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

5 Lived Experience Findings: Service Experiences and Impacts

Once participants have successfully accessed support services, there are a number of factors which impact the likelihood of them remaining engaged, and of them achieving successful outcomes in collaboration with that service. During their engagement with the research, participants were asked to discuss their experiences both at any current services they were accessing and services they had engaged with in the past. These responses have been analysed to provide an overview of the factors that participants believe facilitate or prevent continued engagement and contribute to a service making a meaningful impact. Additional consideration is given to the type of impact services can or could have. This report focuses on the impact and actions of services, but it should be remembered that alongside these, many of the social barriers identified around access such as the role of peers, abusive partners and exploitative others present ongoing challenges to engagement. Whilst their role is outwith the scope of the report, the challenging context in which, for many participants, engagement with services is occurring should be kept in mind.

The graphic below is compiled from positive descriptions participants gave of services during the surveys and interviews and displays the qualities that participants valued in a service. The most common response was non-judgemental. Other qualities that were highly valued by participants included feeling that the service was caring, understanding and genuine, and that they would help.

The qualities identified in Figure 11 were valued by participants whether they were identified in mainstream or specialist services. Sometimes, rather than the being perceived as the service culture, an individual worker was attributed with exemplifying these qualities and credited with the positive impact that the support had on the participant. The experiences shared demonstrate that when support is effective it can be 'life-changing' [I2]. Participants shared that:

'it really helped me survive, like mentally get by and stuff like that' [I1]

'I feel I could have died if this service wasn't there' [FS11]

Other participants reflected the immense potential for positive impact that effective support can have when they said:

'now my life is in a good place and my life has changed so much' [FS25]

'now I engage well and my whole life has changed' [FS13]

For some, the impact was especially noted on their sense of self-worth and belief:

'My case management worker has made me realise I am much more capable of things than I ever believed I was.' [FS7]

'[they] made me believe that one day it will happen. I don't feel so useless and made me believe in myself.' [FS10]

Whilst many of these experiences reflect the impact of effective support in the long term, other participants also noted the immense impact that appropriate service provision, particularly around practicalities can have on a day-to-day basis, or at a time of crisis. One participant shared that she had no money, no electricity and had reached her limit on food-parcels when she had accessed her service on the day of the interview and they were able to help her. She reflected:

'I don't know what I would have done without them today.' [I9]

These experiences reflect the positive impact that support services can have in both the long and short term. Whilst many people who sell or exchange sex require intense, and varied support, these participants experiences speak to existing good practice, and affirm that this support can be provided effectively. However, far more negative experiences with services were reported in this research than positive. When asked about positive experiences they had had at services other than the one they were completing the research at, the majority of participants reported they had had none. Participants who were not currently engaged with services rarely reported having had any good experiences at all. The comments below are reflective of a large number of experiences participants shared:

'I don't think I have had any good experiences' [FS3]

'Not really had that many good experiences' [FS16]

'I haven't really' [FS14]

'I genuinely don't think I've ever had a 'good' experience with other services, or at least now when I look back I thought they were okay but now I think they weren't that great and did the bare minimum.' [FS29]

'I can't think of any' [FS19]

'There have not been many good experiences. Other services just don't get it' [FS4]

The factors which impact upon service experiences and were identified as making the difference between support being 'life-changing' and ineffective, or even in some circumstances harmful, are discussed here. They have been subdivided into considerations about:

• Workers
• Service offer

5.1 Workers

For the purposes of this report, 'workers' refers to the broad range of professionals and practitioners that participants encountered within mainstream and specialist services when seeking support. The approach of workers was the most prominent theme identified as making the difference between individuals remaining engaged with services or disengaging. Similarly, the individual worker was often credited by participants with making the difference between support that was effective, and a service which felt like it was 'ticking boxes' and not really contributing to fundamental change. This quote from one participant exemplifies the core qualities that were valued in workers by participants. When speaking about her worker she says:

'She has always made me feel comfortable and since day one I knew I'd made the right choice reaching out to [service] for support because we clicked right away and there was no judgment or pitying me, we just got on with it...I can speak to my worker about anything because I know she will just take it as it is and come up with a plan. She gives me a kick up the arse when I need it and I know she is always just a text or phone call away and she will get back to me. I've never had to chase her up or felt like a burden for getting in touch in the first place.' [FS29]

This worker is described as epitomising the key themes identified around good practice in supporting people selling or exchanging sex. She is reported as making the participant feel comfortable, not being judgemental or pitying, providing practical planning and motivation, trusting the participant's narrative, and being consistent.

The core themes illustrated here, and prominent across participant responses, alongside negative qualities in workers are explored in more detail in the following sections. These are:

• Knowledge
• Not being heard
• Consistency
• 'Treat you like a human'
• Judgement

5.1.1 Knowledge

Knowledge of the experiences that people may have when selling or exchanging sex was particularly highly valued in workers. For one participant, it was particularly important for her to know that the workers had supported other women who had sold or exchanged sex and had a practical understanding of the support that may be beneficial. She said:

'She's amazing. They've both been amazing. Both workers I've had. Yes, they really understand. They've got perfect knowledge. Well, not perfect knowledge, they've not as far as I know [sold or exchanged sex], but they've got experience of working with women in my position and it really shows itself. It really helps.' [I1]

For other participants, the opportunity to engage with peer support or be supported by workers who had lived experience was particularly beneficial.

'just knowing what it's like, how it happens and not having to try and imagine it, and just understanding how it happens is a lot easier than someone trying to make it up.' [I3]

'[services] need to include people with lived experiences who know for real how it is, not just assuming' [FS33]

Where workers were not considered to have enough knowledge, participants reported that this undermined the value they were able to receive from support services. For some this manifested as being unable to make suggestions for the direction the support might take and relying on the participant to know exactly what practical support they required. One participant shared:

'The last worker I had was a young lassie and she just didn't know what she was doing, it's not her fault but I had to tell her what to do sometimes it just wasn't what I needed.' [FS19]

Another participant shared that in her experience, this lack of knowledge had resulted in the services not understanding how many different support needs may need addressing simultaneously for some people who sell or exchange sex. She said:

'[I needed] to be able to talk about more than one issue as kept getting told I had too much stuff.' [FS47]

This lack of understanding of the importance of holistic care, and the inter-connectedness of support needs for many people, led to this participant doubting the impact that the service could have, and to her disengaging.

As well as a lack of knowledge making participants feel there is no value in continued engagement with the service, others noted that a lack of knowledge can present itself in a lack of confidence from the worker and therefore a reluctance to discuss the issues they may be having surrounding selling or exchanging sex. This participant said:

'Most workers don't have enough knowledge and fear discussing prostitution.' [FS11]

A lack of knowledge contributing to a reluctance to discuss the sale or exchange of sex is likely to be problematic through both preventing people who sell or exchange sex from feeling comfortable disclosing their experiences, and also meaning that if a disclosure is made the service is unlikely to have adequate knowledge to make a meaningful impact with the support they offer. This reflects the findings around accessing services, particularly that the primary reason given for participants not disclosing that they sold or exchanged sex was that the service did not ask. A lack of worker confidence necessitates the person accessing the service facilitating disclosure and evaluating the potential costs to them of doing this, especially where a worker lacks expertise or is inexperienced. In this way a lack of worker knowledge leading to a lack of confidence is likely to substantially impact on their ability to deliver impactful support.

5.1.2 Not being heard

Related to a lack of knowledge or understanding, participants commonly reported feeling that they were not listened to when they discussed the impact of their involvement in selling or exchanging sex, with services. Some felt that this resulted from services not being interested in supporting them or engaging with the issues they were presenting, and rather making contact to ensure they could demonstrate due diligence if the case was ever examined. One participant said:

'They have phoned me but it's just to 'cover their arse' they don't actually listen.' [FS3]

A number of others reported feeling like they were rushed by services, and that the worker did not really want to hear what they had to say. One participant said:

'When I did counselling before it felt like they made me tell my story but rushed me and just wanted to get it out the way and do paperwork rather than let me tell it in my own way.' [FS29]

Another participant shared that she felt rushed when discussing another important element of her life. She said:

'they asked me to 'quickly' talk about my daughter (daughter is removed from care) and I was like 'how can I quickly talk about her?' and it was the last 15 minutes and I just felt it was rushed and they weren't really listening so after that I left and never went back and told myself that I wasn't ever going to speak about it again.' [FS29]

For this participant, the experience of feeling like the service did not want to listen to her, when she was talking about issues important to her left her reluctant to discuss this with other services in the future. In this way, participants perceiving services do not want to listen to them can block them from receiving meaningful support both at the service they have this experience at, and at other services in the future.

As well as not being given the time and space to talk and feeling that the worker did not want to hear about their experiences, another common perception shared by participants was that services minimised and undermined the impact that selling or exchanging sex had on them. One participant shared her experience:

'I told her I wasn't well (no sleep/stress) - she did not get back in touch.' [FS42]

Other participants reported that the reaction they got from services made them feel like they were over-reacting, and that the issues they were facing were not proportional to their experience. One participant said:

'They just acted as if it's normal and it's fine, and you'll get over it and whatever. Meanwhile I was struggling with my mental health, I was struggling with a lot of things in my life but nobody actually said, 'Right, okay. I can see that you're struggling and you need some help to get out of this situation that you're in.' Nothing. It didn't matter how many times I screamed and shouted about this awful thing I was involved in, nobody did anything anyway.' [I1]

Another participant echoed this, referring to her experiences with a domestic abuse charity where she felt that her experiences and trauma response to them was undermined and minimised. She said:

'They also make you feel like especially at [domestic abuse charity], they deal with some serious abuse, really serious domestic abuse. When I went to go see them, I was looked upon as, 'You're fine. You don't have a lot of problems,' I wasn't getting beaten up on a daily basis by my husband, I was okay. Meanwhile I wasn't okay and I was seeking some kind of support from somewhere and they weren't giving me the support I needed. They actually made me feel like I was being like somebody who was like a drama queen, wanting services that weren't available, there's nothing wrong with you, look at you, you're fine, just go and get a job. Stuff like that. Meanwhile they don't understand what I was going through or how I was feeling and also how alone I was. I was so alone in the world not really knowing how the hell am I going to fix all of this' [I2]

Another participant reflected these experiences, saying that she felt that services judged her for accessing them when she was able to present well and showed no visible signs of trauma. She said:

'I often feel judged by other services because I appear to be coping' [FS2]

For her, not presenting as visibly or stereotypically vulnerable seemed to be impacting on the support she was offered. As well as expectations of performative victimhood, one participant suggested that prominent narratives around the sale or exchange of sex contribute to workers expectations of what is a proportional response to experiences around this. She said:

'I think, because some women claim that they are comfortable in that industry that maybe they assume everyone is' [I1]

Similarly, a number of participants reported that workers did not listen to their explanation for the source of their trauma, or the issues they were presenting at the service with. This was particularly true of people who were also in addiction, and a number of participants shared that when they attend services, their presenting issues are attributed to addiction, even when they feel they are related to selling or exchanging sex, or another experience. They said:

'I don't contact GP anymore especially not for my mental health because he just says that it's drug related and doesn't listen when I say it's not just that.' [FS28]

'They do not help since they know you are a drug addict, they treat you in a different way' [FS53]

These experiences reflect some of the fears that participants raised around disclosing to mainstream services (section 4), which for these participants were realised. For some, repeated experiences of not feeling heard and feeling like their experiences were undermined and invalidated had an extreme impact on their wellbeing. One participant reported that her mental health had to deteriorate to the point of crisis before she received the support she had been repeatedly asking for:

'it got extreme. I was very, very seriously very suicidal, and it took me to get to that stage to get help. I did attempt suicide in a really bad way, but I thought that whatever happens, well, it's meant to be. I'll either die, or they'll listen.' [I1]

Another participant felt that by ignoring and undermining the harms of selling or exchanging sex, the services she tried to access for support were complicit in keeping her involved. She says:

'I felt they were pushing me into prostitution by not helping me.' [I2]

These experiences reflect the vital importance of participants feeling they are both heard and believed when accessing support services, and their understanding of their needs is respected within provision. Where this does not happen, participants report not feeling supported, and in some cases these experiences contributing directly to a deterioration of their mental health and wellbeing.

5.1.3 Consistency

Consistency was highly valued by participants in facilitating their continued access to support. This was identified both in the consistency of funding and workers, and the consistency of the reception and response they received when accessing a service. High turnover of workers was noted by a number of participants as being particularly problematic, and for some resulted in the disengaging. One participant shared:

'Workers changed over - always someone new.' [FS16]

Issues highlighted around a high turnover of workers included the new worker having a lack of knowledge or experience, having to repeat their story again and the associated emotional toll, and feeling that they have to build up trust again with the new worker. A number of participants expressed that there was a substantial emotional cost to them in sharing their experiences and doing this repeatedly left them feeling drained. For those who did have a designated worker who was in role long term, this was considered a positive to service provision. One participant said of her worker:

'I like the fact that I have my own personal worker that deals with me and is absolutely great. Always there for me if I have a problem, feeling a certain way or in general just need a chat, my worker is always there and that makes me feel better alone knowing there is someone there for me.' [FS23]

The opportunity to develop these personal support relationships and associated trust had a strong impact on how successful support experiences were. As well as the individual workers changing, a number of participants shared experiences of having been engaged with a service, which then lost its funding, resulting in significant interruption to support. Another shared a story of engaging successfully with a pilot programme which was then not funded. Consistency of both workers and services was considered essential to allow participants to engage in a meaningful way, and for services to have maximum positive impact.

As well as consistency in the practical sense, consistency was highly valued in terms of participants feeling they can rely on a consistent response when they access the service. For some, this took the form of knowing how a worker will react to any disclosures they make, and therefore feeling confident to share all their issues with them. One participant says:

'it is laid back and I can connect with the worker so can say when I am struggling without worrying about how she will react' [FS3]

A number of participant experiences reflected how helpful a consistent response from services was at times when they had struggled to engage. As would be expected in line with the many complexities people who sell or exchange sex may face in engaging with services, many participants reported periods where they had been inconsistent with their engagement. Participants reported particularly valuing knowing that they would still receive a supportive, and consistent response when they returned to the service, and they would not be made to feel guilty or have to explain themselves. They said:

'[service] never gave up on me even when I wasn't attending appointments or speaking with my worker when she called. They took time with me and let me go at my pace I didn't feel pressured I felt supported.' [FS13]

'I sometimes don't see [her] for a while but that doesn't change how [she is] with me. I know I've been flakey before and not turned up but [she] still makes time for me' [FS19]

'She has stuck with me even when I've had tough times and shut myself away. I didn't want to speak to anyone and even avoided her but she would still send texts asking how I was and when we met up again when I was feeling better she didn't have a go at me for missing appointments.' [FS28]

Unlike services where there are penalties for disengaging, or where only a limited number of appointments are provided, participants experiences highlighted the value of being able to provide flexible support and allowing people to engage as and when they are able. Other participants valued the occasions where services had gone beyond that, and actively sought them out for support when they stopped engaging. One participant shared:

'Today they hadn't heard from me for a while so they came down to check in on me to see if I was alright. They know I self-harm and have attempted suicide in the past so they check in on me if they don't hear from me for a while. Today they have given me a mobile phone so that they can get in touch because they weren't able to get in touch with me.' [I9]

Participants reported valuing that services will bring the support to them and continue to attempt to engage them even when there are periods where they are not responding. This feeling that support is consistently available, and that the support relationship remains intact during difficult periods was credited by a number of participants with their success in remaining engaged, even when they were unable to make appointments themselves.

Another circumstance where participants reported valuing this consistency was where they felt that they had been unpleasant to workers. They valued knowing that this did not result in the withdrawal of support, and that the support relationship remained intact. One participant said:

'On my bad days I can be moody and my worker doesn't argue or make things worse.' [FS10]

Another reflected this when she said:

'I had been so angry the first time I met [worker]. I had no-one else to turn to and then I had to go back and connect with her. There was no issue about how nasty I had been - I was treated really well.' [FS32]

Through providing a consistent, professional reception, participants suggested that services are facilitating continued engagement and this is something they valued highly. One participant expands on this further by saying she believes that workers:

'need to be mindful of how they might be coming across even if they have to deal with challenging behaviour - they should think about why someone might be behaving that way.' [FS33]

Whilst there need to be limits on the behaviour which it is acceptable for people to exhibit towards workers, these participant experiences suggest the value of being able to always present as pleasant not being a pre-requisite for receiving support. Specifically, if someone has presented with challenging behaviour at one appointment, this should not preclude them from engaging again at another time and any permanent ban from services should be avoided where there are any alternatives. These experiences shared point to the importance of workers considering the context of the people they are supporting and attempting to understand some of the more challenging presentations.

All of these demonstrations of consistency were highly valued by participants. In contrast, where a consistent service was not provided, this was often reported to result in people disengaging from services. Alongside a high turnover of workers and inconsistent funding, this lack of consistency was most commonly identified by participants as workers not delivering on their promises, and not taking the action or providing the service that they said they would. Participants said:

'most services say they will do something and then they don't.' [FS6]

'I find it hard to trust services. I stopped going to addictions as the workers never did the things they promised and I lost trust' [FS6]

These participants reflected the experiences of many others, who felt that the effort required from them to engage with services and talk about their experiences was not matched by the level of support they were receiving. For some participants, their experiences of broken promises left them feelings hurt and upset as they did not receive support that they felt would have benefitted them. This unmet hope was experienced by some as leaving them feeling worse than they did before the initial promise was made. One participant explains:

'They were promising me things that never happened. There is no point in promising things - like that my house was going to get sorted - because I will get my hopes up and then feel gutted when they don't happen and end up even worse than I was before. I basically just said 'f**k that' and eventually they went away cos I stopped answering the door and phone. They sent a letter saying they were discharging me from support, I was like 'what support?' [FS18]

As well as resulting in a loss of trust, and motivation to engage, one participant noted that for her, the services not delivering served to highlight the uneven power dynamic within the support relationship. She says:

'They are unreliable, they say they will do things but don't but if I don't do things then it's the end of the world. They aren't really interested, they just want things done to say that it's done, they're not interested in you or things that have happened. They do one job and you're supposed to be grateful.' [FS19]

For this participant the imbalance between the penalties for her not meeting a service expectation and the worker not delivering contributed to making her feel she was not valued. She understood the lack of delivery on promises to be a sign that the worker did not care about her, and instead was doing the bare minimum. This left her with a negative impression of the service and she felt it damaged any opportunities for her to achieve positive impact from engaging.

5.1.4 'Treat you like a human'

As well as being consistent, participants reported that feeling that they were 'treated as a human' [FS11] was central to an impactful and positive experience within support services. This is in contrast to some of the experiences that participants reported where they felt like interactions with services were about ticking boxes or covering themselves against future repercussions. One participant said of workers who did treat her like a human:

'I felt safe and I mattered, they wanted to make sure I was ok I felt like a human being not just a number.' [FS21]

An important element of feeling like they were being treated like a human for participants, was that their worker related to them as a person too. Participants valued the opportunity to build a relationship with the worker that was not solely focussed on their support needs. One participant said:

'She is a real person and we can speak about things that aren't just about support, like a normal conversation.' [FS3]

These opportunities to relate to the worker and build a broader relationship was further considered helpful to demonstrate to people who had sold or exchanged sex that although this was their reason for accessing support, it did not need to be their defining feature within the support relationship or going forwards. One participant shared:

'[Service] don't treat me like selling sex is a stigma or the be all and end all of me.' [FS7]

Reflecting this, another participant noted that it was beneficial for her that the worker was not focussed solely on the issues of her past but was meeting her in the present and working towards the future. She said:

'She wasn't interested in what I had done in my past, she was interested in how she could help me move on, and how she can support me.' [I4]

Additionally, one participant shared that being treated as a human allowed her to feel comfortable sharing when she was struggling. She said:

'I don't need to pretend I am okay' [FS18]

The option to relate to someone as human rather than feeling that they had to act in a certain way within the support relationship opened up the potential for more meaningful and reportedly impactful support. This approach was widely praised where it was identified by participants.

5.1.5 Judgement

In contrast to being treated like a human, many of the negative experiences which participants reported having at services involved feeling judged. This manifested as participants feeling workers were making assumptions about them based on one particular action or attribute, without getting to know them or fully engaging with their experiences. The prevalence of judgement was so extensive that finding a worker who did not judge was notable, with participants identifying 'non-judgemental' as one of the key elements they valued in a service. When asked what she liked about her current service provision one participant responded:

'She doesn't look down her nose at me.' [FS3]

That not being judged is worthy of note, highlights the prominence of experiences of judgement and stigma. In the majority of reported circumstances these judgements were subtle, rather than overt. Participants described this judgement manifesting as:

'Just the general looks and they make you feel like you're doing something dirty and disgusting and inappropriate' [I8]

'Even a little, 'Tut,' thing or something, especially older women, they always do that just as a habit thing. They don't mean anything by it but you're, 'Oh well, that's that gone.' [I3]

Although subtle, these judgements have substantial impact on service provision, as participants shared that this prevents them from talking further about their experiences and is likely to mean they are unable to access the full or meaningful support they require. One participant shared:

'Obviously, if you say it, and then you can tell from people's facial expressions and stuff sometimes. You wouldn't want that because then you're not going to go into it. If there are any more details which were unpleasant, then you're not going to say that, I think' [I3]

For people who were also experiencing addiction, they felt that their place at the intersection of two stigmatised identities exacerbated the judgement they experienced when accessing services. This participant shared:

'I feel judged and people only see me as an addict and when I mention prostitution peoples attitude changes for the worst.' [FS11]

As well as feeling like they are being judged for selling or exchanging sex and for any addiction, participants further reported that workers made assumptions about their future, and their potential to change their situation. One participant said:

'I have to go the chemist but if I didn't have to I wouldn't. They look down on you and think that you can't turn things around and that you will be there forever so they can speak to you how they want because they know I rely on them for my OST.' [FS29]

For some, feeling that the workers felt they were never going to make the changes they wanted in their lives was linked to other problematic experiences of not feeling heard, or being treated like a human. Only one participant who spoke about feeling judged reported that their decision to access services was not impacted by this. For her judgement, whilst uncomfortable, is something which is worth enduring for the importance of the services received. She said:

'some of them are lovely and they never caused any issues it's just silent judgement, it didn't stop me from going though because that's my own health and safety, that's important' [I8]

The experience of all other participants however was that experiencing judgement and stigma from workers substantially negatively impacted their engagement with support services.

Combined, all these experiences highlight the pivotal importance of workers in ensuring people who sell or exchange sex are able to engage with support and achieve meaningful impact. Consistent best practice including being knowledgeable, non-judgemental and ensuring participants feel heard and treated like a human, supported by sustainable funding and the provision of training would likely make a strong impact on service outcomes and the number of people who are able to remain engaged with services.

5.2 Service Offer

Alongside the importance of the approach of the workers, the service offer itself was raised by participants as crucial to successful engagement in support. Three key factors were identified from the data which impacted on ability to successfully engage with support and achieve meaningful change where this was a desired outcome and these have been explored here. These were:

Clear service offer

Tailored Support

Combination of practical and emotional support

Additional consideration has been given to the potential for offering group work, and related complexities.

A clear service offer, that could be understood before engaging with the service was considered vital to impactful support. Participants shared their experiences of attempting to engage with services that could not meet their needs:

'I was involved with a pro sex work organisation before and I felt that they did not understand why I was struggling and it felt as if I didn't speak positively about my involvement in [selling sex] then they wanted rid of me' [FS4]

'Initially I approached a peer support service looking for help. They were difficult because I no longer wanted to be involved in [selling sex] for an Escort Service. They billed themselves as experts because they were sex workers however if remaining [selling sex] was NOT what I wanted to do they could not get rid of me quick enough.' [FS8]

The importance of ensuring that service offer and the support that each service will, and will not provide is made clear is reflected in this participant's experience:

'If I had not found [this service] and only had the original service I initially approached then I would have been put off as I was left feeling stupid after not wanting to remain in the sale of sex' [FS8]

The potential for this participant to believe there was no suitable support for her highlights the importance, both of people who sell or exchange sex understanding the support offer of the service they are approaching before they engage with them, and also the importance of joined up and partnership working to ensure that where the initial service approached cannot meet a person's needs, they can be effectively referred to a more appropriate service. It is likely that for other people, the experience of not having their needs met at an initial engagement would have prevented them from accessing any further support.

For others, services were often not successful in offering what they claimed to do. Services that were billed as offering 'support' broadly defined, were frequently reported as not providing people with the support that they felt they needed or what they had expected support to constitute. The data reflected the wide range of experiences and support requirements that people who sell or exchange sex have, and the importance of services being tailored to meet individual needs, within the broader remit of what they offer e.g. harm reduction or exiting services. Where participants did feel that they were able to guide their own service provision they reflected this positively. One participant said:

'it goes at my pace which helps massively' [FS62]

Particularly valued amongst experiences of tailored support, was participants feeling that there were not conditions on them receiving support, or particular 'hoops you have to jump through' [I1]. Other participants said of this:

'[Service] are the only people who don't expect something back from me or make me feel I owe them because they helped me.' [FS10]

'I feel so comfortable. No demands. No pressure' [FS12]

For a large number of the participants the feeling that they were leading their own support, and not bound by particular conditions was important to their continued engagement with the service. This provides a strong argument for individually tailored support, within a clearly defined broader remit, for example of exiting support or harm reduction.

Alongside this call for bespoke service provision, there were some clear messages within the data around the type of support that is particularly effective: where there is a combination of practical and emotional support offered in parallel. Participants spoke to the benefits of a whole range of practical support, from the provision of toiletries and condoms during outreach, to sexual health testing and food parcels, and to help with 'letters, reading and filling in forms' [FS46]. Practical provision was also praised where it took the form of developing life-skills, such as for this participant who spoke positively about her cooking group:

'At a cooking group we've been doing, there's a lot of females in there, and see the confidence boost that even a six-week block has done for people - it's amazing.' [I4]

For other participants, this development of practical skills involved learning the skills required to manage their own support, and engagement with necessary agencies. One participant shared:

'although in my eyes my problems were huge I was shown how to break them down and make them manageable.' [FS8]

However, whilst the provision of practical support and tangible benefits to service support was valued, participants also spoke about the challenges in trying to engage with practical support in services which are not trauma-informed and where they do not feel emotionally supported. For some, the provision of practical support without any additional consideration for their wellbeing left them wanting to disengage but feeling trapped by the necessity of the practical support on offer. One participant shared:

'The only reason I answer the phone is because I have to, to make sure I still get my methadone. They don't care.' [FS3]

Another participant spoke about her experiences in trying to engage with business support:

'You're not getting the specialist support that you need so then you're getting triggered every 5 minutes, so then you just end up retreating home, probably into bed because you just can't cope with the world and everybody in it because you keep getting triggered by all sorts of little things that happened. If you go to [business support] obviously there's lots of men there, so that's always not helpful too just because of the experiences you've had. In order to go there where there's hundreds of men and you've got issues with men, you can't concentrate, you can't sit in a group of people to try and learn when you're getting triggered every 5 minutes. Then you go home in a mess, you're upset and angry with the world because you feel like, 'I can't even go to a business course because of my past and how it's bringing up things for me and I really just can't cope.'

In this circumstance, attempts to access support that was not trauma-informed led the participant to not only have a very challenging experience, but to feel disempowered and as if she had failed. Related to this participants difficulty in engaging with support that is not delivered in a trauma-informed way, other participants also spoke to negative experiences they had had where services had not handled their disclosures or experiences of trauma effectively. They said:

'When I went to them before, they opened up a can of worms and there was no help, I left the appointment completely broken and in pieces and was left to sort myself out, they didn't care. They make you speak about things that have happened and don't make you feel better before leaving. I will not go back and put myself through that again.' [FS3]

'[they] ask so many personal questions for no reason because they don't address your issues' [FS10]

These experiences speak not only to the barriers people who sell or exchange sex may have in accessing mainstream or generic support, but also in the potential harm that services may cause in asking about potentially traumatic experiences either without appropriate training, or where their next steps on disclosure are not fully considered. Whilst the findings from the mapping survey that 'asking the question' about whether someone is involved in selling or exchanging sex is likely to increase disclosures, these findings raise additional considerations to be taken. These experiences suggest it is important to balance the need for information for onwards referrals with robust trauma-informed practice, and the wellbeing of the individual seeking support must be prioritised.

As these experiences illustrate, where only practical support was provided with no consideration of trauma, participants were often unable to participate fully, or left feeling that the support they received was not addressing their real concerns. In contrast, however, participants also spoke to the challenges they found in engaging with support that sought to provide emotional support but could not offer anything practical. One participant spoke of her experiences with a worker who provided emotional support but without clear tangible benefits:

'The woman that was my worker there, she was very, very nice and it was nice to meet up with her at least just to have a coffee and a chat, you know? It was nice but she couldn't help me in a lot of the areas that I needed help. It wasn't her fault but it just wasn't available. She always used to say, 'Oh, I wish there was something I could do, something more I can do' [I2]

She continues to explain how this emotional support without tangible benefit or any sense of progress made her feel:

'It does infuriate people and people that find themselves in my position they become infuriated because they become a person that just floats around in these organisations where they're kind of being helped but they're kind of not being helped. You're not really able to move forward and you're just floating around in all these different charities and organisations. You're doing things but it's not actually doing what you needed to be doing.' [I2]

These experiences strongly suggest the value of services offering a combination of emotional and practical support with tangible benefits. On occasions where this balance was realised for participants, they felt they benefitted from this provision and were able to achieve meaningful impact in collaboration with the support services. One participant spoke of a positive experience being given a route into self-employment:

'I studied beauty therapy and I was supported by them through that course. And then I did get an opportunity to rent a beauty room. I was really well supported' [I1]

Others also spoke to the balance of feeling emotionally supported with practical help. They said:

'The staff, everyone, are open welcoming and genuinely friendly to me and I find the service extremely resourceful.' [FS50]

'You can really talk to these girls. They do help.' [FS45]

'They are caring. They did a lot for me when I was struggling.' [FS36]

'[They are] thoughtful e.g. the provision of cake, toiletries. You can tell they really care genuinely' [FS33]

As well as experiences with practical and emotional support, one participant spoke to her experiences with services that offer an opportunity to engage with projects that may have a wider societal benefit, but do not offer direct tangible benefits. She spoke to her difficulties in understanding decisions to fund these projects over more practical support, saying:

'I became so frustrated and I just thought really nobody gives a damn and then they're running art projects and they're getting grants from the government, huge amounts of money like £20,000, all sorts, to run art projects. I was like, 'No art project is going to help me move on with my life.' Do you know what I mean? I just thought, 'All that money is going into these organisations is supposed to be supporting me but meanwhile they're just asking me to make art.' I'm like, 'That's really not going to help me to move on with my life. It might make a stand and it might make a statement to say what I've been through I shouldn't have gone through and it might help to change laws, and do all of these kinds of things, but it's not going to actually help me move forward with my life.' [I2]

She continues:

'somehow we get involved in this because we've been in the industry because we are the statistics, we are the people that can help other people in the future maybe, to not go through the same things that we've been through. But at the end of the day, we're still sat in the same position though, where our lives haven't quite moved on and we've still not employed, bringing in the money.' [I2]

Whilst this participant identified the potential wider benefits of these projects that sought to contribute to social change, for her it was essential that they were offered as a complement, rather than an alternative to services that offered tangible individual benefits. No other participants explicitly shared their experiences with these projects.

5.2.1 Group Work

Group work was raised by participants both as having the potential to be particularly beneficial as part of a complete service offer, and also as something that requires careful management to ensure that all members of the group are safe and supported throughout. Experiences of group work were not directly asked about within this research, and where participants shared their experiences, the groups referred to range from exercise or art groups with no therapeutic element, through to groups such as Narcotics Anonymous, and structured courses such as SMART recovery.

Group work was most frequently raised as something participants would like more opportunities to engage with, rather than something they already had extensive experience of. A number of participants who had attended groups spoke about them as an element of support they particularly enjoyed. They said:

'I feel good after group activities. I meet other women and I have a break from looking after my daughter.' [FS37]

'Sometimes it's good to be able to start a voluntary group and feel like there is no stigma attached with what I used to do' [FS23]

However, a number of complexities were also raised around safely running groups and ensuring that all participants are adequately protected. One participant shared her experiences of feeling manipulated by another member of the group:

'It just triggered all my insecurities, and people pleasing, and feeling inferior, and it just triggered it. Everything played out in that group, and there was only me and two women who did the whole course, the whole 6 months, and I was getting a bit used by one of the women, to help her move flat, and just different things she asked of me, and I wasn't able to say no. Because, within prostitution, there's this thing about pleasing personalities, and I've found boundaries extremely difficult, like I didn't have the right to say no, to anyone. And it was even happening in the therapy group.' [I1]

Another participant reflected the importance of managing the group dynamic. She said:

'I think I am easily manipulated so I need to be able to rely on workers to pick up on that because I don't always notice myself.' [FS3]

These experiences suggest the value of conducting work around healthy relationships and boundaries preceding the introduction of people to a group environment, with others who may be vulnerable or even exploitative. This additionally flags the requirement for expert facilitation to safely manage the group dynamic. As well as feeling manipulated, others experienced difficulty within a group setting through clashes of personality or feeling judged by other participants. One participant shared:

'I stopped going to the addiction groups because they comment on me weight and when I call them a name back the group runner blames me!!!!' [FS27]

Another experience shared within groups was participants feeling that they had to take on the trauma of others or feeling triggered by hearing the experience of others. One participant shared:

'I have been to recovery groups before but I didn't feel they were helpful and they dwelled on the past, I get that people need support and sometimes bad things happen and it helps to speak about it but I don't always want to speak about it or think about it or listen to other people, I have enough going on myself.' [FS29]

This experience of feeling that they need to support others when they may be emotionally vulnerable themselves points to the importance of ensuring that any groups with a therapeutic element are only offered at a time when it is mutually agreed all participants are safe and ready. This further emphasises the importance of expert facilitation and ensuring every group member feels well supported and empowered to leave the group if they need to.

These experiences combine to suggest that whilst there are likely to be benefits from group engagement, it is important that these are carefully managed to ensure that they are experienced positively by all members and do not cause any harm, or additional risk to participants. Additional work is suggested to explore the potential for group work with people who sell or exchange sex in more detail, and the appropriate methods of facilitating this safely.

5.3 Distinct challenges in accessing services, experiences and impact

The majority of participants in this study were women (n=65). This section briefly considers any distinct challenges which the research has been able to identify which may impact men, and non-binary individuals, as shared by these participants.

5.3.1 Men

The majority of experiences shared by the small number of men who participated in this study reflected the experiences shared by women, and their data has been included and analysed alongside that of all other participants. However, there were a number of distinct challenges identified related to selling or exchanging sex as a male, which are outlined here.

5.3.1.1 Eligibility for Services

Related to the themes identified amongst all participants, male participants noted the benefits of services explicitly advertising who was eligible for support. Participants noted that in this sector, the legislative focus on violence against women and girls, means that where services specify 'adults' the default assumption can still be that support is for women. The implication here is that there would be value in services stating that support is available for men to ensure clarity around eligibility.

Additionally, none of the men reported being asked directly about selling or exchanging sex. The participants who had spoken to services, had told them proactively due to the relevance to the provision of sexual health and blood-borne virus (BBV) testing. With a small sample it is unclear whether this reflects the same issue that many women reported in services not asking directly, or if this is related to the assumption that they have not sold or exchanged sex, with the understanding that the majority of people who sell or exchange sex in Scotland are female. Further exploration into this may provide useful insights.

5.3.1.2 Judgement

The male participants reported experiencing judgement for selling or exchanging sex differently. One participant felt that he was judged less harshly for having sold sex than a woman might be. He explained:

'I've told my friends about it but as more as a funny story thing, I don't really need to go into it and talk about it in a serious way because the most serious thing is that it was a bit reckless of me. None of my friends have really judged me for it. They're a bit like, 'Wait, really?' That was it.' [I3]

'I don't think there are any negative stereotypes associated with [men selling sex]. I don't think there's any real image of it in people's heads. I think it's very easy for people to be a bit, 'Oh well, that's just a thing you do, so that's fine,' instead of a bunch a stigma attached to it.' [I3]

This participant usually has sex with men outside the sale of sex, and his sexuality is known by friends and family. Another participant reflected these experiences when he said:

'I don't feel like I am judged.' [FS51]

However, the participant who did not usually have sex with men reported that selling sex to men opened him up to additional stigma and judgement, both for selling sex, and for the people paying him for sex being male. As nearly all those who buy sex are believed to be male, this intersecting stigma and judgement represents an additional challenge for some men who sell or exchange sex.

5.3.1.3 Opportunity

The final distinctive feature of the men's reported selling or exchanging of sex was that for these participants, it is not seen as something that is an identity, rather something that is occasionally done, driven largely by opportunity. One participant spoke to the availability of opportunity, and the offers of money for sex he received frequently without soliciting them. He said:

'I have a Twitter which I post photos on, and someone reached out - I was, 'No thanks, you're 30 and I don't really do that for fun.' He was, 'Oh no, I'll pay you.' I was, 'No, I don't want to.' Then I was, 'Okay, well that's done, I've actually said no a few times.' He was, 'No, I'll pay you £1,000.' 'That's just a desperation thing. On Grindr, you have a lot of bots and spam things, saying, 'I'll pay you £4,000 a week.' [I3]

These experiences suggest that services may need to be aware that men who have sold sex, may not see this as something they do on an ongoing basis, and therefore may not identify with services that are for 'men who sell sex' as this may not be an identity they recognise in themselves. Another participant reflected this when he said participants likely do not access services because they are:

'In denial about what they are actually doing.' [FS51]

Whilst this may also have been the experience of female participants, they were much more likely to report selling or exchanging sex either as an identity they ascribed to themselves or one that was put on them by other such as escort, sex worker or prostitute.

Overall, these participants' experience provide useful insight into potential additional considerations required around supporting men who sell or exchange sex. It is likely that additional research in this area with a larger number of participants would be beneficial to ensuring support services meet the needs of men who sell or exchange as well as women.

5.3.2 Non-Binary Participants

The experiences of the three non-binary participants were considered as a subset to identify any distinct challenges or requirements for service access. The information and experiences shared by these participants largely aligned with those of the larger cohort of participants. However, reflecting the experiences of men selling sex to other men, one non-binary participant did indicate that they felt a heightened risk of judgement due to occupying two stigmatised identities: that of someone who sells or exchanges sex, and also as someone non-binary. They said:

'LGBT - can be treated differently after disclosing' [FS17]

No additional distinct needs were identified for non-binary people who sell or exchange sex within this group of participants.