while my body went through the motions, protect the part that is me. But there is a reason we use the word “intimate.” Sex cuts closer to our core than any other physical act. It can rip away the garb and the façade, break through the boundaries, ease loneliness, soothe anxiety, restore a sense of self. Even its biochemistry is rigged to emotion, to tenderness. Oxytocin floods us after orgasm.

It takes me a while to muster the nerve to ask Shellington if she ever had orgasms on the job. “Yes, I did,” she answers, but the words have a clenched sound, no joy in them. After a pause, she says, “There was some shame. Definitely some shame. It felt kind of dirty.” Disassociating let her feel she was not really part of what was happening. Pleasure, even for a second, tore that curtain.

Purchased intimacy is an odd but widespread phenomenon. People are desperate to open themselves to someone, yet they feel ugly or perverse or ashamed, or their bodies do not work the way they want them to, or they need the confidence of paying, the assurance that they will have the upper hand, the emotional safety of a stranger, the relief of dictating what they need. Maybe they want to practice, or test a quirk of desire. To be flattered. To make someone do their bidding. To avoid vulnerability, the risk of rejection, the chance that they are inadequate. To escape the boredom or emotional fuss of an established relationship. Is this intimacy? They hunger for release, but they could manage that alone. They buy sex to not be alone, Malhotra says. “They want to be wanted.”

I give a little terrier shake, trying to clear my head. “They feel wanted even when they’re paying?”

She shrugs. “They have crappy marriages, and their wives are not respectful or kind.”

Sex workers have told Berg that sometimes this is the only place straight men can be vulnerable: “Something about the power dynamic makes them feel they can relax.”

I hate the implications of that.

“Dammit, Tracy Marie, you know better,” Shellington’s mom used to say. But it was not until she brought a trick home and found her mother lying dead in the hall that the knowledge rose up inside her. “Get out,” she screamed at him, blocking his view of her mother’s body. His eyes on her body would be sacrilege.

From that night on, Shellington worked to get sober. She won back custody of her son. She found work as a customer-service trainer. (“Transferable job skills,” she giggles.). AA was helping her believe in something bigger than herself, bigger than the booze and drugs that cut a jagged line through her family history.

At one of the meetings, a kind-voiced man asked her out.

“Look,” she warned him, “this is how it’s going to be. You’re going to hear a lot of stuff about me, and people will warn you to stay away from me.” He started to promise that he would not listen. “Please,” she said, hand on his arm, “hear me out. Let’s just say, it’s all true. And it’s not anymore.”

A year and a half later, they married.

One night, they were curled up watching Casino , and he exclaimed, “What is the matter with her?” Sharon Stone’s character was gorgeous and smart, yet she kept sneaking off to see some loser.

“She doesn’t know,” Shellington said quietly. “She doesn’t believe who she is.”

Sex workers have told Berg that sometimes this is the only place straight men can be vulnerable: “Something about the power dynamic makes them feel they can relax.” I hate the implications of that.

Since the age of five, abused by a young uncle her family doted on, Tracy Shellington has been terrified that no one would believe her. Even as she tells me her story, she often checks: “You know what I mean?” “If that makes sense?” She is testing my response.

On the surface, our childhoods were so similar—a mother on her own, a stern grandmother, a kindly grandfather going off by himself to drink beer. But my mom stayed home in the evenings, and nobody abused me, and I was shy with boys and finished school. There but for the grace.

Shellington dropped out of high school, but “in eighth grade I would have been voted ‘most likely to succeed’ by a landslide,” she says. “But that’s not how I felt . I was popular and pretty, and I did not cut myself any corners. It had to be the top or nothing at all. But I always had this fear that I was going to get found out.”

When a teacher wrote, “Tracy’s an absolute delight,” she heard, “ Do you feel that, nasty girl ?” Praise and awards seemed unreal, a stage set for a made-up play. Only the dark stuff felt true.

Now, though, the world is right side up again. She is happy in her marriage and beamingly proud of her nearly grown son. She works as a certified alcohol and drug counselor and case manager, pulling anyone she can reach away from the darkness. It is the best job she can imagine.

Another thing she says a lot? “You can live two lives.”

About The Common Reader

The Common Reader , a publication of Washington University in St. Louis, offers the best in reviews, articles and creative non-fiction engaging the essential debates and issues of our time.

The Current Issue

The word “stories” was used often at the annual NABIP Capitol Conference, held in the Hyatt Regency Capitol Hill, Washington, DC, February 25-28, 2024. I went because I have my own stories of frustration with health care, and because I am interested when someone seems ready to try to make things better in the largely incomprehensible and vaguely menacing system we all rely on.

Never see this message again.

University of Minnesota Twin Cities

University digital conservancy.

The Digital Conservancy is an online service and space that allows the University of Minnesota Libraries to continue its mission to collect, preserve, and make information accessible to students, faculty, researchers, and community members in digital formats. The UDC supports systemwide offices and programs through public access and long-term preservation of publications.

The repository accepts submissions from University affiliates for digital archiving and access. Learn more about depositing to the repository and other services to manage your data.

Voices from the Gaps

Persistent link for this community

About Voices from the Gaps

University of Minnesota professors Toni McNaron (English) and Carol Miller (American Studies and American Indian Studies) founded VG/Voices from the Gaps in 1996 to uncover, highlight, and share the works of marginalized artists, predominately women writers of color living and working in North America. The pioneering site’s focus was largely educational, aimed at a diverse audience of students in secondary schools and institutions of higher education. Created just as Internet use exploded, VG reached a global readership and cultivated a collaborative and intercommunal group of scholars, students, educators, and women artists. Students, volunteers, and VG readers submitted the majority of the site’s entries, including author biographies, book reviews, academic essays, and interviews with women artists. Additionally, the site’s creators developed a robust selection of pedagogical materials to help instructors incorporate VG resources in secondary school and undergraduate classrooms.

Hosted by the English department at the University of Minnesota – Twin Cities, VG underwent two major redesigns during its 18 years as an active website. The first in 2004 expanded the materials included in the collection, incorporating multimedia works, such as interview video/audio files. This project also expanded the scope of the collection to feature women artists regardless of genre of work, race, minority status, or geographical location. The second project three years later updated the site’s design and navigation.

VG was decommissioned as an active website in 2014; the site’s content is now hosted by the University Digital Conservancy. The transition ensures VG will still be free and accessible over time, and enhances the collection’s visibility to search engines such as Google Scholar. Users of VG are still encouraged to use site content in their personal research or in the classroom, but the site is no longer able to accept submissions for new author pages, reviews/essays, or interviews.

If you wish to explore VG/Voices from the Gaps as it existed as an active website, it is archived on the UDC’s WebArchive page ( https://wayback.archive-it.org/org-121/*/http://voices.cla.umn.edu/ ).

Navigating This Site

There are many ways to navigate the VG archives. If you know the author’s name, title of the work, time period in which the author lived, or the ethnicity with which the author identified, you may enter it into the search bar. All documents included in this site are full-text searchable, so searching for a term may yield results from several sub-collections.

If you wish to browse the collection, start with one of the sub-collections: Artist Pages, Essays & Reviews, Interviews, and Teaching Materials. These works are arranged reverse-alphabetically for the most part, and each page includes links to the authors of the document (VG volunteers, students, etc.), keywords, a link from which to download the file, and a suggested citation.

If you wish to browse more generally, we suggest beginning with the “Titles” or “Subjects” categories, found by clicking “Browse This Collection” at the top of each collection and sub-collection home page. These categories will allow you to browse alphabetically by document titles or by subject keywords. Choosing “Author” here allows you to see the author(s) of each document—not the woman writer featured in the document.

Collections in this Community

Results per page, sort options.

• Artists Pages   242
• Essays & Reviews   106
• Interviews   24
• Teaching Materials   7

Reviewed by Psychology Today Staff

Empathy is the ability to recognize, understand, and share the thoughts and feelings of another person, animal, or fictional character. Developing empathy is crucial for establishing relationships and behaving compassionately. It involves experiencing another person’s point of view, rather than just one’s own, and enables prosocial or helping behaviors that come from within, rather than being forced.

Some surveys indicate that empathy is on the decline in the United States and elsewhere, findings that motivate parents, schools, and communities to support programs that help people of all ages enhance and maintain their ability to walk in each other’s shoes.

• Developing Empathy
• Empathy in Relationships
• The Downside of Empathy

Empathy helps us cooperate with others, build friendships, make moral decisions, and intervene when we see others being bullied. Humans begin to show signs of empathy in infancy and the trait develops steadily through childhood and adolescence . Still, most people are likely to feel greater empathy for people like themselves and may feel less empathy for those outside their family, community, ethnicity , or race.

Empathy helps us connect and help others, but like other traits, it may have evolved with a selfish motive: using others as a “social antenna” to help detect danger. From an evolutionary perspective, creating a mental model of another person's intent is critical: the arrival of an interloper, for example, could be deadly, so developing sensitivity to the signals of others could be life-saving.

Babies display an understanding that people’s actions are guided by intentions and are able to act on that understanding before they are 18 months old , including trying to comfort a parent. More advanced reasoning about other people’s thoughts develops by around age 5 or 6, and research shows that parents who promote and model empathy raise more empathetic children.

Empathy, sympathy, and compassion are often used interchangeably, but they are not the same . Sympathy is feeling of concern for someone else, and a desire that they become happier or better off, while empathy involves sharing the other person’s emotions. Compassion is an empathic understanding of a person's feelings accompanied by altruism , or a desire to act on that person's behalf. 

Researchers believe people can choose to cultivate and prioritize empathy. People who spend more time with individuals different from themselves tend to adopt a more empathic outlook toward others. Other research finds that reading novels can help foster the ability to put ourselves in the minds of others. Meditation has also been shown to help cultivate brain states that increase empathy.

Some neuroscientists have advanced the concept of "mirror neurons” as a possible source of empathy . These neurons, it is theorized, enhance the capacity to display, read, and mimic emotional signals through facial expressions and other forms of  body language , enhancing empathy. But whether mirror neurons actually operate this way in humans is a subject of longstanding scientific debate, and some scientists question their very existence. 

The ability to convey support for a partner, relative, or friend is crucial to establishing positive relationships. Empathy enables us to establish rapport with another person , make them feel that they are being heard, and, through words and body language, mimic their emotions. Perspective-taking , or the empathic ability to assume the cognitive state of another person and see a problem through their eyes, can further cement a connection.

In healthy relationships, people expect their partners to empathize with them when they face hardship or personal struggles, but the ability to empathize with a partner in good times may be at least as important. In one study, displaying empathy for a partner’s positive emotions was five times more beneficial for relationship satisfaction than only empathizing with his or her negative emotions.

People high in narcissism, or who have narcissistic personality disorder , can exhibit empathy and even compassion. However, that ability only goes so far, as ultimately their own needs come first. Some researchers believe narcissists can develop greater empathy by developing greater self-compassion, which can increase their own feelings of security and self-worth and enable them to open up to hearing others.

Putting yourself in someone else’s shoes can be beneficial, but when it becomes one’s default mode of relating to others, it can blind an individual to their own needs and even make them vulnerable to those who would take advantage of them.

People who regularly put the feelings and perspectives of others above their own may experience feelings of emptiness or alienation and develop generalized anxiety or low-level depression . Psychopaths, on the other hand, are capable of empathic accuracy , or correctly inferring thoughts and feelings, but may have no experiential referent for it: a true psychopath does not feel empathy.

First responders, humanitarian aid workers, doctors, therapists, journalists, and others whose work involves opening themselves up to others’ pain tend to be highly empathic. However, they may come to share the heartbreak of those they help or whose stories they record. As such “emotional residue” accumulates, they may shut down , burn out , and become less willing or able to give of themselves.

Empaths are often characterized as being highly sensitive and overly focused on the needs of others. They may benefit from time alone, as they find it draining to be in the presence of other people. People who are very empathic are more likely to be targeted by manipulative individuals. For this reason, it is important to create healthy boundaries in all relationships, and to be cognizant of relationships with "energy vampires," who are draining to empaths and non-empaths alike.

Most parents care a lot about how their kids perform in school. Here's why social-emotional learning can be an important part of academic success.

When a parent or adolescent requests the other person change some behavior, the other’s efforts to comply may not be perceived by the requester or may be judged as inadequate.

It's dangerous to look at yourself through the narcissist’s distorted lens, but you may not realize it's skewed. It's like looking in a fun house mirror, not knowing it's warped.

There is more to good communication than using "I-statements," yet little has been written about other aspects of speaking that can help us get heard and connect.

Music with deep, reflective, romantic, and gentle attributes tends to enhance empathy.

When smart people looking at the same evidence disagree, the reason might be that they define basic concepts differently and talk past each other.

There’s a hunger for empathic leadership today in corporations, governments, medical centers, and small businesses across the globe.

Never underestimate the value of empathizing with your parents: The benefits could surprise you.

Have you ever wondered why people want to become philanthropists? What more is there to it than writing checks?

Learn 10 vital strategies for raising emotionally healthy children (as opposed to narcissists).

• Find a Therapist
• Find a Treatment Center
• Find a Psychiatrist
• Find a Support Group
• Find Online Therapy
• United States
• Brooklyn, NY
• Chicago, IL
• Houston, TX
• Los Angeles, CA
• New York, NY
• Portland, OR
• San Diego, CA
• San Francisco, CA
• Seattle, WA
• Washington, DC
• Asperger's
• Bipolar Disorder
• Chronic Pain
• Eating Disorders
• Passive Aggression
• Personality
• Goal Setting
• Positive Psychology
• Stopping Smoking
• Low Sexual Desire
• Relationships
• Child Development
• Self Tests NEW
• Therapy Center
• Diagnosis Dictionary
• Types of Therapy

At any moment, someone’s aggravating behavior or our own bad luck can set us off on an emotional spiral that threatens to derail our entire day. Here’s how we can face our triggers with less reactivity so that we can get on with our lives.

• Emotional Intelligence
• Gaslighting
• Affective Forecasting
• Neuroscience

Bureau of Educational and Cultural Affairs Exchange Programs

• Opportunities for Non-U.S. Citizens
• Opportunities for U.S. Citizens