Disproportionate and Unique Health Risks for Women in Prostitution

This blog post is available in video form.

“Sex workers sell their bodies” you developed arthritis from standing up all day at your cashier job that pays you $7.50 please humble yourself

— Fiona Applebum says #BlockShaunKing 🍎 (@WrittenByHanna) August 26, 2021

You’ve probably seen a lot of people write or say things like the quote above. It’s usually well-intentioned: we don’t want to other women in the sex trade, by suggesting that what they do for a living is “dirty” or “disgusting”. We don’t want a future potential employer to think that they’re interviewing someone who is physically and/or mentally “difficult” or “broken”. Nor do we want a woman who discloses to a friend, family member or partner that she is or was in the sex trade to have the other person make assumptions about the state of her body and psyche. Stigma on women in the sex industry is very real and prevalent in society.

However, not talking about the risks of the sex trade and pretending like our retail or desk jobs are basically the same is not a solution.

Women in the sex trade are at higher and sometimes unique risks compared to other occupations, whether the industry is criminalized, partially or completely legal. This is an uncomfortable truth that we have to acknowledge if we want adequate support and health services for people in and exited from prostitution. It is also vital to paint a realistic picture of what entry into the sex trade may entail for those considering it in the future. We cannot structure our conversations around what the most unempathetic people will inevitably take away, otherwise, we could never discuss any health impacts on stigmatized populations, incl. survivors of rape, incest, domestic violence or war. Relativist or rosy pictures of the industry do not automatically confer dignity to people in it, they will in fact often hide perpetrators of harm.

It’s not the woman (man, or trans person) selling sex who is the issue, the dangers stem frequently very specifically from the sex buyer.

The sex buyer is rarely discussed, even though for every sex seller there are many many more of him (yes, him, because female buyers are exceedingly rare). He is the one who demands certain sex acts, he is the one refusing condom or dental dam use, he is often a perpetrator of mental and physical violence (ample sources will follow). So when we talk about the risks, let’s try not to imagine a woman alone in a room, but to include in our mental picture the man/men whose physical presence and behaviour pose the risk.

With this in mind, I will list disproportionate and unique health risks for women in prostitution – with a focus on the body, rather than the mind – and with an emphasis that depressingly these risks are not simply a product of prohibitionist policies, but continue to be experienced by women in countries like Germany or New Zealand. These risks are also shared between women who might legally be defined as “trafficked” and those who are not, those with and without health coverage [1, 2], those driven by poverty and those with options – the absence of a tangible third-party exploiter simply does not create a reliable shield from the following risks. Sources will be listed at the end and include both authors who view prostitution as “violence” and others who view it as “work”, as well as meta-analysis, national studies and in-depth reports from medical practitioners.

Chronic Pain

Since this blog post was inspired by the assertion that the impacts of retail work are similar or worse to those from the sex trade, let’s begin with a look at chronic pain: Joint pain and arthritis are common long-term consequences women in the sex industry suffer from. This includes chronic wrist, arm and shoulder pain (from handjobs), jaw and throat pain (from blowjobs; this leads some women to use dental numbing sprays), hip and back pain (from the heavy weight of sex buyers) as well as knee and feet pain (from high heels and crouched positions) [3, 4, 5, 6, 19]. Also common are muscle and chest pain [7].

These health problems do not materialize out of thin air but are a direct consequence of everyday requirements made of women in the sex trade, as well as the aggressive motions and heavy bodies of sex buyers – who are quite aware that the women they’re paying, are frequently in pain during or after the act.

“Like all the girls here, [she] has back pain. Wasn’t allowed to touch her in a few places. […] just lies there, uninterested and expects it to be over in a few minutes.”

– Sex Buyer in Germany

“[She] has back pain and her vagina stings. […] Missionary is tricky because of her back. […] She’s either hurting or I’m tickeling her. […] Total rip-off!”

– Sex buyer in Germany

“Within this profession pain often goes along with regular intercourse or even oral – the ladies simply want to get things over with fast.”

– Sex buyer in Germany

Injuries

There is a range of injuries that can result from prostitution – both from additional violence perpetrated usually by sex buyers (or pimps), but also from the everyday demands made of the body. These include bruises, contusions, pulled muscles, wounds, fractures, broken bones and even internal injuries [2, 3, 4, 8]. Several studies point to the exceptionally high number of head injuries, concussion and brain trauma amongst prostituted women, which result from being hit with objects, having their heads slammed against hard surfaces, or being violently shaken or asphyxiated [7, 9].

These types of harms are not unique to the sex trade – however, they are things we don’t commonly tolerate sustaining during sex and would be concerned if we or a loved one suffered them. In the context of the sex trade, it also has to be understood that many women cannot afford to take time off to fully heal, but have to go “right back to work” despite pain and risk of worsening injury [2, 6, 20].

“[The client] asked me: Are you okay with fisting? I answered: you can if you do carefully. It resulted in three cuts, I was bleeding and he threw me naked out on the stairwell.”

– Woman in the sex trade in Ukraine

“Nobody asked me what was going on, when I showed up [to the brothel] with bruises. I wasn’t different though, I didn’t want to know what was going on, when I saw two Romanian women putting make-up over hematomas.”

– Survivor of legal brothels in Germany

“Well, she’s got a few bruises. Maybe the last punter wasn’t all that nice to her.”

– Sex buyer in Germany

Gynocological and Abdominal Health

Prostitution is the only “job” that occurs inside the body. Consequently, unique risks include gynaecological health problems, such as vaginal PH damage, inflammation, infection, tears, fissures, injury and prolapse, increased risk of cervical cancer, weakened pelvic floor, irregular and painful menstruation (which most women continue “working” through by use of sponges etc.) and even infertility [3, 6, 7, 10, 23, 24]. Procotocological health problems – a direct consequence of high demand for (brutal) anal sex and frequent enemas – include chronic abdominal pain, gastrointestinal and digestive issues, bowel inflammation, destroyed bowel environments, anal tears, fissures, injury and prolapse [3, 6].

A highly common impact of prostitution on women’s bodies include reoccurring bladder infections (from repeated penetration by men with inadequate hygiene, as well as the use of diaphragms), which can worsen into cystitis and kidney problems [3, 4, 6, 8] with some women being forced (not just by pimps, but economic necessity) to keep selling despite being in pain [20]. To avoid this many women preemptively take antibiotics, which pose myriad potential side effects [11]. Some women also suffer temporary or permanent urine and stool incontinence.

All of these are a direct cause of overexertion and mechanical trauma of sexual organs by more penetration than the body can physically handle and excessive cleanliness practices (e.g. repeated rinsing/douching of the vulva/vagina, sometimes with harmful chemicals) [2, 6, 8, 24]. They are a direct cause of sex buyers demand for quick easy access to female bodies, such that it’s not rare for women to see multiple buyers a day, sometimes up to 10-20 men. Again, sex buyers are fully aware that the women they see frequently suffer from such health problems.

“She doesn’t want [anal], because it causes her terrible pain and she already has a fissure because of it.”

– Sex Buyer in Germany

Sexually Transmitted Infections

As is commonly known, prostitution exposes you to risk of infection with STIs including thrush, crabs, scabies, bacterial vaginosis, pelvic inflammatory disease, trichomoniasis, genital warts, genital herpes, gonorrhoea, chlamydia, syphilis and hepatitis [2, 6, 8, 10, 19, 20, 21]. “Sex worker safety guides” inform women on how to inspect men’s genitals for signs of e.g. sores [20, 24], although how easily she can kick him out when he’s already naked below the waist is another question. There is also a risk of contracting HIV/AIDS, though there is a debate about how much is due to shared needle versus contact with sex buyers [4, 10] – the presence of many sex-trade-specific prevention programs suggest that there is a significant problem. These are some of the concerns associated with condom slippage and breaking, as well as sex buyers resisting and refusing condom use [19, 21, 23].

Frequent condom use unfortunately also has adverse risks for some, as a minority develop a latex allergy that may result in asthma, anaphylaxis and other serious reactions [19]. There’s also the fact that condom use does not protect from all types of STIs such as HPV and genital ulcers and that transmission of e.g. gonorrhoea and chlamydia may also occur when men ejaculate on women’s faces and their semen makes contact with her eyes [21]. On a side note: STIs are not the only kinds of infections women try to protect themselves from: One reason many women refuse to kiss sex buyers include the risk of pneumonia, bronchitis, and possibly tuberculosis [4].

There are indeed other jobs where people may become infected with various diseases including STIs, however, e.g. a hospital requires staff to wear gloves, facemasks and other protective gear when (potentially) handling bodily fluids for this precise reason. It is not possible to align prostitution with Occupational Health and Safety requirements, because sexual access to a woman who is in full-body protective gear is not appealing to the men who pay (nor would it even then pass the OSHA regulations in e.g. the U.S. [21]). Additionally, there exists a subset of sex buyers who purposefully seek out vulnerable women, esp. homeless or addicted, for a maximal power trip and the thrill of playing “Russian roulette” with the lives of everyone involved.

Prostitution is the only “job” that involves direct contact with saliva, semen, blood and potentially urine and feces [24].

Historically a huge amount of stigma against women in prostitution has been the association with sexually transmitted illnesses – public and policies framing them as “disease carriers”, often involving forced medical exams which are slowly being recognized as human rights violations (but still are a regular practice in some places with legal prostitution, e.g. Austria and Nevada [1, 8]):

“Here in Austria we check each and everyone [of the women for STIs] […] [and still] we deport 7-8 girls per week, cause they’ve gotten infected. Sometime it’s only (!) syphilis, but sometimes it’s HIV. Well, it’s up to you to decide if you want to keep seeing that Eastern [European] vermin.”

– Sex buyer in Austria

Anyone who investigates the sex trade will quickly learn that women fight a hard battle to protect themselves as best as is possible (though practices like repetitive vaginal douching unfortunately increase the risk of STIs [8]) and that it is sex buyers (and pimps) actively and intentionally fighting against the use of condoms and passing on STIs to long-term or casual partners outside the sex trade (or from there to women in the trade) [13]. It is sex buyers who come up with such demeaning and harmful practices as making women drink their urine, such as that outreach NGOs have to warn women that this, too, risks STD infection [24]. Sex buyers are the cause and the problem, not the allies in the battle for sex sellers’ sexual health and against the spread of sexual diseases, which with the advent of new incurable STIs such as super-gonorrhoea and the continued prevalence of HIV/AIDS (despite life-extending treatments available to some) are not a pearl-clutching matter, but a real public health risk.

Pregnancy and Abortion

Prostitution is the only “occupation” that can result in an unwanted pregnancy, which may require an abortion (if available) [8, 19, 23]. To avoid these women in prostitution take contraceptives (if available), which may carry health risks (blood clots, increased risk of some cancers, cardiovascular disease esp. in connection with smoking) and which are more likely to fail if the woman is suffering from aforementioned health issues, such as chronic digestive problems [6, 12, 23]. Many sex buyers very much do not want to use a condom and may push and pressure a woman or simply exploit her economic distress to not use it [1]. Sex buyers also frequently commit stealthing, i.e. removing the condom during intercourse without consent [19].

There is also a demand among sex buyers for pregnant women, including for practices such as “gang bangs” – one woman being penetrated by a series of men (in Germany up to 30). Prostitution is a high-risk environment for a pregnant woman, putting her at increased risk for STD infection, fetal injury and miscarriage [2, 3].

The prostitution of pregnant women is in violation of nearly all aspects of maternal protection law.

In the example of Germany that includes the ban on night shifts, double shifts, working weekends, doing physically strenuous work, repetitive motions, and coming into contact with hazardous substances, etc. Most women in prostitution are independent contractors with no maternity leave and are forced to “work” in accordance with their economic distress – many continue close or up to the day of delivery and return right after giving birth which puts them at risk of severe and sometimes permanent gynaecological injuries such as perineal tears [2]. And of course, women may run risk of passing on e.g. HIV/AIDS to the fetus and they still die in childbirth and from unsafe self-attempted or illegal abortions [23]. Women in prostitution being forced to give children up for adoption or having them removed occurs frequently not just under prohibition but in places with legal prostitution, too – as living situations are frequently considered unsafe by authorities, esp. for women in street prostitution [23].

“The kitten still let’s you pump her full of cum, though she’s currently heavily pregnant. Who dunnit, huh? Those who like that kind of thing should make use of the opportunity pretty soon. […] But the lady only manages to do 1-2 positions and constantly has to take breaks…”

– Sex buyer in Germany

Cosmetic procedures

As much as we like to say that the sex industry sells as “service”, it’s the attractiveness of women’s bodies that’s central to their ability to make money and put food on the table – therefore looks are paramount. The sex trade is not the only industry with a high rate of plastic surgery (yes, there is modelling and acting), but it takes cosmetic interventions to a new extreme as all parts of the body are under scrutiny:

Procedures on the face include injections and reshaping surgeries on the brows, forehead, eyes, nose, cheeks, lips and chin. The abdomen area may be altered via tummy tuck or liposuction (which can cause damage to internal organs). Breast and butt implants are common and labiaplasty rates are likely highest for women in prostitution and pornography than for any other group [14]. All major surgical interventions include risk of bruising, swelling, scarring, pain, infection and in the worst cases necrosis [15]. It should come as no surprise that it is “beauty trends” set by the porn industry that propel a lot of the overall sex trade surgery market:

“Never had such fucking awesome porn-sex. Absolute optic-fuck with top-notch service. Tattooed with perfectly sculptured silicone breasts. Chances of returning: 100%.”

– Sex Buyer in Germany

Youth is a factor sought after by most sex buyers, meaning that women age out of the market by their late 30s. There are middle-aged and older women selling sex, but most men will pay the highest price for women 18-25, creating an economic need for cosmetic interventions that give the appearance of youth, such as botox, facelifts, and again, as no part of the body is off limits, vaginal “rejuvenation” surgery, which tightens the vaginal and perineum area, but risks nerve damage and scarring [14].

“The gal looks like a run-down porn actress […] and is surgically altered to look young and skinny (had facelift) with a slightly mask-like face. The breasts (B-cups) were tuned, but the result is second-rate. [She] is slim, but she doesn’t show her belly or waist (probably her visual weak point).”

– Sex Buyer in Germany

There are entire plastic surgery clinics leeching off strip clubs and brothels…

Make no mistake, the plastic surgery industry is a multi-billion dollar business and it does not care about women’s well-being any more than any other capitalist industry. Women in the sex trade moving through the revolving doors of plastic surgeons is such a common phenomenon, that some NGOs have issued guidance for surgeons to recognize victims of human trafficking. Women and trans people in prostitution are also sometimes victimized by black market cosmetic product sellers carrying out illegal and particularly medically unsound procedures [8]. And of course, there is always a small but substantial risk of death on the surgery table – especially people who have undergone multiple procedures may suffer deep vein thrombosis and pulmonary embolism [15].

Physical violence, rape and murder

Women in prostitution are at risk of robbery, rape and murder on the job, mostly at the hands of sex buyers, but also brothel owners, pimps, organized crime, strangers and police [1, 3, 4, 8, 10, 16, 19]. Forms of harassment include verbal abuse, threats, unwanted touching or kissing and stalking [3, 19]. Violent acts include slapping, arm twisting, kicking, punching, strangling, being tied up, being locked up, being burned and being threatened with a knife or gun [3, 7, 10]. In the age of digital media, it should be noted that perpetrators repeatedly film these crimes – sometimes in the form of torture porn – and that rapes include forced reenactment of pornographic scenes.

Women in prostitution in the U.S. are 18x more likely to be murdered than a comparable sample of the general population [17] – at a rate higher than soldiers, taxi drivers or liquor store salespeople. Their murders are usually in direct connection with the sex trade, i.e. were committed by sex buyers, robbers, rapists, sadists and/or pimps (with all these frequently overlapping) [10, 17, 18]. See here for an in-depth discussion of femicide in the legal German sex trade.

Violence is not an issue tangential to the sex trade: One of the most common scenarios where violence occurs is during the sale of sex, when price negotiations escalate or “customers” are dissatisfied with the “service” or transfer their rage over impotence and other personal frustrations onto women who are physically vulnerable due to being naked, being penetrated, being tied up in BDSM practices or when intoxicated or high [7, 8, 18, 19]. The assumption that women get rich from prostitution and that they often carry large sums of money is an additional motivator to misogynistic attackers and robbers [8].

Violence at the hands of the men who pay is a real everyday concern for women in all sectors of the sex trade

It’s why groups and individuals of all political persuasions give advice that includes dress codes (to avoid being grabbed or dragged), rape alarms, informing another person about whereabouts, photographing license plates, carrying and sharing “bad client lists”, obtaining a protector (pimp) etc [8, 19, 22]. Contrary to frequent claims extensive screening techniques (demanding an ID, extended interviews with men before meeting them, etc.) are not tools available to the vast majority of women – including in countries where sex buying is legal. Market forces alone force the majority to repeatedly accept men who appear dubious or unsafe. While not all will end up experiencing these kinds of violence, all live with the fear that they might.

Mental Health

This blog post does not focus on the mental health risks associated with prostitution, but because they make up a huge section of what women in and out of the trade report to be suffering from I will give a brief overview here: Women in the sex trade suffer disproportionate rates of sleep disorders including insomnia, hypersomnia and chronic nightmares (worsened by long shifts, night-shifts, irregular sleeping patterns, sleeping in the “work” bed, etc.) [3, 5, 6]. Eating disorders are not unusual either, including binge eating, bulimia and anorexia [3, 6] – malnutrition is also helped along by the high-stress environment of prostitution which worsens all other physical and mental health symptoms [2].

Physical symptoms of revulsion and emotional distress include chronic headaches, dizziness, exhaustion, nausea, vomiting, abdominal cramps, skin disorders, hair loss and premature ageing [2, 3, 6, 7].

„Surpressing your digust is one of the most important skills, that you need in prostitution, many punters aren’t even bothered when the prostitute throws up…”

– Woman in prostitution in Germany

While not the most obviously distressing, women also report decreased libido and the inability to experience sexual pleasure [3]. Trauma symptoms include low self-esteem, irritability, depression, anxiety, panic attacks, obsessive-compulsive behaviours, compulsive spending, dissociation (not being emotionally present, esp. while experiencing unwanted touch and penetration by sex buyers – a common survival mechanism and trauma response shared with victims of rape and domestic violence), self-harm (e.g. cutting which leaves scars – which sex buyers can and do see), suicidal thoughts and suicide (attempts) [3, 5, 8, 16]. These mental symptoms for many women last longer than the physical ones and many who have left the sex trade report struggling with these years or decades later.

„[She said:] ‘The job is destroying me’. I had a hunch from the facial expressions, the quick leaving of the bed and running into the shower, etc., but only really registered it when […] she made comments like ‚this fucks me up in the head‘ or, that she can only do the job for a couple of weeks and then needs really long breaks in order not to break.“

– Sex Buyer in Germany

“The reality is that this job essentially kills the soul of a lot of girls over time – alcohol and drugs are then used to numb the pain.”

– Sex Buyer in Germany

Substance Use & Addiction

As a consequence of constant unbearable situations, many women in the sex trade – especially but by no means exclusively on the street – consume legal and illicit substances at above-average rates, such that advice on safer drug consumption is part of many “sex worker safety manuals” handed out by outreach organizations [1, 3, 4, 5, 7, 8]. Addiction tends to precede prostitution, but it may be worsened or caused by the reality of prostitution [4]. Legal recreational drugs often consumed in high quantities or constituting an addiction include alcohol, cigarettes and hashish [3, 8, 10]. Prescription pills common in the prostituted population include pain killers, sedatives, sleeping pills, anti-depressants and anti-anxiety agents [2, 3]. Psychostimulants include speed, meth, cocaine, crack, ecstasy, angel dust, acid and others. Opioids include fentanyl and heroin [3, 8, 10]. It is not unusual for women to consume multiple substances in short succession or to suffer from polyaddiction. All of these substances are associated with various risks to physical and mental health, including severe organ damage and of course death by accident, overdose and HIV/AIDS [8, 17].

Many women consume mind-altering substances while they’re selling sex, which means they are not able to consent. Sex buyers are, again, completely aware of this, but they’re rarely worried about consequences for accessing a woman intoxicated, dissociated via a drug or struggling with addiction, as this is commonly a tolerated part of the (legal) sex trade. It is also not rare for sex buyers to encourage alcohol or drug consumption – in the case of illicit substances the buyer is often the one providing the substance – and of course, sometimes he pays in the form of drugs rather than money. Many sex buyers are also drunk or high while paying for prostitution which makes them even more dangerous [22].

“I noticed immedietly that she was plastered. But that wasn’t a problem for me because I’ve always wanted to fuck a drunk whore.”

– Sex Buyer in Germany

“Of course she looks sick and her arms show she’s shooting drugs. […] Banging a junkie is just some people’s kink. […] She’s the only one […] who agreed to blow me […] and swallow.”

– Sex Buyer in Germany

“She was also on Chrystal Meth, which was not good. I still wank about her.”

– Sex Buyer in New Zealand

Conclusion

Nothing written in this blog post is intended to frame women in prostitution as “broken”, “disgusting” or “weak”. Women in and exited from the sex trade are a diverse group of people, equally intelligent and capable to the rest of the population. Many of the risks listed here, however, do showcase very clearly why the sex industry is not a “job provider” and the sex buyer is not a “customer like any other”. The only groups of people deserving of the labels “broken” and “disgusting” are men who ignore women’s economic distress and physical pain to cause this harm to their bodies and minds and/or profit from it.

Women in the sex trade are extremely resilient, but they shouldn’t have to be.

Sacrificing women’s health for men’s pleasure is unacceptable. Women deserve a life free from objectification, injury and violence and the continuance of the sex trade is diametrically opposed to these goals.

This blog post in video form:

Sources

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