FOSTA-SESTA Threatens Sex Worker Livelihoods: What Mental Health Providers Should Know

Silhouette girl
Silhouette girl
Sex workers already operate at the social and economic margins. SESTA-FOSTA makes it increasingly difficult for them to advertise and screen clients safely, deeply cutting into their incomes and threatening their livelihoods.

On April 11, 2018, President Trump signed into law the Stop Enabling Sex Traffickers Act and Allow States and Victims to Fight Online Sex Trafficking Act (SESTA-FOSTA). SESTA-FOSTA is a set of bills that were ostensibly designed to hold website publishers accountable if their sites are used to facilitate sex trafficking. In response, websites such as Craigslist, CityVibe, and Nightshift, who hosted content from consensual sex workers advertising their services, have eliminated that content for fear of legal action.

Sex workers already operate at the social and economic margins. SESTA-FOSTA makes it increasingly difficult for them to advertise and screen clients safely, deeply cutting into their incomes and threatening their livelihoods. Those lucky enough to be able to afford mental healthcare need our support more than ever. What do you need to know?

Avoiding the Kneejerk Reaction

The conflation of consensual sex work with trafficking, abuse, moral decrepitude, and shame is as pervasive as is it is lacking nuance. An effective mental health provider must sift through these half-truths and character attacks to find the individual experiences of sex workers beneath.

Mental health providers must wade through social discourse thick with misinformation to be effective allies to sex workers in their practice. Scholars and practitioners alike propose harmful and stigmatizing models of understanding sex work, often claiming that the complete abolition of the trade is the only way forward. For example, in the preparation of this article, a source, Rev. Sheri Heller, LCSW, came forward stating: “[R]egardless of whether the sex worker was a homeless drug addict being sold by a brutal pimp or the ‘entrepreneur’ of a high-end brothel, commoditizing one’s sexuality is damaging to one’s psyche, body, and spirit.”

Similarly, an academic piece from the Journal of Political Economy argued that “a woman cannot be both a prostitute and a wife,”1 and Victor Hugo famously wrote, “We say that slavery has vanished from European civilization, but this is not true. Slavery still exists, but now it applies only to women and its name is prostitution.”

Sex workers experience more than their fair share of trauma and pain, undoubtedly, but effective allyship acknowledges how these individuals also shape their own lives with dignity and autonomy, despite difficult circumstances. Although sensationalist media outlets frequently use sex trafficking as a boogeyman to encourage tougher policing of sex work, research from New Zealand, Australia, and Spain shows that decriminalizing sex work has made the industry safer for workers and reduced incidents of trafficking.2 In the wake of SESTA-FOSTA, sex workers are scared that they won’t be able to provide for themselves and their families. “They are hurt and angry,” said Brittany Sherwood, a psychiatric nurse practitioner who works with sex workers, “because they are being targeted for not doing anything but working.”

Being a Sex Worker Is Hard

Even before SESTA-FOSTA and in countries beyond its reach, the unmet mental health needs of sex workers were tremendous. Seventy-four percent of American sex workers report symptoms of serious mental illness, nearly half of Australian sex workers have some form of posttraumatic stress disorder, and in Hong Kong, 26% of sex workers reported suicidal ideation or attempts.3

These health burdens are stratified by race and other marginalized identities. Black and indigenous workers are more likely to be engaged in street-based sex work, which is less safe and more exposed to police violence. LGBTQ sex workers, survivors of childhood trauma, and noninjection drug users are at increased likelihood of dealing with a mental health diagnosis.4

Sex workers operate without the workplace protections afforded to any other industry and often suffer violence from clients, unstable income, police harassment, and criminalization of their work. In Canada, half of all interviewed sex workers experienced workplace violence in the last 6 months, and nearly one-third (31%) had been displaced by police while working, putting them at a 30% to 50% increased likelihood of difficulty accessing healthcare.3,5

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What Sex Workers Need From Therapists

Sex workers report a variety of negative elements of their work that would benefit from mental health support, including fear of infection, the feeling of leading a double life, problems with intimate relationships, shame, and feelings of guilt.6 However, mental health providers need to be able to discuss these elements of sex work without a knee-jerk response encouraging clients to leave the industry. Sex worker and blogger Carly S. says she is always “out” as a sex worker to her healthcare providers, but she has yet to find someone who can help her without wanting her to quit sex work. Carly explains, “The most important thing…is to not overreact when I’m telling a story about something negative that has happened. Treat me like a normal person. I don’t need your sympathy or apologies.”

The intense environmental and structural pressures placed on sex workers means that therapists and mental health providers have a role in problem-solving the practical elements of a sex worker’s life. Psychiatric nurse practitioner Brittany Sherwood explains, “I don’t give someone an antidepressant because their partner died, so I’m not going to update an antipsychotic because a sex worker is being followed and threatened. Part of my job is acknowledging that my client isn’t making up these threats or fears and saying, ‘How do we keep you safe?’ “

Sherwood says that the key to effectively supporting sex workers in her practice is that she has always been aware of the professional, economic relationship sex workers have with their job. “Sex work is work,” she explains, and just like any job, it has positive and negative elements. For sex workers, some of the positive elements of the job include money, independence, an ability to help others, self-confidence, and power.6

Although many sex workers would certainly benefit from therapeutic support in addressing the stress from their work, research from St. James Infirmary in San Francisco indicates many sex workers do not trust healthcare providers to offer unbiased care.4 Medical distrust runs deep within sex work communities. In the post-SESTA-FOSTA environment, this distrust is likely to be even higher, as sex workers face increased penalties for being open about their work.

By investing in strategies such as peer support, collective organizing, and group work to bring sex workers together, mental health providers can create spaces in which sex workers can take full advantage of the benefits of therapeutic support. When sex workers are given the opportunity to tell their own stories, they can reassert a sense of control over their lives and better process their emotional reactions to a difficult experience.7 This offers the opportunity for sex workers to support each other and for a medical provider to establish trust and “social proof” with this deeply stigmatized community.


  1. Edlund L, Korn E. A theory of prostitution. J Political Econ. 2002;110(1):181-214.
  2. McNeill M. Lies, damned lies and sex work statistics. The Washington Post. Updated March 27, 2014. Accessed July 13, 2018.
  3. P Duff, J Sou, J Chapman, et al. Poor working conditions and work stress among Canadian sex workers. Occup Med. 2017;67(7):515-521.
  4. Puri N, Shannon K, Nguyen P, Goldenberg S. Burden and correlates of mental health diagnoses among sex workers in an urban setting. BMC Women’s Health. 2017;17:1-9.
  5. Socías M, Shoveller J, Bean C, Nguyen P, Montaner J, Shannon K. Universal coverage without universal access: institutional barriers to health care among women sex workers in Vancouver, Canada. Plos ONE. 2016;11(5):1-15.
  6. Rössler W, Koch U, Landolt K, et al. The mental health of female sex workers. Acta Psychiatrica Scandinavica. 2010;122(2):143-152.
  7. Gunn J, Roth A, Center K, Wiehe S. The unanticipated benefits of behavioral assessments and interviews on anxiety, self-esteem and depression among women engaging in transactional sex.Community Ment Health J. 2016;52(8):1064-1069.