mily Warfield is a busy graduate student in the last semester of her Master of Social Work (MSW) program, focusing on policy. She is also a trafficking survivor who supports herself working as a dominatrix.
Recently, in seeking a therapist to help her work through some of her past trauma, she turned to an app that is aimed at matching patients with therapists who fit their needs.
While Warfield doesn’t necessarily identify as queer, she explains she listed LGBT-competent as one of her search criteria as she believes “people who are trained in that often have more experience in sex work.”
While her background as a sex worker isn’t the sole reason Warfield was seeking therapy, she knew it was imperative that she found someone open to treating—and not pathologizing—sex working patients. “It’s very difficult to find a therapist who doesn’t make assumptions about the relationship between your trauma and your sex work,” Warfield says.
While the app did match her with someone experienced in trauma, this therapist didn’t mention anything on her profile about being open to working with LGBT clients. This worried Warfield a bit, but she decided to give her a try anyway.
On her first session, Warfield told the therapist directly, “This is not the thing I wanna work on but just so you’re aware, I’m a dominatrix. And as long as you’re open to having me explain what that means to me, I think we’ll be fine.”
Warfield recounts that the therapist seemed nervous. She says, “I could sort of see on her face that she was trying to [...] remember, you know, what she had been taught about sexual diversity and how could she present as accepting. You could see the gears turning.” And sure enough, Warfield received an email after the session from the therapist.
“I’m sorry,” it read, “but I feel like I’m not the best match for you.”
Warfield is certainly not the only sex worker who has been turned away from therapy, or who has received inadequate or problematic therapeutic services because of their involvement in the sex trades. “Very few clinicians are competent in that area.”
Mistress Blunt is an NYC-based dominatrix who once worked alongside with Persist Health Project, a peer-led,comminity-based non profit that provided safe, affordable health care for sex workers and trafficking survivors. (The org has since closed.) Blunt says she was not only responsible for vetting health care providers to make sure that they were sex worker competent, but gave trainings to mental health professionals and doctors to fill in the gaps between what was taught in school and what they needed to know in the field.
Unfortunately, as Blunt found out through this work, these gaps are enormous.
They’re chasms really. She recalls giving a workshop to third-year medical students who told her after the seminar that this was the first time in their medical school education that they had even discussed the role of sexuality in providing healthcare.
And this persistent absence isn’t isolated to medical training.
Jasmine Johnson is a licensed clinical psychotherapist and owner of Blue Pearl Therapy; she also does sex worker under the name Jet Setting Jasmine. Johnson says that in her own schooling and therapy training, sex work was always taught through the lens of stigma.
“We definitely learn in school about sex work being survivor-based, or through the lens of sex trafficking, or through the lens of helping someone exit sex work,” she says. “You know, we never... or at least, I’ve never taken a class about helping someone sustain their career in sex work.”
Johnson believes this narrow understanding of sex work prevents practitioners from seeing sex workers in their totality. The majority of providers and therapists have been steeped in an education system — and a society — predicate on the belief that sex work is something to be solved, not integrated into an individual’s sense of self, work, or activism.
“There are a lot of well-intended therapy students and well-intended professors, but there’s also this larger hierarchy, this larger institution,” she explains. “I don’t necessarily think it is an ‘anti-sex work’ curriculum as much as I think there is a very narrow curriculum, especially for people interested in working in the realm of sex, sexuality, human behavior, or working with sex workers.”
Johnson believes one way to bridge these gaps and misunderstandings is the creation of space for more nuanced conversations about sex, sex work, and relationships in the curriculum.
“There should really be a class for that,” she insists, or “a space where people can explore working with people who work in non-traditional spaces, or people who have non-traditional relationships, even.”
Not providing training of this sort leads to providers who don’t know how to support sex working patients without reducing them to their jobs. femi babylon — author, blogger, and sex worker — says that this dynamic has been a major frustration. She’s learned to avoid disclosing her work as a sex worker because it gets in the way of what she actually needs to talk about in therapy.
“Most of the time, people don’t even respond with hostility, they just have this ‘eyebrows raised’ kind of thing,” babylon says. “They either display overt discomfort or they start stumbling over stuff, or suddenly sex work starts becoming a factor for everything.”
Babylon explains it doesn’t matter what topic she brings up, the therapist always wants to circle back. “I could be like, ‘I’m having trouble with my son, he has ADHD,’ and they’ll be like, ‘Well, does he know you’re a sex worker?’”
Alan, a chaplain who coordinates the Community Support Line for the Sex Worker Outreach Project (SWOP), says that he gets a lot of calls from sex workers whose experiences with therapists also echo the journeys of Johnson’s and babylon’s.
Alan says that folks he’s talked to were upset with their therpiasts because they fixated on sex work. Certainly sex work is a job that requires a high degree of emotional labor, and it undeniably impacts one’s emotional wellbeing, but it’s not necessarily the defining factor in why someone seeks out therapy.
“I mean it’s okay to holistically consider [sex work] as part of what someone’s going through, mental health-wise,” he says. “But, at the same time, focusing solely on that is not going to really get rid of a lot of the issues that people have because it may or may not be related to it.”
Sex work involving sex is something that many people can’t see past.
As a clinician, Johnson says sex working patients want to talk about the same things that non-sex working patients want to talk about, and not allowing them to do so is part of the problem.
Emily Warfield points out that therapists (albeit more rarely) can also overcorrect. “I see a lot of therapists who call themselves ‘sex-positive’ which is cool,” she explains. “But that doesn’t necessarily tell me that they’re open-minded about sex work. I also don’t want to go to a therapist and have them be like, ‘Oh that sounds so empowering for you,’ when for me, it’s not. For a lot of people it’s just work. And some people do experience it as violence. [You’ve got] to be able to work with the whole spectrum of experiences, and really that’s just allowing people to define that for themselves.”
The lack of sex work-competent therapists isn’t the only barrier to care however. “Sex workers tend to be working class or poor or queer —all these different things and are lacking in certain resources” femi babylon points out. “There’s a high proportion of us who are home insecure and what not. And, I really think that this is part of a larger issue that is related to health care.”
Blunt echoes this, saying, “I think there are a myriad of barriers to receiving mental health services as a sex worker. I think that just the fact that, often times, a sex worker-competent therapist or kink-positive therapist don’t take health insurance, or that so many people are uninsured creates a huge barrier.”
Racism and classism also play into accessibility. Femi babylon says she feels as though she has to tip-toe around providers who judge her. “I’m always having to gauge what I can and cannot say. And it’s very irritating. I know this one doctor, I knew I couldn’t say anything to her because she kept saying stuff to me, she kept being patronizing in a weird way and made weird comments about me homeschooling my son.”
Historically — and this continues today — sex workers have responded to a lack of care on an institutional level by filling in the gaps themselves. But community resources and public networks of sex-worker competent therapists have made the process of finding a provider more manageable.
For example, Manhattan Alternative is a website that lists many sex-worker-friendly mental health care providers. But networks like these are primarily found in select metropolitan areas. As Warfield explains, “unless you are in New York City or San Francisco, it’s hard. You should be able to find someone in rural Illinois.”
SWOP’s community help line does operate nationally to provide current and former sex workers to access mental health resources; however, it faces similar struggles identifying providers outside major metropolitan areas.
Blunt suggests that initial conversations can reveal a lot about a provider. She recommends asking therapists about their previous experience working with sex workers and observing how they respond. “People often give a lot away in their response whether or not they’re saying anything useful,” she says.
Warfield wants to “encourage other people to just be open when you’re interviewing potential therapists.” Be honest about your sex work and recognize when a provider is pathologizing it. She also suggests that sex workers ought to “feel empowered to get another therapist.”
Blunt recommends vetting therapists in the third person. “I would get better care if someone thought that I was having someone advocate for me.
I wouldn’t get put on hold as much. And it was just mentally easier for me to dissociate through the medical industrial complex to get the shit that I needed.”
One of the ways that providers can make their services more accessible is by opening up sliding scale spots or offering services for free when able. But it is not enough to simply make your services more accessible if those services are not adequately informed on sex-worker care. When therapists do not educate themselves, the responsibility falls on clients.
Jasmine asserts, “[Therapists] shouldn’t put the burden of learning about the different types of sex work and/or the challenges that we have or don’t have on the client.”
Blunt continues this sentiment, “I think therapists could complete sex worker competency trainings as well as paying sex workers for their expertise [and] their lived expertise.” Giving adequate care includes putting clients first, which can’t happen if clients are the ones educating their providers without compensation.
There are several ways in which therapists can counteract the inadequacies of larger institutions to make their care more sex work-informed. Getting involved in sex work organizing and reading articles and books written by sex workers themselves allows for an understanding of the issues impacting the community. Additionally, trainings and certifications help therapists become more sex-work competent like the Equitable Care Certification which enables providers to become more competent in sex work and care for other marginalized groups.
Jasmine Johnson says that therapists should also consider how their own history dovetails with the care they’re offering. “I think a lot of therapists go into being therapists without doing an inventory of their own sexual shame as well as their sexual traumas and feelings of mental health,” she warns. “What happens is it operates in your subconscious so you are always pushing an agenda you’re not even aware of.”
Blunt talks about the need for therapists to understand the intricacies of sexual labor and the necessary skill of carrying seemingly disparate parts. “You can hold overlapping, complicated feelings about that work at the same time,” she explains. She says therapists need to be providers “who can hold space for people’s complicated lived experiences around work without passing judgement."
She says therapists can also signal to clients by keeping a few books on their shelves that could open a conversation so a client could assess where their new therapist’s sex worker competency is and if they feel comfortable disclosing their background. (This signaling can also be done through advertising that you are queer, BDSM/kink, and/or sex worker-friendly so that sex workers can find your services.)
femi babylon suggests that in order to make marginalized patients, including sex workers, more comfortable, they need to be vocal about their support.
“I think they should state it up front that they care for all these marginalized populations, because all these populations intersect,” babylon says, “They should be studying us and different groups of people and putting aside their biases to treat people.”
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