Caring for sex workers
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4011 (Published 05 August 2015) Cite this as: BMJ 2015;351:h4011
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Thank you Prof Rekart for your excellent overview. The topic could fill a book in any speciality. As a sexual health doctor I often think that the sexual health part of looking after sex workers is overrated. Poor mental health, drug and alcohol use, and violence are much dangerous than gonorrhoea, chlamydia and syphilis. Many sex workers come from parts of the population that is already marginalised and may benefit most from interventions that are not sex worker specific. Rightly Prof Rekart mentions mental health and addiction care. It is important not to pigeon-hole sex workers and treat each of them as a patient.
I fully agree with Prof Rekart’s comment that we must avoid intrusive and unnecessary questions. Having said all this, some questions should however always be asked. These include assessment for the need for HIV post exposure prophylaxis, emergency contraception, forensic evaluation, physical and mental safety and the safety and well-being of any children s/he might be caring for.
Competing interests: No competing interests
Thank you for a comprehensive and informative paper on an under-discussed topic.
If I may make a single suggestion: I think the language in this article would benefit from clarification. For example, descriptions of the risks for men who have sex with men in situations where they act as either "insertive" or "receptive" partners are difficult to interpret without elucidation of the particular activity under discussion (e.g. oral or anal intercourse).
The language may be familiar and euphemistically understood by those working in the field, but not necessarily by the broader BMJ audience. In one case, I had to read through the referenced papers to understand that it was anal sex between men that was being discussed - it wasn't even clear from the titles of the papers cited.
Despite this, I still found this article very interesting and useful. Thank you again.
Competing interests: No competing interests
Oaths are straw before the fire in the blood, said William Shakespeare in a different context. Yet how true it is, for sex and sexuality are human traits that overwhelm society. An improper balance between hormones, societal and environmental factors influence sexual behavior. Aberrant sexual behavior or sexuoerotic orientation cause many incidents of sexual violence, rape and even homicides. Many incidents are bizarre when children fall victims to devouring sexually violent biological instincts. Providing sexual services or areas has become a market for sex workers who by their own will or forced social circumstances offer sexual gratification for an economic incentive.
Many do not understand they are also humans harboring normal social instincts and a desire to live a life which could at least be healthy, Aberrant sexual activities are exposed to them and they carry risks of exposure to HIV infection, Hepatitis virus infection (A,B, C), social exclusion, loss of personal self esteem and the need for special care for their physical ailments along with their psychological trauma.
They may need an exclusive package of care which includes therapy, psychological counseling and rehabilitation. They also fall victim to alcoholism and drug abuse. They need care and empathy..
How such a care can be provided is for society to decide as they extract such painful service for their bodily pleasures.
Sex workers are adults who receive money or goods for sexual services, either regularly or occasionally,1 including female, male, and transgendered sex workers.2 3 Youths under 18 years who sell sex are sexually exploited and not included in the definition.
Competing interests: No competing interests
Which of your patients are 'sex workers'?
I'd bet a pound to a penny that many of the GPs who read this informative article do not know which of their patients are sex workers. No matter how well motivated and informed you are about the topic, you face a major handicap if you don't know who the patients in need are.
My practice was in one of the most rural areas in England and I found six female prostitutes amongst the patients over a twenty year period and have reason to suspect that they were not alone. They varied in age from late teens to sixties+, none were destitute, none were substance abusers or had alcohol problems, none disclosed adverse social or sexual antecedent experiences - they chose to prostitute themselves. One patient asked for my 'career advice' when she was considering going on the game.
Figures from Germany, where all sex workers must be registered, suggest, after a 'back of a fag packet' calculation, that about one per cent of the population are or have been engaged in sex work of one sort or another. How many of your prostitutes or porn 'stars' do you know?
A gynae/sexual history taking will often provide pointers. One's clinical antennae and knowledge of the patient's social milieu will provide other evidence. Once the subject is broached, confidentiality assured and providing the clinician does not go into paroxysms of embarrassment, morbid delicacy, faux modesty or engage in obfuscatory circumlocution, the patients are not only willing to disclose information readily but even show marked relief that consultation on the many issues of concern is possible.
Our local GU clinic, I discovered, has established care pathways and was keen to recruit those in need.
For the sake of example, let us say that each full time GP has 1,500 patients - that's 15 sex workers. Every GP needs to know who their sex workers are.
Steve Ford
Competing interests: No competing interests