Unfinished Solidarities

N is a seemingly quiet, perceptive woman in her late 20s whose only caveat before she came in for her first therapy appointment was to ask that she be the last client of the evening. She didn’t fill her intake form which is a preliminary information gathering sheet that helps me get some basic medical and personal history of clients/patients before the appointment in order to better understand them.

A lot of clients either forget or need several reminders to fill it before an appointment. Nothing unusual there. N dropped me an email and asked me if it was ok for her to verbally give an intake when she came to the clinic. I agreed.

We began our session with a cup of tea; she seemed apprehensive, uncomfortable. Again, nothing unusual for first timers in therapy. I assumed it was the sudden exposure to the contemplative silence of a therapeutic setting. Suddenly she burst forth with a single, shaking sentence –“Ma’am, I have to tell you about my job.” My assumption was that she perhaps was unemployed and maybe needed pro bono help or wanted to inquire about sliding scale payments in which clients pay as per financial wherewithal per session. Before I could ask anything, she sighed – “I work as an escort. I am not sure if you counsel people like me. I am sorry if I am wasting your time.”

“People like me” is a phrase that can carry such translucent contradictions; evident yet indistinct. A person using it either feels mousetrapped, isolated in their identity or very sui generis. The only response that felt suitable in that moment was to sit back and listen rather than assume what was N’s story.

Over a period in time as I have gotten to know her, I reckon she is a rarity among those who use sex work in India as their main source of income. N works on her own, can exert some autonomy and makes choices based on her own discretion when it comes to her clientele. This has not come easy to her. She is a high-school dropout who was slung headfirst in Bombay’s chaotic riddle when she was barely 16. The map to her present has been involute. Over the years as she moved from being a dancer in one of Bombay’s infamous dance bars to her current profile of being what she calls a date-for-pay. She is incredibly smart and she has taken time and effort to educate herself on her rights even though the realistic expression of those rights is usually negligible and compromised in a country that pivots on patriarchal supremacy dehumanizing and delegitimizing the personhood of women.

Accessing mental health help is already a thorny path in most parts of the world. Common cultural stigmas, limited funding, poor practitioner-to-patient ratios, disorganized psychiatric epidemiology and a widespread inclination towards a pathologizing, purely bio-medical model that often doesn’t factor psychosocial causation for mental and emotional wellness all contribute to this quagmire. This is especially flagrant in the Global South where poverty, climate apocalypse and increasing ethno-fascist regimes have impaired an already derelict public health infrastructure, if at all one call it that.

“In South Asia, depressive disorders accounted for 9.8 million DALYs (95% UI: 6.8–13.2 million) or 577.8 (95% UI: 399.9–778.9) per 100,000 population in 2016. Of these, major depressive disorders (MDD) accounted for 7.8 million DALYs (95% UI: 5.3–10.5 million). India generated the largest numbers of DALYs due to depressive disorders and MDD, followed by Bangladesh and Pakistan.”

The burden of depressive disorders in South Asia, 1990–2016: findings from the global burden of disease study (Ogbo, Mathsyaraja, Koti, Perez & Page)

The high prevalence of depression-spectrum conditions cause a massive overall health challenge to physical well being leading to increased co-morbidity for diabetes, coronary diseases, poor infant mortality rates and neo-natal health, increased self-harm and suicidal ideation as well as substance abuse. This complex weave is rendered more inelastic due to prolonged wait time for getting any reliable medical assistance and a general lack of affordability. This is exacerbated when you are positioned at the intersection of caste, gender, class and sexual orientation in such a way that disenfranchisement is means to keep an electoral imbalance for cheap political wins.

Sex work till date carries its own taboos irrespective of how progressive a society claims to be. While studying for a forensic course, I was always appalled by how victims of “serial offenders” especially murderers who started their trajectory by attacking sex workers were referred to as “high risk” as if the nature of their work was solely responsible for the inhumane treatment meted out to them, not the internalised misogyny of the those who committed the violence.

In a no-nonsense essay, “How being a sex worker affected my mental health”, British sex worker and activist who uses the pseudonym Mitzi Poesener wrote -

“However, contrary to popular view of sex work, it is not a one way ticket to a breakdown. The difference between us and workers in other industries is that when we seek help we are asked to look at the ways we’ve kept ourselves out of poverty as shameful.”

N’s hesitation towards revealing her profession became more palpable when she described her attempts at visiting a psychiatrist while in the throes of a heavy depressive spiral brought about by her mother’s death a few years ago. She was both mentally and physically violated in a place designated to be refuge away from judgment. This had put her off from seeking any further help till, wait for it, a regular client of hers convinced her to try therapy again and passed her my details. Apparently, he had a significant social media presence and that’s how he’d chanced upon me. She researched me for days before she called my practice for an appointment.

The National Human Rights Commission of India has recently issued an advisory that now lists sex workers as informal workers in India. This move came in the wake of COVID 19 and also to take cognizance of the fact that a lot of sex workers in India are from marginalised sections of the society. The real-time impact of this declaration is something we can only wait and assess over time. A close friend who works towards providing affordable healthcare to sex workers in remote, often neglected red-light districts in two-tier and three-tier Indian cities is not as jubilant about this new development because they believe that systemic corruption coupled with a pervasive casteist, sexist bent of our society won’t let such proliferation make any real dents. Their pessimism has its own historicity.

There is also the more vicious and embittering side of this coin which involves human trafficking, sex tourism and forced prostitution that often sweeps up the most defenseless amongst us. Young girls, particularly from oppressed communities (e.g. lower castes in India or BIPOC and immigrants elsewhere) are often sold into flesh trade and these rackets stretch across a vast geopolitical radius. Socio-economic disparities are growing as capitalism fails to realise most of its promises. Once again, there is limited community-focused work on rehabilitation for those who have experienced these atrocities.

In a study titled “Burden and correlates of mental health diagnoses among sex workers in an urban setting”, the researchers drew a valid and significant conclusion –

Women in sex work faced disproportionate social and health inequities compared to the general population.

Evidence-informed interventions tailored to sex workers that address intersections between trauma and mental health should be further explored, alongside policies to foster access to safer workspaces and health services.

The key challenges to mental health help for sex workers can be listed as follows –

Compound Stigma– Even trained professionals often show stringent biases stiffened by inflexible echo chambers in which they exist. It is harrowing for someone to wade through all the aforementioned complexities that make mental health care usually unreachable to then face reproach or flippant remarks about the nature of their work or worse, character. Clients of mine have narrated abdominal experiences of dealing with GPs, psychiatrists and psychologists that bordered on uninformed, invasive and prejudiced/small-minded abuse. In a world that often invisibilizes people who engage in consensual sex work or, worse, makes them feel chronically unsafe, trusting a professional is an act of courage. This courage extinguishes itself when the professional is unable to remove themselves from a regressive and essentialist understanding of sex and sexuality. For example, a former sex worker and single mother who visited a local hospital for guidance about what she believed to be PTSD and vaginismus, she was repeatedly chided about her past just because she chose to be honest while providing her medical history.

Affordability & Access – Sex work– for a significant percentage of people who willingly engage in it– is still an unsteady source of regular income. If you are not covered by sufficient insurance which again is hard to access if you are primarily working as a freelancer within an irregular setup, being able to find a reliably inexpensive psychiatric or therapeutic intervention is often a pipe dream.

Individualizing of Harm – The most popular contemporary models for assessing mental health tends to lean heavily towards a biomedical model that has its uses but often doesn’t make enough space for psychosocial factors involved in a person’s suffering. One can’t deny that neurochemical and biological markers are relatively important when discussing mental health and illness but we need to be more receptive to the formulation around social inequities linked to race, class, caste, gender and sexuality based discriminations that dent people’s wellbeing on several levels. The DSM or the Diagnostic Statistic Manual which of often used by mental health practitioners to code and diagnose mental illness is a debated creed and for good reason but still it considers/includes both disorder/disease and distress models of mental health. Yet, there is a disproportionate attention paid to pathology where a person’s wellness or illness is often attributed to faulty wiring on an individual level v/s ecology where a person’s response to acute and persistent exposure to debilitating circumstances is relegated to the back-burner.

Marginalisation – Queer and trans folks are further penalised for engaging in sex work and often experience the most dreadful consequence – an ever looming threat to their lives. Fighting for a dignified acceptance of identity is compounded by limited vocational options that respect the whole human being. In a report published by National Center for Transgender Equality, it was noted that in the US nearly 40% of the respondents were denied shelter when homeless and almost 60% reported that they had attempted suicide at some point in their lives. In India, the presence of caste further stigmatizes a transgender person’s right to safety and acceptance. This often enables hyper-sexualization of transgender identities by cisfolks to devastating consequences. Till date, there is little to no inclusion about trans rights in most mental health syllabi used in colleges in India. Queer theorists and academics are working to change this but it is slow. Most research around their health and wellbeing is often carried under a cis gaze as well.

The sizable role played by law enforcement’s frequent viciousness against those in sex work is also undeniable. Most sex workers report frequently barbaric encounters with members of the police force. There have been various news stories and investigative journalism pieces that refer to collusion by members of such agencies in sex trafficking rings.

Sex work is a complex conversation that can’t take place if we begin viewing its entire existence with a jaundiced eye. It involves precarity for those who participate in it. There are evident dangers to mental health and wellness for sex workers but let us also understand and pay attention to how much of that is caused by social prejudice against sex and sexuality. On the one hand, independent sex workers who engage is mutually consented activities are pathologized, limited rehabilitation is available for those women/persons who have been rescued from illegal sex trade that festers across the landscape of the Global South.

Mental health practitioners need to educate themselves and be open to learning as they go. Accessibility for on-time healthcare is a matter of human rights. Antipathy cloaked in “traditionalism” is an offshoot of social conditioning and it needs to be disassembled. This has to be a process that rests on unconditional compassion, not a one-time event hinged on dubious charity. Challenging our own programming as therapists, psychologists and psychiatrists, our implicit scripts built on vague morality and questioning the lack of support for folks merely on account of their profession is only the entry point of this change. Centering the needs of our clients in therapy is the first rule of therapy. This shouldn’t be forgotten or compromised.

Citations:

The burden of depressive disorders in South Asia, 1990–2016: findings from the global burden of disease study (Felix Akpojene Ogbo, Sruthi Mathsyaraja, Rajeendra Kashyap Koti, Janette Perz & Andrew Page) https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-018-1918-1

How being a sex worker affected my mental health (Mitzi Poesener, Dazed Digital)

https://www.dazeddigital.com/artsandculture/article/35938/1/how-being-a-sex-worker-affected-my-mental-health

Criminalisation of clients: reproducing vulnerabilities for violence and poor health among street-based sex workers in Canada—a qualitative study (A Krüsi, K Pacey, L Bird, C Taylor1, J Chettiar, S Allan, D Bennett, J S Montaner, T Kerr, K Shannon)

http://bmjopen.bmj.com/content/4/6/e005191.full

Psychiatric morbidity among female commercial sex workers (Marboh Goretti Iaisuklang and Arif Ali) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5806326/

Burden and correlates of mental health diagnoses among sex workers in an urban setting (Nitasha Puri, Kate Shannon, Paul Nguyen & Shira M. Goldenberg) https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-017-0491-y

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Scherezade Siobhan is an award-winning psychologist, writer, educator and a community catalyst who founded and runs The Talking Compass — a therapeutic space dedicated to providing mental counseling services and decolonizing mental health care. Her work is published or forthcoming in Medium, Berfrois, Quint, Vice, HuffPost, Feministing, Jubilat, The London Magazine among others. She is the author of “Bone Tongue” (Thought Catalog Books, 2015), “Father, Husband” (Salopress, 2016) and “The Bluest Kali” ( Lithic Press, 2018). Find her @zaharaesque on twitter. Send her chocolate and puppies — nihilistwaffles@gmail.com. Tweet at her @zaharaesque.