Eighty-two percent of the respondents reported physical violence and 68 percent reported rape. A staggering 68 percent of these prostitutes also met criteria for PTSD. Similarly, Walls 3 reported those who engaged in survival sex a consequence of poverty and minimal opportunity for improvement carried a far greater risk of developing depression, were more often psychiatrically hospitalized, and 4.
Holsopple 4 studied exotic dancers. One-hundred percent of the dancers reported that they had been physically assaulted during work-related activities at least once. The prevalence or assaults ranged from 3 to 15 times during the time of employment in the sex industry, with a mean occurrence of eight incidents.
Forty-four percent of the women interviewed in that study reported that they had been verbally threatened, with a range of 3 to threats for those who reported threats. These findings were substantiated by Maticka-Tyndale et al 5 who found similar results. A greater prevalence of physical assaults and unwanted sexual contact occurred in indoor settings e. The outdoor workers reported being slapped, punched, and kicked in contrast to the indoor workers who reported attempted rape more frequently.
Wesley 8 found that dancers accepted as commonplace these physical violations of their bodies. Complicating the problem of documenting the prevalence of violence against sex workers is their reluctance to disclose it for fear of incriminating themselves or making themselves targets of additional verbal, physical, and sexual abuse.
Navigating the secrecy of working in the sex industry coupled with societal stigmatization also often results in social isolation, further complicating reporting, mental health, and subsequent treatment options. M was a divorced year-old woman who was a former exotic dancer and escort.
She resided in a homeless shelter and only had temporary employment. M had been seen by a different psychiatrist at the clinic the previous year and followed through in therapy with biweekly to monthly appointments during that time. When scheduling the current appointment, she was surprised to learn her initial psychiatrist had left the clinic and she would need to reinitiate treatment with a new psychiatrist. Staff turnover in mental health clinics is inevitable, and this must be clearly explained to the patient.
A clear line of communication is essential as this may represent an inconsequential shift for staff, but an irreparable loss for the vulnerable patient.
This is of special importance to the individual who has endured repeated betrayals and rejections to prevent this from being interpreted as yet another episode of abandonment. M arrived early for the reevaluation; her worn-looking apparel consisted of a faded gray zip-down sweatshirt, torn jeans, and old tennis shoes.
Her hygiene was mediocre. She seemed to carry a bit of shame in her appearance; this was unspoken, but it was clear self-confidence was lacking. Old scars were visible on her face and arms, each one depicting a harrowing tale. The deep ridges and multiple creases in her skin revealed a deteriorated woman appearing much older than her chronological age.
Her speech was spontaneous and intentional and there was no interruption in eye contact. Overall, her mood was euthymic and affect was full range and easily accessible. M became dramatically blunted in affect when she recounted the horrific trauma of her past in a mechanical way. She readily opened the session depicting interpersonal discord and her current psychosocial stressors, including being unemployed, financially strapped, and in an unstable living environment.
At first, the conversation flowed seamlessly without much break. Upon the first major pause, there fell a silence, leaving her visibly apprehensive. And how am I supposed to feed my children? The psychiatrist reinitiated the conversation after a pause and offered words of encouragement to proceed. Moments of silence during the psychotherapy hour can communicate important psychodynamic information as well as serve to foster the therapeutic relationship.
It is an opportunity for the patient to convey emotional and relational messages of need and meaning. The psychiatrist could use silence to provide safety, understanding, and containment. R was a year-old single woman working as an escort at a location just off the main road of a popular tourist resort. She presented to the mental health clinic after she was allegedly sexually assaulted at work in a commonly frequented motel two weeks prior.
She reported the onset of acute anxiety and fearfulness after her most recent attack, and these feelings re-emerged as she described the attack to the psychiatrist.
She quickly transitioned into the events of her youth. Notably detached from her graphic depictions, she described her earlier experiences. She began to chronologically relate incidents starting at the age of five when she was first sexually violated. She was aware that her mother had used alcohol and street drugs while pregnant and that this caused her to have learning disabilities and developmental delay. As a toddler, she would have at most a single meal daily and frequently was locked in a dark closet.
She was placed in multiple foster and group homes. Being the youngest of three siblings, she told a story of manipulation, negligence, public humiliation, and betrayal. By the age of 15, Ms. This allowed easy access to some money and afforded her a sense of importance and desirability. The allure of instant acceptance and adoration was captivating and kept her immersed in the sex business for several years. Unfortunately, she sustained attacks both physical and sexual in nature, plus ruthless disparagement and humiliation by the intoxicated patrons.
Eventually, she acquired employment in retail and attempted to exit the profession. After being cut, beaten, robbed, gang raped and sodomized, tied up, and left to bleed to death, she again tried to dissolve all ties to the industry and sought help. After her second visit with the psychiatrist a male , staff noticed her transformation, which involved an overly enthusiastic demeanor and enhanced appearance jewelry and makeup plus more stylish and seductive attire when presenting for appointments.
I was just getting used to Dr. You make the decisions about what we discuss. It is important for members of the treatment team to communicate their observations to the treating psychiatrist and that staff on the team, including the doctor, not be changed abruptly without notice.
The psychiatrist should discuss with the staff possible behavioral changes that may occur, and endorse the importance of understanding how transference, countertransference, and concern about professional boundaries can affect such complicated situations.
In this case, when the psychiatrist was changed, the patient did not return for a long time. Yeah, I called off work and took the bus to get here because I know I did much better while I was in treatment. I wonder how the termination with the previous doctor might have affected your feelings about returning?
Transference is the process of the patient unconsciously attributing aspects of important past relationships, especially those of early caregivers, onto the psychiatrist. Dismissal or complete avoidance of the possibility of erotic transference issues especially with this population would be a therapeutic misstep; rather, transference should be confronted and worked through.
For example, although sex workers are over-represented among female murder victims, 9 sex workers often are viewed culturally as voluntarily bringing on the increased risk for violence themselves or are somehow impervious to such risk. The patient may not keep herself safe because she does not know how to do so or does not think she has value.
The patient who has been victimized deserves validation, and it should be articulated that she has value and is deserving of the same rights and protections as every other person. The sex worker is subject to multiple and repeated trauma, often has few options for assistance, and often keeps her experiences secret. If the first disclosure is not well received or results in a negative or unsupportive response, it greatly impacts subsequent disclosures.
If there is a perceived or actual lack of support, it may significantly limit opportunities or willingness to access social support and resources. However, of this study group, only 40 percent had any interface with mental health services. When a group of women who had suffered a trauma history were separated into those working in the sex industry and those not, it was found that only 25 percent of sex workers sought mental health treatment while 45 percent of the other traumatized women did so.
L was a year-old sex worker with no prior mental health treatment who was seen for weekly psychotherapy for treatment of depressive symptoms. The patient had divulged her trauma history to the male psychiatrist in the prior session. Her ambivalence toward men was apparent. They treat you so nice at first, only to manipulate and take advantage of.
Psychiatry, Volume 1, Second Edition. Many female and male patients have difficulty articulating their sense of injury to male psychiatrists. Clearly, these patients are very vulnerable when there are boundary transgressions by the psychiatrist.
Adapted from Gabbard G. Levy R, Lieberman SJ eds. Handbook of Evidence-Based Psychodynamic Psychotherapy. Psychodynamic psychotherapy uses self-reflection and self-evaluation.
This is made possible in part by the therapeutic alliance and inter-relationship with the psychiatrist. The patient explores coping strategies and relationship patterns. The psychiatrist attempts to reveal any unconscious components of maladaptive functioning, and addresses resistances as they reveal themselves.
Change is accomplished over time via a trusting alliance, where resistance is managed and deeper understanding has developed Table 4. Similar to the psychodynamic type, supportive psychotherapy also relies on a trusting and secure relationship with the psychiatrist; however, supportive psychotherapy is more suitable for a patient in crisis. Through reinforcement of coping strategies, encouraging emotional expression, and enhancement of self-esteem, the supportive mode of psychotherapy can assist in guiding the patient through the crisis at hand.
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