Sex Work and Sexual Health

This blog is written by a sex worker and former sexual health practitioner. The opinions within do not replace advice given to you by your own sexual health clinic. As the term sex work is so broad, this first blog will focus on sex workers who provide full contact sexual services, with a focus on those who were born biologically female.

Having sat at both sides of the table when it comes to sexual health in our industry, I wanted to give a brief insight into how sexual health clinics operate and destigmatize any concerns.

Confidentiality during your sexual health appointment

This first thing to say is that it is unacceptable for any clinician to make you feel ashamed, unwelcome, or judged. In short, it should never happen. A good sexual health practitioner will never make assumptions on patients and their lifestyles, and instead they will encourage an environment where you feel comfortable speaking freely about your sexual history. You should also be made to feel welcome to return regularly, whether or not you have symptoms. 

If you have any concerns about the attitude or behaviour of any clinician towards you, do raise your concerns as officially as you feel comfortable doing. The service you are using should have a method of providing anonymous feedback.

When you use a sexual health service, the notes taken are completely anonymous and coded with a unique identification number. This is NOT fed back or linked to your GP, your hospital notes or another sexual health clinic, unless you have already attended there for treatment. 

The only time this confidentiality could be broken, is if a clinician has an immediate concern that you pose a serious threat to yourself or someone else. Be reassured that being a sex worker on its own does NOT put you in this category. In the event that there are other concerns, the clinician is obliged to inform you that they intend to break your confidentiality, except in a few unique circumstances.

I am making the point that your GP will not be informed of your profession or sexual history and there’s no need to worry about what you disclose. Any questions asked are never to judge, but to ensure you are offered appropriate testing and services specific to your needs.

Attending a sexual health appointment

What really helped me give the best service when I worked in sexual health was knowing that my patient was a sex worker. Why? Because the questions I ask would then be tailored without trying to second guess or make assumptions about why you made the  appointment. 

One great tip I learned from sex workers attending my clinic, is to write down my sexual history so that my appointment is punctual and efficient. The clinician can then tailor their service to me, knowing exactly why I’m there and what I need or want. 

An example of what you write might look something like this:

• I am a sex worker/escort/professional companion (I use the term I feel best describes me)
• My last sexual health appointment was about ‘x’ weeks/months ago
• I do/do not have symptoms
• I see clients on an outcall/incall basis/ both
• I see ‘x’ number of clients per week/month
• The clients I see are always/mostly male. I do/do not have bookings with females/couples
• I do/do not provide oral sex (condom use is always/sometimes/never)
• I do/do not provide vaginal sex (condom use is always/sometimes/never)
• I do/do not provide anal sex (condom use is always/sometimes/never)
• I do/do not know my vaccination history
• I do/do not know when I last had a blood test to check for blood borne viruses 

Things you might be offered or asked

Your clinician is obliged to ask you if you feel at risk or pressured to be a sex worker at each appointment. This is usual practice and not done because you have alarmed them in some way.

A vaginal swab: which can usually be done by you, unless your clinician recommends an examination after you have given your sexual history. Please note that if it is suggested you consent to an examination, although the couch you are sitting on and the position you’re in may feel weird or embarrassing; to a practitioner, it’s really no weirder than examining an arm. The experience is generally no more uncomfortable than a standard cervical smear test. 

Throat swab: if you are not offered one, I recommend you request one. Even with a condom, no sexual act is risk free and although the risk of harm to you if you did have a throat/oral STI may not be as serious as other types of penetrative sex, it is still important to bear in mind, particularly when we will almost certainly not know the sexual history of our clients.

Anal swab: you may also be offered an anal swab, even if you never engage in any form of anal sexual activity. Women’s vaginas and bottoms are very close together and at some point during a client booking, it is not inconceivable that semen/ seminal fluid/ pre-ejaculate/pre-cum, may have come into contact with your anus and pose a risk of infection. Again, if you are offered one, I think it’s a good idea to accept it. You will probably be able to perform this yourself, unless you’d rather not (it’s a swab with a tip as small as a cotton bud that is inserted into your bum and swizzled around for a few seconds).

Vaccinations: As a sex worker, you should be offered free vaccinations for Hepatitis B. You might also be offered a vaccination for Hepatitis A. If you are not asked about your Hepatitis B vaccination history and you are unsure or concerned you haven’t had a full course, I would bring it up. Full protection against Hepatitis B involves 3 injections, spread over a variety of time frames, which will differ depending on where you have them.

Blood tests: Depending on the sexual history given at your appointment you may be offered a blood test. If so, I advise you to accept it, regardless of if you or your clinician deem you to be of low risk of blood borne viruses since your last blood test. If you are NOT offered a blood test, ask for the reason why. There may be a sound clinical reason why it is unnecessary for you to have one at that appointment. However, your clinician should be able to justify why they decided this.

Follow up appointment: depending on your sexual history you may be advised to arrange follow up appointments, regardless of whether you did or didn’t have symptoms.

How often should you attend?

If you see 1-2 clients or more per week, you should ideally consider an appointment every 12 weeks, and if you have any symptoms you should contact your clinic and arrange an urgent appointment or attend a walk in service straight away.

Remember there are walk-in clinics available and you do not have to live in the locality of the clinic to visit it.

Risk reduction for sex work

As you are aware there is no such thing as a risk-free life, but here are a few basic tips to reduce the risk of an STI. No matter who you are and what you do, the more people you have sex with, the more risk there is of an STI. 

There may seem like there is a stigma surrounding sex work and sexual health, but quite often we are more clued up and risk aware than the general public. The last thing I want is to preach or teach. If you know and accept the risks you are taking, you are in charge of your body and no one else.

Condoms, condoms, condoms: that’s right, condoms are best practice for risk reduction, whether engaging in oral, vaginal or anal sex. If a client attempts to remove a condom without your knowledge or consent and continues with any form of sexual activity, this is a criminal offence. 

You should purchase condoms in small (trim), regular and large as clients come in all shapes and sizes. A condom that is too small for the client is more prone to split, and a condom that is too large may come off. Condoms can be bought in bulk from Amazon or the NHS Freedoms shop. As soon as you feel your condom starting to get ‘dry’ during sexual activity, swap it for a new one. Again, this is a breakage risk.

If you notice open wounds, splits on you or your client’s genitals or mouth, do not engage in sexual activity, with or without a condom. If a client is keen to turn off the lights before getting naked, maybe put them back on so you can check. You don’t need to shout “I’M CHECKING YOUR PENIS ISN’T BROKEN” but if it were me, I would want to develop a subtle strategy for checking, before engaging in any activity. Does your client want to finger you? If so, the same applies, visibly dirty hands, broken skin or jagged fingernails pose a risk of infection. Carrying latex gloves is inexpensive and provides a type of ‘condom for fingers’ with clients. 

Oral sex may be perceived as lower risk and you may decide to engage in oral without a condom (OWO) and/or cum in mouth services (CIM) and that is ok as long as your are aware of the potential risks and the benefit of getting tested for oral STIs. Please note that even if a client doesn’t cum in your mouth, you are still potentially risking an STI. If you have broken skin in your mouth such as a mouth ulcer, this increases the risk. NHS guidelines also suggest avoiding brushing your teeth immediately before a penis goes in your mouth, in case you cause small abrasions. As an alternative, I like to take along a chlorohexidine- based mouthwash, to use after oral sex. 

For vaginal sex I would suggest a condom always. If your client is offering more money for you to not use one; consider how many other sex workers he has proposed this to and how he may not be aware of the risk he poses to himself or others (or may not care). Please also be mindful of clients rubbing against you when you’re both naked, attempting a bit of ‘dry humping,’ or the old ‘lie on your back and let me give you a massage’ (with an erect penis pressed between your butt cheeks). This is also a potential risk.

A word on anal sex: receiving anal sex, poses a greater risk of infection than vaginal sex, even when using a condom. This skin inside your bottom is less stretchy and lubricated than the skin in your vagina, making it more likely to split. This in turn means a greater risk of blood borne viruses as well other STIs. As for anal sex I would again always advise using a condom, combined with a water-based lubricant to lessen friction. Using a lubricant will minimise the risk of harming your skin and the chance of a condom breaking. If any oil-based lubricant has been used by you or your client beforehand, it can weaken the condom if it isn’t washed off first.

Sex toys: I would suggest always using your own toys only. If you choose to use a sex toy your client has provided, ideally it should be new and in its original packaging… Even so, always cover with a condom to use on yourself rather than allow a client to use it on you. Even with no malicious intent, any sex toy being thrust inside you, with no knowledge of where else it’s been and no control of how vigorously it’s used; does pose a risk.

Online sexual health testing

These are better than no testing at all, so please do use them if you are unable to have a face-to-face appointment, but it is best to see a sexual health practitioner. 

A word to clients

You need regular testing too, and if you don’t you are doing the sex workers you see a disservice (along with anyone else you have sex with). Please please please, get yourself down to the clinic on a regular basis to make sure all is in order.

Questions?

Wishing you all great sex and better sexual health!  If you have any questions on this topic, feel free to email hello@indiecollective.co.uk and one of the team will pass your message on to me. Obviously I cannot diagnose anything remotely, so for any pressing health concerns get yourself to you local clinic for prompt treatment.

Photo by Charles Deluvio on Unsplash