The experience of prostitution commonly produces complex post-traumatic stress disorder. (Herman, 1992). The remarkable difference between working with prostitution survivors and others with complex PTSD is not in the symptoms, but in the context in which they must be treated. It is most similar to working with torture victims in a country where the torturing government is still in power. (Kordon, Parong, 1992) Prostitution survivors remain exposed to the tremendous presence of the sex industry in all types of communications media, as well as clubs, bars, hotels, and truck stops. The majority of prostitution survivors were prostituted in or near the communities in which they grew up. They may encounter former pimps and johns, as well as people from their "previous life" anywhere in the community.

In war, the greatest feat of generalship is to conduct an orderly withdrawal in close contact with a superior enemy. This is exactly what the therapist and client are trying to do. The therapist is in the unusual position of having to work between two powerful forces opposing a therapeutic outcome. The hammer is the pervasive power of the sex industry. The anvil is the judging and vilifying "normal community" and its laws.

The Hammer

In work with child abuse and domestic violence survivors, the perpetrators are few in number compared to their victims, and their identities are usually well known. There no longer is much community support for child abuse and domestic violence, though victim blaming remains a problem. In prostitution, the perpetrators are too many to be known with certainty, and the sex industry has considerable tacit community support.

In prostitution, an important element of the hammer is the tremendous customer base. According to the National Health and Social Life Survey (1992), 16% of the men questioned had used a prostituted person at some time in their lives. If we assume that half of them are no longer active users, this still would leave enough johns to have a large impact on anyone attempting to make a new life in the community.

In a metropolitan area like Portland, Oregon, with a population of 1.2 million, the customer pool would be about 48,000 men (and a few women). There are about 200 escort services, including 104 listed in the yellow pages. The city vice squad estimates there are about 2,000 people working in prostitution at any time. (Personal communication)

The prostitution customers, the johns, do not passively wait to be contacted for purposes of prostitution. They actively scan the environment for vulnerable people to use. Neighborhood groups in "high vice" areas frequently complain of johns accosting ordinary women going about their legitimate daily business, seeking to buy sex. More experienced johns readily recognize the syndrome of false happiness and inner brokenness that indicates a victim may be available for use. The depressed, damaged appearing prostitution survivor may expect more frequent confrontations, even when they have been out of the trade for years. These lead to a whole range of flashback phenomena.

Likewise, pimps are perpetually "on the hunt" for vulnerable women, in high school parking lots, shopping malls, bus stations, and even within drug and alcohol treatment programs. They look for the isolated, the needy, and those already "broken in" by previous abuse. They then apply sophisticated psychological manipulation skills, backed by outright violence as needed.

Survivors may have crises and episodes of decompensation due to contacts with former pimps, johns who have become stalkers, and especially judgmental people from their earlier lives.

The sex industry pervades ordinary daily life, in forms ranging from "glamour" magazines at the supermarket, to sex-based commercial advertising, "adult" entertainment, and Internet pornography. For a large portion of the population, the mixture of sex and violence produces a mild "high". Because it is so profitable, such material is produced in stunning variety and quantity. In most PTSD, flashbacks are triggered accidentally and unpredictably. For a prostitution survivor, flashback material often is provided intrusively, and in whole, commercially produced form.

The Law as Hammer

When feminist anti-prostitution activists refer to "systems of prostitution," they are referring not only to the machinations of pimps and johns. Some government practices (originally meant to be "in the best interest of the child") also make major contributions toward forcing young people into prostitution.

For example, in Oregon, a work permit is required for any employer to hire minors from age 14 to 17 years. In practice, few employers hire before age 16 years. Minors cannot receive a driver's license or emancipated minor status before age 16 years. (ORS 419 B 550-558) They cannot consent for medical or mental health care until age 14 years, and if they do, their parents are not obligated to pay for it. (ORS 109.675 and 690) It is common for a minor who is not criminal, but who is a lot of trouble for the system to deal with, to be dismissed from juvenile court supervision at the age of 15 years.

Numerous studies place the average age entering prostitution at between 14 and 16 years in the United States. The fact that this is an average indicates that entry before age 15 years is not rare. One of the factors confounding the age estimate is how to define the situation in which children are lent or rented to friends and relatives by their own families, before they ever have to service complete strangers. If this were counted as prostitution, it would pull the average age of entry downward.

The multiple age barriers to legitimate employment and mental health care virtually force the child into the hands of the pimps and johns. Laws intended to be protective of minors, or perhaps more specifically, to be protective of their parents property rights over them, have become a systemic "feeder" of children into the sex industry.

Once they have become involved in prostitution, their legal status changes to that of criminal, and their relationship to the juvenile system, and the community as a whole, becomes overtly adversarial. They are vilified for playing a role "normal society" has virtually forced upon them.

As adults, prostitution, and in many jurisdictions pimping as well, are punished with fines. The fines require more prostitution to pay them. Many prostituted women have had the experience of being extorted for sexual services by police, corrections officers, bail bondsmen, and attorneys, in lieu of some other punishment. In essence, more prostitution is demanded by officials of the system tasked with suppressing prostitution.

Slavery

Societies choose whom they will defend and whom they will not. Our society chooses not to defend prostituted people, except in very limited circumstances and after the fact, as in the case of a homicide. For example prostitution customers are almost never prosecuted for statutory rape if there is money involved, regardless of the age of the child they use.

An estimated 90% of prostitution is pimp controlled. This figure varies with definitions. What makes a pimp, versus a corrupt parent, versus a parasitic boyfriend, versus a dope dealer? One thing is certain. When survivors leave prostitution they leave penniless. Those working under pimps meet criteria for slavery: unlimited sexual access by the pimp, use of violence to control and prevent escape, confiscation of earnings, and the liability to be bought and sold.

One of the essential features of slavery is the psycho-social death which occurs when a victim is placed outside the protection of the law. (Patterson, 1982) Whatever positive identity the person may have had, or potentially have had, is extinguished. Their identity becomes only what they are not. The protection of the community is extended only to real human beings, and the prostituted person is a slave, a thing, within a culture where democracy and freedom are taken for granted. (Meltzer, 1993)

Death Immersion

People victimized in prostitution experience, over time, a death immersion and acquire a death imprint. (Lifton, RJ, 1967) Pimps and johns frequently threaten them with death. They have friends die by murder, suicide, and quasi-accidental overdoses. In a Canadian study, the mortality rate of those in prostitution was 40 times the rate of the general population. (Committee on Pornography and Prostitution, 1985) If they live on into middle age, they often are aware of only one or two survivors from the cohort of street youth with whom they started out. They may feel like their survival was a fluke, and that they "have lived too long". This impacts the therapist as well, as anyone working with prostituted clients can expect to have deaths on his or her caseload.

The Anvil

The death imprint is tacitly recognized by the client and others, but not actively enforced by the general public. However, the defilement imprint most certainly is. (Herman, 1992) Prostitution survivors are viewed by the public as both sexually and morally defiled. Some people show a prurient interest in the number of johns the client has serviced, and the activities involved. Others start "hitting on" the client as soon as her history is known. Many cut off any relationship they may have had with the survivor. The stigma of moral defilement is imposed for ever having been prostituted at all, regardless of the duress involved. The community is not satisfied with whatever resistance the client may have been able to put up. Many raise the moral bar so high as to require the survivor's death, if that is the only alternative to prostitution, to be morally respectable.

The "normal" community, the anvil, takes the same position the pimps and johns do: "Once a prostitute, always a prostitute." Nothing the survivor does with his or her later life can restore moral respectability. This attitude also rubs off on the therapist, in the common remark "How can you work with people like that?"

Many of the clients' losses, such as loss of children, loss of friends, incarceration, and addiction, are not recognized as legitimate losses, worthy of grieving. The public views them as deserved punishments, and withholds its support. The client is expected to go on as if what happened to him or her was appropriate and not an occasion for grief.

Bystanders

These judging and reviling bystanders can be divided into three groups. Innocent bystanders do not use the products of the sex industry. Their attitudes can be improved by providing them with more accurate information on how the sex industry actually works.

Guilty bystanders do use the products of the sex industry, ranging from sex and violence in the entertainment media to actual prostitution. Their attitude usually is "I don't see anything wrong with it". Despite, or perhaps because of, their own involvement, they still see prostituted people as sub-human and legitimately available for use.

The punishers may or may not use the products of the sex industry. Some of the most vociferous do. They mix the aggressive stance of moral superiority, with the desire to impose further suffering on prostituted people. Given an opportunity, they usually do.

The Therapeutic Alliance

As if working between the hammer and the anvil were not complicated enough, the attempt to develop a therapeutic alliance between a therapist and her client is confounded by dissociation, suspicion, and fear. (Herman, 1992) Professionals working with prostitution survivors have noted their "chameleon personalities". Who the survivor appears to be changes from situation to situation.

Dissociation is a critical survival skill when repeatedly having sex with strangers. (Herman, 1992) The other alternative is to stay intoxicated while working and in response to past traumatic experiences. Most prostitution survivors use a mixture of both.

In addition to dissociation, many prostituted people develop a "street personality" and/or a "jail personality" in order to lower their victim profile in those very harsh environments. These adaptations are more or less conscious, and serve the rational objective of reducing their apparent vulnerability to being hurt. In a safer environment, they often can successfully be asked to "turn it off".

People in prostitution must continually make high stakes risk assessments of customers and others. (Is he a trick? What will be his demands? Will he be violent?) This reflects an assessment process which goes on when meeting a mental health professional as well. Most people who have worked in prostitution very long have serviced mental health professionals, and have had at least a few tricks involving women. If they have had multiple episodes of mental health care, one or more professionals may have also responded to them in sexually inappropriate ways.

Developing a therapeutic alliance must await the outcome of this risk assessment, which may require prolonged samples of the new therapist's behavior. Some clients are not capable of trust at all. Overt efforts to "develop trust" often backfire when they are interpreted by the client as asking him or her to prematurely drop defenses.

Prostituted people seldom have much "combat power" of their own. Their chief defenses are dissociation, intoxication, and deception. These are best viewed as evidence of fear, and responded to very carefully. Sorting through these states is a basic cost of working with this client population. Expecting them never to lie is unrealistic. A dignified way out must be kept open to allow for insight into dissociation, and to allow the client to back away from a lie.

It is isolating to work with a population for whose treatment there is so little social support. It is painful for a good therapist to be the target of such suspicion. The client is trying to determine whether the therapist represents the hammer, the anvil, or hopefully something better.


References

1) Giobbe, Evalina: Michigan Journal of Gender and the Law, Vol.1 , 1993

2) Herman, Judith: Trauma and Recovery, 1992; Basic Books, NY

3) Kordon et al, Parong et al: Torture and Its Consequences (edited by Metin Basoglu); Cambridge University Press, 1992

4) Laumann, Edward O., Michaels, Robert T. , Gagnon, John H., & Michaels, V.: "National Health and Social Life Survey", University of Chicago, 1992

5) Lifton, Robert J (page 30) Death in Life; 1967, Random House, NY

6) Meltzor, Milton: Slavery: A World History, 1993; DeCaro Press, NY

7) ORS 419 B 550-558 Juvenile Code of Oregon, Legislative Counsel Committee, State of Oregon

8) ORS 109.675 and 109.690 Oregon Revised Statutes Relating to Mental Health and Developmental Disability; Mental Health and Developmental Disability Services Division, 1997

9) Patterson, Orlando: Slavery and Social Death, 1982; Howard University Press, Cambridge