The Motivation and Mental Health

of Sex Workers

Bella Chudakov, MD², Keren Ilan, BA1, RH Belmaker, MD¹,

Julie Cwikel, PhD²

¹Center for Women’s Health Studies and Promotion and

Dept of Social Work, ²Faculty of Health Sciences,

Ben Gurion University of the Negev, Beer Sheva, Israel

Correspondence:       RH Belmaker, MD

                                 Beer-Sheba Mental Health Center

            PO Box 4600

Beer-Sheba, ISRAEL. 

Phone:  (972 7) 640-1602.  Fax:  (972 7) 640-1621

                                    e-mail: belmaker@bgumail.bgu.ac.il

Abstract

Objective: Commercial sex work presents specific mental health concerns.  We aimed to study motivation for sex work and mental health issues in a sample of such women.

Methods:  Fifty-five consenting women contacted through organized brothels were interviewed using the Farley questionnaire and screening items for PTSD and depression.

Results: Eighty-two percent of the women had arrived illegally and had been “trafficked”.  All but two were engaged voluntarily in sex work.   Seventeen percent met criteria for PTSD and 19% were likely to be clinically depressed.  Representative case histories are presented.

Conclusions: Availability of mental health treatment for workers in the sex industry could improve compliance with HIV prevention programs and enlarge options for women to leave the sex industry.  Stereotypes of sex workers as always having abused childhoods, or on the contrary, as being always “happy hookers”, are shown to be incorrect.

Recent news reports suggest a large-scale migration of East European women to the West to work in the sex industry.  This phenomenon, catalyzed by the break-up of the former USSR and the resultant sharp decline in economic stability and standard of living in countries such as Moldova, Ukraine and Latvia, is surprising in light of the sexual revolution in the West and the easy access for most men to non-commercial sexual partners (Bullough & Bullough, 1996).  Moreover, the HIV epidemic and the possibility that sex workers are poorly compliant to safe sex practices makes for possible widespread health consequences of this migration of sex workers (Carr, 1995).  The sex workers themselves are a cause for mental health care concern as they have been reported in the past to have high rates of depression and PTSD (Farley & Barkan, 1998).  We studied a sample of sex workers largely from the former USSR in three Israeli cities with  special emphasis on 1) motivation for migration and intent to work in the sex industry  2) types of sexual activity and use of condoms and 3) personal health, satisfaction and psychological symptoms.

Methods

            Large newspaper ads in Israeli newspapers for escort services were contacted by telephone and the purpose of the study explained.  Only a small number agreed to participate, but appointments for interviews led to some interviews for a fee. Later contact was made with a lawyer representing some of the prominent escort services, who then arranged interviews with brothel workers in two Israeli cities.  Two interviewers conducted interviews, at least one of whom was female, one Russian speaking and almost always one psychiatrist.  The interview was an expanded version of the Farley questionnaire for sex workers with a validated Russian translation (Farley & Barkan, 1998).  The interviews were conducted out of hearing of any third parties and full anonymity was guaranteed. Oral consent was obtained after explaining the study and this procedure was approved by our IRB.  Some of the interviewees were paid but the bulk of the interviews in two cities were conducted with unpaid volunteers. 

PTSD symptoms were measured using the PTSD checklist (PCL) 17 item scale (Stein et al, 2000).  The questions were asked about symptoms in the past month using a five point severity scale. Depression was measured with six questions derived from the CES-D depression scale (Radloff, 1977).  Questions were asked about feelings associated with depressive mood in the past week using a four point scale.  This abbreviated scale has been used in community surveys by the Commonwealth

Fund in the United States (Sherbourne et al, 2001) and in a women’s health survey in Israel (Cwikel, 2000).  Data relating to physical symptoms and sexally transmitted disease risk are published elsewhere (Cwikel, submitted).

Results

Fifty-five interviews were conducted. Descriptive data on the sample are shown in Table 1.  All but two of the sex workers had arrived in Israel from countries of the former USSR.  The majority (82%) had arrived illegally, some by boat evading port immigration authorities and some on camel back smuggled by Bedouin from Egypt across the unguarded points on the Sinai border.  Thus, a majority of women had been “trafficked”, although only two reported that it was against their will.  Furthermore, 17% reported being sold against their wishes to a brothel owner, 64% were transferred with their consent to other places of work and 19% were not sold or transferred.  Almost all women reported engaging in sex work of their own volition and reported that they knew before leaving their country of origin that this was to be their occupation upon destination.

All women reported using condoms with clients for vaginal sex but most reported no use of condoms for oral sex.  Women reported difficult conditions of work:  an average of 12 clients per day (range 4-25),  with 42% reporting that they worked throughout the month including during their menstrual cycle.   However, most (78%) reported ability to send $1,285 on average per month ($1,000 was the modal sum with range of $125 to $3,000) back to family in their country of origin.  All of those of the mothers in the sample reported supporting their children economically.

 The PCL average score was 38.5 (s.d. 13.5).  Using a cut-off point of 3.0 or greater 17% showed signs of PTSD which meet DSM-IV criteria compared to 11.8% in a US primary care study (Stein et al, 2000).   There were 33% who had an average depression score over 2.5 (presence of depressive symptoms) and 19% with averages over 3.0 (likely to be clinically depressed).  In a community sample of Israeli women with the same scale and same cut-off points, 6% had averages over 2.5 and 2% had averages over 3.0 (Cwikel, 2000).

However, the richness of the clinical interviews could not be captured by the questionnaire data.  In particular, public stereotypes of sex workers as entirely the products of abused childhoods, or alternatively, as happy-go-lucky sexual enthusiasts (e.g. book “The Happy Hooker”), or good girls waiting for their handsome prince to save them (e.g. the movie “ Pretty Woman”) were negated by the tremendous heterogeneity of the phenomena of commercial sex work that we became aware of in our interviews (Hollander, 1996).  In particular, women’s current mental health, their reported physical symptoms and their exposure to childhood and work-related violence and abuse were quite diverse.

We therefore felt it useful to bring to scientific attention this heterogeneity via a case history approach.  On the basis of consensus among two psychiatrists, one social worker and one philosopher involved in the interviews, we divided the cases into five prototypes.  One case representative (not a composite) of each type is presented here.

“Angie”  

Angie is a very pretty girl, with blue eyes and hair dyed strawberry blond. Nineteen years old, from Moldova, Angie has 10 years of formal education plus an eight-month sewing course, but she never worked in that field. Her parents remain in Moldova; her mother is a cook and her father drives a tractor. Angie sends them money, around $1200 every month, but says they don’t know what she is doing in Israel.

When Angie was 16, she had sex for the first time, with the boyfriend whom she loved.  A year later, at 17, she began to work in the sex trade. She worked in Turkey for sixteen months and was arrested there twice. She went to Moscow, flew to Egypt, and from there walked over the border (a three hour hike) into Israel. 

Angie has been working for seven months in Israel. She sees between 5 to 17 clients daily, averaging around eleven.  She offers regular sexual services and ‘does parties’, but does not do striptease, pornography, or dancing.  She feels that people use her services “to have a good time”.

Angie was last seen by a gynecologist two years ago, and by a family physician about a year ago.  She had an AIDs test this past month. She feels her health is good, but has some small problems with her vision,  her teeth need dental care; she also reports occasional stomach cramps, sore throat, and nausea.  Her overall self image is positive, and except for occasional trouble sleeping her mental health seems satisfactory. She smokes 1 – 1 ½  packs of cigarettes daily, and drinks occasionally “to feel good”.

Angie reports that she has not experienced rape or abuse, neither as a child nor in Israel.  If clients curse or insult her, she curses them back. She is working of her own free will, and wants to continue in the trade. She says she likes what she does and feels that she is satisfied with, and has some control over, her life.  She has no plans for the future.

Angie was typical of a “uncomplicated” among our sample, where education level was medium to low, psychosocial problems were not prominent, motivation seemed economic and ego-syntonic. Despite the present satisfaction with their work, most of these respondents wanted to leave prostitution after acquiring a specific amount of money.  Fifteen of the 55 women were judged to be in this group.

 “Nora”

Nora is also a nineteen year old from Moldova. Tall, slim, long legged and with long dark hair, Nora is a fairly pretty girl. She is, however, very bitter and angry about her life.

Nora grew up with a mother who was often drunk and who neglected her both physically and emotionally. Sometimes they were homeless, and she remembers times when she was hungry and had no food. There was a stepfather in the home who beat her regularly – threw her against the wall, threw things at her, kicked her – and then raped her when she was 14 years old.  Tense but without tears, Nora then described how, following the rape, she ran away to a girlfriend’s house, but was found and gang raped in the snow by eight strangers.  She went to the police but was told that there was no evidence with which to make a case, and that since she was a prostitute anyway, she should just go on working in the sex trade. She recalls this response from the police with great pain and bitterness, and says that it finally destroyed her ability to trust others.

Nora began to work as a prostitute, in Turkey, when she was seventeen.  She reports being twice sold in Turkey against her will, and was also subjected to violence. Knife cuts across her stomach left scars which required corrective surgery, and she was also threatened with a knife, by clients and by the police.  Eventually, she ran away, was able to recover her passport, and fled Turkey.  She arrived in Israel ten months ago. When asked if she was working in Israel of her own free will, she replied that it was “fate”.  She sees between 10 and 20 clients daily, most often 12 to 13, and always showers afterwards.  She provides the regular sexual services but prefers not to do group orgies, as it reminds her of the gang rape. She was once asked to act sadistically to a client, but started hitting him so hard that she almost killed him, and now refuses to play that role.  She says that she can’t have contact with clients if she doesn’t talk to them, and often reaches orgasm with them. She likes it that most clients treat her nicely, although she is sometimes insulted by things said to her. She would not reveal how much money she is making, but said that she does send an undisclosed amount of money home, via a cousin, to be used to take care of her younger sister (now 14), who lives with Nora’s mother and step-father and about whom Nora worries a great deal. She would also like to save money in order to continue her education; she completed only nine grades and has no profession besides sex worker.

Nora had been checked by a gynecologist about three weeks prior to the interview, and had seen a family physician about six months previously.  She reports health problems including high blood pressure, arthritis/rheumatism (for which she has been hospitalized), repeated urinary tract infections, and occasional muscle weakness, dizziness, and nausea. She also reports pains in the neck, back, stomach, chest, pelvic region, vagina, breasts, hands, and backside, as well as numbness in her legs.  In addition, she suffers from anxiety and depression, and would be considered a clinical case of post-traumatic stress disorder.  She does not drink (the heavy drinking of her mother and step father repulsed her), but she smokes up to one pack per day.

Nora intends to finish working out her year and then quit the sex trade “no matter what”. She feels that she will need psychological help in order to make the transition, and in the meanwhile, she confides to a close friend. She is not happy with what she is doing and is unsatisfied with her life, over which she feels she has partial control, and she is not at all optimistic about her future. 

Nora was typical of an “abused type” among our sample, where childhood abuse and rape and violence during sex work had occurred, and where depression and PTSD symptoms were prominent.  Nevertheless, there was evidence of personal choice of type of client, orgasm at work, and feelings of good personal contact with most clients.  Twenty-three of the 55 women were judged to be in this group.

“Melody”

Melody is very petite and somewhat shy and has the height of a 12 year-old.  She has a very nice figure but her features are irregular, with a scar on her lip and her nose askew.  Twenty years old, Moldovan, Melody completed three years of high school and has been trained as a manicurist. Her father died when she was three, and she was sent away to a boarding school. At thirteen, she attempted suicide after she was beaten by her mother when the mother discovered that Melody was no longer a virgin; at fourteen, she was homeless and on the street for five months.  She was first raped when she was twelve, by a neighborhood boy some five years older than herself, and with whom she continued to be in contact for some time thereafter.  At fifteen, she was the victim of another (attempted) rape, which was very violent; she suffered broken ribs, a broken nose, and a cut on her lip that required surgery. She recalls being raped at least ten times before turning 18, but she never told anyone or asked for help.  She has been arrested once in Moldova, for marijuana possession, has used other drugs, and has undergone treatment for alcohol addiction.

Melody decided to enter prostitution after being rejected by a striptease bar in Yugoslavia.   She came through Egypt and was taken by car to Tel Aviv and from there to Eilat.  While it was her decision to come here, after two months she now feels that she is trapped. She is here illegally, her passport has been taken away, and she has been told that it will only be returned when she has completed a year of work. She works seven days a week, 16 hours per day, and on a usual day will see between 10 and fifteen clients (although she has seen as many as 25 in one day).  In addition to regular services, she will also perform lesbian sex and “sado”.   She has never been attacked while at work, although she has had her feelings hurt by clients who insulted her. She mentioned that she was most hurt by being told that she wasn’t pretty by clients.  She has a cell phone to use to call for help should the need arise.  She is earning around $3000 per month, of which she sends about $1500 home; she would like to save up $10,000 for her studies, her family, and to buy an apartment.

    Melody does not remember when she last saw a family physician, although she did see a gynecologist about a week before our interview.  While still in Moldova, she had four abortions.  She contracted syphilis from her boyfriend at age 15, which remained untreated for a year.  Currently, she reports gynecological problems, recurrent urinary tract infections, low blood pressure, and occasional shakes/tremors, dizziness, headaches, sore throat, and nausea. In addition, she complains of pain in the lower pelvic area, vagina, ovaries, mouth, and jaw.  In addition, she shows symptoms of PTSD, depression, and has low self-esteem.  She takes oral contraceptives, and smokes a pack of cigarettes daily.

   Melody is another type of story that fits the background of those who have suffered from a traumatic background.  She is less symptomatic than Nora with regard to depression and PTSD but lacks self-confidence.  She is unusual in this sample in reporting a background that includes both drug and alcohol use. Her traumatic background also led to adverse effects on her overall health, not just psychological trauma.  In spite of feeling in control of her life, Melody is not at all satisfied with her present life and is not happy with her job.  She would like to leave prostitution but needs money.  However, she has hopes for the future and speculated that five years hence she will have several children and a good job. 

“Lana”

  A petite and slender 21-year-old Moldovan girl with long dark hair, Lana is animated and open.  An intelligent girl who speaks five languages, the daughter of two educated parents, Lana was trained as a midwife but never worked in that field.  She reports a loving and caring family back home, and misses her parents very much.  She sends money home every month – about $800 – but refrains from sending more so as not to arouse the suspicions of her family, who do not know what she is doing to earn the money.

  At age 18 Lana fell in love with a man in his 40’s, and her first sexual experience was with him. Their relationship lasted for about a year, and to this day they are still in phone contact.  When the relationship ended, Lana drifted into prostitution. She spent six months in Turkey – getting arrested five times and deported once.  She arrived in Israel 8 months ago after being smuggled over the border from Egypt, and is in Israel on a one year “contract”. Her boss holds her passport and her money. If a serious crisis should occur – such as a death in the family – Lana would be allowed to leave. Otherwise, she is required to fulfill her contract, and ‘misbehavior’ can be punished by sanctions such as being restricted to her apartment, or being forced to work for a week without pay.  On the other hand, Lana is a personal favorite of the brothel owner, and he uses her services more than those of any of the other girls – and for this, he pays well. 

  Lana works seven days a week, 29-30 days per month, 16 – 20 hours per day.  She routinely works during her menstrual cycle. She usually sees between 10 and 15 clients per day, although during busy periods she has seen as many as 25.  In addition to vaginal, oral, and manual sex Lana provides services such as dancing, massage, striptease, orgies, and a lesbian “act” which she performs together with a girlfriend.  She gets 20 shekels ($5.00) for up to half an hour, 50 shekels for an hour, and 100 shekels for an hour which includes “special services”  such as those mentioned above.  She has had some unpleasant experiences while working in Israel, including a client who enjoyed hurting her physically and other clients who, high on Ecstasy, grass, coke, crystal, or LSD, “act like animals and think that a girl doesn’t have any feelings”. If she feels endangered, she calls the office and they send someone down to “straighten them out”. She also can refuse clients who seem dangerous.  In general, Lana likes to talk with her clients, as this also allows the time to pass more quickly, and she occasionally allows herself to reach orgasm with clients.

Lana describes her health as “so-so to good”.  Her last visit to a family physician was about six months ago; a month ago she was seen by a gynecologist, who took a blood test for AIDS.  She is often tired and tense, and reports frequent pain in the back, pelvic region and vagina; she sometimes experiences pain in the neck, stomach, hands, and mouth.  Current health problems which have been diagnosed in the past five years include bronchitis, ovarian cysts, recurrent urinary tract infections, and dental problems. She has received alternative treatments to ease her pelvic pain but she still is symptomatic.  She drinks, sometimes enough to make herself dizzy, and smokes about a pack a day.  Her self-esteem is low, she is often sad and sometimes depressed, but not at clinical levels.  She shows some symptoms of PTSD but also not over the clinical cut-off.

  Lana reports that before the age of 18 she had never experienced abuse, neglect, or any form of assault.  She has, as noted, experienced some violence since beginning to work as a prostitute. She is working in prostitution out of choice; she does not like the work itself but does like the money that she earns. She is hoping to leave prostitution at the end of her year, and would like to earn $50,000 for psychological and medical treatment, and to continue her education.  She is not very satisfied with her current life and feels only partly in control, but she is optimistic about the future: she would like to return to Moldova, marry, raise children, and work in the field of translation.

Lana is representative of a subgroup in our sample with high level of personal resources, clear plans to continue education, considerable evidence of choice and control over her life. Furthermore, she described many methods of reducing risk in her job.  Twelve of the 55 women were judged to be in this group. However, five of the twelve in this group of high personal resources had histories of rape, homelessness, abuse or abandonment before they began sex work.

 “Gena”

Gena is a very pretty, long legged and attractive 23 year old from Uzbekistan.  She began studies at the university level, but did not complete them; she has hopes to continue eventually, perhaps in economics or accounting.  She had a comfortable and pampered childhood with no reports of trauma or abuse in a fairly well established family; both parents are academic, and do not require money from Gena in order to get along. She does, however, send them money every few months so they can buy presents. 

Gena first had sex with her boyfriend; she was seventeen, and he was three years older.  At twenty, Gena began to work in prostitution, at first in exchange for money, jewelry, and expensive gifts.  She came to Israel specifically to work in the sex trade, on the recommendation of a girlfriend, and has been here (illegally) for almost a year now working as an “independent”. Gena explains that she works in prostitution because she enjoys the work; she likes variety in sex and would be ‘giving it away for free’, so feels she may as well make money from it.  She reaches orgasm with clients 2-3 times per day. She enjoys talking with her clients, and often has “a good laugh” with those who speak Russian.  She works 5-6 days per week, and does not work during her menses.  She uses condoms with customers, but not with her Israeli boyfriend, and because of this she also takes birth control pills.  She earns about $25 for a half hour, which is the same as what the pimp gets.  She earns about $5000 per month but manages to save only about $1000. She hopes to “earn a million dollars”.

Gena rates her overall health as good; she has no major illnesses and only minor complaints (occasional toothache, occasional pain in her left leg). She smokes about 1 ½ packs per day; she has never had an abortion.

Gena is satisfied with her life, feels that she has control over her life, and is optimistic about the future. When asked to envision herself five years into the future, she says that she hopes to remain in Israel, to get married, and to have children.

Gena is representative of a subgroup in our sample with a specific attraction to sex work, enjoyment and pride in the work.  Five of the 55 women were judged to be in this group.

Discussion

            This study is limited by the fact that is based on self-report, that indirect coercion of responses was possible since contact was made through brothel owners, and that sampling bias may have led to an unrepresentative sample. However, replies on legal status suggest that the interviewees were not afraid to tell the truth.  Several conclusions are likely to be valid and may be required for policy makers until better data is available.  1) Prostitution is a large-scale social phenomenon closely allied to illegal trafficking in women and not based on local female workers.  2) Despite #1, almost all women involved are consenting adults in the legal sense even if coerced by severe economic disadvantage in their country of origin (Pederson, 1994).  3) Use of condoms seems adequate for vaginal sex but inadequate for oral sex (Perkins & Lovejoy, 1996).  4) Rates of PTSD and depression are lower than in some studies of prostitutes (Farley & Barkan, 1998) but still deserve attention and treatment.  The rate reported here is similar to the rate reported in samples of women who have reported a history of physical or sexual abuse in childhood and higher than what is found in the general population (Farley & Barkan, 1998;Stein et al, 2000). Unlike other studies (Green et al, 1993), this study focused exclusively on brothel workers whose working conditions are more protected than street prostitutes. Also not represented in this study were self-employed escort workers.

            A new Israeli law against trafficking in women makes the issue of consent of the women involved legally irrelevant. However, economic history suggests that vices indulged by consenting adults are not likely to be eradicated by law.  Thus education of prostitutes and their clients and supervisors to the importance of condom use is critical for prevention of spread of HIV to the large clientele of these workers. Furthermore, their status as illegal workers makes access to appropriate health care problematic, using requiring significant out of pocket expenses. Thus, identification and treatment of sexually transmitted diseases is unlikely.   It is critical to make social services including counseling available to such women both to reduce mental health burden in those suffering PTSD or depression and to inform them of their rights to leave prostitution and obtain alternative employment.

            The sample from which these cases were derived is clearly not systematic and exact proportions of each subtype cannot be estimated.  Moreover, commercial sex work is a constantly evolving human phenomenon and varies greatly from country to country and place to place.  The great economic pressure in Eastern Europe may have resulted in a larger number of young women from “normal” psychological background to be willing to do commercial sex work in the West than at other times.   Undoubtedly streetwalkers in say, Nairobi, are a very different sample (Farley & Barkan, 1998). It is important for hypothesis formation to realize the tremendous potential heterogeneity of commercial sex workers as evidenced in the case histories presented here.

References

Bullough, B., & Bullough, V. (1996). Female prostitution: current research and changing interpretations.  Annual Review of Sex Research, 7,158-180.

Carr, S.V. (1995).  The health of women working in the sex industry – a moral and ethical perspective.  Sexual and Marital Therapy, 10,201-213.

Cwikel, J.(2000). Results from the telephone survey of women's health in the Negev. Paper presented at the Overcoming barriers to women's health promotion, Beer Sheva.

Cwikel, J., Ilan, K., Chadukov, B., Belmaker, RH. Women brothel workers, trafficking and STD risk. Submitted.

Farley, M.., & Barkan, H. (1998). Prostitution, violence against women and Post-traumatic Stress Disorder.  Women and Health, 27,37-49.

Green, S.T., Goldberg, D.J., Christie, P.R., Frischer, M., Thomson, A., Carr, S.V., Taylor, A. (1993). Female streetworker-prostitutes in Glasgow: a descriptive study of their lifestyle. AIDS Care, 5,321-335.

Hollander X (1996) The Happy Hooker, Buccaneer Books.

Pederson, K. (1994). Prostitution or sex work in the common market? International Journal of Health Services, 24,649-653.

Perkins, R., & Lovejoy, F. (1996). Healthy and unhealthy life styles of female brothel workers and call girls (private sex workers) in Sydney.  Australian and New Zealand Journal of Public Health, 20,512-516.

Radloff, L. (1997). The CES-D scale: a self-report depression scale for research in the general population.  Applied Psychological Measurement, 3, 385-401.

Stein, M.,B., McQuaid, J.R., Pedrelli, P., Lenox, R., McCahill. M.E. (2000). Posttraumatic stress disorder in the primary care medical setting.  Gen Hosp Psychiatry, 4,261-269.

Sherbourne, C.D., Dwight-Johnson, M., and Klap, R. (2001). Psychological distress, unmet need, and barriers to mental health care for women. Women’s Health Issues, 11,231-243.

Stein, M.B., McQuaid, J.R., Pedrelli, P., Lenox, R., McCahill, M.E. (2000).  Posttraumatic stress disorder in the primary care medical setting.  Gen Hosp Psychiatry, 4,261-269.

Table 1 - Descriptors of Sex Workers Sample