Stigma faced by Transgender Sex Workers in the Healthcare System

Oct 31, 2021
7 min read

Updated: Mar 30, 2022

By: Jules Ferguson

Definitions and Introduction

It is critical for healthcare workers to establish trust with patients who have experienced discrimination throughout their life. Many transgender patients in Canada experience discrimination when accessing primary, emergency or gender-affirming healthcare, and these experiences are exacerbated for those working in sex work.

Let's start with understanding the basics:

Transgender: “Those whose psychological self (gender identity) differs from the social expectations for the physical sex they were born with" (National Center for Transgender Equity, 2015).

Nonbinary: "Nonbinary is a term for gender identities that are outside the gender binary (man/woman). Nonbinary identities typically fall under the transgender umbrella because nonbinary people typically identify with a gender that is different from their assigned sex."(Pulse Canada)

Sex Worker: A sex worker is a person who receives money or goods in exchange for sexual services (Roche and Keith, 2014).

Stigma: The process of marginalizing a group of people by labelling them as different and understanding them in terms of stereotypes. This results in the loss of social status and discrimination, and affects many areas of life for those who are stigmatized.

When people feel unwelcome in healthcare settings, they are less likely to return in the future for care. For the duration of this article we will refer to a trans sex worker as TSW and nonbinary people as NB. Stigma towards TSWs is perpetuated by personal and societal prejudices. This article seeks to explore this cycle of stigmatic treatment of TSWs and consider what this means for TSWs in healthcare systems worldwide.

Why might trans people be overrepresented in sex work?

About 6% of sex workers are transgender, while less than 1% of the general population is estimated to be trans. Some people begin working in sex work because of a lack of opportunities. Some Trans people are more likely to leave school early due to bullying, which can limit other employment and education opportunities, others will continue their studies after highschool.

More than half of trans people have a college or university degree, but only 43% of trans and NB Canadians work full time. 35% of this population works part time, and 16% are unemployed or on leave, which is significantly higher than average in Canada. Despite high levels of education, half of trans/NB people over 25 had an income below $30,000 and 40% live in a low income household. While the reasons behind these patterns are complex, they cannot be detached from trans people's experiences in the workplace.

Those who do enter the workforce often experience judgement, discriminations and disrespect.

90% of trans people experience harassment/discrimination at work.
47% were fired, not hired and denied promotions because of being trans.

Objectification, depersonalization and sexualization of trans identities can decrease self worth and some may see sex work as their most viable option.

Some trans people immigrate to escape oppression or to seek better job opportunities, but may face employment restrictions based on their immigration status. Others may have low levels of education and language barriers that limit their employment opportunities. Thus many trans immigrants find themselves in vulnerable situations, increasing their likelihood of entering sex work. While many turn to the industry as an opportunity for financial independence, some trans people are forced into sex work because of threats, fraud or coercion. This population is experiences elevated risks and stigma due to their intersectional identities (transgender, sex workers, immigrants, and possibly racial minorities).

TSW often find it challenging to leave the industry because those who engage in sexual relationships with TSW may reject the advancements of their rights and may benefit from their oppression. Those who are victims of human trafficking experience a multitude of additional challenges when trying to escape traffickers, which often involves threats to their physical safety.

How can stigma affect healthcare access for TSW?

Stigma, prejudice and discrimination are some of the barriers that TSW face when accessing healthcare. Those who experience discriminations in healthcare facilities are less likely to return for care.

31% of patients who felt disrespected by care providers delayed seeking further medical care.
28% of trans people have delayed seeking medical care because of fear of discrimination.
In Canada, 12% of trans/NB people delayed seeking emergency care when required due to fear of discrimination.
45% of trans Canadians had 1 or more unmet healthcare needs in the past year.

Delaying treatment can make medical issues more serious, difficult to treat, or life threatening. It is healthcare workers' responsibility to understand the risks faced by TSW and recognize their patients’ needs in order to provide them with adequate care.

16% of trans and NB people experience physical assault, while 26% experience sexual assault.
10% of trans/NB people experience insecure housing.
Sex workers are at an increased risk of HIV and hepatitis infections if they are trans. This may be due to sharing of needles for drug, hormone, or silicone injection or unprotected sex.

If a person senses stigma from their provider they are less likely to share information about their health and lifestyle which can contribute to a misdiagnosis. The patient's pain may be mismanaged, inadequate information may worsen conditions, and they may not receive the resources they need. When one feels disrespected, it is easy to lose trust, or not develop trust at all towards healthcare workers.

One TSW stated: "I used to get tested every 3 months prior to working in the sex industry, as I believed it was always a good idea to stay safe and inform partner(s) if anything did happen. However, as a trans individual, I was hesitant to go to the clinics as you never know the criticisms you might get from staff or doctors. For one, you never know who you are going to get—one week you could get a real positive person and another you could be getting someone that is real sex negative or transphobic. Once I started sex work I put it off or avoided getting checked because I just don’t want to deal with the judgement from the staff. If I got this much grief and negative attitude just for being trans and getting an STI check, I could only imagine what would be the judgements if I told them I am a sex worker. (‘Amy’, British Columbia, Canada, 2013)

Sources of stigma towards TSW among healthcare workers

Prior Experience

A healthcare worker may be at a loss when treating a patient who doesn’t follow traditional gender norms, especially if they have only treated cisgender patients,
A healthcare provider who has not been exposed to diverse gender identities may not know how to address their patients or what is appropriate to ask.
Practitioners may not be familiar with the specific health needs of trans patients, sex workers, or the resources available to LGBTQ+ patients.

Fear

TSW may face discrimination from healthcare workers who fear being hurt by one of their patients.
TSW patients have higher prevalence of HIV than other sex workers and the general population due to the nature of sex work. Additionally, the sharing of needles for silicone, drug, or hormone injections can increase TSW's risk for HIV infections. Because of these high rates of HIV, many practitioners fear transmission when treating these patients, regardless of their HIV status.

Perceived difficulty in providing care

Many healthcare providers may have negative perceptions of sex workers and/or trans patients. Many of these patients may battle addiction and other mental illnesses. Some may be perceived as unmotivated to take care of their health, access community resources, or to leave sex work, which can lead practitioners to be frustrated and judgmental.

Enactment of Stigmatization

Those who face stigma are often looked upon as if their circumstances have been brought on by their own actions. When healthcare providers devalue their patients by making assumptions, they may provide inequitable care.
According to the US National transgender Survey:
- 11% of trans patients experienced unequal treatment when receiving mental healthcare.
- 13% were treated unequally in an emergency department and 24% experienced unequal treatment in hospital/doctors office.
- 19% of participants were refused medical care due to their gender.

Implications

Reserving judgements

Consider the patient's experiences and circumstances, what assumptions you may be making, and how your patient may not be fulfilling the stereotypes you have in your mind. When in doubt, ask your patient rather than assuming anything about their lifestyle or health.
Be aware of body language that can be interpreted as judgmental, or disrespectful, as well as tone and inflections of voice. Demonstrate that you are listening, as this can help patients feel at ease and respected.
LGBTQ+ youth are 14x more likely to struggle with substance use. Those with a history of drug use may have a higher tolerance to pain management medications. Healthcare providers should reserve their judgements when patients complain of pain and consider why a specific patient may not be responding as expected to medication.
If practitioners struggle to put aside their judgements when working with TSW, they should reflect on why they are uncomfortable, when these feelings may have developed and engage in conversations with a trusted person about these emotions.

Establish a safe environment

Establishing a safe environment is critical for a patient's care, as they are more likely to disclose personal information.
One of the best methods to achieve a safe environment is to ask a patient how they can best be supported, which can include asking and respecting their pronouns and gender identity.
If a staff member makes inappropriate comments about a patient, other team members should speak privately with them or the team manager about treating patients respectfully.
If the patient is comfortable, speak to them and apologize for the staff member's behavior and reassure them by explaining the actions you will take after their appointment. Remind them to tell you about any other inappropriate behavior at the facility.

Know the Issues

TSW's experience high rates of domestic and partner abuse, as well as other abuse. Discussing violence prevention strategies and conducting assessments for abuse and mental health is critical to providing care. If abuse is suspected, discuss this with the patient and notify a social worker if possible/appropriate. Many sex workers do not enter the industry voluntarily, and healthcare providers should be aware of signs of trafficking and resources for victims.
Knowledge of resources available for TSW facing specific issues is pertinent to connecting patients to resources to support their health and wellbeing.

Limitations

Majority of the literature on trans sex workers includes samples of only trans women. While NB and trans men may experience many of the same challenges, this information is mostly informed by the experiences of trans women in sex work.