By Joseph Parker, Clinical Director
The Lola Greene Baldwin Foundation

Many people used in prostitution are thereafter described as "emotionally unstable" and "unpredictable". This leads to diagnoses of borderline personality disorder and bipolar mood disorder, as well as the correct diagnosis of complex PTSD.

Misdiagnosis as "a borderline" is serious because it enables about half of the people in the mental health professions to feel free to become hostile and manipulative themselves. Incorrect identification as bipolar is less serious because the medications used to treat it are almost the same as for PTSD. Many public sector mental health clinics are restricted to treating the major mental illnesses such as schizophrenia and bipolar mood disorder, and not PTSD. Some survivors may have to accept a bipolar diagnosis, rather than receive no treatment at all.

Survivors alternate between five emotional states, which are a quite consistent feature of their lives.

RAGE

Being hurt by others produces anger. The accumulation of hurtful experiences caused intentionally by others usually begins in childhood, and often continues for decades. It is useful to make an estimate of the lifetime total number of such experiences, because research on PTSD has consistently shown that the severity of PTSD symptoms is directly related to the amount of trauma incurred.

This may be done by multiplying the average number of involuntary sex acts, beatings, and other assaults per week or month by the total time exposed to various abusers. It may be useful to break out of the total particular types of abuse, or assaults attributable to specific perpetrators, because they may have different meanings or degrees of impact on a given survivor. The numbers arrived at often run into the thousands or even tens of thousands.

This rather concrete process of counting may have the painful but therapeutic effect of breaking through the survivors minimization of the abuse, or the conviction that "I must just be overreacting." Others are reassured that their feelings are real and proportional to their experiences, and not the result of the spontaneous onset of some sort of mental illness.

Additional weight must be given to those incidents which left permanent damage, such as back injuries, brain damage, scars, unwanted tattoos (pimp branding), or vaginal and rectal injuries. These permanent reminders to some extent retraumatize the survivor every day, when they run up against the pain, disability and disfigurement which have become an ongoing feature of their lives.

The rage also is fed by external triggers pervasive in society, such as the ever-present nude dance clubs, the near-pornographic women's "glamor" magazines in the supermarket checkout lines, and the loud, sexually abusive comments from drunk men behaving badly in public.

The normal response to being hurt on purpose by others is anger. Although the feelings can be covered by dissociation or drugs and alcohol, one does not "get used to" being hurt. The anger gets stronger over time, so that rage becomes a permanent feature of their emotional landscape. That degree of anger becomes painful in itself, and managing it becomes an ongoing energy drain. It is one of the reasons people used in prostitution are so often chronically tired.

GRIEF

It is easy to forget that, while all these bad things are going on, a whole range of normal and good things are not.

Prostituted people pass through the same world everyone else does. They go to stores, pass by schools, and see people living in houses and driving cars. They are aware that, by their 20's, most people have some degree of education, a job, a house and a car, perhaps a spouse and children, a pet, or whatever portion of those things they may choose.

Most people are free of compulsive alcohol and drug use, are free to go wherever they want without the permission of the criminal justice system, and are allowed to keep most of the money they earn. They see others treated as people, not things to be used, hurt, or stolen from. They watch all this as if through a wall of glass, able to see, but not able to touch.

They grieve for all that the have lost, including good health, children, and a normal identity, as well as for all the things they never had, but see that others take for granted.

There is a difference between grief and depression. Most survivors have depression, and respond to treatment for it, but even the best treatment cannot give back the things they have lost.

People grieving the expectable losses of normal life usually can count on the support of others, because others can understand the losses, and know that they could have or have had similar losses themselves. Grieving survivors of prostitution are isolated because they dare not tell anyone how they lost what they lost. They justifiably fear that they will be told that they brought the losses on themselves, and even deserved them.

The intensity of the grief is another problem. People who have had luckier lives often choose not to tolerate contact with that degree of distress, and withdraw from the survivor, whether or not they even know that the losses are prostitution related.

The pain must be managed some way to survive. The crude way is with alcohol and drugs, but that method is retraumatizing because of what is involved in obtaining and using them. They trigger intrusive recollections and flashbacks of bad things that happened previously, related to substance use. The chemicals may "release" feelings and behaviors which are even more painful or destructive than those the substances were being used to control.

SELF HATRED

People who have been used in prostitution typically feel tremendous self blame for what happened to their lives. They literally hate themselves. Although self hatred is well known as a symptom of severe depression, prostitution survivors come to it in a much more complex way.

A large portion of those used in prostitution were first abused in childhood, during a time in which children think they are the center of the universe, and incidentally, to blame for anything that goes wrong.

The child's physical and attachment needs require continuing contact with caretakers, even when that contact is painful.

Normal adults find sadistic, psychopathic and chemically induced behavior hard to understand. For a child, it is simply impossible, so they believe that they must somehow cause it themselves.

The concept of "identification with the aggressor" has been used to describe someone who has been a victim of violence, who chooses to change roles and attack others. Males often express this role change by attacking others generally. Both males and females may reenact their own abuse with their own children or others to whom they have access. Women most often attack themselves.

In prostitution, what is more subtle, and more common than physical assault, is to identify with the aggressor's view of the victim. They learn to have hatred and contempt for themselves. They expect and accept abuse from later offenders in the belief that they cause and deserve it, as their original abusers taught them.

Because they believe that they cause the abuse, they do not realize that changing their life situation can make a difference. They may not reach out for help and protection until their lives, and those of their children, are in immediate, unmistakable, serious danger.

An early goal in treatment is to help the client see that this view of themselves is actually not their own, but that of their abusers. They typically have no separate, personal idea of who they are, or what they are worth.

Body hatred often begins in early childhood, when the child knows that what is being done to them hurts, even if they do not know what it means otherwise. They cannot comprehend why an adult is hurting them, but do know that certain body parts are the preferred targets. They come to hate having those parts. (It would have been better to be an alligator or something.)

As they grow older, and are forced into prostitution, they come to specifically hate their appearance and the body parts that others want to use. During their prime years as sexual merchandise, their youth chiefly prevents changing this. Their drug use and nonstop sex work keeps them thin, but, if need be, pimps will literally starve them to keep them in saleable condition.

Later, when they escape the sex trade, they usually gain substantial weight, both as physiologic rebound to long term malnutrition, and as a result of body changes related to having had children. A few go on to become morbidly obese as "armor" against the sexual interest of men. Most find the weight gain frightening and humiliating. Their experience has been that their only identity and place in the world is as sexual objects. When their appearance no longer fits with that role, they feel as if they are nobody and nothing.

Several years after leaving the industry, some of the weight may be lost again, but usually their physiological "set point" is permanently raised to some degree.

As survivors grow older, their health usually deteriorates prematurely. Some have such severe problems that supportive psychotherapy actually evolves into psychological hospice care. Added to the pain, disability, and poverty which accompany poor health, are the inevitable recollections of how their health was damaged.

Self hatred often is fed by intrusive images and experiences which continue to humiliate the survivor even decades later. Their time in the sex industry may have left them with triggers and chained associations that they cannot control. They often do not understand that stimulation of the right nerve endings will produce the physical changes of sexual arousal despite their most determined psychological resistance. They conclude that they are somehow sexually perverted.

They may become physically sexually aroused when afraid, have panic attacks during consensual sex, or have complete sexual anesthesia even with a chosen partner who is good to them. A therapist who explains these phenomena in a sensitive way often will alleviate the guilt the survivor feels about these reactions, but may or may not be able to modify the reactions themselves.

The subconscious mind seems to "float" the images up at random. They may or may not be pictures of the worst things that ever happened. They may be composites of several incidents, or represent incidents that just somehow "got the survivors goat". They may be random slices of the banal, soul-killing routine of one blow job after another, and sex with one disgusting trick after another.

The problem is that the pictures interfere with feeling secure in a new identity. They usually fade over time from color to black-and-white, and come further and further apart. Sometimes a survivor still has the pictures or "physical flashbacks", but they come to react to them less strongly, in a way getting used to them and becoming able to tune them out.

Many survivors loathe themselves for losing custody of their children. Many were in foster care at some time in their own lives. Many remember being physically or sexually abused in one home or institution or another, and know that the conditions that allowed that have not changed. They fear the same fate for their own children. They fear that their children will not remember them, will be told lies about them, or grow up hating them.

Our society tends to have low regard for the work of raising children. It often is delegated to low-paid baby sitters, nannies, and low functioning relatives, implying that "almost any idiot can do child care." When survivors are faced with failure as mothers, they may not only be losing the only positive identity they ever had, but they are failing at something society views as unskilled and easy to do.

It is important to remember that the self hatred does not originate only within the survivor. A lot of so-called normal people consider prostitution a permanent change of identity. Whether in public discussion, or in private contact with a survivor if they know of one, they will keep pushing the survivor down, back into the whore identity. They may be looking for a opportunity to use him or her themselves, or they may use the survivor as a example, to support their own sense of moral superiority.

FEAR

Prostitution, at the level where pimps are directly involved, is essentially slavery. The pimp has the same problem any slave holder has: how to get human beings to submit to total domination, work 7 days a week without pay, and to keep them from escaping. Slavebreaking is an ancient art. The forms range from those which use a lot of psychological manipulation and only sporadic violence ("finesse pimping") to those which rely on almost nothing but violence ("gorilla pimping"). The process involves three elements:

1. Torture involves the infliction of overwhelming and unbearable pain, while yet not killing the victim nor leaving them too disabled to use in slavery. Beatings may be administered with fists and feet, improvised weapons such as towel bars and shower curtain rods, appliance cords, or the steel whip make out of coat hanger wire called a "pimp stick".
   
   The victim may be choked repeatedly to or near unconsciousness, using hands, clothing items, or plastic bags. Burns may be inflicted with cigarettes, curling irons, or a pimp stick heated with cigarette lighters or on a stove. Chemical burns may be produced by pouring rubbing alcohol or whiskey into eyes or up noses.
   
   Most of these items are available or can be made in hotel/motel rooms. Many pimps are career criminals already on parole or probation, and cannot afford to be caught with purpose-built weapons. Nonetheless, they usually have a gun available, which may be frequently pointed at the victim, thrust up any handy body orifice, and used to emphasize the danger the pimp can present to the victim's loved ones.


2. Sleep deprivation is a central element in "brainwashing". Pimps often keep their victims awake doing check and credit card fraud during the daytime, then turning them out to prostitute at night. Some get as little as 2-4 hours sleep per day for long periods.
   
   People used in prostitution almost always are given "quotas" of money which they must bring in every day before they are allowed to rest. If they come back without their quota, they are beaten, not allowed to eat, and/or sent right back out. Many are on their feed for 48 hours or more at times.


3. Unpredictability also deprives them of rest and increases domination. Pimps watch their victims work at random times, have friends, family or other pimps watch them, and often have particular prostituted women who will inform on the others.
   
   If a victim breaks any of a set of "rules", or sometimes just randomly, the pimp will fly into a rage and beat or torture them. The purpose is to keep the victim from ever feeling safe, because the rules, and the pimps moods, can change at any time. The pimpâs rages may or may not have an understandable cause, and some may simply be acted out to terrorize as the only goal.
   
   The victim also never knows exactly how far the violence will go. Pimps routinely threaten to kill those they enslave, their children, or their family members. Particularly where drugs and alcohol are involved, the pimp actually may be out of control, and death may occur unintentionally. Cold-blooded, businesslike murders also occur.

This complex of experiences, plus the atrocities and lesser assaults by tricks, combine to produce a level of fear which is beyond expression in words. It is always present, never in the past. The fear may be conscious, or it may reveal itself only in behavioral flashbacks, such as waking up with a weapon, or hiding under a bed. The experience of being broken, of being stripped of all humanity, remains with survivors all their lives, even if they have been relatively save and the acute symptoms have been dormant for years. The sickness is in knowing what can happen, independent of whatever may be going on now.

ALIENATION AND LONELINESS

People who have survived horrific experiences, such as war or concentration camps often feel as if they have been immersed in death, and are ever after marked by it. They may or may not be able to articulate the feeling of having a "death imprint", but it makes them feel different and separate from more fortunate people. They fear that other people will somehow see it, and they are quite aware that most people do not want to hear about the experiences that produced it.

Survivors of the sex industry often feel that they have a "sexual perversity" imprint. They fear that somehow other people will perceive that they have been used in prostitution, even years later, and when detected, they will be judged. They, too, know that most "normal" people do not want to know in any meaningful way what happened to their lives.

They feel as if the sex industry still pursues them, from the near-pornographic "womenâs" magazines at the supermarket checkout counter, to the strip clubs they see on major streets, to seeing men who were or look like former tricks, they feel they cannot escape from it. It is especially painful to see others, not so different from themselves, still being prostituted.

It is painful to hear supposedly normal people talking about "hot pussy", "filthy whores", and the "choice" of prostitution, and not be able to defend their brothers and sisters.

Their responses range from rage to grief and back, but always there is the loneliness. They feel like they are on the wrong side of a piece of glass, and they will never be like other people. It is the loneliness that makes it so important to have the support of other, relatively healthy survivors of the sex industry, and of professionals who have knowingly and intelligently chosen to work with people like them.