When Community Complicates Healthcare for Sex Workers

I’ve struggled with severe insomnia for years. A few weeks ago I received a recommendation for a local hypnotherapist who specializes in sleep disorder issues, so I rang her up for an hour-long phone intake. “Liz” had a very distinctive voice — deep, raspy, commanding — and, as we exchanged information, I couldn’t shake the feeling that I’d heard it before. My stomach grew restless with anticipatory dread. When she directed me to her website to reference some materials, my reluctance was palpable. Sure enough, a professional photo of her smiling face stretched across the homepage. I let out a groan as soon as I recognized her.

Liz owned the domination house in which I saw private clients in San Francisco. We’d shared each other’s company dozens of times, whether to exchange money or to work doubles sessions together. My most recent memory of Liz is of her face, skin flushed and smile wide, as we suspended a man from the ceiling while taking matching leather whips to his balls. I’d had no idea that she managed a hypnotherapy practice on the side, advertising her services under a different name.

Liz was amused when I interrupted her to share my discovery.

“Andre! I thought you sounded familiar, too,” she chuckled. “Sorry about the insomnia, but you know I can’t help you now, right?”

“I know,” I acknowledged mechanically. I terminated the call before Liz could respond, collapsed on my bed, and took a long, defeated drag off a fat joint.

Sex workers and LGBT individuals already face unparallelled challenges when it comes to receiving comprehensive, non-discriminatory, financially accessible healthcare in the United States. We’re disproportionately uninsured and routinely expected to endure being condescended to, misgendered, victimized, criminalized, and shamed by those we’re going to for help. To make matters worse, we’re frequently forced to educate our own providers on how to best serve and treat us, taking on undue emotional labor when we’re at our most vulnerable. That’s why it’s so important that our providers prioritize inclusivity, accessibility and familiarity with our unique care. Finding one of those magical providers — and building trust with them — can sometimes feel like a pipe dream.

When queer sex workers like me seek healthcare, we can’t afford to take chances by calling our insurance companies for recommendations or perusing Yelp reviews. We instead research non-profit organizations and clinics with sliding-scale payment options only to be put on lengthy waitlists with no guarantees, or rely on personal referrals from peers to ensure that we’ll be entering informed, respectful safe spaces. You’d think this process would significantly narrow the chances of a professional incompatibility, but apparently that’s only the case if you’re a queer sex worker who never leaves the house and has a subtle social media presence. If you’re “unpopular.” If you’re invisible.

My interaction with Liz was the latest in a long string of providers denying me services because of my connections and “stature” within the very marginalized communities that limited me. Over the course of two agonizing years I had MFT interns recognize me from my pornographic work mid-session, psychiatrists cancel upcoming appointments after discovering we had mutual Facebook friends and relationship coaches bolt when realizing they’d taken workshops from me at sexuality conferences. I was even recently denied access to a sex worker support group because the group facilitator and I had shot a porn scene together almost four years ago.

With each letdown came the same message: “I can’t. It would be an ethics violation.” It became a running joke between my partners and I, that I was both too stigmatized and too famous to get my needs met. For a while, one of my partners took on the role of secretary, calling around and vetting providers on my behalf. He’d sacrifice entire afternoons collecting fresh leads when my feelings of being “othered” paralyzed my search.

Considering that sex workers and LGBT folks are dramatically impacted by suicide — oftentimes motivated by feelings of extreme isolation — my situation seemed darkly ironic.

In the end, I’m sorry to say that I burned out. I lost drive; I lost hope. These days I mostly rely on Planned Parenthood for physical health needs, personal growth programs to fill my mental health services void and physician friends across the country to write me emergency prescriptions if time is of the essence. I’ve maintained my fitness routine, started a new vitamin and supplement regiment and upped my self-care ante. A friend recommended 7 Cups of Tea, a complementary online app that has trained listeners available 24/7, and I use it occasionally in times of extreme stress and anxiety.

I wouldn’t even have half of these minimal resources available to me if I weren’t so well-networked, and if I didn’t live in the state of California. Under an impending Trump presidency, California is one of the few places in the country that stands a chance of continuing to accept and protect people like me. I’m also a white, middle-class cisgender woman with functional depression. Even as a marginalized person, my privilege is directly responsible for the small survival gains on which I’ve come to depend.

I’m no stranger to professional codes of ethics. I can empathize with providers having to make challenging judgment calls around exhibiting healthy boundaries and not treating people they “know.” But where do we draw the line? Are there ever acceptable ways of knowing a potential patient outside of one’s practice? I strongly believe that part of being an ethical provider is making sure treatment isn’t withheld when it is needed, particularly when that treatment involves services for underprivileged communities. Due to how tightknit these communities can be — and how much overlap can exist between them — there’s a good chance that you’ll “know” any provider to which you’re referred. If the current knee-jerk reaction in these circumstances prevails — one where providers are so fearful of incurring an ethics violation that they don’t even bother to strategize alternative or creative care for the community member right in front of them — then we’re doomed. This litany of complex and amorphous barriers to care impacts far too many queer sex workers, and ensures that they don’t receive the healthcare services they desire and deserve. I, for one, would like to live a long, happy, healthy life. I just wish I didn’t have to fight tooth and nail to do so.

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Andre Shakti is a queer journalist, educator, performer, activist, and professional slut living in the San Francisco Bay Area. She is devoted to normalizing alternative desires, de-stigmatizing sex workers and their clients, and not taking herself too seriously. Andre wrestles mediocre white men into submission and writes about sex work, queerness and non-monogamy for Cosmopolitan, Thrillist, Rewire, MEL, Vice, and more. She can frequently be found marathoning Law & Order: SVU under a chaotic pile of partners and pitbulls, and yes, she knows how problematic that show is.

Andre has written 3 articles for us.


  1. It’s disappointing to me, as a counseling master’s student, that this keeps happening in the name of “ethics.” One of the important points I remember from my own counseling ethics class is that in small communities dual relationships are almost inevitable. You have to work with them, knowing it takes extra effort and brings extra risks, because the only other option is to deny care. People tend to think of “small communities” as small towns in rural locations, but of course LGBT populations even in large cities are “small communities.” I think it’s pretty inexcusable that service providers are so callously looking out for themselves around this issue at the expense of their clients. Client abandonment is an ethical violation too.

  2. Thank you so much for sharing your perspective. I am learning a lot from your writing, and I appreciate you choosing to help educate. Also, your writing is so intelligent and fluid, it’s a pleasure to read for its own sake.

  3. Do any other sex workers, current or past, find this article off-putting? This article seems to reflect the experiences of a queer sex worker who is out, has a visible online presence, and whose work spans genres, i.e., porn, workshops, and Domming. And that is perfectly fine. Perhaps it speaks to the experiences of a broader community of queer sex workers. Good. But why the author does not have to put down and diminish the experiences of other sex workers, those who aren’t out or “visible,” to make her point?

    “You’d think this process would significantly narrow the chances of a professional incompatibility, but apparently that’s only the case if you’re a queer sex worker who never leaves the house and has a subtle social media presence. If you’re “unpopular.” If you’re invisible.”

    Queer sex workers who are not out and visible on social media do, in fact, leave their houses and are not necessarily “unpopular” or invisible, whatever the hell that means. Your experiences and anger are valid. But so are mine. Don’t throw me under the bus because I’m not famous like you.

    • She means in a celebrity sense. She’s expressing difficulty finding access because “everyone” knows her somehow through some way and it’s even more limiting. “Unpopular” was put in quotes because it wasn’t meant literally, but again in the sense of celebrity. By invisibility, she means public recognition from that celebrity. There was no clear intention in the text to throw anyone under the bus or invalidate the experiences of others. Rather, the author is struggling to find a way to express herself and her difficulties, very clearly NOT at the expense of others—which may be seen throughout the work.

  4. I live in Philly where I see health providers who know me through queer community and they’ve never mentioned anything about a possible ethics violation. I think it’s normal here?? Lots of people I know see health professionals who are acquaintances. The Mazzoni Center is the main LGBTQ health center here and no one has mentioned it to me there, nor has the herbalist I see separately or my old therapist. They just said that if we saw each other in public, it was up to me if I wanted to acknowledge our professional relationship. It’s interesting to me that there is such a severe cultural difference around this. Unless there is some CA state law about it?
    Even with these resources I’ve still had difficulty accessing healthcare many times, solidarity! <3

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