– An evaluation of possible health interventions

Introduction

Globally, by 2020, mental health and substance use disorders will be a greater cause of disability than all other physical diseases (SAMHSA, 2016). This also affects members of society that are at higher risk of developing such restricting health conditions due to the environments they live and work in. Generally, post traumatic stress disorder (PTSD) is widely associated with post-war veterans, however, there exist other social targets groups that appear to be more primed for developing such disorder. In this essay, I want to focus on prostitutes and sex workers who tend to suffer from ill mental health due to their employment. According to the American Psychiatric Association, the exposure to violence through sex work can cause symptoms of PTSD, including the traumatic stressors that are listed in the DSM-IV criterion of the diagnosis of PTSD (American Psychiatric Association, 1994).

The WHO targets issues regarding the sex worker’s physical health, namely their proneness for sexually transmitted diseases, including HIV. However, the mental health of sex workers is widely suffering from their occupation as prostitutes and causes for mental disorders such as PTSD. The insufficient acknowledgement and stigmatization of mental disorders follows a dangerous trend of increase in the modern world. By means of writing this essay, it is my aim to raise more awareness about the prevalent issue faced by many individuals who do not receive appropriate – if any – treatment. Furthermore, I want to reveal unknown truths about the mental health regarding prostitution and show that not only their physical well-being needs to be addressed through health interventions. Subsequently, I will not only explain the deeper correlations between prostitution and PTSD but I will also generate possible intervention strategies that might contribute to solving the presented issues.

Factors causing the problem

Prostitution is sexual violence. While it is widely and almost universally existent and practiced (Jenness, 1990), it remains far from uncritical acceptance as a platform for male and female sexual expression. Going along with stigmatization and discrimination towards prostitutes, their occupation as sex workers can have serious impacts not only on their physical health, but also on their mental health. Physically, individuals employed in the sex industry are more likely to get infected with sexually transmittable diseases and are therefore primed for HIV infections (12%) (Baral et al., 2012), among others. This prevalence may also be modified by drug use and thus, unsafe injection methods leading to HIV infections. Their vulnerability toward STDs also expresses possible conditions of helplessness and anxiety, contributing to the development of serious mental disorders such as general anxiety disorder, phobias or posttraumatic stress disorder.

Other contextual factors such as poverty must be regarded as cofounders. The problems described in this article have highly complex origins and cannot be simplified without risking to misunderstand the issue and draw false conclusions. An individual’s personal history and prior life events may contribute to possible risk factors for physical as well as mental health disorders, however, certain factors appear to be found in the majority of patients. As mentioned before, poverty can potentially increase levels of dependency, financial desperation and eventually lead to prostitution. By means of invading the sex workers’ human rights, their conditions of worth are severely impacted and lowered, causing low levels of self-esteem, perceptions of worthlessness and leading toward conditions of depression. High levels of dependency also contribute to these effects and force many to remain in exploiting working conditions within the sex industry. These dependencies can involve financial components and dept, economic reliance, the lack of other job opportunities due to insufficient educational standards, oppression or human trafficking.

The concept of prostitution underlies evolutionary mechanisms, biological features and is another reflection of men’s greater desire for casual sex (Symons, 1979). As data suggests, prostitution is existent in societies across the world, explicitly in every society that has been studied in depth. The variety of such societies ranges from tribes such as the Azande in Africa to the Zuni in North America (Burley & Symanski, 1981). Statistics show that the numbers of prostitutes may vary country-dependent, however, they do exist in large quantities. While data in the US suggests an amount between 100,000 and 500,000, there are more than 130,000 prostitutes to be found in Tokyo , 230,000 in Poland and 80,000 in Addis Ababa in Ethiopia. In Germany, there are 50,000 legally registered prostitutes and triple that number working illegally (Buss, 2014). In all these locations mentioned above, men appear to be the dominating customers.

Symptoms and Severity of PTSD

The term PTSD describes a collection of symptoms experienced by affected individuals due to “overwhelming, frightening, or horrifying life experiences” (Ditmore, 2006). In order to generate a universal basis for diagnosis, psychotherapeutic institutions determined certain disorder-characteristics and symptoms within the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). The symptoms responding to the condition of PTSD refer to the following clusters: “re-experiencing the trauma through intrusive memories, dreams and flashbacks; physical and mental distress in response to reminders of the event; avoidance of thoughts, feelings, and reminders of the trauma; loss of interest in activities; a general numbing of feelings; feelings of estrangement from others; and persistent symptoms of increased bodily arousal manifested in sleep problems, irritability, and anger, concentration problems, hypervigilance, and exaggerated startle responses” (Ditmore, 2006 ). This form of mental disorder can significantly inhibit an individual’s ability to take an active part in society, fulfill their role within a social framework as well as lower one’s quality of life.

As researchers suggest, approximately two thirds of prostitutes suffer from PTSD-related conditions (Farley et al., 2003). This ratio is to be compared with the severity of PTSD among war veterans (Weathers et al., 1993). Most commonly, this disorder is associated as a frequent syndrome observed in such war service survivors, who experienced traumatic events when being on guard. Through triggers like images and sounds, individuals with PTSD often find themselves in a state of shock, unable to appropriately react toward environmental changes, social interactions and circumstantial situations. In such situations, affected patients often fail to identify the environment as harmless but rather perceive their surroundings a threatening, feeling as if they are put back in their state of helplessness, which was experienced in the original traumatizing event. Other symptoms are expressed depression, anxiety, irritability, insomnia, flashbacks as well as nightmares (summarized in Table 1).

TABLE 1

Symptoms of post-traumatic stress disorder (PTSD)

Criteria for diagnosis of PTSD:

Symptoms must last longer than three months Symptoms cause great distress Symptoms disrupt work or private life

__________________________________________________________________________________

Reliving the event (also called re-experiencing symptoms) Nightmares Flashbacks Triggers Avoiding situations that remind of the event Eg. Avoiding crowds, driving cars etc. Negative changes in beliefs and feelings Affecting relationships Repression of traumatic memories Inability to discuss traumatic events Issues to trust Feeling keyed up (also called hyperarousal) Sleep issues Concentration issues Noise distraction

These events may occur soon after a traumatic event has happened, however, in some cases it might take several months or even years until first symptoms are shown. Furthermore, these symptoms may vary in severity over time, ranging from becoming increasingly worse or gradually improving. The official advice given by the National Center for PTSD is to contact a health professional in case some or all of these symptoms occur after having witnessed a traumatic event (U.S Department of Veterans Affairs, 2015).

Correlation sex work and developing PTSD

A study found that sex work appears to be significantly correlated with the prevalence of PTSD. The researchers in this study have interviewed almost five hundred prostitutes from different origin, namely The United States, South Africa, Thailand, Turkey and lastly, Zambia. The results show generally coinciding findings, such as PTSD being common among sex-related work.

The study further investigated whether prostitution can be regarded simply as a job or if it needs to be considered a “violation of human rights” (Farley, 1998). It is suggested that intended violent events such as experienced in war, rape, incest, torture prostitution are indicators of the severity of one’s traumatic disorder. Through the distribution of questionnaires to 475 participants of the study – including women, men and transgendered individuals who practice as sex workers – “current and lifetime history of physical and sexual violence” could be investigated (Farley, 1998). The findings of the study show a strong correlation between physical and psychological abuse and the development of mental disorders, namely PTSD. Furthermore, the researchers of the study state that “violence marked the lives of these prostituted people”, causing for severe symptoms of PTSD across different sociocultural backgrounds. Regarding the fact that different countries were chosen for the research target, it is important to mention that themes such as abuse and violence are consistent in their findings. “Across countries, 73 percent [of the victims/prostitutes] reported physical assault in prostitution, 62 percent reported having been raped since entering prostitution, 67 percent met criteria for a diagnosis of PTSD” (Farley, 1998).

Correlation violence, prostitution and PTSD

Another study investigated the relation between the development of PTSD and prior experienced forms of violence among prostitutes. Within this research, one hundred and thirty prostitutes who are based in San Francisco were surveyed and stated which form of violence they have witnessed. Among these 130 participants, 75% were female, 13% were male and the remaining 12% were transgendered. Farley and Barkan found that 57% had been “sexually assaulted as children”, while 49% were “physically assaulted as children” (Barkan & Farley, 1998). Additionally, the results showed that among these interviewed individuals who were now working in the sex industry as adults, “82% had been physically assaulted, 83% had been threatened with a weapon” and “68% had been raped while working as prostitutes” (Barkan & Farley, 1998). A total of 84% had also stated to have lived in homelessness, either currently or in the past. Furthermore, 50% of the interviewed prostitutes indicated to suffer from physical health issues, namely joint pain (14%), cardiovascular symptoms (12%), liver disorders (11%), reproductive system issues (10%), respiratory symptoms (9%) and other neurological symptoms (9%). Only 8% stated to be infected with HIV. Respectively, “a drug abuse problem was reported by 75% of the respondents and an alcohol abuse problem by 17%”. In addition, 5% mentioned suicidal tendencies.

To analyse this gathered data, the researchers distinguished between different lifetime violence and considered the following categories: childhood sexual assault, childhood physical abuse, rape in prostitution and other physical assault in prostitution. As presented in their findings, “PTSD severity was significantly associated with the total number of types of lifetime violence (r = .21, p = 0.2), with childhood physical abuse (t = 2.97, p = .004), rape in adult prostitution (t = 2.77, p = 0.1) ” as well as the “total number of times raped in prostitution (chi square = 13.51, p = .01) (Barkan & Farley, 1998). These findings suggest that the development of PTSD is strongly associated with the execution of sex work, namely prostitution. Out of the amount of people who were surveyed for this research, 68% could be diagnosed with PTSD according to the diagnostic criteria collected in the DSM III-R. Moreover, 88% of the participants of the study expressed their desire to end their working commitment.

In summary, these results generated by two independent studies show that there seems to be an observable and significant link between working as a prostitute and suffering from PTSD. Not only are sex workers more prone to get infected with sexually transmitted diseases, but they are also at a significantly higher risk of developing mental health disorders, namely due to traumatic experience and often resulting in PTSD-symptoms. It appears to be essential to target this issue when aiming to improve the working conditions for sex workers, not only acknowledging their physical troubles with STDs.

Factor adjustments and Intervention strategies

To discuss possible strategies to tackle the poor mental state across many prostitutes worldwide, I want to mention several steps that need to be taken in order to establish feasible, cost-effective and relevant intervention strategies.

First of all, the issue of the relatively high prevalence of PTSD among prostitutes needs to be acknowledged. Rather than primarily focusing on preventive care and curative treatment for physical health states such as HIV infections and other communicable sexual health diseases, medical professionals and responsible institutions need to address the detection and effective treatment of mental disorders among sex workers, such as PTSD. Target institutions for this purpose are for instance the WHO – primarily health-related issues – and Amnesty International – primarily human rights-related issues. Through the evaluation of listed criteria in the DSM-IV, the target group can be reliably diagnosed and subsequently, referred to treatment programmes.

Second of all, more research needs to be conducted on the basis of correlating mental disorders and prostitution. Although the above mentioned studies have found significant results that effectively reveal the severity of this matter, it is important to gather more data and information about this issue, leading to a broader and more profound understanding of how different agents, factors, events and dynamics cofound and influence each other.

As already mentioned, prostitution is a highly complex societal issue that rests deep within human history and has existed in ancient cultures, societies and traditions. The circumstances under which an individual works in prostitution – voluntarily or involuntarily – are not simple to resolve, thus the problem cannot be addressed on a superficial basis. For the same reason, there are no single-root causes or solutions to be found. In order to reduce the suffering experienced by many in the field, it seems necessary to understand the origins and core of the problem. This involves early prevention from physical and mental abuse such as violence and rape, as well as drug and alcohol addiction. The target group of preventive education and care should especially focus on the youth and children but also reach out to individuals who are already active within the sex industry. Having experienced any form of violence and being linked to substance abuse are risk factors that potentially cause individuals to enter prostitution. Other factors such as poverty and resulting human trafficking are also to be taken into account.

Furthermore, prostitution should no longer witness forms of belittlement, as it represents a violation of universal human rights. Public Health Institutions such the WHO and Amnesty International have failed to recognise this issue and define prostitution as a working occupation rather than a human rights abuse. It is important to realise that legalization of prostitution are not sufficient measures in order to effectively protect those who are affected by health issues of physical or mental kind. This is due to the victim’s dependence upon a source of income, which, in many cases, can primarily be generated through sexual services. For example, one victim described her occupation as “domestic violence taken to an extreme” (Leone, 2001), while another claims: “what rape is for others, is normal for us” (Farley et al., in press). Prostitution, as an existent part of modern but also ancient societies, has become a widely tolerated phenomenon. However, it is not willingly broad up and openly discussed but rather discarded as a hidden, societal by-product. Labelling it “sex work” rather than prostitution or, in a more radical manner, “paid sexual abuse”, tends to trivialize the harm it poses towards those who are working in this department. Its institutionalization and social toleration do not contribute to improving the frame conditions and fail to reduce the occurrence of degrading, offending and violent events that happen on a daily basis, worldwide, affecting the physical and mental health of millions of prostitutes.

Instead of leaving individuals to their assumed destiny within the vicious cycle of prostitution, disease, abuse and substance addiction, they should be offered other health-promoting alternatives that enable them to pursue different career paths. Many of those affected end up working in the sex industry due to a lack of other opportunities that satisfy their needs. By means of generating supporting educational programmes and further education, prostitutes should be able to leave their harmful and traumatic environments in order to recover from their disorder(s) and disease(s). Additionally, many of those affected are not aware of their mental health disorder and should be adequately equipped with sufficient information in order to approach institutions suitable for the treatment of their conditions.

Possible arising disadvantages are that prostitutes might not be open for treatment and fail to take their conditions as serious. Furthermore, it may be very difficult for them to accumulate enough strength and willpower to break through the cycle of drug abuse and addiction, as well as to leave the facility they are working in. Often, they find themselves trapped in organised crime structures and cannot escape their oppressors by own means. In order to reduce the burden of limited freedom and forced labour, it is essential to provide prostitutes with external psychological and medical support. This could be achieved through organisations who send out groups that will reach out to prostitutes in their natural working environments and there, distribute the necessary information about whom to contact etc.

Additionally, the targets’ health belief model might not return the output needed to eventually take action and turn behavioral intentions into factual behavior changes. Individual perceptions of the perceived severity of medical conditions – in this case PTSD – might therefore not be sufficient in order to actively invest efforts.

Furthermore, it may be difficult to gather the required resources, equipment and budget in order to realize such intervention measures. Working within the community and seeking help from already existing, well-established facilities will contribute to facilitating this process.

Solutions and concrete health interventions

Regarding prostitution as a highly complex societal issue, its mere abolishment is not possible.Therefore, root causes need to be detected and confronted. Institutions and organizations who are generating support need to assist not only with protection facilities and materials such as condoms and contraception, but also need to address possible ways to exit prostitution. This includes housing facilities, career advice and job trainings. Root causes are, among others, sex inequality, racism, poverty, sex tourism as well as the globalizing process. Both domestic and international human trafficking greatly influence the implication and bandwidth of human rights violations.

Furthermore, statistical assumptions of consensual prostitution need to be adapted to the factual situation: The majority of people working in prostitution is lacking a range of other economically profit-yielding options and therefore cannot autonomously and responsibly decide for a different career path. In fact, the prevalence of homelessness (75%) and the request to escape the sex industry (89%) display the opposition between the necessity to satisfy existential needs and the absence of promising alternatives (Farley et al., 2003). Other important factors that play arole in guarding a prostitutes physical and mental health are the creation of physical safety, power equalization and the offering of realistic alternatives.

Another aspect that needs to be addressed is the comorbidity that influences the diagnosis of each case. When suffering from PTSD, it is possible that other conditions such as anxiety disorder, mood disorder, depression, acute suicidality as well as substance abuse are present. For this reason, multiple disciplines need to be combined and health facilities need to cooperate to generate effective treatment measures. This involves mental health clinics, public health institutions, substance abuse clinics as well as shelters.

These goals of improving sex workers’ health environments can only be achieved through broad approaches that make use of all existent facilities and resources regarding both domain-general and domain-specific interventions.

Conclusion

The positive correlation between prostitution and PTSD appears evident. While mental disorders among prostitutes remain an under acknowledged issue, the prevalence of PTSD calls for action and can be targeted through a wide set of health interventions, including preventive care, educational manifestations, improving the access to health care, providing medical treatment and planning future oriented aiding programmes such as job trainings. However, the initial causes for the existence of prostitution and therefore its global spread can not be directly targeted. Complex factors such as poverty, criminal violence and lack of economic power are difficult to tackle, yet form the underlying causes and lead to systemic issues. By means of specifically targeting the immediate causes and modifying the exposure risks, the spread of PTSD among prostitutes can be effectively reduced.

When dealing with individual cases, it becomes clearer that it is critical to apply generalizing models, however, certain trends of motivation and nature of the sex workers’ agencies are observable. In an online blog, one paradigmatic victim has written down experienced trauma and has found emotional relief in confronting PTSD and prostitution. There, she writes about her childhood and abusive events, as well as her entry in the sex industry. In one part of her blog she states the following:

– “Prostitution is a trap, and simply having exited is not enough to stay safe. The mental trauma it causes serves to make women who have survived it incredibly vulnerable to going back – not because we want to (you can hear the johns rubbing their hands, gleefully saying see! They love it really!) but because in a society which has swallowed the lies and language of the sex industry, there’s quite simply no place else to go.” (Angel K., 2012)

Reading about an individual’s experience is a powerful way to illustrate the dramatic circumstances and conditions of despair that many victims find themselves in. These and other experience reports may clear our image of the vast range of issues related to sex work, including health-related consequences of physical, mental and social kind.

– Judith Gilles

References

American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C.: American Psychiatric Press.

Baral, S. et al (2012) ‘Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis’ The Lancet 12(7):538-549

Barkan, H., Farley, M. (1998). Prostitution, Violence, and Posttraumatic Stress Disorder. Women & Health, Vol 27(3). The Haworth Press Inc. http://www.ncbi.nlm.nih.gov/pubmed/10395159

Buss, David (2014). Evolutionary Psychology. The New Science of the Mind. Fourth Edition. Pearson Education Limited. P. 188.

Ditmore, Melissa Hope (2006). Encyclopedia of Prostitution and Sex Work. Volume 2. Greenwood Publishing Group, Inc.

Farley M, Cotton A, Lynne J et al. (2003), Prostitution and trafficking in nine countries: an update on violence and posttraumatic stress disorder. In: Prostitution, Trafficking and Traumatic Stress, Farley M, ed. Binghamton, New York: Haworth Press, pp33-74.

Farley M, Lynne J, Cotton A (in press), Prostitution in Vancouver: violence and the colonization of First Nations Women. J Transcult Psychiatry.

Jenness, Valerie (1990). “From Sex as Sin to Sex as Work: COYOTE and the Reorganization of Prostitution as a Social Problem,” Social Problems, 37(3), 403-420.

Leone D (2001), One in 100 children in sex trade, study says. Honolulu Star Bulletin, Sept. 10.

Weathers FW, Litz BT, Herman JA et al. (1993), The PTSD Checklist (PCL): reliability, validity, and diagnostic utility. Presented at the 9th Annual Meeting of the International Society for Traumatic Stress Studies. San Antonio; Oct. 24-27.

Online Resources

Online Blog: ‘Surviving prostitution and addiction’ , PTSD and The Prostitution Trap. Posted Monday 12 March 2012, by Angel K. http://survivingprostitutionandaddiction.blogspot.nl/2012/03/ptsd-and-prostitution-trap.html

SAMHSA (2016). Substance Abuse and Mental Health Services Administration. Prevention of Substance Abuse and Mental Illness. http://www.samhsa.gov/prevention

U.S. Department of Veterans Affairs (2015). PTSD: National Center for PTSD. Symptoms of PTSD. Washington. last retrieved: May 15 2016

http://www.ptsd.va.gov/public/PTSD-overview/basics/symptoms_of_ptsd.asp