Stigma’s Invisible Barriers

Kate D’Adamo, Partner, Reframe Health and Justice

If we learned anything in the last year and a half, accessing services for support is a fraught process for many people. Gaps in the social safety net, not being sure of the right place to go and other accessibility barriers can put resources out of reach. For people in the sex trade, the silent barrier of stigma and discrimination can make finding the right service provider almost impossible. Sex workers have long-reported that judgment from service providers has made services difficult to access, and led to non-disclosure, or not seeking out services at all. One sex worker named, “I used to be very open about it until going to see a male OBGYN who literally said to me, ‘Oh that’s fucking stupid.’ And that’s when I made the decision to just not talk about it [the sex trade] anymore.”

I come to the work that I do now because I came up as an organizer, and a lot of what we did was answer questions. Beyond the community information, there was rarely a week when someone didn’t ask for a referral or recommendation on other forms of support professionals to reach out to. While we could pull lists from other organizations or google around, it never answered the question that was one of the most significant barriers to accessing help — are you going to be an asshole when you pick up the phone? Trying to figure out whether an organization understood sex work, and would take the necessary level of care and thoughtfulness towards community members was harder than the question of whether they took Medicaid or were a close enough walk to the train stop, but it was often more important than the other concerns people had.

A number of organizers who had worked together for several years embarked on a new effort in New York City — PERSIST Health Project. The (now closed) organization was born from a need for health care and support that was rooted in community care, and served many who found hostility in other places. In the initial iteration of the project, we hosted a series of focus groups to hear from sex workers what the needs and barriers were, and one of the most pressing and prominent was that stigma, both experienced by sex workers and other community members who had warned folks, and perceived based on organizational histories, was one of the biggest reasons people weren’t seeking out help, or were leaving sex work out of their story.

Stigma is negative attitudes or discrimination against someone for a characteristic — in the case, for trading sex. And sex workers have named that stigma has impacted access to health care, government support programs during COVID, mental health care, and other social service providers — meaning lack of care and further isolation from support. Feelings that someone is judging you for trading sex can mean that people don’t bother sharing important information about their situation, or may not reach out for help at all. If someone thinks they’ll only face more judgment and trauma or not be taken seriously, why would they risk the emotional effort to tell someone they need help? This especially is compounded by the other forms of marginalization that sex workers may be experiencing. Sex workers with HIV, who are parenting or who are substance users can face additional layers of bias and barriers from service providers, clients, and even other sex workers for living in that intersection.

Stigma, and its impacts, contribute to the perception that sex workers are targets for harm, and make individuals more vulnerable to violence. Stigma is the public voice that tells service providers that sex workers sign up for violence and HIV/STI transmission. Stigma is the public voice that tells sex workers that they deserve the harm they receive. Stigma is the public voice that tells people who look to cause harm that not only sex workers are the perfect target for that hate, but also that no one else will take a sex worker seriously. Stigma is a driver of violence.

But there can be changes made. While stigma and judgment are influenced by structural violence, these can be interpersonal changes that service providers can make in order to better serve people who trade sex. There is a dire need for organizations recognize the barriers that they craft for people who trade sex — considerations such as privacy considerations, safer drop-ins, mandatory reporting considerations. And in the meantime, a service provider who can be a safe place to go is still a step forward.

As an organizer, I had a resource list for people trying to access health care and we had two categories — organizations we trusted and people at organizations we trusted. Being able to send somewhere that you knew they would be taken care of, and their full identity welcomed, was an incredibly heartening experience both for that person and for our organizing team. It means a lot to know you aren’t alone in trying to support your community. But the second list — people we trusted — was just as valuable. It meant that we could prepare people for the organizational barriers, and let people know to keep their hearts protected, but that these initial barriers wouldn’t mean we had nowhere to send someone. That list still expanded the resources for support that we could offer, even if it came with an asterisk.

At Reframe, we have the privilege of working with many organizations who are looking to more intentionally serve people who trade sex, and to better understand the needs and gaps in support. While we love developing workshops on outreach, and walking through safety planning techniques, one of the most important things we always do is to ask service providers to assess themselves and their organizations and find the points where we can all re-evaluate our assumptions and heal some of our judgments.

But there is also reason to be cautiously optimistic about structural change as well. On December 1, the Administration put out their National HIV/AIDS Strategy, a document which offers guidance and a directive for addressing the issue, which offers some promise. The strategy comes after years of sex worker advocates and allies and co-conspirators pushing for inclusion and a focus on how sex workers are frequently put at risk for negative health outcomes. The strategy specifically stigma and discrimination as a barrier to health for sex workers, and called upon service providers to address these issues. In light of this release, AIDS United as written a letter of response that we encourage organizations to sign on to in support to call for more inclusion moving forward.

Ending stigma truly takes all of us. The cultural narratives which harm sex workers are pervasive and need to be fought in our media, our conversations, and our structures, and it is upon all of us to fight them. As we move towards December 17 and recognize the violence that sex workers face, may we all make commitments to dismantle this barrier in our workplaces, our communities, and our every day lives.

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Learn more about how we can help support you on these issues: https://www.reframehealthandjustice.com/services.

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