Sex workers are frequently put in the position of having to strategically hide an illness or injury for fear of losing business, and that process can be both exhausting and isolating.

At 28 years old, I’m a sex worker who is starting to feel the limitations of her body.

Andre Shakti

Last Wednesday started off like many weekdays had before it. I woke up around 9 a.m., fed my animals, and prepared breakfast. My breakfast was high in good fat and lean protein, and it was accompanied by a performance recovery shake as well as a number of medications and supplements including pre-exposure prophylaxis (PrEP), Paxil, calcium, vitamin D, cranberry, and women’s probiotics. I topped off my vitamin cocktail with a few citrus bioflavonoids, which are said to strengthen capillaries and reduce bruising, for good measure. While I ate, I strapped an ice pack and half a dozen therapeutic e-stim pads to the area around my right knee to reduce pain and inflammation from an old meniscus injury. Afterward, I spent 15 minutes stretching, then another 15 minutes strategically applying kinesiology tape to support my knee. Then I hopped in the shower, applying a face mask and a deep conditioning treatment to my hair while I diligently shaved my entire body.

After my shower, I laid on the cold linoleum floor of my bathroom and checked my genitals with a hand mirror to make sure I hadn’t missed any stray hairs. I then rehearsed my enema routine, alternating positions from floor to toilet for an additional 10 minutes until I was “cleaned out,” before shoving a few triangular makeup sponges up my vagina. I had gotten my period the day before, and this way I could still receive penetration without any visible blood or tampon strings. I precociously staged several bags of Epsom salts for my evening soak and texted my massage therapist to confirm our session the following afternoon. Finally, I tossed clothes on, grabbed a small suitcase, my knee brace, and my orthopedic cane, and fled out the front door to work.

What do I do for work, you ask? I’m a sex worker in the porn industry. And at 28 years old, I’m a sex worker who is starting to feel the limitations of her body: a body prone to vaginal infections such as urinary tract infections, yeast infections, and bacterial vaginosis. A body that has shattered an ankle, torn a meniscus, and ripped a rotator cuff. A body that, despite its limitations, still has to perform as though it is superhuman. This has made me keenly aware of the flaws in the system that put those in my profession in a precarious situation: one in which we’re kept from receiving care due to lack of coverage and stigma, while providers are not given the tools they need to offer more inclusive services.

The vast majority of sex workers are independent contractors. As such, although we operate in an industry where we’re the equivalent of “sexual athletes,” we have no workplace protections to speak of. This often means we’re working while being sick, injured, navigating chronic pain or mental illness, or suffering from temporary or permanent disabilities. And unlike many desk-jockey freelancers in other industries, we can’t “fake it ’til we make it.” If I’m a stripper and break an ankle, there’s no “work from home” option to be had.

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Worse is the stigma or inexperience we must confront when we do break down and seek treatment.

“For many sex workers—even those in legalized professions—the biggest barriers to accessing health care are stigma and a lack of provider expertise,” said Maxine Holloway, a Bay Area sex worker and teacher who earned her master’s in public health degree last year. “I do not feel as though most health-care providers are well-equipped to serve sex worker populations. There’s a significant gap in knowledge and cultural ability in the [U.S.] health-care system when it comes to sex work, and sex workers report a rarity of health-care providers who understand and have the knowledge to help with their unique health problems.”

“Many sex workers—even those who can financially afford health care—avoid pursuing it for fear of being shamed or judged by their provider, or being forced to face legal ramifications for their disclosure,” Holloway continued. “Just as often, the sex worker is put in the uncomfortable position of having to educate their own provider on the work they do, any actual risks associated with their work, and the services best suited for them. It’s a lot of pressure to put on someone who’s just trying to get some antibiotics.”

Some sex workers in my home state of California either utilize Medi-Cal, the state-funded Medicaid insurance program for low-income individuals and families, or purchase coverage under former President Obama’s Affordable Care Act (ACA).

“However, [the ACA] is in the process of being picked apart and possibly revoked by new national leadership,” Holloway pointed out, “leaving the future health care of millions of marginalized people, including sex workers, in jeopardy. It’s a class and access issue above anything else.”

It’s a likelier scenario that we’re just plain uninsured. We often have to resort to going to free clinics that often have severe limitations (hours, funding, waitlists, clinician expertise) instead of having a primary care doctor, access to specialists, or agency to visit the emergency room. The work being done by sex-worker-specific health-care facilities, such as the St. James Infirmary in San Francisco, which thankfully litter California, is monumental. But if “for us, by us” care is the only way sex workers can get their needs met, it really illustrates how broken the system is.

Ironically, in my experience, many individuals with invisible disabilities and pre-existing health conditions either actively choose or are reluctantly positioned into sex work because working a traditional 9-to-5 isn’t a feasible or sustainable option for them. The autonomy and flexibility of the sex industry presents creative income opportunities that don’t come with having to report to a supervisor, meet strict deadlines, or adhere to rigid work hours. Occasionally these workers, who often stick to more remote forms of sex work—like phone sex, live webcamming, or porn—will be transparent about their health conditions to their consumers, but largely it’s a game of concealment.

Sex workers are frequently put in the position of having to strategically hide an illness or injury for fear of losing business, and that process can be both exhausting and isolating. Plus, the sex industry is simply a raunchy facet of the mainstream entertainment industry. Consistency and relevance are paramount to one’s career, particularly in porn, just as they are in theatrical film. With how volatile the industry can be, long hiatuses from it can completely screw up your career.

I spent a full year of my adult life only being able to receive vaginal penetration very occasionally. In mid-2013, just as I was really getting into my porn industry grind, I was diagnosed with chronic yeast infections. It eventually took a team of gynecological specialists and infectious disease specialists to drum up a pharmaceutical cocktail persistent enough to knock it out of my system. Until then, I had to rebrand myself to save my career, and fast. I went from pulling the majority of my income from submissive sex scenes, where I was getting penetrated, to marketing myself exclusively as a dominatrix (who did most of the penetrating herself!). It was only through this dramatic shift that I was able to maintain a semblance of my livelihood, and throughout the entire process I couldn’t be transparent about what I was going through to anyone but my closest non-industry confidants. After all, no one in the porn industry likes a broken vagina.

So what would it take to improve the experiences of sex workers, who like other workers need access to basic health-care services?

Industry employers should offer employment contracts to their employees if at all feasible—as opposed to independent contractor agreements—and take responsibility for improving workplace conditions. This could include, but is not limited to: offering some form of workers’ compensation for injuries sustained on the job, providing unambiguous and consistently enforced sexual harassment and confidential reporting policies, and covering or eliminating excessive or unnecessary worker costs when possible (i.e. taking financial responsibility for sexually transmitted infections panel testing or doing away with unethical strip club “stage fees”).

Organizations and clinics offering services to sex workers need to be more widely supported and funded on an institutional and policy level. Among other things, there needs to be more grants available to sex worker-specific organizations and clinics, both on local and federal government levels. Based on what I’ve witnessed and heard from providers, these clinics need more resources (medications, supplies, testing vehicles, etc.) as well as money for payroll to onboard more employees and bolster volunteer and training programs.

Providers across the board need to prioritize educating themselves around the unique needs of sex workers. Most of these needs require providers to check their assumptions, biases, and boundaries around the sex industry and sex work, Holloway advised. For example, using neutral and nonjudgmental language is imperative. The word “prostitute” can be loaded for some, and in most cases it is best to use the term “sex worker.” Holloway further explained that it’s important for providers to understand that not all health issues for sex workers are connected to their job. If a patient is in for a cold or small injury, bringing up their work is probably irrelevant. Providing care for a sex worker is not an opportunity to investigate sex work. As Holloway shared:

I was once being treated for strep throat, and I had a doctor tell me that he and his wife were ‘into kinky things’ while he swabbed the back of my throat. I could only assume he was disclosing this as a way to try to “relate” to me. Sex workers are constantly on the receiving end of inappropriate overshares, and this should not be tolerated in the office of a medical professional.

The cost of health insurance and care needs to be made more affordable for all marginalized people. “Providing access to care for the most marginalized folks will provide more access to health care for more sex workers,” said Holloway, “Sex workers are a diverse community, and there is no way to equitably improve access coverage in one fell swoop—for example, through a union. Things like sex worker health unions would mostly benefit the most privileged, non-criminalized workers, still leaving behind more vulnerable workers without coverage. I view true health justice to include access for all workers, not just some.” Reducing barriers to access like affordability, the bureaucracy of enrollment, and covering pre-existing conditions will help everyone access care easier, added Holloway. In turn, sex workers and other nontraditional laborers, freelancers, and independent contractors are more likely to have health insurance.

As companies and providers move forward in determining the best way for sex workers to access comprehensive, inclusive, and accessible care, I strongly suggest placing sex workers in the center of these conversations and decisions. We know what’s best for us; we just wish the rest of the country would take us at our word.