Book review: Essential clinical care for sex workers: A sex-positive handbook for mental health practitioners

by Theodore R. Burnes PhD and Jamilla M. Dawson LMFT

ISBN:9781623276808

Reviewed by William Pattengill

Whether or not you expect to be providing psychotherapy or counselling services to sex workers, I believe this book is still worth our attention because of how it challenges us to re-examine our personal and professional attitudes toward not only sex work (since 1978 the preferred term for prostitution, street walking, etc.) but sexuality itself.

Although the authors are writing specifically about the U.S., the issues presented may be more pronounced in Ireland due to the robust historical influence of the Catholic Church. The authors introduce the terms “erotophobia”, “whoreophobia” and “sex-negative” to describe the sociocultural prejudices against any non-procreative sexual activity, to which they attribute the chronic avoidance of social services by sex workers, including mental health counselling. Many of the sex workers interviewed claim that their would-be therapists often reveal that same prejudice and unintentionally drive them away.

In researching for a local perspective, I found that there are reportedly only two sex workers operating in Ireland for every 10,000 citizens (ProCon.org, n.d.). I suspect this may not be very accurate for at least two reasons: one is the need for privacy in the face of the pervasive social stigma and legal issues, and the other is the recent proliferation of virtual and remote sex work opportunities that may have given a boost to those numbers as well as providing a greater shield of anonymity. By comparison, the figures reported for the U.S. are 31 and for Russia 200 per 10,000 (ProCon.org, n.d.).

Another example of the attitudes under review by the authors is what they call the “whoreocracy”, the hierarchy that sex workers have been boxed into based on their working environments and numbers of clients. Those who work “in-house” such as escorts and “massage parlour” staff, whose higher prices require fewer clients per week, are seen as superior to those “on the street”, to those who need to hide their true identities, and at the low end, those trading sex for drugs. The industry has changed radically with the advent of digital media, obscuring the aforementioned status markers, and affording a greater level of safety and privacy for providers of video and phone sex.

Nevertheless, it is still a profession with a higher level of danger than most, despite the Irish government’s best intentions. We are currently operating under what is called the Nordic system, which in 2017 superseded the 1993 law that prohibited both the provision of sexual services and the sale of/payment for sex. Things Nordic tend to have a progressive and humane connotation, but in this case, legalising the sale of sex but criminalising the purchase has unintended downsides. A structural error was to conflate domestic sex workers with illegally imported “trafficked” workers, treating both as exploited victims, which might be only partially accurate. Though offering sex for sale is technically legal, there are many easy ways to fall afoul of the law in the process.

A second downside was the prohibition of “brothels” which by definition are any place where two or more sex workers are doing business, including a shared apartment. The result of this is the loss of safety in numbers and oversight provided by shared accommodations, and the requirement that sex workers be alone with clients creates the potential for physical endangerment. Meanwhile, the Gardaí have shown their own tendencies to disapprove of sex work by assaulting one in five workers, according to a report of a study by the University of Limerick and funded by the Department of Justice (Raleigh, 2022). Furthermore, the Amnesty International Report of 2022/2023 states that “. . .the disregard shown for the safety of sex workers (in Ireland) through continued criminalisation of aspects of sex work places the workers at a high risk of abuse and violence including rape, and are less able to trust Gardaí” (Amnesty International, 2023). The criminalised “aspects” in question are “brothels,” and the payments for sex, both of which force sex workers to be alone with clients and thus out of range of any protection that might be afforded by law enforcement.

We can see that there are many reasons why a sex worker might seek out counselling or other support, but there are equally plentiful reasons why they are reluctant to avail themselves of that resource. The authors begin their book with an account of these obstacles that have grown out of old prejudices and lack of education. They maintain that there is an enduring misconception that people (mostly women) either enter the field due to a troubled or traumatic childhood, or are traumatised by the work itself. The other aspect of this belief is that the sex worker is always wishing for a way out and would prefer any other lifestyle. The presence of these misconceptions in the mental health profession is all too apparent to many potential sex worker clients, resulting in the clients being seen as victims when they may conversely feel empowered and fulfilled by their work and less like the stereotypical wayward soul in need of salvation.

Therapists working under the above misconceptions may focus on sex work itself as the source of whatever malaise the client is experiencing, missing the presence of underlying stressors such as the occupational hazards of stigma, harassment, or threats of violence, as well as basic family, economic, or health concerns. The authors invite the reader to review their own feelings about this type of work and attitudes about what constitutes “healthy” or acceptable sexual activity. Lack of graduate-level sex education and the retention of old conservative “family values” may hinder clinicians in their attempts to meet the needs of the contemporary sex worker, as outdated stereotypes of “fallen women” may still be present. This situation has not been helped by what the authors see as historically faulty research methods used for studies of sex workers’ mental health even in recent years, contaminated by “erotophobia”, “sex-negativity”, and patriarchal attitudes.

Current economic conditions provide an increased incentive for younger people to consider sex work as a viable primary or secondary source of income: higher costs of housing, education and resulting student loans, the relative safety and anonymity of virtual/remote work, and the increase in popularity of online porn. This is the new reality, whereas it once was believed that drug and/or alcohol addiction or low self-esteem were the main contributing factors. However, the stressors that often arise, and the perceived lack of mental health options, can result in those same harmful behaviours.

The book includes some sociological exploration of how sex work in the U.S. is impacted by critical race theory, feminism, and white male privilege, and it appears that those issues may also be present in this country. Searching the internet to get a sense of the resources available to Ireland’s sex worker community, I found a far different picture than what the authors were painting in their Essential clinical care project, with its references to empowerment and fulfilment. Most of the advocacy groups and support services here seem to be based on the belief that their service users are exploited, downtrodden, and desperate to escape dependence on selling their bodies. That may be due to the high percentage of undocumented and trafficked foreigners who have been coerced into the trade against their will or better judgement, with few other options for survival.

The only available statistics I found, which again may be currently inaccurate, claimed that only six per cent of our sex workers were Irish citizens, and only eight per cent were registered with a GP. Of the remaining great majority, about one third were listed as Brazilian, and another third as Roma, and most of the emigrants reported difficulty with the English language (UCD, 2021). There are many organisations tasked with providing services to this diverse community, and most are concerned with findings ways for their clients to transition out of sex work in order to save their physical and emotional health. This reality was corroborated by a recent study conducted by the University College of Dublin, the Sexual Exploitation Research Project and Womens’ Health Services, entitled “Confronting the Harm”. From my reading of the preface to the study, the concept of an empowered and fulfilled sex worker was nowhere to be found.

Possibly the authors of Essential Clinical Care are idealising their American subjects’ potential for fulfillment in pursuit of a feminist ideal. The wide range of support services available to sex workers in the U.S. might imply acceptance or at least tolerance of sex work, but the authors do not acknowledge the gathering gloom of recent trends threatening many of the freedoms that once defined progressive American culture, such as legal restrictions to abortion access and banning books from school libraries.

Nevertheless, their recommendations for clinical care are appropriate for workers on both sides of the Atlantic, administered with a heavy dose of “Woke” awareness with a capital W. The authors introduce us to the types of sex work that may be encountered, a historical perspective of its place in mental health practice, the need for self-examination of one’s own attitudes toward the subject, a guide to assessment, conceptualising treatment, and clinical interventions and process. The use of vignettes of personal and professional experiences brings theory into clearer focus. Their hope is that readers will come away with the tools that equip them to “reframe and shift our understanding” of the whole phenomenon of sex-for-pay, and to become “change makers” in our professional and social communities. Having shed our ingrained prejudices, we can become advocates for sex workers by confronting “whoreophobic” comments or attitudes among our colleagues, supervisees, friends, and family members. Most of all, in their own practices, therapists can begin to correct the harm done to sex workers by their profession.

These concluding remarks seem better suited to a society where sex workers can hope for a life of “empowerment and fulfilment” in their careers and receive the same benefit from therapy as other members of the community, with their clinicians able to refrain from blaming their work for most of their problems. At present, the current work environment in Ireland seems to provide little opportunity for much of the hopes described above to come to fruition, so the authors’ calls for increased awareness, tolerance, and support are even more urgent.

William Pattengill is a member of the editorial board and an occasional contributor to Inside Out. After retiring from the home renovation business, he has enjoyed the opportunity to return to his roots as a journalist.

References

Amnesty International (2023) Amnesty International Report 2022 https://www.amnesty.ie/annual-report-2022/

BeyondExploitation (n.d.) https://www.beyondexploitation.ie

ProCon.org (n.d.) How many prostitutes are there in the United States and other countries? https:// prostitution.procon.org/questions/how-many-prostitutes-are-in-the-united-states-and- the-rest-of-the-world/

Raleigh, David (2022, Aug. 25). One in five sex workers sexually exploited by Gardai, report finds BreakingNews.ie https://www.breakingnews.ie/ireland/sex-worker-face-discriminatory-behaviour-from-Gardai- report-finds-1354712.html

UCD (2021) Confronting the harm - Ireland. https://www.ucd.ie/geary/static/publications/Confronting_ the_Harm.pdf

IAHIP 2023 - INSIDE OUT 100 - Summer 2023