Posttraumatic Stress Disorder

Exposure to paid or unpaid sexual violence may result in symptoms of PTSD. Most prostitution includes the traumatic stressors that are categorized as DSM-IV criterion A1 of the diagnosis of PTSD (American Psychiatric Association, 1994):

Direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's personal integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person.

In response to these events, the person with PTSD experiences fear and powerlessness, oscillating between emotional numbing and emotional/physiologic hyperarousal. Posttraumatic stress disorder is known to be especially severe when the stressor is planned and implemented (as in war, rape, incest, battering, torture or prostitution).

In nine countries, across widely varying cultures, we found that two-thirds of 854 women in prostitution had symptoms of PTSD (Farley et al., 2003) at a severity that was comparable to treatment-seeking combat veterans (Weathers et al., 1993), battered women seeking shelter (Houskamp and Foy, 1991; Kemp et al., 1991), rape survivors (Bownes et al., 1991) and refugees from state-organized torture (Ramsay et al., 1993).

The women were interviewed in a range of contexts (Farley et al., 2003). Interviewers from supportive local agencies accompanied the researchers, and agency referrals were given in writing. In some countries, women and girls were interviewed at agencies that offered services specifically to women and girls in prostitution (Colombia, Thailand, Zambia). Elsewhere, women were interviewed in an STD clinic (Germany, Turkey), in the street (Canada, United States), or in brothels, strip clubs and massage parlors, as well as in the street (Mexico, South Africa). Women often reported that they prostituted in both indoor and outdoor locations.

The intensity of trauma-related symptoms was related to the intensity of involvement in prostitution. Women who serviced more customers in prostitution reported more severe physical symptoms (Vanwesenbeeck, 1994). The longer women were in prostitution, the more STDs they were likely to have experienced (Parriott, 1994).

It is a cruel lie to suggest that decriminalization or legalization will protect anyone in prostitution. It is not possible to protect someone whose source of income exposes them to the likelihood of being raped on average once a week (Hunter, 1994). One woman explained that prostitution is "like domestic violence taken to the extreme" (Leone, 2001). Another woman said, "What is rape for others, is normal for us" (Farley et al., in press).

Much of the literature has viewed prostitution as a vocational choice. Yet the notion that prostitution is work tends to make its harm invisible. Prostitution is institutionalized and mainstreamed when it is considered to be unpleasant but legitimate "sex work." Even organizations such as the World Health Organization and Amnesty International USA have made the policy error of defining prostitution as a job rather than as human rights abuse.

The solutions are complex. Organizations offering assistance to prostitutes must be queried about whether they offer not only condoms and unions, but also options for escape such as housing and job training. It is essential to abolish not only prostitution, but its root causes as well: sex inequality, racism and colonialism, poverty, prostitution tourism, and economic development that destroys traditional ways of living.

Despite the illogical attempt of some to distinguish prostitution from trafficking, trafficking is simply the global form of prostitution. Sex trafficking may occur within or across international borders, thus women may be either domestically or internationally trafficked or both. Young women are trafficked--taken and sold for sexual use--from the countryside to the city, from one part of town to another, and across international borders to wherever there are customers.

It is a clinical and a statistical error to assume that most women in prostitution have consented. Instead of the question, "Did she voluntarily consent to prostitution?" the more relevant question would be, "Did she have real alternatives to prostitution for survival?" The incidence of homelessness (75%) among our respondents and their desire to get out of prostitution (89%) reflect their lack of options for escape (Farley et al., 2003).

Until it is understood that prostitution and trafficking can appear voluntary but are not really free choices made from a range of options, it will be difficult to garner adequate support to assist those who wish to escape but have no other economic choices. The conditions that make genuine consent possible are absent from prostitution: physical safety, equal power with customers and real alternatives (Hernandez, 2001; MacKinnon, 1993).

Just as clinicians now screen for physical and sexual abuse and substance abuse history, prostitution history should be addressed at intake. It should be re-addressed after a therapeutic relationship is established, since an initial denial of prostitution is not unusual (Schwartz, 2000). The questions "Have you ever exchanged sex for money, drugs, housing, food or clothes?" and "Have you ever worked in the sex industry: for example, dancing, escort, massage, prostitution, pornography or phone sex?" are routine in our intake inquiry. We also recommend asking the question, "Have you ever had sex of any kind with a professional sex worker [call girl, escort, massage parlor worker or prostitute]?"

In addition to acute and chronic PTSD, comorbid diagnoses may include generalized anxiety disorder, mood disorders (including depressive and bipolar disorders), acute suicidality, substance abuse and dependence, personality disorders, dissociative disorders, and symptoms of traumatic brain injury. Although special clinics and shelters for women escaping prostitution are recommended, at this time, services are sometimes accessed at rape crisis centers, public health agencies, substance abuse treatment clinics, shelters for battered women and community mental health clinics.

Conclusion

Certainly there is an urgent need to address the mental health needs of women during prostitution and after escape. However, it is equally important to address men's demand for prostitution. Acceptance of prostitution is one of a cluster of harmful attitudes that encourage and justify violence against women. Violent behaviors against women have been associated with attitudes that promote men's beliefs that they are entitled to sexual access to women, that they are superior to women and that they are licensed as sexual aggressors (White and Koss, 1993). Customers of prostitutes strongly endorse these attitudes toward women.

Although a statistical minority, the college-aged customers of prostitutes we surveyed were significantly different from the other young men (Table 2). Those college students who had purchased women in prostitution were more accepting of prostitution myths and rape myths than the other students. Chillingly, the college-aged customers of prostitutes differed from the other students not only in their attitudes but in their actual behaviors toward women. They acknowledged having perpetrated more sexually coercive acts with their partners than the other men in the survey.

Those of us concerned with human rights must address the social invisibility of prostitution, the massive denial regarding its harms, its normalization as an inevitable social evil, and the failure to educate students of psychiatry, psychology and public health. Prostitution and trafficking can only exist in an atmosphere of public, professional and academic indifference.

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