Sex Work - A Brief Overview

For the purposes of this paper, sex work is presented as a broad and inclusive category of erotic labor. In order to challenge what the sociological literature describes as "anti-sex work bias," we call into question and challenge the assumption that individuals are not able to engage in consensual and pleasurable erotic labor (Jackson, 2016; Lerum & Brents, 2016, p. 19; O'Brien, 2015). Indeed, sex work is often conflated with sex trafficking, and gendered and racialized "victim" frames often describe all sex work as coercive, forceful, and violent labor (Jackson, 2016; O'Brien, 2015; Schwarz et al., 2017; Weitzer, 2010). By naming sexual labor as patriarchal violence against women, this framework overlooks important complexities and nuance, such as the numerous and diverse pathways into sex work economies. In many ways, this framework is, in itself, violent; denying agency to both those who engage in erotic labor consensually and those who do so under conditions of coercion (Dennis, 2008; Jackson, 2016; Levy & Jakobsson, 2013; Stabile, 2020; Worthen, 2011).

This victim-frame leads to harmful social stigma and detrimental policy outcomes, rather than empowering or supporting people's lived realities; and this is especially true for those who experience multiplicative minoritization at the nexus of ableism, cissexism, racism, and other forms of oppression (Bettio et al., 2017; Kulig & Butler, 2019). Policies constructed to mobilize the carceral and police state to protect "victims" often utilize dubious and sensational statistics and are perceived by many to primarily function as a vehicle of "punishment and control" for sex workers (Augustín, 2007; Brooks, 2020, p. 516; Hagen, 2018; Lerum & Brents, 2016; O'Brien, 2015; Weitzer, 2014). Policies aimed at stopping sex trafficking expand the ability of the state to criminally punish erotic labor of all kinds (Sagar et al., 2015a; Stabile, 2020).

It is also critical to highlight how the institutions of psychiatry and biomedicine have often acted as another extension of the carceral state, criminally punishing "non-normative" (so framed by those institutions) sexual desires, behaviors, and identities (Das, 2016; Kirkup, 2018; Smilges, 2022; Vogler, 2019). This includes a long, eugenicist history of the denial of disabled and neurodivergent people's sexual desires, sexual agency, and sexual citizenship, including the general assumption that disabled and neurodivergent people are non-sexual or undesiring of sexual relationships and experiences (Brown, 2017). This history also includes targeted efforts to "cure" gay and lesbian individuals of their sexual desires via conversion "therapy" techniques such as castration, bladder washing, and rectal massage. Even after those techniques were proven not to work, psychologists, psychiatrists, and other medical professionals continued the implementation of electroshock therapy and lobotomies, then more recently aversive techniques via behavioral therapy (Graham, 2018). Finally, we see continued and sustained efforts to legislate trans people out of existence by limiting their access to gender-affirming care, criminalizing the doctors who choose to continue offering that care, and, in some instances, aiming to incarcerate the parents of trans children who consent to their care (Witt & Medina-Martinez, 2022).

In this way, we know that to understand trans disabled sex workers' choices and lives fully, we must challenge the pleasure/danger dichotomy (Vance, 1984), or the assumption that full sexual pleasure is only possible in the complete absence of sexual danger. This binary understanding of sexuality obscures the possibilities of everyone's sexual agency and choice, and is largely unproductive, given that many people find pleasure in sex work and their "context-specific agency and survival," while locating danger specifically in the "looming forces of the security state, criminality, and structural inequalities" (Schwarz et al., 2017: 1).

Transgender Sex Workers

The literature on transgender individuals' engagements in sex work is heavily skewed towards examinations of transgender women's HIV and STI risk prevalence and incidence, substance use, and experiences of both intimate partner violence and violence from clients; this includes a number of systematic reviews and meta-analyses on this HIV syndemic (Baral et al., 2013; Becasen et al., 2018; Cotaina et al., 2022; Operario, Soma, & Underhill, 2008), as well as on health outcomes (such as depression and suicidality) and health behaviors/barriers to care among trans sex workers (Brookfield et al., 2020; Pellicane & Ciesla, 2022; Platt et al., 2018) The majority of this work comes out of public health and medical sciences, and disappointingly, but largely unsurprisingly, researchers in these fields often study cisgender men and transgender women as if they are the same target population: "male sex workers" (see Perez-Brumer et al., 2016; Jones, 2020b).

Ultimately, the foundation of research in this area is focused on "survival" and "street-based" sex work, often framing transgender women as "victims" to poverty, joblessness, and other discriminatory housing and employment policies, forced into erotic labor (Rev & Geist, 2017). The hyperfocus on trans women as survival sex workers contributes to the "walking while trans" (Mogul et al. 2011: 61) phenomenon, describing how "transgender women, particularly transgender women of color, are… frequently perceived to be sex workers by police," to the extent that "transgender women cannot walk down the street without being stopped, harassed, verbally, sexually and physically abused and arrested, regardless of what they are doing at the time" (61).

If we look at studies using U.S. based samples, there are only a few, recent deviations from this stigmatizing frame; but what does exist has offered that sex work provides the monetary ability to take better care of oneself (Orchard et al., 2020), the freedom to set one's own hours of labor and terms of labor production (Glover & Glover, 2019), produces affirming feelings vis-à-vis being desirable/desired (Capous-Desyllas & Loy, 2020), and is a space that allows for joy in fulfilling people's fantasies (Del Rio & Pezzutto, 2020). There is still almost no research on the experiences of trans men and non-binary/genderqueer/gender expansive sex workers (see Jones, 2022).

Disabled Sex Workers

In contrast to the literature on trans individuals' experiences with(in) sex work, where disabled individuals are included, they are most often represented as the consumers of erotic labor (Earp & Moen, 2016; Freckelton, 2013; Mannino et al., 2017; Thomsen, 2015; Wotton & Isbister, 2017). In particular, scholars often focus on the ethics of "sexual surrogacy," and sometimes, research concludes that there should be a legal exception for disabled people in the prohibition of buying erotic labor (Yau, 2013). Much like the literature on trans sex work focuses nearly exclusively on trans women (primarily trans women of color), the research on disabled consumers of sex work focuses almost entirely on cisgender disabled men (Jeffreys, 2008; Jones, 2013; Liddiard, 2014; Sanders, 2007).

There is, overall, a dearth of literature on disabled sex workers. Indeed, you are likely to find fewer than 15 articles on Google Scholar if you search (in quotations) "disabled sex worker" (we found 13 at the time of writing this piece), and fewer than 60 for "disabled sex workers" (54 at the time of writing), not all of which are empirical or include the voices of disabled sex workers themselves. This is likely due to the dominant presumption, made by scholars, clinicians, and not-disabled others who misunderstand and often misrepresent disabled sex and sexuality, that disabled people are asexual or non-sexual (Brown, 2017). Asexuality is a valid sexual identity, and yet sexuality studies scholars and broader U.S. culture still often assumes alosexuality, and a superiority of being sexual shapes conversations about sexual identities. This largely erases the legitimacy of asexuality, and it is not true that a majority of disabled people are asexual (Brown, 2017; Rembis, 2010). It is through this lack of acknowledgment of disabled desire, pleasure, and erotic labor, that the scholarship in this area has (whether intentional or not) positioned disabled people as incapable of sexual agency and sexual self-determination (Tepper, 2000).

What's more, in the few circumstances where disabled individuals are represented as workers, they are uncomplicatedly discussed within the victim-frame (Dick-Mosher, 2015; Kuosmanen & Starke, 2011). Disabled people are also included in ethical and theoretical debates about minoritized sex workers' rights (Laws & Drew, 2022; Russo, 2019; Sanders, 2007). Like the literature on trans women sex workers, disabled workers are often described in terms of their relation to drug use and HIV/STIs (see Blewett, 2019; Rugoho, 2019). Though still primarily oriented towards sexual surrogacy, Fritsch et al. (2016) consider the links between sex workers, disabled people, and disabled sex workers, finding them all seeking to "legitimize a range of forms of marginalized, stigmatized, and erased sexuality" (92).

College Student Sex Workers

Scholarship surrounding the engagement of college students in paid erotic labor is mostly concentrated outside of the United States (Betzer et al., 2015; Ernst et al., 2021; Roberts et al., 2007; Sagar et al., 2015, 2016; Sanders & Hardy, 2015; Simpson & Smith, 2019, 2021; Wylęgły, 2019). A number of these pieces are written with the intent of considering the characteristics of students who engage in sex work, such as personality traits, substance use, financial circumstances, sexuality, and gender (binarily–and often sex assigned at birth–defined) (Betzer et al., 2015; Roberts et al., 2007; Wylęgły, 2019). Some work on cisgender women college student populations considers their attitudes towards sex work, but without apparent attention to whether participants might be engaged as sex workers (Long et al., 2012). Other scholarship considers more closely the experiences and motivations of college students engaged in sex work, but does not attend to the needs or experiences of trans and/or disabled students (Haeger & Deil-Amen, 2010; Sagar et al., 2016; Simpson & Smith, 2019, 2021; Upadhyay, 2021).

We know from this existing literature that financial circumstances are essential to motivating students to engage in sex work, but it is not the only factor at play; students describe varying degrees of enjoyment, flexibility, and the benefits of alternative employment. For instance, cis women sex workers in college report that even if their role is temporary, it may become an important and positive part of their identity (Simpson & Smith, 2021). Moreover, camming, specifically, may be an important axis through which college sex workers fulfill desire and experience pleasure (Jones 2020a). It has also been theorized that cultures of consumption in college student populations have "mainstreamed" the idea of engaging in sex work (Sanders & Hardy, 2015). Lastly, college sex workers describe stigma as a primary cost of their role, rather than the risk of violence, as the victim-frame might suggest (Haeger & Deil-Amen, 2010).

Methods

Building on this existing literature, our paper focuses primarily on describing the population of disabled transgender college students who engage in sex work economies. Utilizing the U.S. Transgender Discrimination Survey (USTS 2015; N = 27,715), we focus on a few key areas that have not been explored adequately in the literature, in the hopes that we might not only illuminate some of the pathways trans disabled college students take into sex work, but also highlight the need for comprehensive, holistic, competent, sex-positive and disability justice-oriented college student services. Our key areas of inquiry include detailing the 1) demographic characteristics of sex working disabled transgender students, 2) their experiences within other labor forces, 3) their experiences while in/at college, and 3) some of their self-reported health-related outcomes. You can find more detailed information on each of these areas, including sampling techniques, survey items that constitute our key variables of interest, and related documentation in our methodological addendum.

Participants

Disability is measured in various ways. There is an option to self-identify as "disabled," as well as answer affirmatively to one or more standardized questions validated by Healthy People 2020 that are meant to identify disabled adults. In the USTS sample, 40.09% (N = 10,913) of transgender adults are categorized as disabled, while around 28% of the sample self-identify as disabled. 2 As Table 1 (below) shows, more college students self-identify as disabled than the general sample (nearly 32%), with 10% more reporting difficulty concentrating, remembering things, and/or making decisions. In total, nearly half of the transgender college student sample meets the criteria for disability.

Despite the USTS's efforts to avoid internet survey sampling biases, (Table 2, below), the sample of disabled college students is predominately white (73%), with the largest geographic representation coming from the Pacific (26%) Census division (California, Oregon, and Washington). Additionally, participants are largely non-binary and assigned female at birth (40%), queer (31%) or pansexual (25%), under 35 years old (95%), and variably religious.

Measures

Analysis

The analyses in this paper were conducted with Stata/MP 14 quantitative data analysis software for large datasets, and we primarily engaged with descriptive statistics and a series of chi-square analyses. Descriptive statistics include the reporting of percentages and means (such as rates of "yes" or "no" responses to particular questions). At the same time, chi-square tests determine if there are significant differences between one or more of the groups (disabled vs. not-disabled, sex worker vs. not a sex worker, etc.) in their reported college experiences, economic experiences, and sex work experiences. To assess which group is contributing most to any significant chi-square result, adjusted standardized Pearson residuals are computed. A standardized or Pearson residual is calculated by dividing the raw residual by the square root of the expected proportion, as an estimate of the raw residual's standard deviation. According to Agresti, "a[n adjusted] standardized residual having an absolute value that exceeds about 2 when there are few cells or about 3 when there are many cells indicates lack of fit of H₀ in that cell" (1997: 38).

The Incidence and Prevalence of Disability Among Transgender College Students

Contrary to what some might assume about the nature of disability, the transgender emerging adult (under 35) college student population is more likely to report various types of disabilities and more likely to self-identify as disabled than older folks. This paper finds that, in the U.S. Transgender Survey (2015), 49.18% of trans college students report a specific disability and/or identify as disabled. While there is no "cisgender" sample of college students to compare our data to (because national surveys use "male" and "female," and most primary data collected on college students doesn't survey gender identity and disability), we do know that approximately 19% of college students meet the Healthy People 2020 standardized disability assessment threshold (U.S. Department of Education, National Center for Education Statistics, 2021). There are numerous reasons why we might see higher rates of disability in this survey, versus general education statistics data collection. The first is that the Department of Education data does not include the option to self-identify, while ours does. Because over 30% of trans college students self-identify, we might be seeing "elevated" rates of disability that reflect a diagnostic change and/or reduction in stigma over time, rather than a prevalent increase in disability itself. Another explanation might be that the size of the trans college student population is not large enough to greatly impact the Department of Education averages, but that if we did collect data on gender identity, we would see higher rates among our trans students.

Disabled Transgender College Student Wellbeing

Importantly, for our trans college student population, the nature of their disabilities is most frequently invisible to those around them (e.g., 40.19% of trans college students report difficulty concentrating, memory, and decision-making). Invisible disabilities are often seen by and framed, interpersonally and socially, as "illegitimate" or "made up," and result in bias, stigma, and internalized shame (Kreider, Benedixen, & Lutz, 2015; Olkin et al., 2019; Ysasi, Becton, & Chen, 2018). This may be one reason for the significantly high psychological distress and suicidality rates among disabled trans college students. Regardless of engagement in sex work, no fewer than 64% of disabled trans college students met the criteria for serious psychological distress; meaning, 64-76% of disabled trans college students experience feelings of nervousness, hopelessness, restlessness, worthlessness, and depression that is not impacted by the efforts of others around them, most or all of the time in the past 30 days. In general U.S.A. college student samples (that use the Kessler-6 Distress Scale used in this study, but that do not assess gender identity), rates of serious psychological distress hover around 9% (Knowlden, Hackman, & Sharma, 2016; Shafer, Koenig, & Becker, 2017), with one more recent study from one mid-sized, four-year, public institution finding rates of 21.4% (Becerra & Becerra, 2020).

Moreover, an overwhelming 90% or more of disabled trans students reported lifetime suicidal ideation, with sex working students significantly more likely to report lifetime suicide attempts and suicide attempts while in college; specifically, two-thirds (65%) of disabled trans sex working college students report attempts while enrolled in their degree-seeking programs, a rate that is twice that of their non-sex working peers. While most of the data on transgender mental health aligns with our findings here (e.g., high rates of suicidality), it should be noted that a recent meta-review of the literature found that lifetime suicidal ideation among college students in the U.S.A is 22.3%, lifetime suicide attempt is 3.2%, and past-year suicide attempt is 1.2% (Mortier et al., 2018). This means that disabled trans college students are, on average, approximately four times more likely to report lifetime suicidal ideation than the general college student population and 13-23 times more likely to report a lifetime suicide attempt. To the authors' knowledge, there are no other studies that assess suicide attempts while enrolled in college (typically, surveys assess lifetime and/or past 12-month rates), but given that past-year attempts usually fall between 1-2% for the college student population, we wouldn't expect to see rates close to those we see for disabled trans students here (e.g., 65%).

The Systemic and Structural Nature of Health Disparities

These mental health outcomes are significantly higher for disabled trans student sex workers, which may be partially explained by the other forms of systemic exclusion and violence those students face. For instance, disabled trans sex working students are significantly more likely to report having been fired from or lost a job in their lifetime–many indicating that gender identity and/or disability-based prejudice and bias was the reason–with BIPOC students reporting the highest levels of lifetime job loss. Additionally, nearly twice as many sex working students indicated they experienced past-year job harassment/violence, compared to non sex-working students. Perhaps the prevalence of harm in the workplace is one of the reasons, if not a primary reason, that approximately 33% of disabled trans sex working students decided to quit their jobs in the past year.

Moreover, while a majority of disabled trans students are "out" to their peers in school, most students report that their peers are not supportive; indeed, while about half of non-sex working disabled trans student population say their peers are supportive, only 37% of sex working students report such support. Interestingly, we do find that sex working students are less likely to report past year harassment and physical/sexual assault in bathrooms, even though they report nearly double the amount of harassment in other situations (e.g. extracurriculars, by peers in the classroom, by faculty, by support staff). In total, and likely due to the overwhelmingly high numbers of harassment, discrimination, and violence faced by disabled trans students, about half are not living full time as their gender identity, specifically because of fear of mistreatment at school, unsupportive peers, fear of mistreatment by peers, and past year harassment/violence in college. The impacts of this mistreatment are likely pronounced for many BIPOC students, who–despite our not having the sample size to confirm statistically–preliminarily report much higher rates of past year physical assault in bathrooms.

Compounding the effects of job loss and violence at work, unsupportive peers, and violence at school, we must also consider how the "risk" and "deviance" discourse further stigmatizes disabled trans students (Dir et al., 2015; Dir et al., 2018; Ingram et al., 2019; Liong & Cheng, 2019; Reyns et al., 2014; Strassberg et al., 2017). Although trans disabled people engaged in this work may not be seeking to be clearly and publicly visible, negative visibility of being a sex worker (related to stigma) and the invisibility of engaging in sex work from home–particularly as a trans person who may or may not have told peers or family they are trans–has the potential to create environments of isolation and exclusion that contribute to the negative health outcomes previously discussed (Hamilton, Barakat, & Redmiles, 2022).

Implications for Identity-Based Student Services Providers

Given the demographics of our sample population being relatively diverse regarding sexual orientation, gender identity, and religiosity, it's safe to assume that students are coming into contact with a large number of identity-based student resources and student service providers such as student disability services, women's centers, LGBTQ+ centers, multicultural centers, religious groups, and other affinity groups. Students who live at the intersection of multiple minoritized identities (e.g., BIPOC, disabled, trans sex workers) are often left with a number of student service offices to choose from, each one only engaging one facet of their identity (for example, an LGBTQ+ student center, disability services office, Black Student Association, etc.). As these multiply-minoritized students have the potential to utilize any one of these identity-based resources, student service providers must challenge themselves to understand the populations they serve through the lens of intersectionality and not just their specific competency area. As Duran, Pope, and Jones (2020: 521) pointedly ask, "How do educators attend to the unique experiences of individuals while also considering larger structures of inequality in which people reside, institutional policies are created, and the disproportionate ways structures and policies impact certain groups?"

Further, student service providers' general lack of awareness and information regarding sex working students (Sagar et al., 2015b; Stewart, 2022) poses a significant barrier in approaching the needs of today's college students. As engagement in sex work becomes more common and normalized among college students, student affairs professionals must educate and adapt to avoid further stigmatization, pathologization, and/or criminalization. The Student Sex Work Project Report's Key Recommendations is a great place to start (Sagar et al., 2015b: 39), as it outlines key professional development, staffing, and policy-related decisions universities should engage in for the well-being of their student sex worker population.

Implications for Health-Based Student Services Providers

Student service providers positioned in health-based offices, such as counseling, wellness, and student health centers, face specific issues with LGBTQ+ students' concerns involving confidentiality, sensitivity, and discrimination (Reeves et al., 2021), all of which create a level of mistrust and act as barriers to entry for disabled trans students. This is magnified for BIPOC students, who often experience structural racism in health care settings, and report microaggressions, model-minority stereotypes, and a lack of cultural competence around familial and spiritual influences on their mental health from psychological student service providers (Hingwe, 2020). To counteract this level of uncertainty and mistrust, health-based student services must continue and enhance their outreach efforts, programming, and staff specialization regarding serving minoritized populations. We believe that psychological and health-based student services offices should hire, and work to retain, adequately compensated, diverse staff and clinicians. More than that, as health providers continue to enhance the pipelines that bring in a diverse range of students, providers are then ethically obligated to expand their current level of knowledge and practice to provide culturally and clinically competent care to the students that they serve, which includes educating themselves and implementing evidence-based practices.

Specific to this study, the increased experiences of psychological distress, thoughts of suicide, and suicide attempts among disabled trans students engaging in sex work suggest that all health providers meeting with trans students and/or disabled students must be well-versed in suicide assessment and safety planning, as well as how psychological distress and suicidality impact and are magnified by other aspects of identity and structural inequality. Once more, it's also crucial for health service providers to understand student engagement in sex work from a sex-positive perspective. Sex work is no more emotionally taxing to person's overall well-being than any other job, including psychology/psychiatry (Russell & Garcia, 2014), and sex work is not an inherently unhealthy choice. Rather, it is "whore stigma" (Benoit et al., 2018) itself that is the culprit of sex workers' differential working conditions and health outcomes (Krüsi et al., 2018).

Implications for Administrative and Policy-Based Student Services Providers

Those professionals operating in administrative or policy-oriented roles such as career centers, Dean of Students' offices, or conduct offices need to recognize that no policy or practice will affect every student in the same way, many policies act as "double-edged swords" that bring both benefit and cost to students, and some policies are simply enacted for show, without any adequate enforcement or regulation. For example, though the Americans with Disabilities Act (ADA) requirements create "protections" for disabled individuals in schools and workplaces—much like anti-discrimination laws say they protect transgender people–they often ultimately provide more decision-making power to the state or institution, than to the individual (Spade, 2015). Transgender people already face many challenges to their identities via the legal system. Disability, and the way it interacts with the law, multiplies these effects. With regards to employment, trans people notably have their gender policed by identity documentation requirements, which creates a barrier to employment, and, in this way, employers can fairly easily choose to not hire and/or fire trans people, whose documents do not align with their identities (Spade, 2015: 80).

Similarly, career services or career centers at colleges and universities need to consider who their practices benefit. First, the damaging stigma regarding sex work must be challenged by providers in these settings. Providers must also be willing to validate the legitimacy of sex work as work. The "professionalism" idealized in career counseling has harmful roots in white supremacy - which is inextricably linked to heterosexism, transphobia, classism, and ableism (Cumberbatch, 2021; Gray, 2019; Marom, 2019; McCluney et al., 2021; Small, 2021). Without critical consideration of the realities of disabled trans sex working students, career counseling practices may ask already minoritized students to engage in a politics of respectability that intensifies their health-related outcomes and compounds harm.

Lastly, existing sex trafficking policies at the state and federal levels often have a disproportionately negative impact on sex workers, trans folks, and disabled people, which we've found in this analysis are prominently overlapping groups of students (Brooks, 2020: 516; Hagen, 2018; O'Brien, 2015, Stabile, 2020). Colleges and universities should take strong stances of support for sex working students, just as they often do (and, if not, should) for Black, Indigenous, and other students of color, disabled students, and trans students.

Implications Across Student Services Providers

Cross-functional collaboration (i.e., collaboration across and between student services offices, faculty, and the university community) has become an increasingly popular theoretical approach to providing student services (Kezar, 2006). Cross-functional collaboration lends itself to an intersectional ontology. It challenges student service providers with different content areas (e.g., development, health, administrative and policy-based) to work together to understand the needs of the "whole" student, rather than the individual facet of the student's identity. If given space, usually through task forces or working groups, identity-based student service providers could talk with students about their lived experiences and shape policy decisions and cross-sector collaboration around the findings

Here, we can look to the work of Trueman, Hagelberg, and Sanders (2020), at the University of Leicester, who suggest not only education and cultural competency trainings for staff, but also challenging university policy reporting procedures (e.g., challenging mandatory reporting requirements that break student confidentiality and trust), challenging university "decency" policies (that would see "outed" sex workers expelled for ruining a university's reputation), not involving the police in any matters regarding students, and utilizing a harm reduction approach that does not reinforce the "victim" narrative. Additionally, specific services that sex working students request in Stewart (2021), include: free sexually-transmitted infection (STI) testing, increased access to birth control and contraceptives, comprehensive sexual health education, staffing a diverse (e.g., not cisgender men, not white women) counseling services center, specific emergency financial aid/loan programs, food banks or free food resources, putting on sponsored events (speakers, programs, workshops, tabling) through key offices on/by/for sex workers (from an accepting and competent, not stigmatizing perspective), and inclusion on institutional messaging, advertising, websites, and brochures.