The experiences of people who sell or exchange sex and their interaction with support services: lived experience engagement

1 Introduction

LKJ Research was commissioned by The Scottish Government's Violence Against Women and Girls Justice Unit, on behalf of the Scottish Ministers to conduct lived experience research with people who sell or exchange sex in Scotland. This research aimed to inform work related to the Scottish Government Programme for Government commitment to develop a model for Scotland which effectively tackles and challenges men's demand for prostitution – which will also aim to reduce stigma and criminalisation experienced by women and encourage better access to services and support. The Scottish Government has committed to engaging with those with lived experience of selling or exchanging sex in the development of this approach. Within the suite of research designed to inform the model for Scotland, the remit of this research was to focus on support service provision. To this aim, the research looked to map service provision in Scotland with a view to understanding the current service landscape and identifying any gaps. In addition to this mapping, lived experience input was sought across three areas: accessing service provision, experiences and impact of support and ideas for future service design. The research took place over a period of 6 months from December 2021 to May 2022.

1.1 Background

There is no accurate information on how many people sell or exchange sex in Scotland. This lack of population-level data is not unique to Scotland, it is reflected globally and can be attributed to the hidden nature of selling or exchanging sex, likely fuelled by concerns around legality, stigma and judgement. The complexities of estimating the population who sell or exchange sex are widely acknowledged, with additional complexity associated with the move to online selling and advertising (Sanders et al., 2018). There is some limited demographic data in Scotland, for example the Encompass Network conducted a snapshot survey of people accessing their services, which collected the information of 150 women accessing support in November 2021^[1]. The women in the report gave useful information on the needs of women accessing services, however without a sense of the overall population of people who sell or exchange sex, it is impossible to know whether the results of this are representative of the overall population who sell or exchange sex in Scotland. Despite the lack of conclusive data, the majority of people who sell or exchange sex are widely believed to be women (see for example, Pitcher, 2015).

This research begins from the standpoint that qualitative research is not only the most practical approach, with it not being possible to take generalisable samples of an unknown population, but also that it is the most appropriate to gain the rich, nuanced understanding of the experiences and ideas people have. When looking at the provision of support, this understanding of detailed experience on an individual level is essential to inform a system that supports all the needs each person may present with and can be appropriately tailored to provide maximum benefit to people who wish to engage. The majority of data in this report is therefore qualitative, but additional quantitative data has been collated around demographics, as well as specifics of services accessed, routes-in and methods of accessing services. These choices were made as numeric data and were considered especially useful in enhancing current understandings around service access. This report does not claim to provide a definitive answer or framework for support, but rather reflects suggestions and ideas from those with lived experience, that could be revisited, and adapted as knowledge in this sector evolves.

1.2 Identified Support Needs

In September 2020, the Scottish Government undertook a national public consultation on challenging men's demand for prostitution, working to reduce the harms associated with prostitution and helping women to exit.^[2] Alongside gathering views on the Scottish Government's approach to tackling prostitution, the impact of Covid-19 restrictions on women involved, and the violence against women policy approach, the consultation responses provided some insights into support service provision. The key messages from the consultation around support suggested that common support needs for people who sell or exchange sex are likely to include financial support, peer-led support, housing support, healthcare including addiction support, education, employment, and training. Responses stressed the importance of support being holistic, tailored, and person-centred, and highlighted the negative impacts of stigma and judgement on accessing services and support provision. The consultation reflected the importance of recognising that not all those who sell or exchange sex need or want to exit and ensuring that support should never be contingent on exiting. A substantial barrier raised in relation to accessing support was criminalisation of the selling of sex. Building on this public and professional input into the consultation, this research sought to provide detail and nuance about the ways in which these support aims can best be met, as well as identifying additional considerations for providing effective support from those with lived experience.

The Encompass Network Snapshot provides a useful indication of the support needs women selling or exchanging sex in Scotland might have. The review of the support needs of 150 women engaged with services during a week in November 2021 revealed that support was most frequently required around mental health (n=89), finances (n=83), safety (n=81), housing (n=78), benefits (n=71), and addictions (n=68). A substantial number of women required some form of practical assistance (n=74). Other identified support needs amongst this group include civil and criminal justice, debt, digital access, exiting, homelessness and immigration. Whilst this only reflects the needs of women supported by 7 Encompass Network services, it does provide a useful indicator of the range of support needs people who sell or exchange sex in Scotland may experience. Other research from Scotland reflects this picture too. Although dated, work conducted in Scotland in the 1990's identified the prevalence of multiple complex needs amongst those who sell sex on the street, including addictions, poverty, abuse and homelessness (McKeganey et al., 1990).

Globally, there are a number of pieces of research that provide an insight into the support that people who sell or exchange sex might require. Whilst it is acknowledged that not everyone who sells or exchanges sex will want or need support, for those who do, the range of identified support needs are consistent. Reflecting the Encompass Network Snapshot study, as well as the Scottish consultation, these identified support needs include: poverty, mental health and trauma support, physical health, employment, addiction, accommodation, and personal safety. A key selection of studies highlighting these needs internationally and in Scotland are explored here.

Research from the US found that all participants engaged with one support programme required assistance around poverty (Shdaimah and Bailey-Kloch, 2014). Numerous other studies reflect poverty as the core identified support need. In Scotland, research in Aberdeen identified financial hardship as being a key driver to selling or exchanging sex (Lister, 2008). This was further reflected by one ethnographic study where participants in Glasgow reportedly began selling sex out of extreme financial need (McKeganey, 2006). Related, is the finding from two small Scottish studies that many men and women who sell sex have experienced homelessness (Connell, 2010; Connell and Hart, 2003).

Childhood abuse and trauma has been noted to be prevalent in populations who sell or exchange sex (Thorlby, 2015). Ethnographic research in Glasgow found a prevalence of childhood abuse amongst women selling sex on-street (McKeganey, 2006). Additionally, research has identified high levels of emotional abuse resulting in increased diagnoses of post-traumatic stress and depression (Roe-Sepowitz, 2012). Identified mental health needs have alternately been described as 'burnout' (Vanwesenbeeck, 2005) and psychological strain and stress (Sanders, 2006). Regardless of researcher explanations, the need for robust mental health support to be available is clear.

Risks to physical health related to selling or exchanging sex have been studied in Scotland, with a quarter of the men and women selling sex in Edinburgh interviewed for one study sharing that they would acquiesce to the pressure from sex buyers and have sex without a condom for extra money (Morgan Thomas, 1990). This necessarily carries substantial risk of sexually transmitted infections, and illness. Addiction is also often identified as a core support need with attention given to the complex interplay between addiction and selling or exchanging sex (Roe-Sepowitz, 2012; Shdaimah and Bailey-Kloch, 2014). Substance use and the sale of sex is considered to be mutually enforcing with drugs understood to both be used as a coping mechanism to deal with experiences selling sex, and also necessitate the sale of sex financially (Matthews et al, 2014; Gorry, Roen, and Reilly, 2010; Cusick and Hickman, 2005). One study found that in the US over half of all women entering treatment for addiction had either sold or exchanged sex (Burnette et al., 2008). Research in Scotland has largely focussed on the street-based selling of sex and amongst this population levels of addiction are reportedly high. One study in Glasgow estimated that 97% of the 1400 individuals involved in selling sex on-street were injecting drugs users (Payne et al., 2004). Another study indicated that 95% of those involved in street-based selling of sex in Glasgow were injecting drugs users, with the figure for those in Edinburgh estimated at 50% (Holmes, 2005). Additionally, a series of studies in Glasgow found that women who injected drugs sold sex more frequently, and spent longer selling sex on each occasion than those who did not inject drugs (Bloor et al, 1991; McKeganey et al., 1990). One Edinburgh study however, did identify much lower levels of injecting drugs amongst participants who sold sex in saunas, massage parlours and private accommodation than those who were street-based (Morgan Thomas, 1990). Building on this, a study in Glasgow identified that drugs use is a feature of both on-street and off-street sale of sex, but the drugs use varied with crack-cocaine and heroin used more on-street, whereas those selling sex indoors were reportedly more likely to take cocaine or alcohol either with men buying sex, or to alleviate boredom (Cusick, 1998). This study was particularly important in highlighting the variance in the relationships that individuals have to substance use, even though it challenges the perceived divide between prevalence of the use of drugs on-street and off-street. This differentiation is particularly important when considering the change of dynamic of the sale of sex since these studies were conducted, brought about by the adoption of technology and online methods, and the observed decline in the sale or exchange of sex on-street.

Support around safety and dealing with the impact of crime are other commonly identified requirements. Substantial evidence indicates that people who sell or exchange sex are at higher risk of violence and assault. US based studies found that women who sell sex are eighteen times more likely to be murdered than a woman in the general population (Potterat et al., 2018) and are often targeted by serial offenders (Quintet, 2011). A UK based study indicated that here women who sell sex are five times more likely to be a victim of homicide than a woman who does not, even when controlling for socioeconomic factors (Cunningham, 2018). This high risk of violence can be linked to a need for corresponding support. Research from Glasgow and Edinburgh reflects this high risk of violence, with perpetrators identified as being men buying sex, as well as 'pimps' or managers and the general public, and violence ranging from threats through to rape and murder (Barnard, 1993; McKeganey and Barnard, 1996; Church et. al, 2001; Connell and Hart, 2003; Sanders, 2005). Despite this identified risk of violence and assault, additional papers from Scotland have highlighted the reluctance that many people who sell or exchange have to report these incidents to the police with barriers including stigma, fear of blame, and fear of arrest (Pitcher, 2015; Smith, 2015). The lack of trust in the police and justice systems represents a substantial barrier to accessing justice and associated victim support.

As well as ongoing needs for support, research suggests that many of the issues people who sell or exchange sex face have been exacerbated by the Covid-19 pandemic and associated restrictions. This has been noted either through people losing their income, or through decreased demand from purchasers leading to additional risk-taking (Callander et al., 2021).

1.3 Elements of Effective Support

With the range and interplay of multiple support needs identified amongst those who seek support related to selling or exchanging sex, it is perhaps unsurprising that where effective, support is cited as having the potential to be life changing. (Shdaimah and Bailey-Kloch, 2014). In line with the range of individual needs, there is no universal or agreed formula for providing this support. Practical support however, is a core element. A study in the US found that practical support, including with addictions, housing and procuring identification documents, was a crucial element for participants reporting satisfaction with support provision (Shdaimah and Bailey-Kloch, 2014). Economic support was identified by a number of studies as an essential part of successful support (Gesser and Shdaimah, 2021; Preble et al., 2016). A Scottish study, which identified the additional harm for those at the intersection of selling sex and addiction, advocates for harm reduction measures, such as safer injecting equipment and needle exchange being an essential element of support (McKeganey and Barnard, 1992).

The approach of the workers delivering support is highlighted across the literature as essential to successful engagement. Specific elements identified in the US were that workers should be compassionate, and patient (Shdaimah and Bailey-Kloch, 2014). A number of studies identified that support was particularly effective where there was an element of peer mentorship, particularly from people who had received support or participated in the relevant support programme before (Gesser, 2022; Shdaimah and Leon, 2016; Preble et al., 2016; Thorlby, 2015). One study noted that peer support can include formal groups, friends and family, but also staff members with lived experience within services (Gesser, 2022).

Flexibility is also valued in the literature in delivering effective support. Particularly prominent was the need for support to facilitate people who may have periods where it is more challenging for them to engage (Shdaimah and Bailey-Kloch, 2014). There are a number of studies that suggest that exit from involvement in selling or exchanging sex is rarely linear, and is not best understood as a singular event, or time of exit. Instead, literature suggests that any exit from involvement in selling or exchanging sex is likely to be accompanied by periods of re-entry and exit again (Gesser and Shdaimah,2021; Roe-Sepowitz et al, 2011; Baker et al., 2010; Dalla, 2006). However, alternative studies indicate that where properly supported by agencies, exiting can be achieved relatively quickly and without the necessity of the re-entry cycles identified elsewhere (Matthews et. al, 2014; Bindel, 2012). Despite disagreement, what is clear is that it is important for support provision to accommodate flexibility in order to facilitate continued support following periods of disengagement should they arise.

Closely linked to flexibility is the element of being person led (or often woman-led). A number of studies particularly emphasise going at the pace of the person accessing support so as not to overwhelm them (Roe-Sepowitz, Hickle and Cimino, 2012; Preble et al., 2016). Partnership and joined up working is offered as a potential solution to ensure that multiple services do not place too many demands on the person accessing support at once (Preble et al., 2016; Hester and Westmarland, 2004). In Scotland, two Glasgow based evaluations have identified benefits to improved partnership and joined up working, in providing a cohesive response with a common approach and position (Matthews and Easton, 2010; McKay et al., 2004)

Perhaps unsurprisingly, adequate resourcing has been hailed in the literature as essential to facilitate exiting, where this is desired, in light of the multiple support needs many individuals may have (Cusick et. al, 2011).

1.4 Barriers to Accessing Support

With the understanding of the high level of support needs many people who sell or exchange sex experience, substantial research focus has gone into understanding barriers to accessing support, with the aim of increasing engagement. Fear or experience of judgement was raised as a barrier in several studies (Gesser, 2022; Gerassi et al, 2021; Gorry, Roen, and Reilly, 2010; Sanders, O'Neill and Pitcher 2009). One study focussed on access to sexual health for male and transgender people who sold sex found that stigma was the main barrier. For this population stigma was identified in relation both to the selling of sex, but also due to sexuality, gender identity and HIV status (Brookfield et al., 2019). Concerns around confidentiality and the sharing of information are also frequently cited as barriers to engagement (Brookfield et al., 2019).

Physical accessibility and location are also noted in a number of studies as important considerations for services when improving access (Gesser and Shdaimah, 2021; Preble et al., 2016). Other factors that limited engagement included rigidly structured support with the requirement to engage at scheduled appointments (Gesser and Shdaimah, 2021; Gorry, Roen, and Reilly, 2010). Related was the inability of services to respond immediately at times of crisis or relapse, and long waiting lists (Gesser and Shdaimah, 2021).

1.5 The Current Research

Building on existing literature, this research gathers experience that is current and reflects the changes methods of communication and interaction following the mass adaption of technology during the Covid-19 pandemic and subsequent restrictions. Much of the current literature from Scotland can be considered dated. The focus of the majority of previous studies from Scotland is mainly on the street-based sale of sex, and therefore does not necessarily reflect the experiences of the majority of people who sell or exchange sex. In 2014, Police Scotland estimated on-street to only be 10% of all sex sold, and in the Encompass Network Snapshot study, only 31% of the women supported had been involved in selling sex in this way, with the majority involved in an alternative venue, or online. Research highlights potential issues with this narrow focus, and there are a number of papers suggesting that experiences identified amongst people selling sex on-street such as experience of childhood abuse and exploitation, are less prevalent amongst those who sell sex in indoor venues such as private premises, and saunas (Pitcher, 2015; Sanders, 2005). Additionally, researchers have suggested that there are lower levels of addiction amongst those who sell or exchange sex indoors or that substance use between venues is distinct in its nature (Cusick, 2011). With literature highlighting the potentially distinct support needs across on-street and off-street selling of sex, this research aims to explore the experiences of those in Scotland across all venues.

Previous research in Scotland does offer some information, if dated, on people selling sex in Aberdeen, Edinburgh and Glasgow. There is, however, very limited published information on the situation in Dundee, with one study citing a seeming absence of street-based prostitution in the city (McKeagney, 2006). The focus of existing research on street-based selling of sex also means there is limited research encompassing experiences outside of the major cities where sex is generally sold or exchanged indoors. This research aimed to address these geographical gaps.

In order to improve understandings of the needs and experiences of people selling or exchanging sex in Scotland, this research consists of two elements: a mapping study to gain an overview of current support provision and lived experience engagement aimed at understanding service experiences and impacts, challenges and barriers to access, and gathering ideas for future service design. The mapping study collected data using two online surveys and lived experience input was requested through a combination of interviews and surveys.

A total of 113 participants took part in the research. These were 71 people with lived experience of selling or exchanging sex, and an additional 42 professionals who completed mapping surveys (29 representing their local authority area, and 13 representing specialist services). The key themes and insights are presented within this paper, and the accompanying accessible findings report.

1.6 Research Aims

This research aimed to understand the experiences people who sell or exchange sex have when accessing support services and service provision in Scotland, through engagement with people with lived or living experience. The specific aims of the research were:

1. To map the current provision of services in Scotland for people who sell sex or exchange sex, and to identify any gaps in provision.

2. To understand how people who sell or exchange sex experience engaging with mainstream and specialist support services in Scotland including identifying barriers to access

3. To gather views from those with lived experience on future service design.