Providing online sex therapy to clients in Maine, Massachusetts, New Hampshire, New York, and Texas opens up my practice to all different clients in all different situations. Recently, I have been contacted by those that work in the field of sex seeking out quality mental health care from a therapist that is supportive and knowledgeable of their chosen profession.
Doing therapy with sex workers opens some important ethical and clinical considerations for the therapist that I wanted to share. In aiming to educate myself further in how best to work with sex workers and their unique considerations, I came across a gap in support and guidance for the therapists working with sex workers (much like the gap in support for the sex workers themselves).
And in light of Amnesty International passing a resolution that supports the
decriminalization of all aspects of sex work (read full article here), I wanted to write a little bit about some of the information I have gathered by speaking to sex workers, therapists of sex workers, allies of sex workers and from posting on various forums and researching the topic.
Sex workers are individuals who receive payment for providing sexual or erotic services. This could include street prostitution, indoor prostitution (escort services, brothel work, massage parlor work, bar or casino work), phone sex operation, exotic dancing, lap dancing, webcam nude modeling, adult film performing, and nude peepshow performing (and other forms of sex work). It could also include those that work in the sex industry, such as bartenders, waiters/waitresses, hosts, designers and producers of sex toys, club managers, directors and producers of erotic films, and other people who work in the sex industry. This is a curious point for me: would working as a sex therapist be considered as being a sex worker?
For a point of clarification, I am not talking about trafficked individuals in this blog, or those that
Photo by quinn.anya 
were forced into sex work or held against their will in sex work. While someone who has been human trafficked could also be a sex worker, not all sex workers are trafficked. For the purpose of this blog, I am not talking about trafficked individuals.
From my preliminary research, here are some thoughts I and others had relevant to providing quality and ethical mental health services to individuals who identify as sex workers. This list is by no means exhaustive and is not meant to be controversial or offensive. These are just some points that have been brought up as I seek to provide the best possible services to sex workers that I can.
Respect and Curiosity
Sex work for many is a chosen profession, just as being a mechanic or a garbage collector or a CEO. It should be treated as such with respect and curiosity. As a clinician, you aren’t expected to know the intricacies of every profession on the planet and you certainly aren’t expected to know or be a qualified advisor in the field of sex work. Approach your clients work as you would any other profession and be respectful and curious of how the client is structuring their work and the mental, emotional, psychological etc. factors around the clients profession and their life. Most people are not defined by their career. Be curious and respectful about the client first, and don’t solely focus on what they do for employment.
Safety
When doing therapy with sex workers, it is important to address all aspects of safety around their work. Safety is a unique consideration for sex workers, often times because they are not protected by laws and regulations that focus on safety in the workplace. Sex workers need to be aware of their physical safety, their emotional safety, their financial safety, their sexual safety, their legal safety, safety in regards to their health (especially around STD/STI’s), and the clients safety, amongst other areas. Because sex workers are marginalized and criminalized, they are not afforded the same rights or protection in their work as others. This makes them at increasing risk for being victims of manipulation, abuse, exploitation, and physical and sexual violence (often times at the hands of law enforcement and policy makers). Therapy with sex workers should discuss safety and should be a collaborative process between the client and the therapist in constructing what a safe environment for the client is at work. This process of safety should not be a negative or shameful process. Our clients take risks every day in their life being a sex worker, just as everyone takes risks getting behind the wheel or eating junk food, and our clients safety at work should be approached in the same manner you would approach safety in any line of work.
Boundaries
Boundaries are important part of any work environment, but I found that they were especially important for sex workers. Because sex work can be very intimate and exposing, it is essential that sex workers have strong personal and professional boundaries and a good work-life balance. If clients are in personal relationships, boundaries are a huge consideration in their work. If clients who are sex workers develop personal relationships with their clients, boundaries are even more important.
Balance
Work-life balance is a hot topic amongst many clients, and is especially necessary to be addressed with sex workers. Because of the nature of the work and it being, for many, very personal, it is important that the client have balance in their life around their work. Also important is that there is balance in the therapeutic process as well. All areas of the client’s life should be attended to, not just their work. In fact, some clients may never even talk about their work. There are many other areas to address in therapy, such as past traumas, living environment, future goals, relationships, finances, emotional well-being, grief, loss, joy, personal growth, health, family of origin, friendships, etc. Therapy with sex workers should not just be focused on their work as work is only one part of their entire life. Overall it’s important that there’s balance in the client’s life and in the therapeutic process.
Benefits
I realized that some of my preconceived judgments come into a therapy session with a client who is in sex work in that I may tend to focus on some of the challenges of their chosen profession (and how to minimize the effects of those challenges) and not pay an equal amount of attention to the benefits of the work they do. There are a lot of benefits of sex work. And the type of clients I’ve worked with and am currently working with, were not forced or trafficked into the work, and wouldn’t stay in the field unless they wanted to (I know that is not the experience for every sex worker). In providing therapy with sex workers, it’s really important to talk about the benefits of the work. Sex work can be healing, it can allow you to work through some of your own sexual thoughts and feelings, it can be empowering and engaging and extremely satisfying work, and many liken it to a spiritual journey. Sex work can often inspire clients to face the things that they don’t want to face in their real life and can open up new doors to healing and growth. The work can be rich and fulfilling. This cannot be minimized in providing therapy with sex workers.
Legal issues
I got mixed information about addressing the legality of sex work from professionals and colleagues. I have, in the past, come from the approach that it’s an important conversation for us to have, but needs to be talked about delicately. I do not want to shame, guilt, or scare my clients. I usually ask my clients if it would be helpful if we discuss the legal issues around their work. When I questioned myself on why I did this, I felt that it was an important part of psychoeducation for my clients that they know the legal considerations in their state around their work, especially if I feel that the legality of their work is 
relevant to their treatment goals. I believe it’s important that my clients are aware of the legal guidelines in their jurisdiction. But then I got to thinking about it: if I had a client who was, let’s say, a day care operator, would I sit down and talk to my client about the laws and regulations around day care operation? Probably not, UNLESS my client wanted to and it was relevant to their treatment goals. And if the legal issues around a day care operation was something on the agenda, wouldn’t I refer them to a business law lawyer or let’s say, the Small Business Association, or the town/state? I’m no expert in day care law, but I can’t exactly send sex workers to the federal/state/local government or a lawyer who doesn’t specialize in sex work (is there such a thing, I’m sure, but who?).
So why do I feel the need to talk about the legal issues with my clients? Am I projecting my need for my clients to know what the laws are around their work on to our therapeutic process? As I mentioned before, this issue has some mixed responses, some of the professionals I spoke to were really adamant that this is part of our duty as clinicians to talk to our clients about the laws in their state, and specifically around the sex offender registry. Some people I talked to said that it really shouldn’t come up and is out of my scope as a mental health practitioner. I think in the end after all is said and done, I ask my clients if it would be helpful for us to talk about the laws and legal issues with their states in regards to their profession. For example: “Would it be helpful if we discussed some of the legal issues and risks associated with your work? Is that something you would like to touch upon in our work?”
As mentioned above, I have no idea about the intricacies of the work, but I’ve also been told from clients that the legality is something that gets brushed over in the field, and it might be helpful to talk about. By being curious and asking permission, it allows the client to decide if it’s a productive use of our time. This is also a great opportunity for me, as the therapist, to set a boundary that I’m not an expert in this work, and I can’t ethically encourage my clients to do anything illegal (acceptance of their work does not imply authorization), and I do have a duty to report if at any time I am made aware of any type of risk to a child or dependent adult. Role modeling my boundaries in our therapeutic process without shaming is a great way to encourage my clients to establish their own boundaries without shaming their clients. My profession has a code of ethics, and sex work sort of does too, but many people don’t know about that. This is also another perfect time to talk about resources available for sex workers.
Resources
Prior to providing therapy to sex workers, I had no idea of the richness in resources that are available to sex workers. And I have found that the clients don’t know either. There are a tremendous amount of resources available including advocacy organizations, publications, even a magazine written for and by sex workers. There is some sort of code of ethics out there for sex workers and there are plenty of resources that can point them in the right direction. Part of our work as clinicians is to provide our clients with appropriate resources to assist with their lives and their treatment goals. One of these resources could be a mentor in the field. Now my connections with sex worker mentors is nonexistent, but these organizations have the systems in place for these clients to reach out to people. When providing therapy to sex workers, it’s important that we know about these resources. Some of these organizations can even refer clients to a lawyer that specializes in sex work!
Support
When a therapist provides therapy to sex workers, they are automatically integrated into a world that is marginalized, criminalized, and stigmatized. Not only do sex workers need support, mentors, and education, but the therapists working with them need those things too. We may encourage our clients to seek out a mentor in their professional field, regardless of the profession, and we as practitioners need the support from collaboration groups, peer supervision, and clinical supervision. When working with a unique population it’s really important that we have to support and supervision. This aspect came up across the board with every person I talked to about the special clinical and ethical considerations when providing therapy to sex workers. Just as sex work brings up a lot of benefits and challenges within the sex worker, providing therapy to sex workers does the same. “Person-of-the-therapist” work is essential for clinicians who are working with sex workers. It’s impossible for us to check all of our judgments, biases, and stereotypes at the door working with any client, and working with judged, stereotyped, marginalized, discriminated, and vulnerable populations like sex workers can sometimes activate things in us that we didn’t even know where there. Continuous supervision and reflection is essential when working with unique populations like these.
I do want to thank all those folks that assisted me in gathering this information and I’m open for any additional considerations that anyone might have around this population. Feel free to call or email me at 603. 770. 5099 or Rhiannon@SexTherapy-Online.com.
And if you are a sex worker or know a sex worker living in the states of Maine, Massachusetts, New Hampshire, New York, or Texas and are looking for a therapist, feel free to contact me at the information below.