Breaking down barriers; healthcare for sex workers

Sex workers need full access to primary care services as much as any patient – if not more. In Practice Business, we considered some of the barriers people face and explored how practice managers can enhance patient experience

In a report for the Department of Health, Street Sex Workers’ Experience of Accessing Health Services, by The Griffins Society’s Louise Clark, it was reported that sex workers faced severe stigmatism based on their lifestyle choices. One woman said: “I told the nurse I had a fear of needles and she said that because I was a drug user, I should be used to it. I told her that I smoked, not injected. She said she hadn’t known you could smoke drugs and hadn’t had any drugs training.”

Another woman reported being kept in a treatment room for 20 minutes and subjected to multiple questions about her work and morals. “It became known that I was a methadone user and the conversation led me to saying I was a sex worker.” She was asked what she did for men, how much she charged, what acts she performed and if she’d been raped (and if so, had she fought back).

Needless to say, every person deserves to feel safe and respected whilst seeking medical care and shouldn’t be forced to disclose personal details or withstand unwanted and invasive attention.

Breaking down barriers

Sex workers face several barriers when accessing healthcare, many of which are linked to their living situation. They often live in shared or unstable accommodation so they don’t have utility bills, tenancy agreements or other types of proof of address that GP practices usually ask for from new patients.

“Sex workers who’ve been trafficked or who don’t have regular immigration status in the UK face additional barriers. GP practices often ask registering patients to provide proof of ID and sometimes they’ll even ask to see a valid visa and refuse to register the patient if they can’t provide this,” says Lucy Jones, UK programme manager at Doctors of the World UK.

“As well as blocking access to healthcare, this makes vulnerable people too afraid to try to access healthcare again,” she continues. “The guidance from NHS England is there to protect people like sex workers, and it’s very clear. Practice managers should check their policy to make sure they can welcome vulnerable patients so they can get the healthcare they need.”

In addition to a lack of paperwork or not being able to supply a fixed home address, sex workers face daily stigma that is yet another barrier to accessing health services. “It’s essential that specialist sex worker support services are able to share their expertise with health practitioners so they can understand their needs. This will enable them to assist sex workers to engage positively with health provision,” explains Louise Clark, fellow at The Griffins Society. “To not do so can further stigmatise, ostracise and traumatise sex workers and increase their health risks.”

Lee Brooker, case worker at SWISH (Sex Workers Into Sexual Health), says the first lesson for practice managers and medical staff is to leave preconceived notions and judgment at the door. “Not every sex worker is a victim of circumstance, trafficked, coerced, pimped or devoid of choice; the majority of sex workers accessing practice services see their involvement in sex as a positive choice and not as a subject of discussion or contemplation unless invited to do so.”

Generalising and stereotyping those involved in the sex trade is often the first mistake made by staff –  however, Lee does say there’s often a big difference between street workers and those who are flat based, independent, brothel or agency workers. “Street workers often require more frequent sexual health treatment, are often more chaotic and are more likely to take drugs. In our experience, flat-based workers are often less chaotic and more likely to attend clinics for preventive check-ups and are often involved in other jobs or activities.”

Regardless, comfort – or lack thereof – remains a common barrier, he says. “Waiting rooms and staff areas are often very close and body language or covert staff conversations can be seen by other patients and lead to a feeling of being on display or judged.”

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Understand and assess

Lucy recommends that practice managers familiarise themselves with the NHS England guidance on GP registration and make sure that their registration policy complies. “A GP practice is entitled to have a registration policy in place but they shouldn’t be refusing registration or appointments if a patient isn’t able to provide proof of ID or address,” she warns.

“They can train their staff to respond appropriately when vulnerable patients, such as sex workers, come to register at their practice. People bring an opinion and a moral judgement about who it is they’re dealing with and often draw their own conclusions or are misinformed in terms of the health needs of sex workers.”

Louise says a key way to successfully integrate sex workers into your practice is to ensure that they’re treated like everyone else. “Be mindful that they may have had traumatising experiences and a negative response can not only make them less likely to access services, but it can re-traumatise. People find it a really fascinating world and think they can just ask what they want of that individual and that they don’t really exist outside of what their work might be.”

Lee cites the report, written by Louise in 2009, that highlighted the comments of street-based sex workers accessing clinics. “It was clearly stated in the findings that many had positive things to say when they engaged with services where the staff were judgement-free and professional.”

However, a negative response was recorded when patients became aware that staff were discussing the morality of sex work, rather than why they had attended the clinic. “It’s no surprise that street-based sex workers voted to attend clinics where staff are informed, non-judgemental and trained to understand the differing needs of the client groups.”

An east London sex worker reported hostility when using a GP surgery in a high density Islamic population area. There were posters in the waiting area from local community groups addressing the issue of prostitutes in the area. She moved to another surgery in the area but experienced the same hostility. SWISH placed the client in another practice but not in her locality. 

A safe space  

Westminster City Council recently conducted a survey about what sex workers want and need from the health service, and better training and more discreet staff remain consistent priorities across the board. “Many still report having to engage in unwanted discussions that aren’t connected or relevant to their check-up or treatment,” Lee explains.

“In specialist sexual health clinics privacy and confidentiality is crucial to a successful practice. Waiting areas are arranged so that they’re not within earshot of reception areas. The receptionist is trained alongside clinical staff so questions are answered in an appropriate way from the outset.”

Louise seconds the need for additional training among staff. “While there’s some brilliant engagement by health practitioners – and a lot of the support services are NHS-funded – I think it comes down to training a lot of the time.

“The danger with inadequate training is that people draw their own conclusions; a lot of the time they don’t do so consciously. It’s just that they don’t understand the context of where sex workers are coming from.”

While many of us may take regular access to healthcare for granted, Lucy says a positive relationship with the service is especially important for sex workers. “As well as meeting their (often complex) health needs, healthcare professionals can play a key role in safeguarding those who’ve been trafficked and support them in leaving the situation.”

A sex worker is unlikely to tell a GP receptionist that they are a sex worker and are even less likely to talk about it if they’ve been trafficked. “For this reason, practices need to be open, welcoming, safe places where people feel safe to go. Practice managers are in a unique position to create this culture of welcome and safety.”

 This article was featured in Practice BusinessClick here to read the full article.

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