NMN Submission to the UK Government’s Women’s Health Strategy Consultation

This is the Nordic Model Now! response to the British government’s consultation on its Women’s Health Strategy.

June 2021

About us

Nordic Model Now! is a secular feminist grassroots women’s group that is campaigning for the Nordic Model approach to prostitution. As well as cracking down on pimps, the Nordic Model decriminalises those who are prostituted, provides services to help them exit, and makes buying sex a criminal offence, with the key aim of changing social norms and reducing the demand that drives sex trafficking. All our members are unpaid volunteers, and the group includes survivors of prostitution. See https://nordicmodelnow.org/ for more information.

VAWG is a public health emergency

Male violence against women and girls (VAWG) is at epidemic levels. It is now the norm rather than the exception for girls and young women to be victims of sexual harassment, stalking, sexual assault, and/or rape. The consequences of this for women and girls’ health over their lifetime are profound but remain largely unrecognised. Over and over again, women and girls are blamed and dismissed for the distress and dysfunction caused by the male violence to which they have been subjected.

Even if VAWG stopped tomorrow, the consequences would be with us for decades because of the impact of the trauma it has already caused. There is evidence that childhood trauma can adversely affect not only the individual for their entire lifetime, but also subsequent generations.

Evidence, including research in schools, on google search terms, and among young people, suggests that VAWG is getting progressively worse. The costs to individuals and society are incalculable.

We urge the government to officially recognise VAWG as both a human rights catastrophe and a public health emergency. Urgent action is required to address the underlying causes, to end the impunity of perpetrators, to improve training for healthcare workers, and to provide appropriate long-term trauma-informed therapy to victims.

Underlying causes of VAWG

We have identified four major underlying causes of male VAWG: (a) the proliferation and increasing misogynistic violence of online porn and its seepage into mainstream culture; (b) the trivialisation, normalisation and increase in size of the prostitution system; (c) increasing economic inequality between women and men; and (d) almost total impunity for male perpetrators.

These underlying causes are interlinked and reinforce each other. For example, the increasing impoverishment of women has led to an increase in the numbers of women turning to prostitution and online porn sites such as OnlyFans – often as a last resort against destitution. This has contributed to the increase in the scale of the porn and prostitution industries and has reinforced the objectification of women and girls. This in turn has led to more VAWG generally and to policy makers, who are not immune to these cultural forces, overlooking the distinct needs of women and girls – in a terrifying mutually reinforcing nihilistic cultural vortex.

Investment in improving women’s health services without also addressing the major underlying causes of VAWG, would be like using a sticking plaster on a cancerous lesion.

Porn

There is an abundance of evidence that the increase in VAWG that we are witnessing is connected with the proliferation and ease of access to online porn, the majority of which portrays violence, often extreme, against women and girls. This is toxic propaganda against women and girls, positioning them as objects for the pleasure of men and boys, and conditioning viewers to become sexually aroused by VAWG. Online porn should therefore be understood as a form of VAWG in and of itself and also as a form of propaganda that incites VAWG.

Gail Dines, the veteran academic researcher into pornography and its impact on society, says:

“More than 40 years of research from different disciplines has demonstrated that viewing pornography – regardless of age – is associated with harmful outcomes. And studies show that the younger the age of exposure, the more significant the impact in terms of shaping boys’ sexual templates, behaviors and attitudes.”

It is unconscionable therefore that the government has not commenced Part 3 of the Digital Economy Act (DEA) 2017, which was passed by parliament to introduce age verification on online pornography sites and to take action against extreme pornography. We have age-verification on online gambling sites. How can the government justify not implementing it on online porn sites when the evidence shows that exposing children and young people to such material causes devastation both to individuals and society as a whole? We cannot afford to wait more years for the online harms bill to become law.

Prostitution

Research shows that male sex buyers (punters) are more likely than other men to rape and engage in all forms of male violence against women and girls (VAWG). This is hardly surprising because buying sex feeds men’s sense of entitlement and superiority – the very attitudes that underpin VAWG. Like porn, prostitution leads to more VAWG in the general community.

Instead of being an encounter based on mutuality, prostitution is one-sided. He pays precisely because she doesn’t want to have sex with him but has to – either because she needs the money or because she is being coerced. As a result, she has little room for refusing punters and has to pretend she’s enjoying it, even when every cell in her body is screaming otherwise. This can have a catastrophic impact on her health, which we explore in more detail below.

It is of real concern therefore that over the last decade we have witnessed the cultural normalisation and trivialisation of prostitution and the rise of the misguided idea that it is a normal job (“sex work is work”) and even a form of women’s empowerment. This has been accompanied by lack of effective official action against kerb crawling, pimping, brothel keeping, and sex trafficking.

Prostitution causes untold suffering and damage to both the individual women concerned and also to the wider society. Addressing this requires the reality to be acknowledged and faced. Both the government and the NHS must formally recognise prostitution for what it is – a form of male violence against women and girls and to invest in programmes to reduce men’s demand for it, to support women to exit the industry and to rebuild their lives, and to provide women and girls with viable alternative sources of income, along with a policy of zero tolerance to all third-party profiteers. In other words, a Nordic Model approach.

Economic inequality

There is overwhelming evidence that policies implemented by the UK Government since May 2010 have had a profoundly negative impact on society, with women in general hardest hit, and lone mothers, and Black, Asian, migrant, and disabled women hit the worst of all.

It is increasingly difficult for women, particularly mothers, to survive independently. Women are once again being driven into economic dependence on male partners. This gives the male partner disproportionate power within the relationship, and makes it more likely he will be abusive and violent. Welfare changes and defunding of services for abused women make it hard, if not impossible, for women to leave a violent partner.

This worsening of women’s economic situation relative to men’s has accelerated in the last 15 months as a direct result of government measures in response to Covid 19.

Poverty is itself a direct cause of ill health. It causes enormous stress and makes it hard for people to lead healthy lives. For example, eating the recommended allowance of fresh fruit and vegetables is simply not an option for many people on low incomes and healthy leisure activities are often out of reach. These forces are typically unrecognised by health workers, who often blame the person for making bad choices.

The increasing feminisation of poverty and the accelerating inequality between the sexes is also driving many women into prostitution and related practices, such as webcamming and OnlyFans as a way of making the money needed for survival. All of these practices can cause physical and mental ill health – in both the short and long term – and they generally entrench ever further the disadvantages that led to entry into the industry in the first place.

The accelerating economic inequality between the sexes means that men as a group have greater spending power than women, much of which ends up in the pockets of the sex industry profiteers. Very few women get rich from prostitution, and few leave the industry in better economic shape than they entered – most end up even poorer and with a whole raft of additional problems, like PTSD.

If the government is serious about working to improve women’s health, it must take urgent measures to reverse the disproportionate impact on women of its economic policies over the last 11 years. The government must also ensure that women are never disproportionately negatively impacted by its policies in such a way again. To this aim, the government should work with experts like the Women’s Budget Group and introduce a gender mainstreaming approach in all government departments.

Impunity for male perpetrators

Way back in 1992 Helena Kennedy documented the way the British justice system systematically disadvantages women and girls in her ground-breaking book, Eve was Framed. This led to some improvements, but the system still favours men. For example, in rape trials it is effectively the victim who is on trial rather than the alleged perpetrator, as her behaviour, clothing and sexual history are examined in more detail than his; and men who kill their female partners are likely to get a lower sentence than women who kill their male partners after enduring years of domestic abuse.

More than a decade of austerity and defunding of the Crown Prosecution Service, courts, legal aid, and the police, along with measures taken in response to Covid 19 have resulted in a criminal justice system on its knees.

As a result, it is not an exaggeration to say that rape and many other crimes against women and girls have more or less been decriminalised in practice if not in law. This is a catastrophe not only for justice and human rights, but also for women’s health.

We call for immediate action to reverse this situation and to address the systemic failure to hold men accountable for their VAWG.

Health impacts of involvement in prostitution

Like many predominantly female experiences, the negative impacts of women’s involvement in prostitution have been under-researched and are routinely unrecognised by the NHS.

Wolf Heide is a gynaecologist and obstetrician who provides medical examinations and care to women in prostitution in Germany. He gave a statement to the German federal parliament when it was considering revising the law on prostitution. Here is an edited extract of the translation:

“The overuse and abuse of the women’s sexual organs in prostitution leads to inflammations, STIs and other infections, and makes them more vulnerable to STIs, as the usual resilience is damaged: Bruising, tearing, abrasions in/on those organs, means the slightest infection will lead to illness. In addition, those in street prostitution are out at all times in very little clothing, miniskirts, thin stockings, which again harms. Their general life style also damages any immune-system a normal healthy adult has. (Obviously this will not be helped by condoms, as the overuse, abrasions and exposure to damaging surroundings etc. will continue.)

The women frequently suffer from chronic lower abdominal pain due to inflammation and mechanical trauma that are hard to treat medically and often lead to damage to the internal reproductive organs and makes the women infertile. This is a denial of their reproductive and health rights.

Due to high rents many have to continue to serve clients even while suffering from unbearable pain. They show premature ageing, a symptom of persistent permanent stress. In addition to the injuries to be expected from the overuse of the sexual organs there are those deliberately inflicted by punters.”

A German feminist group provides a summary in English of this and other data from Germany.

Liane Bissinger, another gynaecologist from Germany, has written about her experiences of treating women in street prostitution in Hamburg, describing a similar picture to Wolf Heide.

While some of the specifics of the women’s situations are unique to Germany, most is common to prostitution everywhere, particularly where women must ‘service’ a large number of clients every day. This is probably the majority of women in prostitution – particularly those who are coerced by pimps, traffickers, or ruthless brothel owners, or by extreme poverty or addiction to class A drugs.

The truly independent ‘sex workers’ who dominate the public narrative are likely to have more control over their conditions and the number of men who penetrate them every day than the majority of women involved in prostitution and should therefore not be taken as the norm.

Residents in the Holbeck area of Leeds where street prostitution operates in plain sight, talk of the extremely poor physical condition of the majority of women who are on the streets there. However, this is not unique to on-street prostitution, because women in high-volume brothels typically suffer similarly.

A Canadian study estimated that women in prostitution have a mortality rate 40 times higher than the general rate for women.[1] In one study, 75% of women in escort prostitution had attempted suicide. In another report, prostituted women comprised 15% of all completed suicides.[2] The British police have recognised that women involved in prostitution have the highest rate of murder of any group.[3]

The mental, psychological and emotional impacts of prostitution can be even more devastating than the physical consequences. Multiple peer-reviewed studies have found a very high incidence of PTSD symptoms among women involved in prostitution – ranging from 47-68%.[4] This is double the rate that you would expect to find in soldiers returning from active service in a war zone. In addition, the PTSD that prostituted women suffer is typically more complex than that found in combat veterans. And yet this is not generally recognised by healthcare professionals.

A Swiss study conducted a standardized assessment of the mental health of women involved in prostitution in a variety of settings. It found very high rates of mental disorders and that these were correlated with the high levels of violence from pimps and clients.

Once embedded in prostitution, getting out can be difficult, if not impossible – as similar forces that led them there tend to trap them – poverty, coercion and control from third parties (often intimate male partners), substance abuse (often developed as a way of coping with the intolerable reality), lack of alternatives, homelessness, lack of skills, childhood abuse and neglect, and more.

We are in contact with many women who have exited prostitution and a common theme in their testimony is that it is often only after they have managed to exit and have found some degree of stability that they begin to really understand how serious the negative impact on their physical and mental health has been. For example, Rebecca* said:

“Nobody speaks to these ‘happy hookers’ after they have left prostitution, this is when the effects of it catch up with you. You simply cannot forget years and years of swallowing down your consent, of swallowing down what is, at best, disgust, irritation and boredom during sex and, at worst, anger, humiliation and terror. After you have lived through that, it is fundamentally impossible to have anything near a happy, healthy and ‘normal’ life. By this I mean, a life where you can, at a very basic level, trust and connect to others, men in particular, and, alongside this, feel OK about your own body, humanity and worth. These things, will be constant everyday battles.

Since leaving prostitution I have struggled with chronic depression, flashbacks, anorexia and self-harm. I have not been off psychiatric medication or out of therapy. I have never been able to enjoy sex or be in a loving relationship. The ‘sex-industry’, by which I mean the legally sanctioned rape, humiliation, devaluation and degradation of women, has robbed me of all these things.

I was ‘lucky’ in that I was able to leave and that I did leave when I did. I was unlucky in that, what woke me up to the urgency of needing to leave was a customer choking me until I passed out, doing god knows what to me and then leaving me lying alone and unconscious on his kitchen floor for god knows how long.”

Background

The damage that prostitution causes to the physical and mental health of women and girls is generally not well understood by most UK health professionals. This is compounded by the dominant cultural narrative that positions prostitution as a normal form of work that women have the ‘right’ to choose, that it is a form of female empowerment, and that it is much more lucrative than most low skilled employment options that are available to women.

According to this narrative, the problems associated with prostitution are caused entirely by other people’s attitudes towards it (“stigma”), law and policy that penalises those involved, and the occasional bad client, rather than any intrinsic problems with the system of prostitution itself. The proponents of this narrative argue that the solution is to decriminalise the entire system of prostitution, including pimps and brothel keepers, and bring it under health and safety regulations and allow the “workers” to unionise. Exactly how health and safety regulations would protect women from the kind of damage documented above is never specified – and nor is how giving pimps free rein would make vulnerable women safer.

This narrative was first introduced by promoters of the sex industry as a deliberate attempt to normalise prostitution and unfortunately it has been very successful and it has now become dominant not only in mainstream culture but also in most UK academic institutions, the Royal College of Nursing, many NGOs that provide services to women involved in prostitution, and many of the big foundations that fund such NGOs, along with international human rights organisations like Amnesty International and the WHO.

This understanding is a catastrophe for women who have lived experience of prostitution and yet we believe it is the dominant view in many, perhaps most, UK healthcare settings.

Listening to women who have experienced prostitution

We have heard too many times from women that when she mentions to a healthcare professional or therapist that she’s been in prostitution, empathy and offers of support dry up. Sometimes there’s an unspoken but palpable assumption that “sex work” is a choice that must not be examined, meaning that mentioning the harms except in terms of atypical ‘clients’ becomes taboo. This suggests that the choice narrative is in fact a sophisticated form of victim blaming. It absolves everyone apart from the victims of responsibility and removes the need for society to look its dark side firmly in the face.

One woman told us that her GP would not refer her to trauma counselling on the basis of her many years in the sex trade but would on the basis that she was raped as a teenager. We have heard similar stories from many other women, not only about GPs but also therapists and mental health services. Here are just a few examples:

“I am in therapy now (mainly to address the childhood trauma). When I have talked about the so-called sex work to the therapist, I get a lot of “why didn’t you…?” (I get it about the assault too.) And I leave therapy feeling invalidated and, on bad days, like things were my fault.”

“I found that most female therapists judge me and so I spend my day-to-day life feeling trapped by my past, not knowing if I will ever truly heal.”

“I worked as a stripper and prostitute for three years from ages 17 to 20. I have been exited ten years and have had chronic PTSD since then. I have recently started counselling and am finding it very hard. I feel like I have no right to feel traumatised for what I went through. If what those men did to me was recognised as a crime (e.g. Nordic Model) then I might feel more validated in my pain and able to move on. Right now, however, I feel like I am being gaslit by society.”

A woman who has worked in services for women involved in prostitution told us:

“There is so much suffering which people don’t want to see because it suits their narrative that women ‘choose’ their situation and it takes the spotlight off those who drive demand. The women have almost always had significant trauma, and are being controlled or forced into prostitution by pimps or poverty. And even if they didn’t get forced into it, it becomes almost impossible to get out due to so many barriers, including immigration, debt, substance use, homelessness, fear, low self-esteem, mental health issues, the list could go on and on.”

For healthcare workers to persist with the idea that prostitution is a free and empowering choice for women and that if they don’t like it, they should simply move on, is an utter travesty. This must change.

A holistic trauma-informed approach

Healthcare workers must be trained in the realities of prostitution, its impact on women’s health and wellbeing, and how to provide high-quality trauma-informed care. We recommend that the work of Judith Lewis Herman, is used as a key text.

When a woman is in prostitution, her livelihood depends on upholding the illusion that she chose it and is making lots of money. It is common for women to find it hard to speak negatively about what she is experiencing because this would mean facing up to the reality. This is not feasible when she simply cannot see an alternative – so she clings to the illusion as a survival strategy and coping mechanism. It is often only after she has exited and found some degree of stability that she can recognise the negatives of her experience and of the industry as a whole.

Megan King, who is herself a survivor of prostitution and now helps women exit says:

“One of the biggest barriers of supporting women exploited by the sex trade, in my view, is the denial. Of the former ‘sex workers’ (inverted commas intentional) I know… they all say that at the time, they believed they were strong and free and liberated because they were choosing this.

But upon leaving they realised the opposite was true.

They weren’t free, they were not liberated and they absolutely did not have a choice or were incapable of making an informed choice at the time due to mental health struggles or the control of a pimp or the ‘love’ of their ‘partner’ who didn’t take earnings off them but bought their affection and encouraged them into the industry.”

While women should not be forced to exit prostitution and wanting to exit should never be made a condition of accessing services, women should always be given the possibility of exiting and information about services to help them do that.

For most women who are involved in prostitution, the most immediate barriers to exiting are (a) the lack of an adequate alternative income; (b) drug addiction; (c) being under the control of a pimp or trafficker, who is often their ‘boyfriend’ or intimate partner; and/or (d) homelessness. Longer-term issues can include physical and mental ill-health, including PTSD and crippling anxiety, and the lack of a social network outside of the prostitution milieu. Women need specialised services to help them address these and other specific needs so that they can exit the industry and rebuild their lives.

We do not believe that psychiatric drugs should be considered the solution to the women’s distress. Although they may cause some superficial relief to symptoms of distress, anxiety and PTSD, they do not solve the underlying issues and can ultimately make addressing them harder.

Instead, we recommend provision of trauma-informed talking therapies, and therapies that use psychosensory techniques, such as EMDR, dance and yoga. These should be freely available to women who have lived experience of prostitution for as long as she needs.

While provision of such services would be expensive, the evidence suggests that it would save money in the medium to long term. It typically costs the state £200,000 a year to keep a child in ‘care.’ Providing women who have been severely traumatised by men in the prostitution system with high-quality services to help them recover, address any addictions, and rebuild their lives will reduce the number of children who need to be taken into the care of the state. But the benefits of helping women recover are obviously not restricted to being able to look after their own children. The benefits for individuals and society are potentially enormous. Research from France and Ipswich confirm that the benefits are not just social but economic too.

Recommendations

  1. Declare VAWG a public health emergency and take urgent measures to address its underlying causes, as set out above.
  2. Update policy to explicitly state that prostitution in all its forms (including porn, lap dancing, webcamming, etc) is a form of VAWG and that it is both a cause and a consequence of the inequality between the sexes.
  3. Support a Nordic Model approach to prostitution policy and legislation.
  4. Ensure that all healthcare workers are trained to understand prostitution as a form of VAWG and in providing trauma-informed care, and that information about services to help women exit prostitution is easily available in all healthcare settings.
  5. Investment in high-quality trauma recovery services for women who are in or have been in prostitution, for as long as each woman needs.

* Names have been changed to protect privacy.

Download

Download a PDF version of this paper.


[1] Special Committee on Pornography and Prostitution, 1985, Pornography and Prostitution in Canada

[2] Letter from Susan Kay Hunter, Council for Prostitution Alternatives, Jan 6, 1993, cited by Phyllis Chesler in ‘A Woman’s Right to Self-Defense: the case of Aileen Carol Wuornos,’ in Patriarchy: Notes of an Expert Witness, 1994, Common Courage Press, Monroe, Maine.

[3] Nikki Holland, Assistant Chief Constable, National Police Chiefs’ Council Lead for Prostitution and Sex Work giving oral evidence to the Home Affairs Select Committee, Tuesday 1 March 2016

[4] Park, Decker and Bass 2019; Valera, Sawyer and Schiraldi 2000; Farley et al 2003; Zumbeck 2001

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