Sex worker affirmative therapy is a model for therapists to engage with sex workers in a supportive and strengths-based way to mitigate the many impacts of distal and proximal stressors. As with any client-centered therapeutic approach, these guidelines should be tailored to the individual and their presenting problem(s) in therapy, and therefore, all guidelines may not be applicable to every sex worker client. This article is part of a published paper, Sex Worker Affirmative Therapy: Conceptualization and Case Study, which can be viewed here.
Increase sex work and worker competency
Working ethically with any marginalized population requires the therapist to be understanding of the unique cultural experiences of that population (for a review, see Chu, Leino, Pflum, & Sue, 2016). Although it is common for the therapist to ask their client about unfamiliar terms or customs that are mentioned throughout the course of treatment, the client is not responsible for educating the therapist to the point of cultural competency. The burden is on the therapist to seek out educational opportunities, training, and/or supervision to increase this competency.
Aside from the occasional sex work related presentation at an academic conference, formal educational opportunities to increase competency are rare. When seeking out such opportunities, however, be sure to be aware of the presenter’s background and their own level of competency. Important questions to have answered include: Does the presenter have a personal history of sex work? If not, have they collaborated with current or former sex workers in the creation of this presentation? If it’s a research presentation, was the study developed with the needs of current sex workers centered in its methodology? The answers to these questions will help decipher whether the presentation will enhance your understanding of sex workers and their work or perpetuate tired tropes about sex work that have historically excluded the voices of sex workers.
Beyond formal educational opportunities, many current and former sex workers, as well as academics who have worked closely with sex workers and sex workers’ rights organizations, have written books that can serve as a starting point for therapists seeking greater knowledge of the personal and professional lives of sex workers. Books such as Sex workers unite: A history of the movement from stonewall to slutwalk (Chateauvert, 2014), Thriving in sex work: Heartfelt advice for staying sane in the sex industry (Davina, 2017), Coming out like a porn star: Essays on pornography, protection, and privacy (Lee, 2015), and Sex at the margins: migration, labour markets, and the rescue industry (Agustin, 2007) all present various perspectives on the history of sex workers’ rights, the nuances of the work, and public misconceptions about sex work and sex trafficking. Additionally, informal education can be obtained by following the narratives and activism of various sex workers through their social media, articles, blogs, and podcasts. This online training for therapists is an option to start learning about engaging in therapy with sex workers.
Make connections with the sex work community
Therapists seeking to increase competency in sex worker affirmative therapy can also familiarize and align themselves with sex workers’ rights organizations. There are dozens of sex worker-led organizations throughout all six continents, including, but not limited to, the Sex Workers Outreach Project (SWOP) and its numerous local chapters across the United States, PACE Society (Canada), Sex Work Hive (UK), African Sex Workers Alliance, PROUD Nederland, and Putas Feministas (Argentina). In addition to learning from these organizations’ publications and activism, therapists can become involved in various community initiatives and projects. However, if the therapist does not have a personal history of sex work, caution must be aired in order to not overstep one’s position as an outsider within a marginalized population’s space. In such cases, and to ensure the motto “nothing about us without us” is being strictly adhered to, SWOP-Chicago has published guidelines for allies (Sex Workers Outreach Project-Chicago, 2009). Aligning oneself and volunteering with sex workers’ rights organizations will not only increase cultural competency, but also increase community trust in the therapist’s ability to be affirming.
Visibly identify as a sex worker affirming therapist
Once a therapist is culturally competent to serve the needs of sex workers, it is important for the therapist to make this information known publicly. Just as therapists who are LGBT affirming use symbols (e.g. rainbow flags, safe zone signs) and inclusivity statements in online marketing, sex worker affirming therapists need to openly communicate their competency to the sex work community through inclusivity statements on their websites and other online advertising. Although it is common for sex workers to subtly “interview” therapists on their competency prior to scheduling a first appointment, inclusivity statements make it easier for sex workers to wade through large therapist directories looking for an affirming provider.
Understand sex work experience from a client-centered approach
During the intake session(s) with a new sex worker client, it is important to not make assumptions about their sex work experiences, but to ask clinically-relevant questions to better understand the many nuances of working within the sex industry. Questions such as “What sectors of the sex industry do/have you work/worked in?” “What do you like about your job?” What do you dislike about your job?” “Is there anything about your job you think is important for me to know?” and “Is there any- thing about your job you would like to focus on in therapy?” allows the client to shape the narrative of their own experience as a current or former sex worker without the therapist assuming aspects of their job are the cause or consequence of their reasons for entering therapy. This also allows for collaborative treatment planning, where the therapist and client identify measurable goals that may or may not include their employment in the sex industry.
Therapist disclosure of sex work history
Occasionally, clients may ask therapists about their own history within the sex industry. Similar to being asked for personal information of another nature, therapists should be aware of the ethical issues and therapeutic effectiveness pertaining to self- disclosure of sex work. Overall, self-disclosure has positive therapeutic effects if the disclosure is of a similar characteristic or experience of a client’s. This has resulted in the client perceiving the therapist as more knowledgeable, trustworthy, and has increased therapeutic rapport (Watkins, 1990). Specifically within the LGB population, a therapist disclosing a gay or lesbian sexual orientation had a more positive impact on clients’ perceptions of the therapist than a disclosure of a heterosexual orientation (Borden, Lopresto, Sherman, & Lyons, 2010). Although there was a significant difference in the resultant perception, the disclosure of the dissimilar sexual orientation did not result in a negative impact, and therefore the authors suggested heterosexual therapists are still able to work affirmatively with sexual minority clients.
However, therapist self-disclosure has not been directly studied with the sex work population, and therefore it is unknown how disclosure will impact the therapeutic relationship and treatment progress. It is recommended to explore the motivations behind a client asking if the therapist has a history within the sex industry to gauge the potential impact of a particular answer. As with the ethical guidelines for any type of self-disclosure, disclosures regarding sex work should be brief, and focused on enhancing the therapeutic relationship and/or treatment progress.
Validate experiences of proximal and distal stressors
Given the demonstrated relevance of minority stress to sex workers’ mental health, it is imperative that therapists normalize the anxiety, depression, and other adverse mental health outcomes as an understandable minority stress response. In doing so, therapeutic alliance and trust are built between the therapist and client as the client begins to feel understood and accepted. Helping sex workers reframe their distress and mental health symptoms as rational and legitimate responses to societal treatment of those who sell sex may help reduce such symptoms.
Highlight sex workers’ strengths
Similar to the strengths of LGB individuals highlighted in Pachankis (2015), sex workers are a powerfully resilient group of people who cope with the challenges of stigma and discrimination in a myriad of ways, including demonstrating pride in their identity, sexual creativity, sexual openness and acceptance, social activism, community building, and community outreach. Additionally, sex workers have a plethora of entrepreneurial skills that can assist them inside and outside the sex industry (Sanders, 2004). Furthermore, sex workers understand sexual health and safer sex methods placing them in a unique position to be community sex educators (Sanders, 2006). These strengths should be validated and encouraged to address and mitigate minority stress in a safe, therapeutic environment.
Challenge internalized whorephobia
Ongoing discriminatory and prejudicial experiences explicitly and implicitly communicate to sex workers that they are deviant, deficient, inferior, or impaired. Ongoing threats of arrest, police violence, and incarceration of sex workers may exacerbate this experience for sex workers, particularly among street-based sex workers (Blankenship & Koester, 2002). These messages may be internalized and become ingrained ways that sex workers view themselves. Reworking these negative cognitions may be helpful in decreasing negative mental health symptoms. Addressing these cognitive biases as a natural defense mechanism that was once useful for the client but may no longer be serving them (and may even be doing harm) can help sex workers work through these cognitions and reduce ongoing hypervigilance. It should be noted, however, that it may not be appropriate to reduce hypervigilance for all sex workers in all contexts, especially those living in a criminalized setting in which this hypervigilance serves to keep them safe.
Explore boundary setting
Another guideline to possibly explore with sex workers in therapy is their ongoing experiences with boundary setting with clients. One paradox of the sex industry is that it can be simultaneously a positive, emotionally-gratifying experience, as well as emotionally draining. Identifying this paradox (and others that might come up in therapy) and offering tools to navigate it can be useful for sex workers in gaining clarity and making decisions—particularly decisions about which sex work clients to see and when. Sex work clients who may be more emotionally draining (e.g. those who push boundaries, ask for services not offered, etc.) could impact sex workers in different ways. Therefore, identifying ways to increase emotional capacity before and after work, as well as teaching healthy coping skills may help mitigate this stress.
Furthermore, minority stress can operate in a way that diminishes sex workers’ ability to communicate openly and assertively about their needs and boundaries, largely due to fear of rejection. The predominant societal narrative assumes sex workers are victims and are pathological for engaging in sex work, and these false assumptions may become internalized, which undermine an individual’s ability to articulate their needs relationally. Assertiveness skills training may help sex workers foster their strengths and learn to ask for their relational needs to be met.
Develop a sex worker support network
Assisting clients in the development of a support network can be helpful as these relationships may foster positive physical and mental health outcomes by decreasing social isolation. Sex workers who engage in selective disclosure regarding their work report greater access to social support and sex workers who conceal their work from their support system report feeling lonely and socially isolated (Koken, 2012). Therefore, stigma coping strategies have a significant impact on social relationships and access to social support. As minority stress can give sex workers an ongoing feeling of exclusion from society, they may also struggle to develop close relationships and form strong communities, which can result in increased risk of physical violence and less safe sexual practices (Choudhury, Erausquin, Park, & Anglade, 2015; Hail- Jares et al., 2015). It is important for therapists to assist sex work clients in approach- ing these challenging situations and help them form supportive relationships within (and outside of) the sex work community.
Manage institutional oppression through harm reduction
Due to stigmatization and criminalization, sex workers are at an increased risk of a host of negative health outcomes (primarily due to barriers to care and support services), including sexually transmitted infections (STIs), violence, homelessness, and substance abuse (Ahmad, 2001; Blankenship & Koester, 2002; Morton et al., 2002; Rio, 1991). For therapists not utilizing sex worker affirmative therapy, it may be tempting for the therapist to suggest to their client to quit sex work in order to reduce the risk of harmful outcomes. However, this ignores the myriad of reasons why someone sells sex, and suggesting to stop may not be practical or even the healthiest option for the client. Therefore, it is recommended therapists adopt a harm reduction philosophy when implementing interventions.
Harm reduction strategies have been successful with mitigating the harmful effects of substance use (for a review see Hunt, 2003), and can be applied to selling sexual services. Following general principles of harm reduction (pragmatism, humane values, focus on harms, balancing costs and benefits, and priority of immediate goals; Beirness, Jesseman, Notarandrea, & Perron, 2008), therapists can assist sex working clients reduce the likelihood of violence and negative health outcomes. According to Rekart (2005), there are numerous harm reduction interventions for sex workers, including fostering peer education, accessing sexual health prevention and treatment services, physical safety precautions, and assertiveness communication with clients.
Much like substance use harm reduction interventions, therapists may question the ethics of facilitating, assisting, or suggesting behaviors that may be illegal. However, as noted in Pauly, Goldstone, McCall, Gold, and Payne (2007), harm reduction can align with ethical principles for the helping professions. For psychologists, social workers, marriage and family therapists, and mental health counselors, this may include non-maleficence, justice, and respect for the client’s personal dignity, rights, and autonomy.
Foster bodily awareness
Emotional numbing and avoidance are often considered to be maladaptive coping strategies. However, setting emotional boundaries and emotionally distancing oneself from one’s work can be engaged in a healthy way. As Pachankis (2015) discusses, emotional numbing, excessive worrying, and lack of behavioral assertiveness may be related to minority stress. Working through these issues within the safety of the therapeutic relationship can help reduce adverse symptoms and increase self-awareness for sex workers.
Teach and affirm healthy dating and sexuality
Sex workers may internalize negative stereotypes about themselves that they are “undateable,” shameful, undesirable, and/or incapable of forming loving relationships due to their work. These ideas may prevent individuals from engaging in sexual behavior or forming intimate relationships outside of their work, which can be distressing for some. Examining the communication styles and role sexual expression plays in the lives of sex workers can help them to explore other types of healthy expressions of sexuality and relationships. Supporting sex workers who are dating and forming new intimate relationships may benefit from conversations about when to “come out” as a sex worker and to whom to come out. Exploring sex work boundaries and how they may be different than dating boundaries is a useful starting point, as every sex worker has different boundaries and different experiences in “coming out” to others about their work.
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