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The Motivation and Mental Health

of Sex Workers
BKU,A CnUDAKOV, KERKN ILAN, and R, H, HKIJMAKER

J[)lJIi CWIKEL
L'nierjur Wimivn 's Heatlh Stuiiws and I'mmotioti and Department ofSiKud Wori

Commercial sex work presents specif ic menial bealtb concems. We

aimed to study motivation for sex work and mental bealtb Lssues in
a sample of such women. We contacted 55 consenting ivomen
tbrou^b organized hrotbels and interviewed tbem using tbe Farley
questionnaire and screening items for pasttraumatic stress disor-
der (PTSD) and depression. Eigbty-two Iwrcetit of tbe women bad
C4rrived illegally and bad fx'en trafficked. "All but 2 were engaged
voluntarily in sex work. Seimiteen percent met criteria for PTSD,
and 19% were likely to he clinically depressed. We present repre-

workers in tbe sex industry could improve compliance with HIV

prevention programs and tmlarge options for women to leave the

always having bistories of childhood abuse or as being always

"bappy b<K>kers" u>ere incorrect.

Recent news reports suggest a Iai>;e-scalc migration of Kast European women

to the West It) work in the sex industiy. Thi.s phenomenon, catalyzed by the
breakup of the former Soviet l!nit)n and the resulting sharp decline in eco-
nomic stability and standard of living in countries such as Moldova, Ukraine,
and LiUvia, is surprising in light t)f the sexual revolution in the West and the
easy access ft)r most men tt) nonct)mmercial sexual partners (Hullough Sc
IJullt)ugh, 1996). Mt)ret)ver, the HIV epidemic and the possibility that sex
workers are poorly compliant with safe-sex practices makes for possible
widespread health ct)nsetjuence,sof this migration of sex workers (Carr, 199T).

i6()(). Mt'cr-Shcliji H4t70. isnii.'l, r.-rnail: lx'lm;ikrr@h«umail.hgu.ac.il

The ,sex workers tlieniselve,s are ;i catise Ibr mental health care eoneern
bec:au,se they have been reported in the pa,st to have high nite,s of depres,sion
and pcxsttratmiatie strcs,s cJisorcler (Fl'SD; Farley ik Barkan, ]c;c^H), We studied
a ,saniple of,sex workers largely from the fornier Soviet Union in three Lsi-.teli
cities, and we placed special emphasis on (a) motivation for migration and
intent to work in the ,scx indu,stry, (b) types of sexual activity and use of
eondonts, and (e) personal health, satisfaction, ;incl psychological syniptotns,

METHODS

We responded to large newspaper ads in Israeli new,spapers for escort ser-

vices by telephone and explained the purpose of the ,study. Only a small
number of women agreed to paiticipate, but appointments for intei-views led
to some interviews for a fee. We later contacted a lawyer representing some
of the prominent escort services, who then arranged interviews with brothel
workers in two Israeli cities. Two interviewers conducted inteivic*ws, of whom
at least one was female, or Kussian speaking. Almost always one was a
psychiatrist. The interview was an expanded version of the Farley question-
naire for sex workers with a validated RLissian translation (Farley & Harkan,
lyyS). We condiieted the interviews out of hearing of any third parties and
guaranteed full anonymity to the paiticipants. We ol)tained oral consent after
explaining the study; this proeecUire was approved by our Institutional Re-
view Board (IRB), Some of the intei'viewees were paid, but the bulk of the
interviews in two eities were conducted with unpaid volunteers.
We measured PTSD ,symptoms iisitig the PTSD checklist (PCD 17-item
scale (Slein, McQuaid, I'edrelli, Lenox, & McCahill, 2000), The cjue.stions
u,sed were alioiit symptoms in the past month and used a "i-point severity
scale. We measured depression with six question,s derived from the Center
for I-pidemiologic Sui-vey-Depression (CliS-D) depivssion scale (Kadloff, 1977).
We* asked ciuestions about feelings a,ssociatecl with depressive tiiood in the
past week using a 4-point scale. I'his abbreviated scale has been lusecl in

(Sherbourne, Dwight-lohnson, & Klap, 2001) and in a women's health sur-

vey in Israel (Cwikel, 2000), Data relating to physical symptoms and ,sexiially
transmitted cli,sease risk are published elsewhere (Cwikel, subinitted).

condiieted. Descriptive data on the sample are

two of the ,sex workets had arrived in Israel from
Sinai bordc*r. Thus, a tiiajority of wcjmen had been "trafficked," althoitgh
only 2 reported that it had been against their will. Furthermore, 17'^!. re-
ported being ,sold against their wishes to a brothel owner, (i4% reported
being transferrc*d with tlieir cronsent to other plaees of work, and ^9'^ re-
ported that they were not sold or transferted. Aliiio,st all women reponc,*d
engaging in sex work of their own volition and reported that they knew

All wometi reported using condoms with elients for vaginal ,sex I)ut
most reported no use of condotns for oral sex. The women reported difficult
work conditions. They averaged of 12 clients per day (range ,4—25), and 42%)
reportc*d that they wotkecl throughout the month, including during their
menstrual cycle. However, tnost (7H%) teported being ahle to ,send $1,2S5
on average per month (S1,()OO was the modal sum with range of $125 to
,i;.^,0()0) back to family in their countiy of origin. All of the mothers in the
sample reported supporting their children economically.
The PCI, aveiage scoie was 2.24 (SD = .79), We u,sed a cutoff point of .^,0
or greater, and 17% of the women showed signs of PTSD, whieli meet Dtag-
rtostic aud .Statistical Manual of Menial Disorders (DS,M-IV; American Psy-

stiidy (Stein et al,, 2000), Theie were ii% who had an average clepre,ssion
score? of over 2.5 (pn.*sencc: of depressive symptoms), and 19%i who had
a\ eragc\s over .1.0 (likely to be clinically clepre,s.sed), In a eommunity ,sample

ages over 2.5, and 2'y« had avet-ages over .10 (Cwikel, 2000),
However, the riehness of the clinical interviews could not be captured
by the questiontiaire data. In particulat; public stereotypes of,sex workers as
entirely the products of childhood abuse, or alternatively, as happy-go-luc ky
sexual enthusiasts (eg,, ne Ilap!))'Hooker, Hollander, 1996), or gocxl girls
waiting for their handsome prince to ,save them (e,g,. Pretty Woman) were
negated by the tremendous heterogeneity of cominerdal ,sex work aboul
which we became aware in our interviews (Hollander, 1996), In particular,
women's current mental health, their reported physical symptoms, and their
exposure lo childhood and work-related violence and abuse were cjuite
diverse.
We therefore felt it useful to bring to scientific attention this heterogene-
ity via a case-hi,slory approach. On the ba.sis of c:on,sensiis among two psy-
chiatrists, one social worker and one phikwopher involved in the interviews,
we divided the cases into five prototypes. One ca,se repre,sentative (not a
composite) of each type is presented here.

"Angle"
Vngic is :i very pretty j»irl, with blue eyes and hair dyed strawlierry blond.

n thatfield.Her parents remain in Moldova; her mother is a ccxik and her

ather drives a tractor. Anj»ie sends them money, around $1200 eveiy

itl Turkey lor 16 momhs and wa.s arrested there

and "does parties," but she does noi do striptease, pornograpliy, or danc-
ing. She feels thai people u.-^e her services "to have a g<,)<xl time."

physician about I year ajjo. She had an AIDS test this past month. Shu

her teeth need dental care; she also reports occasional stomach cratiips,

occasional'trxHible sleeping, her menial liealth seems .satisfactoiy. She

smokes 1-1'/i packs of cigarettes daily and drinks occasionally "to feel

says she likes what she does and feels thai she is satisfied with, and has

Angic* was typical ol' an 'uncxjiiiplicaied" among our sample, where

oducatioti level was medium to low, psychosocial problems were not promi-
nent, and niotivatitin appeared economic and ej»o-syntonic. Despite the
present .satisfaction with their work, most of the.se respondents wanted to
leave prostitution after acquiring a specific amount ol money. Fifteen o f t h e
5S women were judged to be in this group.

Noni is also a nineteen-year-old from Moldova. Tall, slim, long-legged,

and with long dark hair, Nora is a fairly pretty girl. She is, however, very
bitter and angry aliout her life.
Nora grew up with a mother who often was drunk and who ne-
glected her both physically and emotionally. Sometimes they were home-
less, and she i-emetnbers times when she was hutigiy and had no fo<id,
There was a .stepfather in lhe home who Ix^at her regularly—threw her
against the wall, threw ihings at her, kicked her—and then niped her
when she was 14 years old. Tense but without tears, Nora then descrilied

police but was told that there was no evidence with which to make a ca.se

pain antl bittertie.ss antt says that itfinallycle.strt)yed her ability to trust

teen. She reports lieing twice .sold in Turkey against her will and al.so
reports being subjected tt) vit)lence. Knife cuts across her stomach left

knife by clients and by the police. Eventually, she ran away, was able to
rei'over her passptirt, antlfledTurkey. She arrived in Israel 10 mt)nths

replied that it was "rate." She sees between 10 antl 20 clients daily, mtwt
often 12 tt) 1,^, and always sht)wers afterwards. Stie provides the regular

ot the gang rape. She was tmce asked to act sadistically to a elietit but
started hitting him so hard that she almo.st killed him, and nt)w she refli.ses

tloes iK>i talk to them, and she t)ften reache.s oi:gasm with them. She likes
it that most clients treat her nicely, altliough .she is .sometitnes insulted by
things said ro lier. She would nt)t reveal how much money she is making

cousin, to be used to take eare t)f her younger sister (now 14), wht) lives

tion; she ct>mpleted only nine grades and has no prt,)fession besides sex
worker.
Noni hati been checked by a gyneet)logist abt>ut 3 weeks prior to the
interview and had seen a family physician about 6 months previously. She
reports health pniblems including high bitjod pressurxi, arthriti.s/rheuma-
tism (for which she has been hospitalized), repeated urinary tract irifec-
 ivpons pains in the neck, back, .stomach, cliest, pelvic region, vagina,
bivasts, hands, and backside, as well as numbness in her legs. In addititin,

drinking t)f her mother and stepfather ivpulscd her,), but she smokes up

trade "tio matter what." She feels that she will need psychc)lt)gical help in

Nora was typical of an "abused type" atnong our .sample, where child-
hood abuse* and rape and vit)lcnt'e during sex work had occurred and where
dcpressitin and ITSl) symptoms were protninent. Nevertheless, there was
evidence of personal choice of type t)f clieni, orgastn at work, and feelings
of gt)()d perstjnal cotitact with most clients. Twenty-three ofthe 5S women
were judj^ed tt) ho in this j^roup.

"Melody"

Melotly has conipleted 3 years of high .schot)l and lias been trained as a

a lioartiing SC1UH)1. At thirteen, she attempted suicitie after slit? was beaten
by her nit)ther when the mtnher disct>veretl thai .Melody was no longer a

cut on her lip that ret|uired surgery. She recalls being niped at least ten

ase irar in Yugoslavia. She came through Fgypt anti was ta

lly be retLirned when she has completed a year of work. She wor
 addition to regular ,services, she will also perform lesbian ,sex and "sado,"
She has never been attacked while at work, although she 1MS had her
feelings hurt hy clients WIKJ insulted her. She mentioned lhat she was

phone lo u,se to call for help should the need ari,se. She is earning around

Melody does not remember when she last saw a famiiy physician,
aithough she dici see a gynecologist about a week beff)re our interview.
While still in Moldova, she had four abortions, ,She contracted ,syphilis

rently, she reports gynecological probletlls, recurrent urinary tract inlec-

lower pelvic area, \agina, ovaries, ]iiouLh, and jaw. In aclclilion, she shows

or.il contiaceplives anci smokes a pack of cigarettes daily,

with regard to depie,ssion and FTSD but lacks ,self-confidonce. She is u

usual in this sample in reporting a background that includes both drug ;ii
alcohol u,se. Her tiatimatic background also led to adverse effec-ts on h
overall health not just psychological trauma. In spite of fc^eling in control
her life. Melody is not at all satisfied with her pre,sent life and is not hapi
with her job. She would like to leave prostitution but needs money. Ho-
e\c'r, she has hopes for the future and speculates that 5 years hence she u
have' ,several children and a good job.

and slender 21-year-old Moldovan girl with long dark hair, Lma
led and open. She is an intelligeni girl who speaks five languages,

orked in lhat field. She reports a loving and caring famiiy back

At age IH, Lana fell in love with a man in his 'id's, and her first ,sexual
experience was with him. Their relationship lasted for about a year, and
lhis day they are still in phone contact. When the relationship ended,
la drifted into prostilulion. She spent A months in Turkey—getting ar-
lt>wed to leave. Otherwise, she is required tt) fulfill her contr
"misbehavior" may be punished by .sanctitms such as being rest

t)ther hand, Lana is a personal favt)rite t)f the brt>thel t)wner, antl

Una wtjrks 7 ilays a week, Z*:)-M) tiays per month, K)-2() h

day. She rt)utinely wt)rks tluring her menstrual cycle. She usu:
between 10 and I'S clients [ler tlay, alth<,)ugh during bu.sy periocb
.seen as many as 25. In additit)n to vaginal, oral, antl manual si
[)r<)vities services such us dancing, massage, .striptease, orgies, a:

>rking in Israel, including t)ne who enjt)yed hurting her physically and

d think that a girl titjcsn t have any leelings.' ll she feels endangered,
L' calls the office, and they senti st)met)ne down to "straighten them

nit)re t|uickly. antl she occasionally allows hei-self tt) reach orgasm with

reports irec|uent pain in the back, pelvic region and vagina: she some-

health pit)blems that have lieen tiiagnosed in the pasl T years include

she still is .sympttmiatic. She drinks, sotiietimes ent)ugh to make herself

her year and would like tt) earn S50,(HH) for psycht)!t)gical at
 Lana is representative of a subgroup in our .sample, with her high l(,'vcl
of personal resources, clear plans to continue educatit)n, and considerable
evidence t)f choice and control over her life. Furthermore, she described
many methods of reducing risk in her joh. Twelve of the 55 women were
judged to be iti this group. However, 5 of the 12 in this group of high
personal resoutces had histories of rape, homelessness, abuse, or abandon-

ment belore they began sex work.

(Jena is a very pretty, long-legged, and attractive 23-year-oId from

I'zbekistan. She lx;gan studies at the university level but did not complete
them; she htjpes to continue eventually, perhaps in econtJinies <ir ac-
ctninting. She had a ct)mft>rtable and pamperecl childhood with no re-
b fairly well-establishetl family; btnh parents

iwever, send them money everyV-w months ,s,;) lhat they can buy
presents
,aflrsthad ,sex wil:h a boyfriend; she was .sevt•nteen, and he was
•( years . I began to work in prt)stitu
change 1 •'or money, jeweiry, and expensive gifts. She <
ciflcally tion of a girlfriend.
has been here illegally for ahnost a year n^uw working as an
indepei ldent," Ciena exjllains that she works in prosti

feels she may as well make mt)ney from it. She i-eaches t)tgasm
• day. She enjoys talking w
iiften lui;s a good laugh"'with tlicxse who speak Russian. She works S-6
Llays per ot work during her menses.
ith her Israeli boyfriend, and, because of this.

la is satisfied with and feels tha

listic abtmt lhe future. When a.s
 DISCUSSION

Thi.s study is limited by the fact that it is based on self-report, the fact that
indirect C(,)crcion of responses was possible since contact was made through
brothel owners, and the fact that sampling bias may have led to an unrepre-
.sentative sample. However, replies t)n legal status sitggest thaL lhe interviewees
were not afraid to tell the truth. Several conclusions are likely to be valid and
may be required for policymakers until better data are available: (a) Prostitu-
lion is a large-scale social phenotnenon closely allied to illegal trafficking in
wt)nK'n and not ha.sed on local female wt)rkers; (b) despite (a), almost all

coerced by severe economic disadvantage in iheir country of <irigin (Pederson,

1994); (c) the women's frequency of use of condt)ms for vaginal sex appears
adequate but for t)ral sex it appears to be inadequate (Perkins ik Lovejt)y,
1996); (d) rates of 1-»TS1) and depression in our study were lower tban in
.sofne studies of prt)stitutes (Farley & Uarkan, 1998), but the conditions still
de.serve attentioti atid treattnent. The rates of PTSO and depfessit)n reptjrted
hetv are sitnilar to the rates teported in satnples of wotnen who have re-
ported a hi.stt)r>' of physical t>r sexual abuse in cbildhood bul higher than
what is ft)und in the general pt)pulatit)n (Farley & I5arkan, 199K; Stein et al.,
2000). Unlike other studies (see, for exatnple, CJreen el al, 1993), this study
focused exclusively on brothel wt)rkers whose wt)rkinj» ctinditions are more
pttHected than street prt)stitutes. Also not represented in this study were self-
sent of the wt)men involved legally irrelevant. However, economic histot^
suggests thai vices indulged by ct)nsenting adults are nt)t likely to be eradi-
cated by law. Thus, education of prostitutes antl their clients and supervist)rs
lo the imponance of condotn use is critical for prevention of spread t)f HIV
tt) ihc large clientele of these workers. FtiUhertTiore, ilicir status as illegal
workers makes ihcir access lo apprt)priate health care probletnatic, ttsually
tvt]Ltiring significant out-ol-pt)cket expenses. Tbus, idctitificatit)n and treat-

tal health burden in lho.se sulferitig 1*TSI) or depressioti and tt) inft>rm them
t)f tlieir rights lo leave prt).siitution atid obtain alternative cnipk)yment.
The sample from which these cases were derived clearly is not systeiii-

clit)logical backgroimds tt) be more willing lo do

lhe West than at other times. Undottbtedly,
bi, are a very different sample (I-arley & Barkan,
1998), It is important for hypotlicsis formation for researchers to realize the
tremendous potential helen)geneity of commercial ,sex workers, as evidenced
in the case histories presented here.

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