This week Eachone acknowledges a beloved woman and activist Lisa Mallet who passed away July 7. Lisa was a dedicated and loving supporter of girls and women and a dear friend.
Our sense of loss is immeasurable.
Her blog, co-authored by her partner and love of her life Liz Waterhouse and dear friend Ari Miller, focusses exclusively on human rights abuses against lesbians and can be found here : https://listening2lesbians.com/category/listening-2-lesbians/ .
Here at Eachone we mourn Lisa’s tragic passing knowing she will always be with us in spirit and living in our hearts.
We publish this paper she wrote on prostitution as yet another testament to her commitment to ending violence against all girls and women with our enduring thanks.
Lisa Mallet, you are loved forever.
Mental Health Policy for Victims of Prostitution
by Lisa A. Mallett
The Ohio State University
MENTAL HEALTH POLICY FOR VICTIMS OF PROSTITUTION
Nowhere in mental health policy in the United States do we see as much inconsistency and inattention to evidence-based research as we do when addressing the mental health of prostituted women and girls. Despite research linking prostitution to increased rates of depression, anxiety, PTSD and substance use disorders, many in government, law enforcement, and society consider prostitution to be a victimless crime; a profession with occupational hazards of negative mental health outcomes, violence and even death.
Although most women in prostitution started as children, our laws attempt to give separate meanings to prostitution and human trafficking, devaluing the impacts of trauma experienced by women once they hit 18 years old. The sex-trafficked girl becomes the sex-worker woman and a rescue from slavery becomes an arrest for crime. All the while, the buyers, almost exclusively men, are seen sympathetically as normalized consumers of female bodies.
This paper will examine federal, state and local law and policy regarding prostitution, with particular attention to the similarities and differences in how human trafficking and prostitution are addressed in legal, medical and social services sectors. Research will be introduced to show the links between prostitution and mental health issues resulting from physical and sexual abuse of prostituted women as children, as well as from trauma related to violence experienced by women in prostitution.
Research will also show that prostitution is very much a condition forced upon mostly Women of Color, poor women and previously victimized women, making “choice” a dubious conclusion for why women enter prostitution.
Finally, this paper will take a global look at the ways countries have addressed prostitution and harms associated with it, and recommendations will be made for a victim-centered, trauma-informed, demand-reducing policy towards prostitution, that seeks to end prostitution and produce positive mental health outcomes for prostituted women.
Federal and State Policy Regarding Prostitution and Human Trafficking:
According to the U.S. Department of Justice, prostitution is “a sexual act or contact with another person in return for giving or receiving a fee or a thing of value” and it is illegal for any person “to cause, compel, induce, entice, or procure or attempt to cause, compel, induce, entice, or procure any individual to engage in prostitution” (The United States Department of Justice, 2014). However, federal policy also allows for states to decide how and to what degree they will implement this law, leaving room for Nevada to legalize prostitution in some counties. In contrast, the Department of Homeland Security defines human trafficking as, “modern-day slavery, involv[ing] the use of force, fraud, or coercion to obtain some type of labor or commercial sex act” (The United States Department of Homeland Security, 2016). Although each identifies the coercive nature of both crimes in relation to the prostituted, federal law still considers some prostituted women as criminals. These are women that the law argues had “choice” when they engaged in prostitution.
In 2002, a National Security Presidential Directive was issued, in which the U.S. Government took the strong position that prostitution should not be legalized, “based on evidence that prostitution is inherently harmful and dehumanizing, and fuels trafficking in persons, a form of modern-day slavery” (U.S. Department of State, 2004). The directive also asserts that state attempts at regulation, including health regulation of prostitution, have failed, because the core problem, “the routine abuse and violence that form the prostitution experience,” leaves women and children, “physically, mentally, emotionally, and spiritually devastated “ (U.S. Department of State, 2004). It cites research showing the link between prostitution and trauma, effectively creating a policy that recognizes that prostitution is not harmless and is not a victimless crime, yet is still punishable by law for those that are prostituted.
With this arguably contradictory federal policy, local governments have adopted their own policies in a myriad of different ways across the country. In Columbus, OH it is a crime to buy or sell sex, unless it is through human trafficking, and then it is not a crime for the person being trafficked. However, local law has been left in a kind of legal limbo, based on similar reasoning expressed in federal policy. Franklin County views prostitution as a crime, but it recognizes that the (mostly) women being prostituted are victims of an inherently harmful institution. Not only that, but the harm being done is leaving lasting physical and psychological damage on not only women who are victims of prostitution, but on the community as well. So into this policy confusion CATCH Court (Judicial), demand-deterrent policing and programs similar to domestic violence programs, were developed to attempt to address the inconsistencies between laws meant to punish prostitution and the history of trauma and re-victimization that forces almost all women into, and to remain in, prostitution.
Prostitution, Violence, Mental Health and Substance Use:
Most studies have found that the average age of entry into prostitution is 12 to 16 years of age (Shively, Kliorys, Wheeler, & Hunt, 2012, p. 11). Studies have also found that 57% to 82% of prostitutes had been sexually abused as children and 49% to 72% reported childhood physical abuse (Farley & Barkan, 1998; Farley, Lynne, & Cotton, 2005). In a U.S. study, (41%) of 61 pregnant prostituted girls reported seriously considering or attempting suicide within the past year (Willis & Levy, 2002, p. 1419).
Studies related to adults in prostitution have shown that 82% had been physically assaulted; 83% had been threatened with a weapon; 68% had been raped while working as prostitutes (Farley, Lynne, & Cotton, 2005). In a study done in Miami, FL, 71.2% of prostitutes had experienced a violent encounter (Surratt, Kurtz, Weaver, & Inciardi, 2005, p. 34). Ina Vanwesenbeeck, in Prostitutes’ Well-being and Risk, found that in the Netherlands, where prostitution is legal, 60% of prostituted women reported being physically assaulted and 40% experienced sexual violence (Farley, 2004). In a study of prostitutes in five countries, 73% percent reported physical assault in prostitution, 62% had been raped in prostitution (Farley, Baral, Kiremire, & Sezgin, 1998, p. 405).
There have been numerous studies over the decades that link prostitution with high rates of PTSD and other mental health issues. In the Vancouver, BC study, 72% of women in prostitution met DSM-IV criteria for PTSD (Farley, Lynne, & Cotton, 2005, p. 242). In the five countries study, 67% met the criteria for PTSD (Farley, Baral, Kiremire, & Sezgin, 1998, p. 405). In San Francisco, a study found that 68% met DSM 111-R criteria for a diagnosis of PTSD (Farley & Barkan, 1998, p. 37). In Miami, 37.4% met criteria for moderate or severe anxiety, 52.9% had symptoms of moderate or severe depression, 69.2% had symptoms of acute traumatic stress (Surratt, Kurtz, Weaver, & Inciardi, 2005, p. 34). In Korea, prostitutes experienced higher levels of, “PTSD re-experiencing and avoidance, somatization, identity problems, relational problems, and affect regulation problems as compared to women in the control group (non-prostituted women) and independent of any history of childhood abuse” (Choi, Klein, Shin, & Lee, 2009, p. 942).
Studies have also shown a strong connection between prostitution and substance abuse disorders (Burnette, et al., 2008).
Those who are not addicted prior to entering prostitution become addicted soon after because of past and continued trauma. They are caught in a cycle of ever greater dependence on drugs in order to self-medicate and support their addiction. This not only works to the pimp’s advantage, but it is also a tactic used by pimps, as it keeps prostituted women and girls destabilized and dependent through addiction and poverty (Shively, Kliorys, Wheeler, & Hunt, 2012, p. 15).
Prostitution, Poverty and Cultural Considerations:
In study after study, women who are prostituted overwhelmingly report wanting to leave prostitution. From Vancouver, B.C. to Indonesia, San Francisco and Mexico (to name a few), 88-96% of women said that they wanted to leave prostitution, regardless of whether prostitution was legal or illegal, in brothels or on the street (Farley, Lynne, & Cotton, 2005; Farley, 2003; Farley & Barkan, 1998; Farley, 2004). Most prostitutes in these studies reported being homeless and listed the need for housing as one of the main barriers to exiting prostitution.
Prostitution disproportionately affects Women of Color. Studies in Canada have shown that Canada’s First Nations People are overrepresented in prostitution by over 50% compared to their racial representation in Canada as a whole (Nixon, Tutty, Downe, Gorkoff, & Ursel, 2002, p. 1022). One study found Aboriginal youth comprised ‘90% of the visible sex trade’ in some Canadian communities (Farley, Lynne, & Cotton, 2005, p. 245). Even in Amsterdam, where prostitution is legal, around three-quarters of prostituted women are from Eastern Europe, Africa or Asia (Holligan, 2011). The free market approach to prostitution in the Netherlands has left a void in supply as demand has risen and domestic-born women willing to “work” as prostitutes has declined. In response, the Netherlands is targeting poor women outside of the country, in effect normalizing prostitution as an “option for the poor” (Raymond, 2004, p. 319). And it’s not just the prostituted that experience the interaction of racism and poverty. For instance,
prostitution often occurs in poor neighborhoods as a part of the local economy. Strip clubs and stores that sell pornography tend to also be zoned into poor neighborhoods and those neighborhoods are typically Communities of Color (Farley, 2003, p. 254).
Considerations for Mental Health Policy:
The body of research available to date suggests that prostitution is largely a crime involving female victims (prostitutes) and male perpetrators (pimps and johns). Most women in prostitution were trafficked as children, and as children, a majority of them were victims of physical and sexual abuse. When these girls turn 18 years of age, the law arbitrarily transforms them from human trafficking victim to criminal prostitute, despite understanding that by this time, these young women are trapped by trauma, abuse, poverty, substance use disorders and numerous other barriers to freedom of choice.
The research also tells us that if these women did not enter prostitution as children, they most likely had experienced sexual abuse as a child, and/or turned to prostitution, often as a result of coercion, in hopes of alleviating their poverty. In prostitution they have experienced continued re-victimization and trauma through violence perpetrated by pimps, johns and police. Research tells us there is a high prevalence of PTSD among women in prostitution and that Women of Color are disproportionately represented in this population. It also tells us that when legalization has been used as a means of reducing harm to women in prostitution, it has only increased demand for women and children trafficking victims into commercial sex slavery (U.S. Department of State, 2004). Finally, the research overwhelmingly suggests that women and girls in prostitution want to get out, but don’t feel that they can, because of homelessness, lack of employment, drug addiction, mental health disorders, threats of violence and other barriers to freedom.
Current Interventions for Addressing Mental Health Issues for Victims of Prostitution:
Approaches to mental health services for victims of prostitution vary all over the world and it is no different in the United States. Typically, non-government organizations (NGO’s), or other non-profit organizations, offer survivor support services to prostitutes exiting prostitution, or to those seeking services for injuries. In the U.S. there are over 400 survivor-focused organizations, many of which were started and staffed by survivors of commercial sexual exploitation (Abt Associates, 2016). One example in Ohio is Safe Harbor in Springfield, OH, a residential program offering trauma-informed, substance abuse treatment for women who have experienced abuse, domestic violence, homelessness and prostitution/trafficking (Safe Harbor, 2014). Safe Harbor is part of a larger collaborative effort, the Central Ohio Rescue and Restore Coalition(CORRC), with a mission of providing “a collaborative community response to human trafficking in central Ohio through education, services, advocacy, and prosecution,” including “victim services, public awareness, demand reduction, legislative advocacy and support for law enforcement” (Central Ohio Rescue and Restore Coalition, 2016). This is a faith-based coalition managed by The Salvation Army, but there are other organizations in Central Ohio, such as The Sexual Assault Response Network of Central Ohio (SARNCO) that have hospital advocates trained to identify and offer support and resources for women who are trafficked and go to the emergency department after a sexual assault.
Part of the CORRC mission is demand reduction, which involves collaborative efforts with government and local law enforcement, among others. Demand reduction tactics are evidence-based approaches to reducing the demand for prostitution, by targeting the buyers of prostitution. These tactics include auto seizure, community service, John School, neighborhood letter writing campaigns, neighborhood action, public education, reverse stings and shaming to name a few. Most cities employing demand-deterrent policing strategies use several tactics at once and Columbus, OH is one of them (Abt Associates, 2016).
Finally, for some women in prostitution, mental health services begin in CATCH Court as defendants who have been charged in the Franklin County Municipal Court with prostitution, solicitation, or loitering to solicit. “CATCH” stands for Changing Actions to Change Habits and was founded in 2009 by Judge Paul M. Herbert. CATCH Court, “blends punitive sentences with a 2-year treatment-oriented non-adversarial program for rearrested prostitutes who suffer from posttraumatic stress syndrome, depression, and drug addiction” (Miner-Romanoff, 2015, p. 1). If a woman has a history of being a victim of human trafficking when arrested, she enters :
a 2-year intensive program emphasizes treatment for drug addiction, depression, and posttraumatic stress disorder by connecting defendants to appropriate substance abuse and mental health facilities and social services resources and by teaching healthy lifestyle choices, including stable housing, supportive interpersonal relationships, and education. (Miner-Romanoff, 2015, p.1)
As of 2015, the graduation rate was 21% and 47.62% of participants reported an increase in mental health (Miner-Romanoff, 2015, p. 2).
A Holistic Approach to Mental Health Interventions for Victims of Prostitution:
Despite current efforts to address mental health issues for victims of prostitution in Central Ohio and across the United States, there still remains a strong dissonance between the way we as society view prostitution and the way we treat people who are sexually exploited. Many in the United States, and globally, view prostitutes as “sex workers”, individuals (mostly women) that trade their bodies to men for some form of payment. Because they consider this a simple business transaction the next logical step is legalization. Legalization allows the woman “choice” and “empowerment” over her body and her destiny. Research shows us that legalization does not produce this result for most, and in fact, increases the demand for prostitution and human trafficking victims.
Our government views prostitution as a crime; one committed by buyers and sellers alike. A prostituted woman faces punitive measures. She becomes a convicted criminal. However, that is not the full story. As examined in this paper, government also recognizes that prostitution has victims. That prostitution causes long-lasting physical and mental harm to its victims; mostly women and girls. Then the judicial system steps in with a trauma-informed approach to address this victimization. CATCH Court becomes the mental health services and resource provider for victims of prostitution, much like the prison system has become the primary mental health provider for some of the most vulnerable people in society.
Delivery of mental health services and social support services for victims of prostitution should not begin in the judicial system. In order to integrate the most current research with government policy, law enforcement tactics and victim-centered services, we must take a comprehensive trauma-informed approach to public policy. This approach must include the decriminalization of all those who are prostituted. The Nordic Model, or Sex Buyer Law, “decriminalizes all those who are prostituted, provides support services to help them exit, and makes buying people for sex a criminal offence, in order to reduce the demand that drives sex trafficking” (Nordic Model Now!, 2016).
The Nordic Model began in Sweden and the latest research is promising. Since criminalization of the buying of sex in 2009, prostitutes have reported a 48% decrease in rapes, a 38% decrease in getting punched with fists, a 50% decrease in pimp violence, a 65% decrease in violence from regular clients and a 60% decrease in violence from an unfamiliar man in a car (Bjorndahl, 2012; Berg, 2013).
Decriminalizing those who are prostituted and targeting sex buyers is not enough. A holistic approach to mental health service delivery for victims of prostitution must also include a robust investment in case management services and anti-poverty measures. Much like consumer advocacy for victims of domestic violence, victims of prostitution need access to housing, stable living conditions for juvenile victims, employment, substance abuse treatment, mental health counseling, education, child-care, victims of crime compensation and all other social services and supports that enable victims to heal from trauma. Instead of the judicial system, crisis intervention services, mental health centers, social services and victims-support organizations should be the foundation from which victims of prostitution begin the process of exiting from commercial sex exploitation and rebuilding their lives.
“I was the guy who used to say, ‘This is the world’s oldest profession.’ I was the guy that would have said this is a victimless crime. Little did I know, really I was ignorant, what was behind this: that there was this clandestine system of pimps and traffickers that are using these women for their own financial gain. And that there was this elaborate system to manipulate and control them and hold them down to be slaves to the drugs, slaves to their lies.” –Judge Paul Herbert (Mcentyre, 2013)
The system Judge Herbert describes is a system fueled by the belief that women are commodities and violence against women is tolerated. This is not surprising as men stand to lose the most if the system crumbles and women and girls are no longer vulnerable to sexual exploitation.
With a prostitution legalization lobby akin to Big Tobacco and Big Oil, the Legal Pro-Legalization lobby in the U.S.s stand to reap billions more dollars on top of an already multi-billion-dollar industry built on oppression and victimization of traumatized and vulnerable women and children;
“As a teenager, I worked in Germany’s legal sex industry. I was, like many girls in the club, underage; most of us were immigrants, nearly all of us had histories of trauma and abuse prior to our entry into commercial sex. Several of us had pimps despite working in a legal establishment; all of us used copious amounts of drugs and alcohol to get through each night.” –Rachel Lloyd author of “Girls Like Us” (Lloyd, 2015)
In order to address mental health concerns for victims of prostitution, government policy must define and defend the concept of prostitutes as victims, not workers;
What the term “sex worker” actually does, most effectively, is to disguise the staggering worldwide abuse of girls and women used in prostitution, by including them as, somehow, part of the same “occupational category” as the men who are abusing them. It is as if we said that the Warden, and the Prisoner incarcerated for life, are both “engaged in Prison-Work.” The crucial issues of power, choice, and ability to leave, are ignored, covered-over, made invisible. –Robert Brannon, Department of Psychology, Brooklyn College C.U.N.Y. (Brannon, 2015)
“However, despite a more cohesive policy for treatment of mental health issues for victims of prostitution, it must be understood that once a person has been pulled into the commercial sex industry, the damage has been done and most will never fully escape the trauma; Dissociation becomes a part of how you operate in daily life. In prevention programs I talk about the possibilities of healing from sexual exploitation, but I have to be truthful that, once you cross that line, you are never the same again. Yes, healing and recovery is possible, but return to pre-exploitation state is not. It is as if once you cross the line of that first ‘date’ or ‘appointment’, something has been done, so the next one and the next one don’t really matter. You are already in it feeling worthless and empty, and never able to return to the person you were before. You are in the servitude in the system of prostitution.”— Autumn Burris, Survivor, “Prostitution Narratives: Stories of Survival in the Sex Trade” (Norma & Tankard Reist, 2016, p. 137)
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