1. Stigma, Social Exclusion and Health: Sex Work in Canadian Society
Prepared By: Rachel Phillips, Josephine MacIntosh & Cecilia Benoit
Department of Sociology - University of Victoria
See Also:
Sara Spencer Foundation
Michael Smith Foundation for Health Research
Prostitutes Empowerment Education and Resource Society
I’d like to begin by introducing myself, Rachel Philips and my colleague, Josephine MacIntosh. Unfortunately, Dr. Cecilia Benoit is not able to be with us today. We are both PhD students from the Sociology Department at the University of Victoria, although Josephine is in an interdisciplinary studies program.
Funding for this research has been provided by: the Sara Spencer Foundation, the Michael Smith Foundation for Health Research, and the Prostitutes Empowerment Education and Resource Society.

2. Paper Objectives
Drawing on a social determinants of health framework, explore the sex trade as a highly marginalized occupation.
Provide a narrative summary of stigma and social exclusion as described by persons involved in the sex trade.
Provide recommendations for further research.
Our goal with this presentation is to situate the health status of sex workers within the social determinants of health framework, specifically focusing on occupation and social exclusion.
·      Drawing on a social determinants of health framework, we will explore the sex trade as a highly marginalized occupation.
·      We will provide a narrative summary of stigma and social exclusion as described by persons involved in the sex trade.
·      We will summarize respondents’ self-reported experiences of stigma, and the effects of the stigma of sex work on personal identity, emotional well-being, interpersonal relationships, and health seeking.
We will also provide a description of our ongoing research.

3. Existing Literature on “Prostitution”
Competing discourses in the social science literature:
Prostitution as male sexual aggression against vulnerable women.
Parallels found in the criminological and epidemiological literature where deviance and “health risks” accompanying sex work are examined, including sexually-transmitted infections (STIs), exposure to violence, and illicit drug use.
Prostitution as freely-chosen economic activity, an occupation – ‘just another way of making a living’.
Focus on sex worker's rights as an emancipation and labour issue rather than as an issue of male criminality/exploitation.
There tend to be two competing discourses in the social science literature:
The first views prostitution as male sexual aggression against vulnerable women. Parallels can be found in the criminological and epidemiological literature where deviance and “health risks” accompanying sex work are examined. The dominant topics in the literature have been: Transmission routes of STI’s, HIV/AIDS and other blood-borne infections; safer sex practices, illicit drug use; contexts of transmission; screening and treatment; violence and psychological distress, and the use of protective health resources.
The second perspective treats prostitution as a freely-chosen economic activity, an occupation, or ‘just another way of making a living’. The focus here is on sex worker's rights, as an emancipation and labour issue rather than as an issue of male criminality and/or exploitation.
Comparatively little data is available on how sex work, as a stigmatized occupation, affects health and access to social resources. Until recently, most research was conducted on outdoor, visible workers; however, there is a limited but growing body of research on indoor workers and other sub-populations.

4. Existing Literature: Occupational Health
Determinants of occupational health:
Autonomy/decision making authority
Social exclusion/social support for occupation
Work demand/reward ratio (e.g. money, status)
Stress
Exposure to dangerous working conditions
Access to employee benefits and workplace protections
Occupational health indicators are rarely applied to the sex trade, which is regarded as a highly risky form of labour. How does stigma interface with these domains and what is the impact on sex workers?
The occupational health literature has identified
·      Autonomy and decision making authority
·      Social Exclusion/Social Support for an occupation
·      Work demand versus reward ratio ( that is, how money, status, self-esteem figure into the picture)
·      Stress
·      Exposure to dangerous working conditions, and
·      Access to employee benefits and workplace protections as the major determinates of health.
These indicators have largely not been applied to the sex trade, which is regarded as a highly risky form of labour. We wonder, how does stigma interface with these domains and what is the impact on sex workers? Sex work is an occupation which offers an ideal case study of marginalized and stigmatized work.

5. Methods and Data
Project initiated by community partner: Prostitutes Empowerment Education and Resource Society (PEERS)
Community-academic collaboration; employed experiential research assistants.
Diverse research tool including closed ended (n=201) and open-ended (n=79) questions on a range of topics.
Full Report: Dispelling Myths and Understanding Realities (2001). Benoit and Millar
Sample Size: 201 respondents located in the Victoria Region
Work Status: 147 active, 54 Retired
Gender: 160 females, 36 males, and 5 transgendered (male to female)
Work Location: majority of respondents had worked in a variety of venues, including both indoor and outdoor sex work. The focus of the study was on indoor workers.
The project was a Community-academic collaboration initiated by our community partner: the Prostitutes Empowerment Education and Resource Society (PEERS) in Victoria and we employed experiential research assistants.
A diverse research tool included both closed ended (n=201) and open-ended (n=79) questions on a range of topics. This paper focuses on the open-ended responses.
The Full Report can be found in: Dispelling Myths and Understanding Realities, Benoit and Millar (2001).
The Sample included 201 respondents located in the Victoria Region active and 54 Retired STW
Gender: 160 females, 36 males, and 5 transgendered (male to female) participated in the study and the majority of respondents had worked in a variety of venues, including both indoor and outdoor sex work. The focus of the study was on indoor workers.

6. Is the Sex Trade Viewed Negatively?
“Some people stereotype you and they think that a hooker on the street, an independent escort or somebody that’s in an agency are all the same. They’re all the same, they’re all whores. I don’t listen to them… I was making a living and supporting myself and children and that’s all there was to it. It was work.” (Female, 32, agency-based)
“If you’re giving away your body for sex, then nobody looks at it as a job. They look at you like a slut. People do look down on you.” (Male, 27, street-based)
“Clients don’t consider what they’re doing… as wrong but they kind of look at the people who are working like they’re a product, you don’t have any feelings, you’re something to be used. It’s not that we’re all dirty little whores or fuckin’ disease ridden whatever, or that we’re all nasty drug addicts. It’s not true... what you see on TV, like the glamour and the glitz and everything like that, it’s not true as well… both are extremes.” (Male, 36, club-based)
These responses are to the question: Do you think that people tend to view sex trade in a negative light?
“Some people stereotype you and they think that a hooker on the street, an independent escort or somebody that’s in an agency are all the same. They’re all the same, they’re all whores.
I don’t listen to them… I was making a living and supporting myself and children and that’s all there was to it. It was work.” (Female, 32, agency-based)
“If you’re giving away your body for sex, then nobody looks at it as a job.
They look at you like a slut. People do look down on you.” (Male, 27, street-based)
“Clients don’t consider what they’re doing… as wrong but they kind of look at the people who are working like they’re a product, you don’t have any feelings, you’re something to be used. It’s not that we’re all dirty little whores or fuckin’ disease ridden whatever, or that we’re all nasty drug addicts. It’s not true... what you see on TV, like the glamour and the glitz and everything like that, it’s not true as well… both are extremes.” (Male, 36, club-based)

7. How Do You View Sex Work?
“To them [clients] it’s fantasy. To me, this is reality. It’s business. This is my money, this is my job. To me it’s not sex. It doesn’t even seem like that because it’s so business oriented. I’m so business oriented and the people I deal with know that. Most of the people that I deal with are businessmen so they have their certain amount of time. They know what they want. They know that I know what they want, and everybody's happy.” (Female, 31, agency)
“When it comes down to it, I have full control over what I’m doing. I know that I can make my own decisions, my own rates, and I can make my own hours.” (Male, 27, home)
“A lot of people look at it like it’s really, really bad. The way I see it, it’s not the greatest thing, but it’s not the worse thing possible.” (Female, 28, street)
Varying views of sex-as-work and be found in the narratives:
“To them, the clients, it’s fantasy. To me, this is reality. It’s business. This is my money, this is my job. To me it’s not sex. It doesn’t even seem like that because it’s so business oriented. I’m so business oriented and the people I deal with know that. Most of the people that I deal with are businessmen so they have their certain amount of time. They know what they want. They know that I know what they want, and everybody's happy.” (Female, 31, agency)
“When it comes down to it, I have full control over what I’m doing. I know that I can make my own decisions, my own rates, and I can make my own hours.” (Male, 27, home)
“A lot of people look at it like it’s really, really bad. The way I see it, it’s not the greatest thing, but it’s not the worse thing possible.” (Female, 28, street)

8. How Do You View Sex Work?
“I have a couple of opinions about it actually. In some ways I think if there’s a woman that’s older and she doesn’t have a problem with it, then I don’t think that there’s anything wrong with it. She should be able to set something up in her home and do it if she wants to. However, I think that it’s people just getting into the sex industry, I think it’s a real dangerous place to be. I don’t think they’d really be there if they had high self-esteem. I think it’s easier to get into it because there’s lots of people who will pay for it. For me it was the easiest thing to get into when I was young. I look around and I see that it’s the same thing for other young people but I think that it’s kind of exploitive. I think it’s very dangerous and it leads to a lot of heavy drugs and destroys a lot of lives. I don’t think that it’s meaningful employment.” (Female, 42, massage parlour, retired)
A 42 year old Female retired from the massage parlour business had this to say about sex-as-work:
“I have a couple of opinions about it actually.
In some ways I think if there’s a woman that’s older and she doesn’t have a problem with it, then I don’t think that there’s anything wrong with it. She should be able to set something up in her home and do it if she wants to.
However, I think that it’s people just getting into the sex industry, I think it’s a real dangerous place to be.
I don’t think they’d really be there if they had high self-esteem.
I think it’s easier to get into it because there’s lots of people who will pay for it.
For me it was the easiest thing to get into when I was young.
I look around and I see that it’s the same thing for other young people but I think that it’s kind of exploitive.
I think it’s very dangerous and it leads to a lot of heavy drugs and destroys a lot of lives.
I don’t think that it’s meaningful employment.” (Female, 42, massage parlour, retired)

9. Effects on Personal Identity
“The comment that came to my attention the most was “she’s a hooker”, that’s not right. I am a hooker, it’s my job, it is not who I am. I thought about it and it’s been weeks, and I couldn’t take it any more. This isn’t right. I am an individual.” (Female, 31, agency)
“Mentally, emotionally it affects everything. You become that person and it seeps into the rest of your life. If you are going to be in the sex trade you’ve got to have the skills to separate the business from home…” (Female, 24, agency)
“I have a boyfriend and I promised him that I would never tell our friends and stuff like that. Basically that’s how we leave it, I consider myself two people. So when I’m at work I’m one person and when I’m at home…” (Female, 20, agency)
“It was a part of my life, but people that meet me today, why should I tell them what I did ten years ago. It’s none of their business. When you meet me today, it’s not written on my forehead “ex-prostitute” and I still believe there is discrimination. It shouldn’t be, but there is discrimination.” (Female, 45, massage, retired)
The negative effects of stigma on personal identity were described by many respondents:
“The comment that came to my attention the most was “she’s a hooker”, that’s not right. I am a hooker, it’s my job, it is not who I am. I thought about it and it’s been weeks, and I couldn’t take it any more. This isn’t right. I am an individual.”
“Mentally, emotionally it affects everything.
You become that person and it seeps into the rest of your life.
If you are going to be in the sex trade you’ve got to have the skills to separate the business from home…” (Female, 24, agency)
“I have a boyfriend and I promised him that I would never tell our friends and stuff like that.
Basically that’s how we leave it, I consider myself two people.
So when I’m at work I’m one person and when I’m at home…” (Female, 20, agency)
“It was a part of my life, but people that meet me today, why should I tell them what I did ten years ago.
It’s none of their business.
When you meet me today, it’s not written on my forehead “ex-prostitute” and I still believe there is discrimination.
It shouldn’t be, but there is discrimination.” (Female, 45, massage, retired)

10. Effects on Emotional Well-Being
“In my experience I have met so many people I’m close to who can keep it in a good place and achieve their goals, and also those who get swallowed up by the whole thing and end up addicted to drugs or in really bad shape emotionally, spiritually and physically.” (Male, 41, clubs)
“It’s just a job that’s it. I don’t come home and break down, there’s been times when I’m not to happy with what I do but…and if I stay in that head space I get depressed and stuff like that but it’s just a job. For me that’s it.” (Female, 25, agency)
“To do this kind of work, you have to be…a strong woman… because sometimes it can get very degrading if you sit around and let that get to you. I think you lose your whole kind of headspace. To keep your humour is very important… sometimes it’s hard because you live a double life, people … some people know and your family doesn’t know and it’s hard…” (Female, 29, home)
Varied effects on on Emotional Well-Being were described:
“In my experience I have met so many people I’m close to who can keep it in a good place and achieve their goals, and also those who get swallowed up by the whole thing and end up addicted to drugs or in really bad shape emotionally, spiritually and physically.” (Male, 41, clubs)
“It’s just a job that’s it.
I don’t come home and break down, there’s been times when I’m not to happy with what I do but…and if I stay in that head space I get depressed and stuff like that but it’s just a job. For me that’s it.” (Female, 25, agency)
“To do this kind of work, you have to be…a strong woman… because sometimes it can get very degrading if you sit around and let that get to you.
I think you lose your whole kind of headspace.
To keep your humour is very important… sometimes it’s hard because you live a double life, people … some people know and your family doesn’t know and it’s hard…” (Female, 29, home)

11. Effects on Personal Relationships
“My children don’t know what I do, as far as they know I clean houses.” (Female, 38, home)
“I was the shame of the family [but] my brothers thought I had nothing to be ashamed of… today it’s just one of those things that happened in the past, it’s not talked about.” (Female, 39, bars, retired)
“With relationships that I have ever had, the majority of relationships I’ve ever been in I have never shared that with them [my involvement in the sex trade]. I was engaged for six years and he didn’t now anything about my past.” (Female, 33, street, retired)
“I talk about it openly with others, but it is also a risk when I do talk about it. So right now I am trying to gauge who can accept it and who can’t and I have suffered as a result of sharing it openly.” (Female, 34, agency, retired)
The stigma of sex work rarely had positive effects on interpersonal relationships with family, lovers, or potential friends:
“My children don’t know what I do, as far as they know I clean houses.” (Female, 38, home)
“With relationships that I have ever had, the majority of relationships I’ve ever been in I have never shared my involvement in the sex trade. I was engaged for six years and he didn’t now anything about my past.” (Female, 33, street, retired)
“I was the shame of the family [but] my brothers thought I had nothing to be ashamed of… today it’s just one of those things that happened in the past, it’s not talked about.” (Female, 39, bars, retired)
“I talk about it openly with others, but it is also a risk when I do talk about it. So right now I am trying to gauge who can accept it and who can’t and I have suffered as a result of sharing it openly.” (Female, 34, agency, retired)

12. Effects on Seeking Help
“I would like to be able to sit down and say, ‘this is what I am’ and not have to worry about them putting on the gloves just to talk to you.” (Female, 41, home)
“I’ve had four doctors tell me… they don’t want to be my doctor any more. They’ve never given me a reason. I walked into an appointment once with my girlfriend and they refused to see either one of us. It… has a lot to do with the stereotypical attitude... people generalizing certain categories together... I think doctors don’t understand, or if they do understand they’re avoid[ing] the whole situation altogether.” (Female, 25, street)
“I had a doctor for 36 years... He never knew that I was in the sex trade and I never told him. I was too ashamed.” (Female, 44, agency, retired)
“[Doctors] are pretty closed minded, they don’t respect what I do as hard work. It’s a lot of lectures on safety. Chances are I’m safer than you.” (Female, 44, agency)
While many participants reported very positive or at least non-problematic experiences with doctors, many others felt stigmatized:
“I would like to be able to sit down and say, ‘this is what I am’ and not have to worry about them putting on the gloves just to talk to you.” (Female, 41, home)
“I’ve had four doctors tell me… they don’t want to be my doctor any more. They’ve never given me a reason.
I walked into an appointment once with my girlfriend and they refused to see either one of us. It has a lot to do with the stereotypical attitude people generalizing certain categories together. I think doctors don’t understand, or if they do understand they are avoiding the whole situation altogether.” (Female, 25, street)
“I had a doctor for 36 years... He never knew that I was in the sex trade and I never told him. I was too ashamed.” (Female, 44, agency, retired)
“[Doctors] are pretty closed minded, they don’t respect what I do as hard work. It’s a lot of lectures on safety. Chances are I’m safer than you.” (Female, 44, agency)

13. Improving the Work
“I think society’s attitude in general needs to change. Also an expansion of support that exists already; and implementation of new support so that the trade is administered with a thought of harm reduction instead of criminality. And once that changes, and society’s attitude changes, then I think the workers in the trade are going to feel more control… “I think minimum work standards would have to include personal safety, freedom from harassment both by law enforcement and general public, accessibility to health care, and just an overall acceptance from people… It’s not going to go away, so let’s improve the situation for everyone involved.” (Male, 41, bars)
“It should be recognized as a profession.” (Female, 52, home)
“I think society’s attitude in general needs to change. Also an expansion of support that exists already; and implementation of new support so that the trade is administered with a thought of harm reduction instead of criminality. And once that changes, and society’s attitude changes, then I think the workers in the trade are going to feel more control… “I think minimum work standards would have to include personal safety, freedom from harassment both by law enforcement and general public, accessibility to health care, and just an overall acceptance from people… It’s not going to go away, so let’s improve the situation for everyone involved.” (Male, 41, bars)
“It should be recognized as a profession.” (Female, 52, home)

14. Improving the Work
“It would look pretty much the same as any other unionized organization. Giving you your medical and your dental and your sick leave. If you have to take a couple of days off you could get paid for it. I guess if women had to take maternity leave, give them that as well. Full medical coverage, so if something goes wrong you’re able to get help.” (Male, 23, street)
“Probably some sort of clinic that’s exclusive to sex trade workers. Something that you would have complete confidentiality with. Something that’s a little cleaner than what we see around here and what we’re used to. A place that has set up therapy groups [that] you can just clean your head with. Someone that’s been through it and been around.” (Male, 41, bars)
“It would look pretty much the same as any other unionized organization. Giving you your medical and your dental and your sick leave. If you have to take a couple of days off you could get paid for it. I guess if women had to take maternity leave, give them that as well. Full medical coverage, so if something goes wrong you’re able to get help.” (Male, 23, street)
“Probably some sort of clinic that’s exclusive to sex trade workers. Something that you would have complete confidentiality with. Something that’s a little cleaner than what we see around here and what we’re used to. A place that has set up therapy groups [that] you can just clean your head with. Someone that’s been through it and been around.” (Male, 41, bars)

15. Conclusions Occupation is a primary social determinant of health
On the positive side, sex workers tend to report that:
They have a reasonable amount of autonomy and decision making authority
The work demand/reward ratio is adequate
However, the stigma of “prostitution” means that sex workers face an additional burden of social exclusion which contributes to:
Hidden and potentially dangerous working conditions
Individual & interpersonal stress
Barriers to social supports (health benefits & workplace protection)
“It’s a heavy thing mentally to deal with and live with. You have to be prepared to shut down, close off parts of your self and not every body can do that.” (Female, 46, street)
Occupation IS a primary social determinant of health.
On the positive side, sex workers tend to report that they have a reasonable amount of autonomy and decision making authority and the work demand/reward ratio is adequate.
However, the stigma of “prostitution” means that sex workers face an additional burden of social exclusion which contributes to hidden and potentially dangerous working conditions, individual & interpersonal stress, and barriers to social supports such as health benefits & workplace protection.

16. Ongoing Research
Interactive Service Workers Occupational Health and Safety and Access to Health Services Study: Victoria, BC and Sacramento, CA.
Principle Investigator: Cecilia Benoit, University of Victoria
A longitudinal comparative model is used to overcome the limitations of cross-sectional data This new study examines occupational experiences, health and health care access across sex work populations and between sex work populations and other lower-income groups.

17. Ongoing Research Courtesy Stigma: A Hidden Health Concern?
Doctoral Dissertation: Rachel Phillips.
How are providers affected by the stigma associated with their clients and how does this, in turn, shape the service context and the occupational health of the service providers?
A complementary investigation of stigma and health care access from the perspective of service providers who serve hidden and stigmatized populations such as sex workers is currently in development.
These studies will add important data to the social determinants of health model, especially regarding the relationship between stigma, social exclusion, health status, and health care access.

18. Abstract
Occupation is recognized as a primary social determinant of health. People who have more control over their work circumstances and fewer stress-related demands on the job tend to be healthier and live longer than individuals in riskier and more stressful work situations. People who work in the sex industry face an additional burden of social exclusion; they tend to be isolated from other workers and within society at large because of the tenacious stigma associated with selling sex services. Drawing on a mixed method study (N=201) of current and former sex workers located in various parts of the sex industry, this paper investigates the interplay between stigma, social exclusion and self-reported health. The findings indicate that sex workers tend to be disadvantaged by an earlier life marked by social and economic disadvantage, and that as adults, many continue to lack access to crucial resources needed to improve their health outcomes. While noting the definite advantages of sex work (often self-determined, largely portable and offers cash-in-hand earnings), many research participants said that their activities often involved a high degree of workplace stress, few workplace supports, and rarely contributed to personal gratification. In addition, many respondents indicated that the stigma of sex work undermined both their personal relationships as well as their access to institutional supports.