Sex Work and Stigma: A Historical Medical Approach

Toby Baratta (2017) is a student at Grinnell College majoring in Computer Science and Political Science with a concentration in Statistics. She loves data analysis, accessible technology, queer life, intersectional feminism, and cats. 

Protesters in France hold up signs that say "Sex Workers Unite!" and hold a large banner that say "SEXWORKERS RIGHTS = HUMAN RIGHTS".
Protestors in France protest for sex workers rights – Image found through youtube under a Creative Commons License at http://bit.ly/27HvMor

Sex work has been a popular conversation lately in the news and pop media. There have been talks about decriminalization, legalization, and about sex workers’ rights. There are the stereotypes of the woman in red, or the woman on the side of the road calling down a john in their car, and there are the ideas of the olden day brothels – perhaps popularized by Game of Thrones’ depictions. There are the students just trying to make ends meet in New York City, and popular debates in liberal culture about how best to help sex workers. There have even been discussions about sexual health and prostitution last year with the movement to end condoms being used as evidence of prostitutions  (which lead to sex workers not carrying condoms, and engaging in less safe activities).  The movement to consider sex work, as just that – work, has gained strength across the US and in other countries as well.

However, there has not been a lot of discussion regarding the medical and historical side of sex work, and how these two sides intersect. Healthcare of sex workers has evolved moderately over time, but overall care of sex workers reflects society’s view of women and women’s health.  When talking about sex work, we must be nuanced in our discussions and note that sex work is not going anywhere – it has always existed, will continue to exist, and is a legitimate career path for some people. When reflecting historically, we must remember that history tells the story of the powerful.  History of sex work usually has focused on cis-women, frankly because that is the history that was recorded, usually through the media or the Johns’ experiences, not the experience of actual sex workers. Discussion regarding their existence needs to take into consideration trans women, men, and all individuals who choose or do not choose to practice sex work. The conversation needs to be nuanced to include everyone affected – particularly those considerably disenfranchised, like trans women of color.

So, to look at how sex workers were treated through the historical narratives that we do have, we need a baseline for how women were treated overall with respect to personhood and to sex. There are different narratives of women throughout history that are at play; for some, women were not expected to be sexual—to the point where being sexual was seen as a problem, or a medical condition in itself. “Defining the absence of sexual desire in women as normal, doctors came to see its presence as disease. […] Sexual appetite was a male quality (to be properly channeled of course). If a woman showed it, she resembled a man.” [1] For some women, marriage in itself was seen as prostitution because they were forced to exchange sex for goods; in this case, they traded sex for the benefits of being married within a society that did not view women as people.

However, other narratives reflect that sex must be pleasurable for both partners (assuming cis-heterosexual penetrative intercourse), in which case women must experience pleasure from sex as well. Overall, this kind of shows that it wasn’t really decided how women should be – but even those that did feel that women should not be passionate, blamed women when men described sex as not being pleasurable enough because of a lack of passion. The double standard of female behavior that still stands today stood back then too. Too prude, too crude, too in between. Women, when looked at through men’s eyes, have to be everything at once.

a zoomed in photo of a door with the description "this is not a brothel. there are no prostitutes at this address".
A sign found on a house in SoHo, found with a Creative Commons License at http://bit.ly/1TrIiks

Moving onto sex work as a profession and how it is seen through history and medicalized, we need a definition of what sex work is and what those health risks include, whether as assumed risks of the job or not considered at all.

“Sex work is an occupation or trade involving exchange of sexual services for economic compensation. Although health problems associated with prostitution, such as sexually transmitted diseases and violence, are commonly assumed to be “risks of the trade,” the illegality and stigma of prostitution have prevented the medical establishment from viewing it through the lens of occupational safety and health. They have also resulted in a failure to look at such day-to-day conditions and illnesses as repetitive stress injuries and other musculoskeletal problems, bladder infections, and work-related stress that may be of more immediate concern to sex workers.” [2]

The health-related problems of sex work are not caused by moral questions, but are intensified by criminalization and public antipathy towards sex workers. [4]

There are three main ways of talking about sex workers and sex work overall – containment, culpability, and contagion. Containment argues that the sex industry is a necessary evil, but necessary because it protects the virtue of well-to-do women. The concern here is not to stop sex work, but to contain it to a certain area of town, and certain lower-class women. Culpability has two contrasting conceptions of the moral agency of sex workers – they are either knowing and culpable actors or entirely morally incompetent, and thus cannot be blamed for their actions. The former is more dominant in the early twentieth century reports overall. Last, contagion argues that sex work causes physical ruin to men and women (partners included) through shame. The historical truth of this was seen through looking at STI transmission, though moral and physical diseases were both included with contagion.

Oftentimes we talk about culpability and the evils of sex workers – stealing men from their homes and teaching boys “dirty things”! Throughout history, we see the pleas of newspapers to clean up the streets from sex workers and the idea that sex workers are dirty or sluts. Frankly, the stigma has changed very little over time, even with the sex positive movements[5] However, this stigma is based on the environment and accommodating of different standards over time for how women should behave or be sexual, if at all.

I looked at historical analysis in San Francisco, Vancouver, Austin, St. Paul, Mexico City, and the United Kingdom about their reactions and health care for sex workers overall. Some trends were seen – such that the majority of sex workers have never discussed their work with their medical providers (or any medical providers). [6] They also talked about domestic violence being extremely prevalent, and that the crackdown and criminalization made it more dangerous for sex workers to keep control of a situation, or assess a scenario before getting involved with a John. [7] The more statistical analyses have also shown that decriminalization is the most effective way of helping sex workers when compared to legalization and criminalization. [8] Why is this not legal then? There’s a high cost – well, a high political cost. When looking back at St. Paul in the 19th century, they separated criminalization, decriminalization, and legalization into a table discussing the cost. Criminalization had a low cost politically or morally and was simplest to enforce. Legalization had too high of a moral cost, due to the image and stigma associated to sex work. Decriminalization, however, was frankly too literally expensive due to organizational and structural change that would need to be done to stop the need or desire for sex workers, but also make it safe for those who choose sex work. Sex workers are not a voting populous who politicians really care about and caring about them may be costly for the care of family values. It’s an easy attack point for adversaries with very little pay-off politically. [9]

A white sign on a stick that states: "Feminism NEEDS sex workers NEED feminism" , where both need/needs are in red.
A sign implying the dual relationship between feminism and sex work. Image found on Flickr through a Creative Commons License, at http://bit.ly/25dxj6I.

When speaking historically about prostitution, we hear the voices of commentators on the morality of sex work and how to save the poor, easily influenced and seduced men. When speaking currently, we hear similar perspectives – but more focusing on consent, as well as legalization. However, many of the voices that are heard are upper-class white women in academia; not sex workers. That much hasn’t really changed, except in more radical feminism.  Overall – the conversation has stayed the same, but evolved in terms of how we treat women generally. The conversation needs to be broader and needs to talk about more aspects of health than just STIs.

We also need to take a look at our past and see what we can learn from it – free testing for sex workers, understanding that sex work is not something that is going away, and realizing that morals have nothing to do with it when it affects people’s daily lives.  We also need to look at what the research is telling us – “a program of social and legal reform based on a decriminalization policy will provide the most effective and the most appropriate means of combatting the negative aspects of contemporary prostitution.” [8] We have to look at who is being the most affected by our laws – and reexamine our goals when setting policy, particularly health care policy. Who is included? Who is ignored? How does this affect our society as a whole?

Endnotes:

[1] Carl N. Degler. “What ought to be and what was: Women’s sexuality in the nineteenth century.” The American historical review 79, no. 5 (1974): 1467-1490.

[2] Priscilla Alexander. “Sex work and health: A question of safety in the workplace.” J Am Med Womens Assoc 53, no. 2 (1998): 77-82.

[3] Ibid.; Tracy M. Clements “Prostitution and the American health care system: Denying access to a group of women in need.” Berkeley Women’s LJ 11 (1996): 49.

[4] Ibid.; Nikki Jeal and Chris Salisbury. “Protecting the health of sex workers: will the real agenda please stand up.” Postgraduate medical journal 89, no. 1053 (2013): 369-370.

[5] Helga Kristín Hallgrímsdóttir, Rachel Phillips, Cecilia Benoit, and Kevin Walby. “Sporting girls, streetwalkers, and inmates of houses of ill repute: Media narratives and the historical mutability of prostitution stigmas.” Sociological Perspectives 51, no. 1 (2008): 119-138.

[6] Deb Cohan, Alexandra Lutnick, Peter Davidson, Charles Cloniger, Antje Herlyn, Johanna Breyer, Cynthia Cobaugh, Daniel Wilson, and Jeffrey Klausner. “Sex Worker Health: San Francisco Style.” Sexually transmitted infections 82, no. 5 (2006): 418-422.

[7] David C. Humphrey “Prostitution and Public Policy in Austin, Texas, 1870-1915.” The Southwestern Historical Quarterly 86, no. 4 (1983): 473-516.

[8] Frances M. Shaver”Prostitution: A critical analysis of three policy approaches.” Canadian Public Policy/Analyse de Politiques (1985): 493-503.

[9] Joel Best. “Controlling vice: Regulating brothel prostitution in St. Paul, 1865-1883.” (1998).

Read More:

Baker, Lynda M., Feleta L. Wilson, and Amy L. Winebarger. “An exploratory study of the health  problems, stigmatization, life satisfaction, and literacy skills of urban, street-level sex workers.” Women & Health 39, no. 2 (2004): 83-96.

Escobar, Laura Maria. “Progressive care: An examination of male to female transgender sex workers’ experiences within the health care and social service systems in San Francisco, California.” (2007).

Levy, Jay. “Criminalising the purchase of sex: lessons from Sweden.” (2014).