Despite the image presented in films, books and television, prostitution places women and children at high risk for PTSD and other comorbid disorders. What experiences lead to this life?
Sexology, the study of sexuality, was built on the uncritical acceptance of prostitution as an institution expressive of both men's and women's sexuality. Alfred C. Kinsey, Sc.D., and his colleagues worked from the 1940s through the 1970s to articulate a sexuality that was graphically portrayed in magazines. Even today, some assume that prostitution is sex. In fact, prostitution is a last-ditch means of economic survival or "paid rape," as one survivor described it. Its harms are made invisible by the idea that prostitution is sex, rather than sexual violence.
Prostitution has much in common with other kinds of violence against women. What incest is to the family, prostitution is to the community. Prostitution is widely socially tolerated and its consumers (commercial sex customers who are called johns or tricks by women in prostitution) are socially invisible.
Herman (2003) polled attendees at a trauma conference, asking how many currently or previously treated patients who had been used in prostitution. Three-quarters of the 600 attendees raised their hands. Describing prostitution as hidden in plain sight, Herman noted that 30 years ago, rape, domestic violence and incest were similarly invisible.
Prostitution Is Violent
Although clinicians are beginning to recognize the overwhelming physical violence in prostitution, the internal ravages of prostitution have not been well understood. Prostitution and trafficking are experiences of being hunted down, dominated, sexually harassed and assaulted. There is a lack of awareness among clinicians regarding the systematic methods of brainwashing, indoctrination and physical control that are used against women in prostitution. There has been far more clinical attention paid to sexually transmitted diseases (STDs) among those prostituted than to their depressions, lethal suicidality, mood disorders, anxiety disorders (including posttraumatic stress disorder) dissociative disorders and chemical dependence.
Regardless of prostitution's status (legal, illegal or decriminalized) or its physical location (strip club, massage parlor, street, escort/home/hotel), prostitution is extremely dangerous for women. Homicide is a frequent cause of death (Potterat et al., 2004).
Prolonged and repeated trauma precedes entry into prostitution, with most women beginning prostitution as sexually abused adolescents (Bagley and Young, 1987; Belton, 1992; Dworkin, 1997; Farley and Barkan, 1998; Silbert and Pines, 1983b, 1981; Simons and Whitbeck, 1991) (Table 1). Homelessness is frequently a precipitating event to prostitution. Women in prostitution are frequently raped and physically assaulted (Farley et al., 2003; Hunter, 1994; Miller, 1995; Parriott, 1994; Silbert and Pines, 1983a).
Prostituted women are unrecognized victims of intimate partner violence by pimps and customers (Stark and Hodgson, 2003). Pimps and customers use methods of coercion and control like those of other batterers: minimization and denial of physical violence, economic exploitation, social isolation, verbal abuse, threats and intimidation, physical violence, sexual assault, and captivity (Giobbe, 1993, 1991; Giobbe et al., 1990). The systematic violence emphasizes the victim's worthlessness except in her role as prostitute.
Clearly, violence is the norm for women in prostitution. Incest, sexual harassment, verbal abuse, stalking, rape, battering and torture are points on a continuum of violence, all of which occur regularly in prostitution. A difference between prostitution and other types of gender violence is the payment of money for the abuse. Yet payment of money does not erase all that we know about sexual harassment, rape and domestic violence.
The experiences of a woman who prostituted primarily in strip clubs, but also in massage, escort and street prostitution, are typical (Farley et al., 2003). In strip club prostitution, she was sexually harassed and assaulted. Stripping required her to smilingly accommodate customers' verbal abuse. Customers grabbed and pinched her legs, arms, breasts, buttocks and crotch, sometimes resulting in bruises and scratches. Customers squeezed her breasts until she was in severe pain, and they humiliated her by ejaculating on her face. Customers and pimps physically brutalized her. She was severely bruised from beatings and frequently had black eyes. Pimps pulled her hair as a means of control and torture. She was repeatedly beaten on the head with closed fists, sometimes resulting in unconsciousness. From these beatings, her eardrum was damaged, and her jaw was dislocated and remains so many years later. She was cut with knives. She was burned with cigarettes by customers who smoked while raping her. She was gang-raped and she was also raped individually by at least 20 men at different times in her life. These rapes by johns and pimps sometimes resulted in internal bleeding.
Yet this woman described the psychological damage of prostitution as far worse than the physical violence. She explained that prostitution "is internally damaging. You become in your own mind what these people do and say with you" (Farley et al., 2003).
Almost two decades earlier, Norwegian researchers noted that women in prostitution were treated like commodities into which men masturbate, causing immense psychological harm to the person acting as receptacle (Hoigard and Finstad, 1986).
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.
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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