“I’d Rather Be Broke Than Harmed”: A Qualitative Analysis of the Experiences of People Engaged in Commercial Sex Work During the COVID-19 Pandemic

Abstract

Objectives:

People involved in commercial sex work during the COVID-19 pandemic, particularly those compelled to sell sex, faced multiple challenges to their safety and well-being. We explored, in real time, the impact of the COVID-19 pandemic on people involved in commercial sex work and the broader commercial sex industry.

Methods:

Using a participatory action research approach, we interviewed 159 English- and Spanish-speaking adults who had engaged in commercial sex work under the direction of a third party in Sacramento County, California, within the past 5 years (approximately 2017-2022). As part of a larger study, our interview protocol included 1 question about the COVID-19 pandemic: “Has COVID-19 changed anything about your experience with sex work?” We transcribed and analyzed interviews using QSR-NVivo, a qualitative coding software.

Results:

Participants described the effects of increased isolation, decreased demand, difficulty accessing social services, fear of contracting COVID-19, difficulty in following public health guidance on social distancing and wearing face masks, and how the pandemic resulted in some people entering or exiting commercial sex work. Most participants were familiar with recommended public health safety measures, but lack of agency and financial need limited their ability to comply with all recommendations. A lack of access to social services added stress to those most in need of emergency housing or substance use treatment and left them vulnerable to continued abuse.

Conclusions:

Stress and financial insecurity generally increased among people involved in commercial sex work during the pandemic, and no efforts were made to understand and mitigate the hardships that this population faced. Future research should address how to maintain social service availability during times of public health emergencies and other crises.

Across the United States, the COVID-19 pandemic affected people’s physical, mental, and financial well-being. However, COVID-19 highlighted how systemic structural weaknesses can have disproportionate consequences in financially underresourced communities.^1-3 Inequitable labor conditions, socioeconomic factors, and historic systemic mistrust among financially underresourced communities challenged how people could or would follow public health guidance about COVID-19. ⁴

People involved in commercial sex work during the pandemic, particularly workers who were involved under conditions of force, fraud, or coercion, faced multiple challenges to their safety and well-being.^5,6 For people selling sex, the onset of COVID-19 resulted in reduced access to community-based social services and further social stigmatization. ⁷ Yet, at the same time, a collective expectation and corresponding social pressure existed to comply with public health mandates and measures. ⁸ The difficulty of navigating decision-making during this time was complicated enough for people with full agency over their bodies and choices but was even more complicated for people who had experienced sex trafficking and the loss of personal agency that comes with this form of exploitation. ⁶

There is much we do not yet understand about how COVID-19 affected people involved in commercial sex work. This qualitative study begins to fill that gap. Findings may help inform efforts to engage and support this population in future instances of public health crises. This study is part of a larger study focused on estimating the prevalence of sex trafficking in Sacramento County and gathering contextual information about the lived experiences of these individuals.

Methods

Participatory Action Research Approach

This study used a participatory action research (PAR) approach, which is characterized by ongoing and meaningful involvement by community members who are affected by the research.^9,10 Well-suited for studies on hidden, marginalized, and stigmatized communities, ¹¹ PAR can help overcome traditional sampling and recruitment challenges with populations that are hard to reach.^12,13 Our PAR approach was practitioner (T.G.) led and included substantial involvement of people who experienced sex trafficking; served on an advisory group; provided input on research questions, instrumentation, and recruitment protocols; recruited initial participants; conducted interviews; and engaged in analysis and dissemination.

Participants and Data Collection

As part of a larger study investigating the prevalence of sex trafficking victims in Sacramento County, California, ¹⁴ we interviewed English- and Spanish-speaking adults who had engaged in commercial sex work under the direction of a third party in Sacramento County, California, within the past 5 years (approximately 2017-2022). If a participant met this eligibility criteria, to prioritize interviews with those who had been exploited, we further asked whether they had given some or all of their money to a third party. Our interview protocol included 1 question specific to the COVID-19 pandemic: “Has COVID-19 changed anything about your experience with sex work?”

From September 2021 through March 2022, the research team recruited 159 interview participants using respondent-driven sampling, which uses social networks to identify and recruit members of the population of interest for inclusion in the study ¹⁵ and has been used in previous human trafficking studies.^16-18 We began with a number of “seed” participants who were already known to the practitioner’s (T.G.’s) organization or members of the advisory group and were believed to have had robust social networks of other people involved in commercial sex work in or around Sacramento County. Interviewees received $50, and at the end of the interview, they were each given the opportunity to recruit up to 3 others to participate. In a few cases, participants were allowed to refer >3 others in an effort to recruit individuals from subpopulations that were particularly hard to identify (eg, men, transgender people). For each person they recruited who completed an interview, interviewees received an additional $25. Those recruited participants were then given the same opportunity to recruit others from their networks, and so on. All participants provided informed consent. This project was approved by Sterling Institutional Review Board (ID#8984).

The study sample included a group of people who were diverse in age, race, and ethnicity. The mean (range) age at the time of the interview was 36 (18-64) years. The mean (range) age when participants first sold or traded sex was 20 (1-49) years. A large number of interviewees identified as Black or African American only (n = 75; 47.5%), followed by White (n = 20; 12.7%) and Latinx (n = 17; 9.3%). Most interviewees identified as female (n = 149; 94.3%), despite intensive efforts to include people who identified as male or transgender, including by allowing >3 referrals by those referring male and/or transgender peers and consulting with a male survivor about recruitment strategies.

Data Analysis

We used an automated transcription service to transcribe recorded interviews. Our research team then reviewed, cleaned, and deidentified transcripts. We then analyzed the deidentified transcripts using QSR NVivo (QSR International), a qualitative coding software. We established a coding system based on (1) describing the nature of sex trafficking exploitation of participants and (2) better understanding their lived experience. As part of this system, we developed codes to capture the effect of COVID-19 on commercial sex markets, sexual exploitation, and help-seeking behaviors. Our research team members met regularly to review and revise the codebook during initial qualitative analysis. In addition, to ensure interrater reliability, all members of the research team involved in qualitative analysis coded several interviews simultaneously and met to discuss any discrepancies and establish processes for areas of disagreement.

Results

Results indicated that the pandemic posed challenges for most participants who were still engaged in commercial sex work during the pandemic but that those challenges were especially pronounced among participants who were being exploited by a third-party pimp or trafficker during that time. Participants described the effects of increased isolation, decreased demand for commercial sex work, difficulty accessing social services, fear of contracting COVID-19, difficulty following public health guidance on social distancing and wearing face masks, and how the pandemic resulted in some people entering or exiting sex work.

Increased Isolation

The widespread curfews and stay-at-home mandates that occurred early in the pandemic were difficult for many people involved in commercial sex work. One participant articulated the extreme disorientation that occurred at the onset of the pandemic that was exacerbated by the isolation imposed by traffickers.

Like, I don’t even know it was a pandemic going on until people keep on telling me, and then we had to wear a mask. . . . When I figure out it was a pandemic going on and I’m like, I’m so confused . . . like how . . . what’s going on with the world? ’Cause I remember when they was talking on the news, I was watching, ’cause we couldn’t have our phones in that place. It was on the news. I was looking at the news and stuff and it was telling about how people was going to the stores and stuff and robbing and all that other stuff, like what is going on with the world? . . . And then like going and then like every other Friday we get to go grocery shopping and every time we go to Walmart, it’s either Walmart or a Fry, but everybody always pick[s] Walmart. So we went to Walmart, it’s really nothing on the shelves and stuff. I’m like, wow, like how we’re gonna survive? (Female, age 23 y)

While most interviewees did not experience this level of physical and social isolation during the pandemic, several interviewees said that the isolation inherent with the social distancing mandates and related business closures early in the pandemic were distressing.

Decreased Demand

Several study participants described how, early in the pandemic, a temporary lull in demand for commercial sex occurred, particularly at the street level because of curfews and stay-at-home orders. For those who were still being forced to sell sex on the streets, this lull presented extra difficulty. Not only were they forced to be outside and break curfew orders, but activity at the street level was slower than before the pandemic. One participant said,

It’s not so many people that come like they used to. So, now it’s like I stay out there extra longer. It’s cold sometimes, but I . . . don’t really feel good, but still it’s like, he just has to have his money, you know, and if I don’t go get like I’m supposed to, then I’m in trouble. I’ve had to, like, go on 2-day shifts. (Female, age 44 y)

One participant, who was being trafficked at the time, described the lull in demand for commercial sex during the beginning of the pandemic as a welcome reprieve because she was not forced to work for a short time, saying, “I didn’t have to do anything for a little bit, but it came back. It started way fast. It wasn’t even a short amount” (female, age 18 y). Importantly, the perspective that demand for commercial sex decreased early in the pandemic was not shared by all; some participants explicitly discussed how there was never a decline in the demand for commercial sex.

Difficulty or Hesitancy in Accessing Social Services

A few participants described trying to access community-based services during the onset of the pandemic but found that community supports were closed or not accepting new clients. One participant described unsuccessfully trying to find a bed in a homeless shelter and then ultimately moving in with her trafficker as a result.

Well, no vehicle for one. Then I had a phone, but it was off. I needed WiFi and the house had WiFi and I really didn’t have like a lot of family to call, growing up in foster care. There was nobody to come get me. I called a few shelters, but no one was taking anybody cause [COVID-19] had hit. So it was kind of hard. I didn’t have anywhere to really go. I was homeless. That’s how I moved in with him in the first place. (Female, age 24 y)

Another participant, a transgender female aged 42 years, described reaching out for counseling services but finding that the agency had closed for good. At a time when social services were critical for some of the community’s most vulnerable people, these services were not available.

Several participants described needing medical services during the pandemic but being afraid to go to their physician or hospital for fear of contracting COVID-19. Others expressed distrust or disinterest in the newly developed vaccines and fear that if they went to the hospital, they would be forced or tricked into getting a vaccine against their will.

Fear of Contracting COVID-19 and Difficulty Following Public Health Guidance

Many participants expressed fear of contracting COVID-19, especially because sex work inherently involves proximity that was not aligned with public health recommendations for social distancing. As one participant described, “I’m like, if you can get COVID-19 from just being at arm[’s] reach, just imagine, you know . . . being in a hotel room and in a bed. And it’s no mask, I’m sure. It’s like close contact. You don’t know who these people are. That’s what’s scaring me through COVID” (female, age 27 y). Another interviewee described getting beaten by her trafficker for refusing to work due to her fear of COVID-19: “I would be like so reluctant. Like sometimes I would have to get my ass beat because I would tell him I’m not doing nothing with this guy. I don’t care . . . so I was getting beat up more for not doing the dates and stuff. ’Cause I’m very scared of it” (transgender female, age 39 y). Another participant described how she felt exposed having to be out on the street while being supervised by her trafficker, who sat safely in his car, more protected from both exposure to COVID-19 and to law enforcement. She explained, “[If] you have a pimp, they don’t care. They’re not really risking their self” (female, age 27 y). Another participant described how her friend was forced to continue selling sex even when she had an active, contagious case of COVID-19.

Many participants described doing what was in their control to follow public health guidelines to prevent them from contracting or spreading COVID-19. They described using condoms, face masks, sanitizing wipes, and hand sanitizer as preventive measures while selling sex during the pandemic. One participant described trying to protect herself while being trafficked: “He [my trafficker] did not care. Yeah. He just said, ‘You’re gonna go get the money.’ . . . I had hand sanitizer, um, but no, no mask, um, just condoms and sanitizer and, um, I had like Lysol wipes, like on the tables, but that’s about it” (female, age 27 y).

Several interviewees described changing their practices in commercial sex as a result of the threats posed by the pandemic. This subset of participants had enough control over their working conditions to make these decisions for themselves. Some of these participants described moving from street-based sex work to internet-facilitated sex work. Some described narrowing in and only selling sex to a small number of regular buyers. One participant said, “I no longer work streets. I developed and accumulated clients that are . . . we call them regulars. They continue to see me by telephone appointments” (female, age 63 y).

How the Pandemic Resulted in Some People Entering or Exiting Sex Work

Some participants described how the pandemic led them to either enter or exit sex work. At least 3 participants described beginning sex work after they lost their jobs due to pandemic-related layoffs early in the pandemic. One participant described the series of events between losing her job and turning to commercial sex work for income.

I lost my job and, like, the income, not going to work, losing housing, like, made me fall back on, like, not being able to pay my registration. Then the [Department of Motor Vehicles] was closed so I couldn’t even go and pay it. And then fast forward to, like, recently I got tickets for expired registration, my car got impounded, and that’s where I even started. (Female, age 29 y)

However, among interview participants with more agency in their involvement in commercial sex work, some described how the pandemic actually prompted their exit from commercial sex work. One respondent turned to working in a strip club instead, where she believes she contracted COVID-19, leading her to leave the industry altogether. She said,

I was just working in the clubs. I hadn’t sold ass in 3 years, I just started working in the club. And then I think I got COVID-19 in there. . . . You wanna still be out here in the club, drinking every night, doing the same thing, risking your life? These diseases and variants that they got, this is real. . . . It [COVID-19] gave me that extra push. (Female, age 29 y)

Another participant described how the risk of contracting COVID-19 was enough to drive her out of sex work. She was particularly concerned about passing the virus on to other loved ones. She said,

It’s [COVID-19] preventing me from walking the streets a lot. I have a young daughter. I am very concerned about not only her or my health, but the people that is in my circle. . . . Even though I have been vaccinated and had the booster shot and all that, my 2-year-old daughter is not. And her 83-year-old grandmother is old. That’s just the risk that I choose not to take. (Female, age 40 y)

Some participants mentioned that having access to unemployment funds during the pandemic was central to their ability to leave the commercial sex industry. As one participant described,

When COVID-19 happened, I started getting unemployment and, like, the whole reason I was doing it was for money. And since I had unemployment, I didn’t need to do it anymore. And so it just kind of like slowly stopped, you know? I’m on unemployment still. Um, but it’s cool. Now I have time to actually look for a job and I’m on like a good path, like going toward getting clean and stuff. So it’s like, even if the unemployment stopped and I don’t feel like I’d go back, you know, cuz it’s much easier not having to worry about all that. (Female, age 28 y)

Several factors affected participants’ decision-making about engaging in commercial sex work during the pandemic, including financial imperative, perception of risk to themselves or others, their level of agency, and the availability of other employment or income options.

Discussion

COVID-19 affected people in all communities as they learned to cope with stay-at-home orders, social distancing requirements, and widespread closures. While the pandemic was stressful for all, those who sold sex, and especially those who were being exploited by a pimp or trafficker, faced additional challenges because of the illicit nature of commercial sex work and lack of control over their work environment, as has been documented in the literature on occupational health and safety as it related to people involved in commercial sex work. ¹⁹

This study found that public health messaging about safety recommendations was effective: most participants were familiar with recommended safety measures. However, both lack of agency and financial need limited the ability of participants to comply with the recommendations. Understanding the risk of close contact did not mean that safe behaviors were adopted by those who were compelled to sell sex. This finding demonstrates a potential limit of public health messaging to victimized people. Specific messaging or supports for people with limited personal autonomy, and using a harm-reduction approach, could be a positive addition to future public health responses. Other processes documented during the early months of the COVID-19 pandemic that may be helpful include administering flexible funding through organizations that serve people involved in commercial sex work, providing assistance with financial relief applications, and offering health and safety guidance for those who are unable to cease commercial sex work.^5,20

Participants reported a lack of access to social services during the COVID-19 pandemic, which created additional stress for those who were most in need of emergency housing or substance use treatment, leaving them more vulnerable to continued abuse. Once these services reopened, many social service agencies, including shelters, required vaccinations for admittance. The social pressure that accompanied public health recommendations to prevent the spread of COVID-19 (eg, wearing face masks, getting vaccinated) was unprecedented and difficult to navigate. For people who have experienced sex trafficking, a general distrust of systems and a desire to maintain a measure of control over one’s body are understandable responses to past abuse and trauma. Expecting or requiring compliance with these measures may have further isolated people from the services they needed. The additional stigma faced by those who were unvaccinated or the requirement of vaccinations to receive emergency services further complicated the lives of sex trafficking survivors. Emerging research indicates that interpersonal trust is an important factor for acceptance of public health measures. ²¹ Therefore, public health departments might consider more tailored strategies, such as establishing and funding emergency advisory councils to ensure understanding and potential gaps in providing necessary care, to engage micro-communities, such as people involved in the sale of commercial sex. Even better, public health organizations should consider including people with lived experience in their response planning efforts ⁵ and consider the community-empowered models that have been developed for other public health prevention initiatives, such as for HIV. ⁶

Further adding to the hardship that people experiencing sex trafficking faced, few involved in commercial sex qualified for unemployment compensation. This hardship was especially pronounced early in the pandemic, when some participants found that the demand for commercial sex temporarily declined. Without even the most basic services available in the community, people who sold sex at the onset of the pandemic were left without any safety net and had to work even longer hours and accept additional risk to survive. For those who were able to access unemployment, the financial support was sufficient to reduce or eliminate the need to sell sex and allowed for greater control over their environment, facilitating the exit from commercial sex for some. This finding is consistent with the literature on exit from the commercial sex industry, which can be facilitated by self-efficacy and economic empowerment,^22,23 suggesting that universal basic income at a sufficient rate may change health outcomes for populations engaged in commercial sex work.

Limitations

This study had several limitations and 1 strength. The strength was that the overarching research questions considered the scope and nature of sex trafficking in Sacramento and, because the study began before the pandemic but continued throughout the pandemic, also presented an opportunity to collect data on the effect of COVID-19 on the experiences of people involved in commercial sex work during the pandemic. The first limitation was that the interview protocol included only 1 open-ended question about the pandemic, which limited how much we could learn about this topic. Second, while we know that all participants experienced sex trafficking within the 5 years before their interview, we did not explicitly ask whether that exploitation occurred during the pandemic. Therefore, we could not delineate the experiences of those whose exploitation had ended before the pandemic from those who were actively trafficked for sex during the pandemic. Third, this analysis did not address layers of risk faced by respondents; as such, we were unable to assess the impact of those differential risks. Finally, these findings do not adequately reflect the experiences of male-, transgender-, or other nonbinary-identifying individuals because they were underrepresented in the sample. As such, our understanding of these experiences was limited to only a subset of people experiencing sex trafficking in Sacramento County during the pandemic.

Conclusion

Given the nature of this study, we were able to understand, in real time, the experiences of people who had experienced exploitation before and during the COVID-19 pandemic. For those trafficked for sex during the pandemic, their stress and financial insecurity generally increased with no community-wide effort to understand and mitigate the hardships that this population was facing. Future research should address how to maintain critical social service availability during times of public health emergencies and other crises that cause service disruption.