The CLASH Wellbeing Guide Version

The CLASH Wellbeing Guide

Version 1.8

This version published: …

This guide was compiled by clinical psychologists Phillip Kelly and Toby Newson, using information from a range of sources including: NHS England, National Ugly Mugs, Beyond the Gaze, Talk to Frank.

It was produced for the CLASH and SHOC sexual health clinics at the Mortimer Market Centre in central London.

Other contributors:

Caitlin Kiddy Kaylee Linton Del Campbell Naomi Adams

A number of people with lived experience of the sex industry also contributed to the development of this guide.

The authors have tried to ensure that all information is correct at the time of release.

Go to: Introduction - Main Menu - Wellbeing and Mental Health - Safety - Physical Health - Drugs and Alcohol - Male, Trans and Non-Binary Sex Workers - Legal Issues, Police and Tax - Exiting Sex Work - Useful Organisations 2

Introduction

This guide was created to help sex workers improve their wellbeing, work safely and know their rights. It was developed with the support of people with lived experience of the sex industry in order to try to make it as relevant and useful as possible. The guide is designed for people living near London, but it may also be of use to people living elsewhere in the UK.

Being a sex worker is a legitimate job. Sex workers have the right to work in safety without facing abuse, harassment or injustice, just like everyone else. Sex workers also have the right to access support to ensure their health and wellbeing.

We know that sex work can often involve feeling lonely and isolated. If you’ve been feeling like this, you aren’t alone. The good news is that there is help out there, from public services like the NHS, from charity and community groups, and from other sex workers.

When writing this guide, we have tried as much as possible to make it for all sex workers. We know that every sex worker works differently, but we didn’t want to exclude some kinds of sex-workers, or prejudge what kinds of information would be useful. As a result, some of the topics may be relevant to you, and some may be less so.

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Wellbeing and Mental Health Safety Physical Health Drugs and Alcohol Male, Trans and Non-Binary Sex Workers Legal Issues, Police and Tax Exiting Sex Work Useful Organisations

Wellbeing and Mental Health

Sex workers can face lots of challenges in their lives. Lots of sex workers feel worried, low, or isolated at times. If you’ve been feeling like this, then you aren’t alone. The following sections contain some suggestions about how to manage these issues.

In this section: Feeling Low, Worried or Anxious Sexual Assault

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Feeling Low, Worried or Anxious

We all feel low or worried sometimes. However, if those feelings don't go away or are stopping you from carrying on with your normal life, you may need to make some changes or get some extra support.

Here are common signs that you may be experiencing difficulties with low mood:

• low mood lasting 2 weeks or more

• not getting any enjoyment out of life

• feeling hopeless

• feeling tired or lacking energy

• not being able to concentrate on everyday things like reading the paper or watching television

• comfort eating or losing your appetite

• sleeping more than usual or being unable to sleep

• having suicidal thoughts or thoughts about harming yourself

Here are common signs that you may be experiencing difficulties with anxiety or worry:

• Feeling nervous, restless or tense • Having a sense of impending danger, panic or doom • Having an increased heart rate • Breathing rapidly, sweating, or trembling • Feeling weak or tired • Trouble concentrating • Having trouble sleeping • Regular stomach problems

The good news is that there are things that can help us manage or cope with these feelings.

Lots of sex workers find talking to other sex workers or people with knowledge of the industry can help with these problems. You could do this in person by attending events run by charities or community groups, or through online sex worker groups. To find out more click here.

You can also talk to your GP about what help they can offer and what other services are available. Sexual health clinics may also be able to tell you about special support services for sex workers.

Another option is to get help from the NHS. You can find your local talking therapies service here.

Making small practical changes can also help. Here is a list of ideas: • Speak to someone you feel supported by about how you’ve been feeling (friends, family, supportive and like-minded sex-worker) • Try to get some regular exercise • Aim to get a good night's sleep • Keep to a healthy diet • Reduce your drug or alcohol intake • There are certain apps that may help in the NHS App Library.

Here are some tips from other sex workers: • Eat something, anything. Ignore the balanced meal and eat what makes your soul happy- I suggest using Ubereats. Finding it hard to face food? Try something easy like yogurt or a banana, or drink something with calories. • Call a friend who ‘gets it’. Other options include venting online, especially in sex worker only spaces. • Changing the format I work in often helps me. If I need routine and structure I head to a parlour. If I need to be at home as much as possible I offer shorter services to reduce the number of hours spent with clients. • Three things I do: bath, wine and a good book. This is my time; no one can interrupt this. Go to: Introduction - Main Menu - Wellbeing and Mental Health - Safety - Physical Health - Drugs and Alcohol - Male, Trans and Non-Binary Sex Workers - Legal Issues, Police and Tax - Exiting Sex Work - Useful Organisations 8

• I also do something to tune out of the world. For me, I reread a favourite book, watch my favourite TV show or eat my favourite food. • Sometimes you might feel like you are backsliding, but if you are trying to fix all your unhelpful habits at once it can be very hard to stay grounded. Its ok to not be perfect, especially if that’s the best way to get through a hard day. You don’t need to try to fix everything at once!

Sexual Assault

Sexual assault means an unwanted sexual experience: when someone does something sexual to someone else without their agreement or consent.

Everyone has the right to work without threat of abuse or assault, whether they are a sex worker or not. Sexual abuse is never acceptable, and is not an ‘occupational hazard’ of being a sex worker. Sex workers do not ‘leave consent at the door’ when they go into a sexual encounter with someone.

If a sex worker has been sexually assaulted or raped, it is not their fault in any way. The responsibility always lies with the attacker, not the victim. UK law recognises this.

If someone is raped or sexually assaulted, they might experience the following: • feel ashamed or even guilty about what happened • feel depressed or suicidal • have flashbacks • have difficulty focusing or sleeping • feel numb and in shock • be tearful, angry or irritable.

These are all normal human reactions and might last for some time. It’s important to remember what happened is not your fault and you’re not alone.

If you have been sexually assaulted, you don't have to have a forensic medical examination. However, it can provide useful evidence if the case goes to court.

The following services will all provide treatment or support depending on your preference: • The Havens, a specialist centre in London for people who have been raped or sexually assaulted. Telephone - 02032996900 • You can find the location of your nearest NHS Sexual Assault Referral Centre here. • You could see a nurse or GP at your local surgery. • Alternatively you could attend a sexual health clinic, a contraception clinic, or an accident and emergency (A&E) department.

For telephone support, you could contact: • The Rape Crisis national freephone helpline: 0808 802 9999 - 12-2.30pm and 7-9.30pm • The 24-hour National Domestic Violence Helpline 0808 2000 247 – 24 hour • NHS 111 – 24 hour

The following charities also offer support: • Women's Aid • Victim Support • Women Against Rape • The Survivors Trust Go to: Introduction - Main Menu - Wellbeing and Mental Health - Safety - Physical Health - Drugs and Alcohol - Male, Trans and Non-Binary Sex Workers - Legal Issues, Police and Tax - Exiting Sex Work - Useful Organisations 11

• Survivors UK (for male victims of sexual assault) If a someone close to you has been raped or sexually assaulted: • Don't judge them, don't blame them. A sexual assault is never the fault of the person who is abused. • Listen to the person, but don't ask for details of the assault. Don't ask them why they didn't stop it. This can make them feel as though you blame them. • Offer practical support, such as going with them to appointments. • Respect their decisions – for example, whether or not they want to report the assault to the police. • Bear in mind they might not want to be touched. Even a hug might upset them, so ask first. If you're in a sexual relationship with them, be aware that sex might be frightening, and don't put pressure on them to have sex. • Don't tell them to forget about the assault. It will take time for them to deal with their feelings and emotions. You can help by listening and being patient.

Websites further information and support for people who have experienced rape or sexual assault are listed on the previous page.

Safety

Everyone has the right to live and work in safety. Danger and abuse should not be an ‘occupational hazard’ of being a sex worker. However, unfortunately, some people who pay for sex do pose risks to sex workers, even if not every client will be dangerous.

This section focuses on ways to manage some risks involved in sex work. Risks around sexual health are covered in another section.

If you think you might be in a dangerous situation, try to trust your instincts or ‘gut reaction’. If you feel uncertain about someone or somewhere, then there is likely to be a good reason for it. It's not worth ignoring your instinct and later wishing you hadn't.

In this section: General Safety Tips The Client National Ugly Mugs Dressing Street Safety Tips Online Safety Working Indoors Own Home / Shared Establishment

The Client’s Home Hotels Working on the Streets Working in Cars If things go wrong If you are being followed in public If a client becomes aggressive If you are attacked Useful links

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General Safety Tips

The Client • Appearances can be deceptive. Don't assume someone is okay just because they look 'respectable'. The same goes for 'regulars'. • Check out clients in advance: sign up to Ugly Mugs to receive warnings about potentially dangerous individuals, make reports and use their mobile number checker every time you receive a call from a potential client. • You can also use sex worker forums can also be a useful for checking out clients. • Avoid accepting food, drink or drugs prepared by a client. It might have been spiked with a drug. Read more here. • Avoid sex positions where you can’t see the client (such as from behind or ‘doggy’). Many sex workers recommend being on top (‘cowgirl’) for vaginal or anal sex. This is safe because you can see the client clearly, your hands are free and you can move easily if you need to. • If you experience abuse or violence from a client, Remember the date and time of the incident try to memorise as much as you can about the person, their house or room and their vehicle.

• Try to write down the date and time of the incident and everything you can remember, whether or not you intend to report it. • Remember there may be CCTV cameras where you were attacked which may help identify attackers. • Did you know you can silently call the police to your mobile phone location? Further information here. • For more safety advice, see here and here.

National Ugly Mugs National Ugly Mugs is a charity which aims to provide greater access to justice and protection for sex workers. It focuses on providing sex workers with information about dangerous individuals who may be targeting sex workers.

If you sign up to National Ugly Mugs, you’ll receive warnings about potentially dangerous individuals, and be able to make reports and use their mobile number checker every time you receive a call from a potential client.

The National Ugly Mugs team are available Monday to Friday between 9am and 5pm on 0161 629 9861. Alternatively you can email [email protected], or visit their website.

Do consider reporting all difficult clients and other attackers to Ugly Mugs. Many local sex work projects will also have schemes where you can report violent and abusive clients to warn others of potentially dangerous people. Many projects have arrangements where they can pass information about attackers to the police, with your permission, and if you wish to make a formal report to the police they can offer you support to do this.

Crimestoppers also have a free phone line where you can anonymously report difficult clients. They are part of a ‘Stop Ugly Mugs’ campaign. Telephone: 0800 555 111.

Dressing • Try to avoid jewellery if you can. • Avoid long or hooped pierced earrings. Use small ones or clip-ons that can come off easily. • Remove body piercings as these could get torn out. • Do not wear a scarf or tie around your neck, as it can be used as a weapon against you. • Try not to wear a long hairstyle at work, as it can be easily grabbed and pulled. • Try to avoid bags using with straps as these could be used to manhandle you. Do not wear bags around your neck. Wear them over your shoulder instead. • Avoid items of clothing that may make it difficult to run if you're in danger: long skirts or high heels. • If you wear necklaces, make sure they come off or break easily. Avoid long necklaces.

Street Safety Tips • Carry a personal alarm. • Study a map of the area. • Familiarise yourself with new areas before you work in them. Avoid work in areas you don't know. Focus on safe escape routes, police stations, pubs, open shops and garages. Know the bus routes and where to get a taxi. • If possible, have a clear idea of where you're going. If you can, tell someone the route you're planning, and arrange to meet up or phone them at agreed times when you are out working. • Avoid working in secluded or difficult to escape areas. But if you have to, make sure you are as familiar with your surroundings as possible. • At night, try to stay in fairly busy, well-lit areas.

Online Safety Tips

One of the most important ideas for staying safe online is to try and keep your personal and sex work information unconnected. The sections below give some ideas about how to do this.

Doxing ‘Doxing’ is a name for when people publish information online about sex workers which breaches their privacy. This usually means publishing information which reveals a sex worker’s real identity, such as photos or links to their personal social media accounts.

If you think someone has breached your online privacy, they may well have committed a criminal offence. You might want to report this to the police. You can do this directly, or ask a National Ugly Mugs worker to help you to do this.

Revenge Porn Some clients may try to film bookings, with or without your permission. They may use a secret camera. Videos or pictures then may end up on the internet without your permission. This falls under the definition of ‘Revenge Porn’. You can find out more about this, get support and understand your rights by visiting the Revenge Porn Helpline for confidential advice.

Other Online Safety Tips • Have a fake work name and stick to it.

• Always have a separate work phone.

• Have separate work and personal emails.

• If possible, try to have a separate laptop / tablet / computer that you only use for work.

• Have separate social media accounts for work and personal use.

• Think carefully about if you want to show your face in your sex work photos. This may have long-term consequences which are difficult to undo.

• Always use separate photo images from those you use in your personal life and on personal social media profiles so you can't be identified.

• Know as much as possible about any app / website / advertising platform you use, such as how they work and their data protection policies.

• If you work from home, make sure you don't have out any personal / family pictures, documents with your real name, or any other kind of identifiable information.

• Don't give the address you work from or even your local area in your advertising.

• Try not to include pictures of your premises in advertising.

• Don’t allow clients to take pictures of you or film you. You don’t know what they may do with the footage.

• Look out for secret cameras at bookings, e.g. in client’s bags bags. Move them or cover them up if you can.

Working Indoors

The following sections give safety tips for different kinds of sex work that happens inside buildings.

Working at your own House or in a Shared Establishment • Avoid working on your own. Have a plan ready in case a client attacks you. Know the escape routes to a safe place in or outside the building. • If you have to work alone in a house, go in another room and talk to yourself loudly. The customer will think there is someone there. Or keep a dog; the larger the better. • Working in the same building as other sex workers is likely to be safer than working alone. However, it’s important for you to be aware of the law around this though. If you are managing or helping to manage a shared establishment, you may be committing a crime. • Always hide your valuables. • Always try to take an alarm into the room with you. If the establishment doesn't have panic buttons fitted, ask them to think about getting them fitted or supplying workers with personal alarms. • Never allow yourself to be locked in a room with a client. If the door to the room you will see the client in locks, know how to open it quickly. Never leave a key in the door in case you are locked in.

• If you're uncertain about the client, let another worker (e.g. the receptionist) know, so they can keep an eye on the time and listen out for anything. • If there are mirrors on the walls, use them to keep an eye on the client at all times, especially when you have your back turned to him. • Ideally get paid upfront, and put the money somewhere apart from your other cash, so that if the client takes the money back, he doesn't get everything you've got. • Don't have anything on you with any personal information, such as your driver's licence or credit cards. • If you get scared, or if you are attacked, try to keep yourself calm and get out of the room to a safe place as quickly as you can. Don't be afraid to run out of the room with no clothes on. • Don’t agree to help run a shared establishment, as this may mean you are committing a crime by breaking the brothel-keeping law. • Be careful about trusting people who run shared establishments. Give them as little personal information about you as possible. They may be trying to exploit you. • Never sign any contracts for sex work without understanding what it's all about. Make sure you know your rights and obligations. Be clear about the services you are prepared to provide and your prices.

The Client’s Home

Bookings at a clients’ house can be dangerous. If you are working in this way, these sections provide information that can help to make it safer.

Before taking the booking: • Always try to have a Check-in Buddy. This means someone one trusted person who you tell where you are going. Make sure they know where you are going. Arrange phone calls with them before and after the booking so they know you are safe, and how you could contact them in an emergency. If this isn't possible, just tell someone else where you're going and when you expect to be back. You might be able to find a buddy who is a sex worker through online sex worker forums. • Always try to speak to the client yourself. Use this opportunity to suss them out so you can find out what they want before you go and to make sure you're comfortable with it. • Be clear about the cost of the service. • If the client sounds drunk or on drugs, seriously consider not taking the job. • Avoid being called out to areas which seem isolated or dangerous.

• Check the client out using Ugly Mugs and sex worker forums. Also, try to find out more about them online to see if they might be dangerous. • Get the details for where you will meet the client and arrange to phone the client back on a landline to confirm. If the client is not happy for you to do that, then don't go, as they are hiding something. Then check the telephone number the client has given with Directory Enquiries. After you've confirmed the landline number is genuine, then phone the client back and arrange to meet him. • Always try to meet first-time clients in a public place, such as the hotel bar, particularly if you haven't managed to speak with them yourself.

When travelling to the booking: • Take a personal alarm. • Be aware how to make silent 999 calls • Pay attention to the area and potential points of safety such as bus routes, taxis, busy streets, open shops, pubs, garages and phone boxes.

When you arrive: • Memorise the layout of the building and note escape routes. • If you are uncertain or have a bad feeling about the client or the situation, leave immediately. • Pay attention to details in the room such as pictures, decor, layout, or furniture so you could identify the room. • Watch out for any hidden cameras in the room – you may be being secretly filmed. • Keep as much clothing on as possible, in case you have to run. • Spend as little time at the booking as is necessary.

Hotels

Sex work in hotels can come with its own unique set of challenges. The ideas in previous sections will also be helpful, but below are some more tips.

• Carry a personal alarm and keep it close to you. • Take time to work out escape routes or sources of help (e.g. staff) in the hotel before you meet the client. • Try to keep the hotel room door unlocked and unobstructed. • If you are in a hotel room with the client and feel unsafe, go into the corridor and try to alert hotel staff. Don't stop to put on clothes or other belongings. • If you are unsure what to tell hotel staff, say that your boyfriend/girlfriend has attacked you or you are afraid they will attack you. It does not matter if you lie. • Don’t be afraid to cause disruption to alert others and reach safety, such as banging on doors or knocking things over. • If you are in other areas of the hotel and feel unsafe, don't be afraid to cause a scene to attract attention in other ways. For example, you could pretend to cry hysterically.

Working on the Streets

• Whenever you can, work in twos or threes. • Let each other know where you usually take your clients. • Agree a sign that you can give each other if you are not happy with a client or situation, so they can help you. • When a potential client approaches, consider if his details ring a bell from previous Ugly Mugs alerts or from information passed on to you by other workers? • Follow your instincts. If you are uncertain or have a bad feeling about the client or the situation do not go with him under any circumstances. • Try to memorise information about the client. • Be clear about the services you are prepared to provide and your prices. • Try to be the one who decides where you go to do business, so you know it’s safe. If the client doesn't agree, ask him where he wants to go. If you don't like the sound of it, don't go. If the place he suggests seems OK, make sure you tell someone where you're going and how long you'll be. • Get paid first, and put the money in a different place from where you keep your other cash • When going away with a client, wave to the others (or pretend to if you are on your own) and shout out your expected return time.

• Keep as much clothing on as possible, in case you have to run.

See also Working in Vehicles More on General Safety and Street Safety

Working in Cars

This section discusses safety tips for sex work happening in an around cars.

Before You Get in the Car: • Does his appearance or the details of the vehicle ring a bell from Ugly Mugs alerts or from information passed on to you by other workers? • Try to stay near busy roads and stay on the same side as oncoming traffic. If a car pulls up and you think that something is not quite right, walk quickly in the opposite direction to the traffic. • Whenever you can, work in twos or threes. The others can take the registration numbers of your clients' vehicles, and you can take the numbers of theirs. • Be clear about the services you are prepared to provide and your prices. Follow your instinct. If you are uncertain or have a bad feeling about the client or the situation, do not get in under any circumstances. • Try to arrange the price, service and location outside the car. You suggest where to go to do business, so you can be sure it’s somewhere safe. If the client doesn't agree, ask him where he wants to go. If you don’t like the sound of it, don’t get in. • Make a note of the registration number and try to remember and memorise details of the vehicle. If you have

time, write down the number and details or store in your mobile. • Tell someone where you’re going and how long you’ll be. • As you get in the car wave and call to someone (or pretend to) and say when you expect to be back. • Once the vehicle is parked, try to leave the door slightly open, particularly if it has central locking. • In two-door cars, insist on staying in the front seat, escaping from the back is very difficult.

When You’re in the Car: • Get paid first, and put the money in a different place from where you keep your other cash. Keep your money well out of sight and put money a client gives you in a different place from other cash. Try not to keep it somewhere obvious like your bag or back pocket. Think of another place, e.g. your shoes. Split up your money and put it in different places, don’t keep it all together. • Most modern cars have central locking so be aware of this. Ask the driver to keep your window wound down; you could say you suffer from asthma or car sickness. • Try to make sure the client doesn't park with the passenger door close to a wall or other obstacle that would make opening the car door difficult. If he does, give him a reason to move it, for example you saw a police car or other people can see you.

• Once the vehicle is parked, try to leave the door slightly open, particularly if it has central locking. In two-door cars insist on staying in the front seat; escaping from the back is very difficult. • If you start to feel scared or you are attacked, try to keep yourself and the situation calm, and get out of the vehicle and to a busy public place as soon as possible. Try to leave a small personal object under or stuffed down the cushions of the car seat - something like an earring, bangle or an unused condom (make sure it's in its wrapper and you know the brand name), anything that you could positively identify if you decide to report the incident to the police.

If things go wrong

Although not all people who pay for sex are dangerous, some can be. If a client has done something that has hurt you or made you feel uncomfortable, try not to blame yourself. The responsibility for abuse or unpleasant behaviour always lies with the perpetrator.

The following sections give suggestions for different safety problems sex workers might encounter.

If you are being followed in public If a client becomes aggressive If you are attacked

If You Are Being Followed in Public

• Cross the road, maybe twice, to be sure that the person is following you. • If you are sure they are following you, head for the nearest pub, police station, garage or open shop as quickly as you can. Go the most public route to the most public place. • Do not head for home, even if someone is waiting for you there. It's safer to go to a public place than to let a stranger know where you live. • Try to keep yourself composed and your thoughts rational. Pay attention to what someone is actually doing, rather than what you think they might do. • Don't add to your fear by letting your imagination take over. Be positive and confident about your actions. Focus on the fact that you are heading to a safe place, where you will be with other people. • If you need to, cause a commotion. Make lots of noise and fuss to attract attention and to deter the person following you. • When you have got to somewhere safer (e.g. a pub), ideally call someone (a friend, a taxi) and ask them to collect you, or talk to the staff there. Alternatively call the police and explain the situation. • Consider making a report to Ugly Mugs.

If a Client Becomes Aggressive

Here are some key points to try to keep in mind if a client becomes aggressive and you are concerned for your safety:

• Try to get away from the client as soon as possible. Keep thinking about how you will get out of the situation.

• Alert others. You could: o Trigger a personal alarm o Call for help o Call your check-in buddy if you have one o Send a phone message to a trusted contact o Make a silent 999 call

• If they just want your money or your possessions it is probably not worth fighting for. You could be seriously hurt or killed.

• You do have the right to use reasonable force to prevent yourself being physically harmed or being forced to have sex when you do not want to. UK law protects your right to do this. You are also allowed to use reasonable force to prevent any kind of serious crime being committed. You can read more here.

Here are some practical ideas for dealing with dangerous clients: • As soon as a situation seems dangerous, try to tell the client that someone (preferably a man) is collecting you / expecting you soon, whether or not they are. • If you are in a hotel, go into the corridor and, if possible, alert hotel staff. Don't stop to pick up clothes or other belongings. • If you are in public, don't be afraid to cause a scene to attract attention. If you are asking people in public for help, you are more likely to gain assistance if you shout a specific instruction like 'Call the police'. • Crying hysterically may help to defuse some situations, even if you have to pretend.

De-escalation Strategies In some situations, you could use de-escalation strategies to try to calm the client down. Only attempt this if you think it safe to do so or you have no other option. De-escalation skills are used by mental health workers and others professionals to try to calm people who have become aggressive. The key ideas are:

• Always stay close to an exit and have an escape plan if things go wrong • Keep well out of arm’s reach of the aggressive person. • Use open-handed gestures; don’t point. • Have a neutral facial expression. • Make some eye contact but don’t stare. • Speak calmly and quietly. Don't raise your voice or shout. • Use relaxed body language. If you stand, try to stand side-on to the client, so you can move away quickly if you need to. If they are standing aggressively, don’t ‘square up’ to them. • Try to stay at the same level as the person. If they are standing, stand. If they are sitting, sit, but make sure you can still make a quick exit if you need to. • Show the person that you’re listening • Use friendly, sensitive language • Try to show understanding and sympathy.

• Summarise what they say back to them, e.g. “It sounds like you’re saying that …”. Try to avoid sounding judgemental, even if what they are doing is wrong.

If you are interested, you can find out more online by searching for ‘de-escalation skills’ or ‘de-escalation strategies’, although not everything you find will be relevant to sex work. Some local sex work projects may also run workshops in de-escalation.

Always consider reporting aggressive incidents to the police or to Ugly Mugs.

More on Emergency Contraception.

If He Has Ejaculated in Your Anus • Try to get rid of the semen by sitting on a toilet or squatting down and squeeze out as much of the semen as possible. • Wash yourself on the outside. Never douche the anus. This can cause cuts and abrasions in the sensitive intestinal walls that will increase the risk of infection.

If He has Ejaculated in Your Mouth • Spit the semen out • Wash your mouth with mouth-wash or salt water. • Do not brush your teeth or use dental floss for at least an hour.

Preventing HIV

What is Prep? • PrEP stands for pre-exposure HIV prophylaxis. It’s a way of preventing HIV infection by taking a pill on an ongoing basis before sex and continued after sex. It’s taken by someone who doesn’t have HIV, to prevent them from getting HIV. • The PrEP pill is an antiretroviral drug – the same type of pill taken by someone who already has HIV to treat HIV. • PrEP is most commonly taken as a once-a-day-pill.

How does Prep work? If a person taking PrEP is exposed to HIV, the PrEP drugs they have taken prevents HIV from entering their cells and from replicating. This stops HIV from establishing itself and stops the person taking PrEP from becoming infected with HIV.

Does Prep Work? The short answer is yes. Studies across the world have shown that daily oral PrEP is highly effective in preventing people becoming infected with HIV. It is most effective when taken every day.

What does Prep not do? Prep does not protect you from other sexually transmitted infections, such as Chlamydia, Gonorrhoea or Syphilis. To make sure you are best protected from sexually transmitted infections, you should use condoms while you take Prep.

How soon does it work? Research shows that PrEP needs to be taken daily for between 4 and 7 days for protective levels to be reached in the blood and the rectum. It takes longer for protective levels to be reached in the vagina and cervix – so you may need to take PrEP on a daily basis for three weeks before it becomes effective, if you are having unprotected vaginal sex.

Are there side effects? Most people who take PrEP don’t experience side effects. When people do get them they tend to go away on their own within a few weeks. Side effects can include stomach problems, headaches or tiredness.

Should I discuss Prep with my doctor or nurse? If you are considering starting PrEP, it is highly recommended that you discuss this with a doctor at a sexual health clinic. Medical staff will be able to help you decide if PrEP is right for you, and will be able to offer important tests before starting PrEP – such as kidney function tests. Go to: Introduction - Main Menu - Wellbeing and Mental Health - Safety - Physical Health - Drugs and Alcohol - Male, Trans and Non-Binary Sex Workers - Legal Issues, Police and Tax - Exiting Sex Work - Useful Organisations 87

How can I get Prep? Prep is not currently available on the NHS, but you may be able to get access to it through participating in a research trial. You can buy Prep online from registered pharmacies for a minimum of £19 a month.

For more information see:

I Want Prep Now The Prep Impact Trial

PEP – If you think you have been exposed to HIV

What is PEP? Post-exposure prophylaxis, or PEP, is a method of preventing HIV infection. It involves using a short course of the drugs used to treat HIV, taken very soon after a person may have been exposed to the virus.

PEP is not a ‘cure’ for HIV. If it works, PEP prevents HIV from entering cells in the body and so stops someone from getting HIV. PEP isn’t 100% effective. However, there have been very few reports of HIV infection after the use of PEP.

It is an emergency measure, rather than one to be used as a regular method of preventing HIV transmission.

When do I need to take PEP? To have the best chance of it being effective, you need to start taking PEP as soon as possible after the possible exposure to HIV. It is best to start PEP within 24 hours, but certainly within 72 hours.

Where do I get PEP? • Go to your local sexual health clinic and explain that you think you have been exposed to HIV and need PEP. • If they operate an appointments system and are fully booked, call and explain that it’s an emergency and that you need to be seen. • If your local sexual health clinic is not open (for example, at the weekend), go to an accident and emergency department at a hospital, where staff will contact an HIV specialist able to prescribe PEP. • GPs (family doctors) cannot prescribe PEP. • When you go to get PEP, you will be asked about the sort of sex (or other activity) you have had, to assess how high your risk of HIV infection is. You will need to have an HIV test to check you don’t already have HIV. You will also need to agree to be tested again when you have finished the course of PEP.

When is it recommended to take PEP? • Vaginal sex: PEP is recommended for women who have had vaginal sex with a man who is known to be HIV positive, unless he has an undetectable viral load. • Oral sex: PEP may be considered if you have given oral sex to a man known to be HIV positive, who has ejaculated into your mouth, only if your mouth is injured or he has a very high viral load. PEP is not recommended in other circumstances, including cunnilingus (oral sex performed Go to: Introduction - Main Menu - Wellbeing and Mental Health - Safety - Physical Health - Drugs and Alcohol - Male, Trans and Non-Binary Sex Workers - Legal Issues, Police and Tax - Exiting Sex Work - Useful Organisations 90

on a woman's vagina), semen splashes on skin or in eyes, or human bites. • Anal sex: PEP is recommended if you have had receptive anal sex with someone who is known to be HIV positive or who is thought to be from a high-prevalence country or risk group, e.g. from sub-Saharan Africa or a man who has sex with men (MSM). The exception to this is if the person you had sex with is known to be on HIV treatment and to have an undetectable viral load. • Using needles: PEP is recommended if you have used injecting equipment previously used by someone who is known to be HIV positive, unless they have an undetectable viral load.

Are there side effects? HIV treatment can cause side-effects which tend to be worst when you first start taking them. If you are taking PEP you could experience some unpleasant side-effects such as feeling sick, being sick, diarrhoea, tiredness, and generally feeling unwell. The drugs used in a course of PEP today are less likely to cause side-effects than those used in the past. It is important to finish the course of PEP.

Contraception & Pregnancy

Contraception If you do not want to get pregnant by a client, then you must always use contraceptives when you have vaginal sex, unless you have been sterilised or know that you cannot have children.

Condoms For sex-workers the condom is the first line of defence - if used properly it can protect you from sexually transmitted infections (including HIV) and prevent you from getting pregnant. More on Using Condoms.

Reliable Back-up Contraception Aside from using a condom to protect against STIs, it’s a good idea to choosing a reliable backup contraceptive lets you decide if, when and with who you get pregnant. The following sections discuss some options for back-up contraception.

Always discuss your contraceptive methods with a doctor. That could be your GP or a doctor at a sexual health clinic. Not everyone can use all of the methods below, so it is important to discuss these with your doctor before making a final decision.

The Contraceptive Pill Contraceptive pills alter your hormonal balance, which prevent your eggs from being fertilised and maturing when sperm enter your uterus. You swallow them once a day with water. If used properly, the pill is 99% effective in preventing pregnancy.

There are a number of different types of pills available by prescription from contraception clinics. Always discuss with your doctor which one would suit you best. • The pill doesn't interrupt sex. • The pill cannot protect you from sexually transmitted infections, including HIV, so you will still need to use condoms or femidoms when you're working. • The pill must be taken every day, at roughly the same time. • If you forget to take the pill, vomit, or have diarrhoea you will not be protected until after your next period. It is important to use additional contraception for the rest of the month to prevent pregnancy. • Some women find their menstruation changes with the pill. This means your it might change how heavy, painful, or long your period is. It might also mean you miss periods. • The pill also stops working when you take other medications. This includes some antibiotics that are

used to treat STIs, so if you are prescribed these you will need to use other contraceptives for a short time. • You can't take the combined pill while you're pregnant, but you can start it 21 days after giving birth, unless you are breastfeeding. The combined pill can slow the flow of breast milk, so if you're nursing you should use another type of contraception, like the progestogen- only pill condoms instead. • If you have a miscarriage or abortion, you can start the pill up to 7 days later and be protected immediately.

Injections and Implants Injections and implants alter your hormonal balance, which prevent your eggs from being fertilised and maturing when sperm enter your uterus. If used properly, injections and implants are 99% effective in preventing pregnancy. They won't protect you from STIs, so you'll still need to use condoms or femidoms when you're working.

There are a number of different types of injections or implants available by prescription from contraception clinics. Always discuss with your doctor which one would suit you best.

Injections can provide protection from pregnancy for up to 3 months. Implants can provide protection from pregnancy for up to 5 years.

You can't get the injection while you're pregnant, but you can get it 6 weeks after giving birth - if you get it earlier than this, you may get bleeding problems

Many women will get extreme changes in their periods - they can become heavier or lighter, but can also become irregular or stop altogether.

Vaginal Ring The vaginal ring (NuvaRing) is a small soft, plastic ring that you place inside your vagina. It releases a continuous dose of the hormones oestrogen and progestogen into the bloodstream to prevent pregnancy. If used correctly, the vaginal ring is more than 99% effective in preventing pregnancy.

• The vaginal ring is available by prescription in some contraception clinics is worth checking with the clinic first. • One ring provides contraception for a month, so you don't have to think about it every day. • You can continue to have sex with the ring in place. • Unlike the pill, the ring still works if you have sickness (vomiting) or diarrhoea. • The ring may ease premenstrual symptoms, and bleeding will probably be lighter and less painful. • Some women have temporary side effects, including more vaginal discharge, breast tenderness and headaches. • The ring can sometimes come out on its own, but you can rinse it in warm water and put it back in as soon as possible. • It doesn't protect against sexually transmitted infections (STIs), so you may need to use condoms as well.

The Contraceptive Patch The contraceptive patch is a small patch that sticks to your skin and releases hormones into your body that prevent your ovaries from releasing an egg, make it harder for sperm to get through your cervix and thin the lining of your womb so that a fertilised egg can't implant. If used properly, the contraceptive patch is more than 99% effective in preventing pregnancy. The contraceptive patch is available by prescription from contraception clinics.

• The injection won't protect you from STIs, so you'll still need to use condoms or femidoms when you're working. • The patch is changed for a new one every week for 3 weeks, and then you have a 'patch-free' week, during which you might have a period (but some women don't). • You need to change the position of the patch every week. • You can't use the patch if you're pregnant or breastfeeding, but you can start as soon as you stop nursing. If you've had an abortion or miscarriage and were pregnant for less than 24 weeks, you can start using the patch immediately.

The IUD The IUD (intrauterine device) is a tiny T shaped device that is placed in the neck of the uterus which prevents fertilised eggs from attaching to the wall of the uterus. If used properly, the IUD is more that 99% effective in preventing pregnancy.

There are a number of different types of IUD available by prescription from contraception clinics. They must be fitted by a medical professional.

• The IUD doesn't interrupt sex • You will need an internal exam to determine the size of your womb, so you can get the right IUD in the right place. • You will also need to be tested for STIs before having them fitted, as some STIs can be a problem with an IUD in place. • The procedure for putting them in takes 5-15 minutes, and it can be a little uncomfortable or painful. • An IUD lasts from 3 to 10 years, depending on which particular one you choose. • Other than checking them monthly and remembering to have them removed and replaced when the time comes, you don't need to think about contraception at all.

• The IUD cannot protect you from sexually transmitted infections, including HIV, so you will still need to use condoms or femidoms when you're working. • The IUD can be inserted 6 weeks after childbirth or 8 weeks after a Caesarean, as long as the uterus has regained its shape. You can use it if you're breastfeeding. The IUS can be fitted 6 weeks after giving birth, and it's safe for breastfeeding mothers. • The IUD can make your menstruation heavier and more painful.

The Diaphragm and Cap The diaphragm and cap are thin rubber/silicon/latex domes that fit inside the vagina and prevent sperm from getting into your womb. If used properly, diaphragms are 92-96% effective in preventing pregnancy.

They must be used with spermicide to be effective as contraception, which carries major risks for sex workers as it increases the risk of being infected with an STI.

Don’t use a diaphragm or cap to prevent blood leaking while having sex during your period, as this can be dangerous for your health.

• You can get one fitted at a GUM clinic or your GP. After you have been fitted, you can buy them and spermicide gel over the counter at your local pharmacy. Many women find their diaphragm or cap will last them for a year before they need to replace it. • It must be fitted over the cervix and 'sealed' with spermicide gel to be effective. The GUM Clinic or GP will advise you on how and when to fit it and what precautions to take. • Diaphragms and caps must be used with spermicide to be effective. Most spermicides contain a chemical (nonoxynol-9), which increases the risk of HIV and STI infection as it irritates the vagina.

• The diaphragm and cap can be used when menstruating to hold back the blood. • Diaphragms and caps do not protect against all STIs, so you will still need to use a condom or femidom. • The inefficiency of diaphragms and the fact that they do not protect against, and actually increase the risk of, HIV and other STIs, means that it is extremely unlikely that they will be a suitable contraceptive choice for a sex worker, even for personal use with a regular partner.

Spermicides Spermicides are creams or gels which kills or weakens sperm entering the vagina, which prevents it from fertilising your eggs - but they does not get all of the sperm and therefore does not always work.

Spermicides are not effective contraceptives on their own but they can increase the effectiveness of diaphragms and caps.

Femidom A femidom, or female condom, is a barrier contraceptive. It protects against STIs and HIV/AIDS as well as pregnancy. It looks like a large condom with an extra ring at the top (which holds it in place against the cervix).

Femidoms can be hard to source. Femidoms aren't offered as part of NHS free sexual health supplies - so you can't get them through GUM clinics or a BBV nurse.

You can get them at some pharmacies and through online retailers like www.condoms.co.uk but they are expensive. Newer latex and nitrile polymer versions are cheaper then the polyurethane ones.

Like condoms, they are very effective in preventing pregnancy as well as preventing STIs and HIV. The femidom can be used during and after pregnancy.

Emergency Contraception

If a client ejaculates inside of your vagina, or you think one of your contraceptive methods have failed (e.g. condom burst, missed a pill, diaphragm came loose) during sex, emergency contraception can be used to prevent pregnancy.

You can get emergency contraception for free from these places: • Contraception clinics • Sexual health or genitourinary medicine (GUM) clinics • Some GP surgeries • Some young people's clinics • Most NHS walk-in centres and minor injuries units • Most pharmacies • Some accident and emergency (A&E) departments (phone first to check)

There are 2 types of emergency contraception: • The emergency contraceptive pill – Levonelle or EllaOne (the "morning after" pill) • The intrauterine device (IUD or Coil)

You need to take the emergency contraceptive pill within 3 days (Levonelle) or 5 days (ellaOne) of unprotected sex for it Go to: Introduction - Main Menu - Wellbeing and Mental Health - Safety - Physical Health - Drugs and Alcohol - Male, Trans and Non-Binary Sex Workers - Legal Issues, Police and Tax - Exiting Sex Work - Useful Organisations 104 to be effective – the sooner you take it, the more effective it'll be.

The IUD can be fitted up to 5 days after unprotected sex, or up to 5 days after the earliest time you could have ovulated, for it to be effective.

The IUD is more effective than the contraceptive pill at preventing pregnancy – less than 1% of women who use the IUD get pregnant.

There are no serious side effects of using emergency contraception. Emergency contraception isn’t an abortion and doesn’t cause abortion.

Pregnancy

You can carry out most pregnancy tests from the first day of a missed period. If you don't know when your next period is due, do the test at least 21 days after you last had unprotected sex. Some very sensitive pregnancy tests can be used even before you miss a period, from as early as 8 days after conception.

You can do a pregnancy test on a sample of urine collected at any time of the day. It doesn't have to be in the morning.

You can also buy pregnancy testing kits from pharmacists and some supermarkets. They can give a quick result and you can do the test in private. You can also get free pregnancy tests provided at contraception clinics or sexual health clinics.

A positive test result is almost certainly correct. A negative result is less reliable. If you get a negative result and still think you're pregnant, wait a few days and try again. Even the most sensitive tests may give false negatives up to 17 days after becoming pregnant. With home testing kits, results are more likely to be reliable after 3 weeks.

Unwanted pregnancies It is important to find out as soon as possible if you do not want to have a baby.

Making the decision to have an abortion can be difficult and painful, but ultimately it is your choice. It can be much less traumatic physically and emotionally than having an unwanted child.

A small percentage of women have long-term feelings of guilt and some feel that it was a mistake. Many women feel relieved once the abortion is over and see their decision as regrettable but necessary. At least a third of all women will have had an abortion by age 45.

The decision to have an abortion is yours alone. But all women requesting an abortion should be offered the opportunity to discuss their options and choices with, and receive support from, a trained pregnancy counsellor.

If you think you might need an abortion, you can be referred to a specialist service by your GP, a contraception clinic or a sexual health clinic.

More Information About Abortions • The safest and easiest time to have an abortion is within the first three months of a pregnancy. • Complications are rare - less than 1% of women have to have the procedure repeated because fragments of pregnancy remain in the womb and cause persistent bleeding and 1-2% of women have an infection and are treated with antibiotics. • There are different methods of having an abortion depending on what stage your pregnancy is at. • To get an abortion, you need to get a referral from two doctors, usually your GP and a doctor at the abortion clinic or hospital. • Abortion is legal up to 24 weeks' gestation, or when there is a risk of serious permanent injury (or death) to the mother, or if the child, if born, would be seriously disabled.

Care During Pregnancy

Antenatal care is the care you get from health professionals during your pregnancy. It's sometimes called pregnancy care or maternity care. You'll be offered appointments with a midwife, or sometimes a doctor who specialises in pregnancy and birth (an obstetrician).

You should start your antenatal care as soon as possible once you know you're pregnant. You can do this by contacting a midwife or GP.

Antenatal care is the care you receive free from the NHS while you're pregnant to make sure you and your baby are as well as possible. This care included will: • check the health of you and your baby • give you useful information to help you have a healthy pregnancy (including advice about healthy eating and exercise • discuss your options and choices for your care during pregnancy, labour and birth • answer any questions you may have • up to 10 antenatal appointments. • two pregnancy ultrasound scans – at 8 to 14 weeks, and 18 to 21 weeks • antenatal screening tests to find out the chance of your baby having certain conditions Go to: Introduction - Main Menu - Wellbeing and Mental Health - Safety - Physical Health - Drugs and Alcohol - Male, Trans and Non-Binary Sex Workers - Legal Issues, Police and Tax - Exiting Sex Work - Useful Organisations 109

• blood tests to check for syphilis, HIV and hepatitis B

STIs During Pregnancy Most STIs can be treated during pregnancy. Some can cause serious complications, so it’s worth being tested early on. Some STIs can be riskier the later you get them in your pregnancy, so always use a condom or femidom and if you think you’ve been put at risk, get tested at the beginning of your last trimester or when you give up working.

Sex During Pregnancy Penetrative sex is usually safe during pregnancy until the 8th month, but you should check with a doctor first. You will probably need to avoid sex during pregnancy if: • You have diabetes or another serious condition. • You’re over 35. • You’re likely to be having multiple births (e.g. twins) • You’re at risk of early labour, miscarriage or still-births before. More on Sex in Pregnancy

Sex Work During Pregnancy • Try to reduce your shifts in the first few months, and try not to see any clients who tend to be rough. • Some clients find pregnant women a turn-on, and you may get a temporary client group. Make sure they understand your boundaries and behave gently. • You may feel more vulnerable and emotional during your pregnancy. • Always use condoms with clients - a mother can pass sexually transmitted infections, including HIV, to her baby during pregnancy and childbirth. • If you have symptoms, are bleeding, or in pain go for a medical check-up immediately. • Remember to be aware of security - don't take chances • A client's body odour or breath may exacerbate morning sickness, as can some lubes and condoms. • As your pregnancy progresses, you'll need to get clothes and underwear that will give you enough support. • Don' t allow clients to blow into or near your vagina - this can cause an air embolism. It's rare, but potentially fatal, and pregnant women are at increased risk - it could cause complications for both you and the foetus.

Sex After Pregnancy After pregnancy, you can usually start having sex 6 weeks after giving birth, depending on whether you had a Caesarean or vaginal birth, and whether there were any complications. Always check with a doctor first.

You could get pregnant as early as 3 weeks after the birth. Remember to use contraception such as condoms or other methods recommended by your GP.

Drugs and Alcohol

When people use alcohol or recreational drugs often, sometimes their use can get out of control. This section describes some typical drugs sex workers may encounter. At the end of the section it also provides some suggestions for managing clients who take drugs or want to take them with you.

In this section: Are You Worried About Your Drug or Alcohol Use? Typical Drugs and Their Effects Cocaine Heroin Poppers Safer Drug Use Overdose Taking Drugs While Working & Managing Clients Who Take Drugs

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Are You Worried About your Drug or Alcohol Use?

When people are using recreational drugs or alcohol, sometimes things can get out of control. Here are some signs that a person’s drug or alcohol use may be becoming a serious problem:

• Needing more and more to get the same effect. • Feeling like you must use the drug or alcohol. • Withdrawal symptoms including feeling sick, cold, sweaty or shaky • when you don’t take them. • Having sudden mood changes. • Having a negative outlook on life. • Loss of motivation. • Problems with relationships. • Borrowing or stealing money to buy drugs.

If you feel that you want to make changes with your drug use, you can find your local service that can provide treatment through these organisations: • Talk to Frank • Change Grow Live • Turning Point

Some Drugs Often Encountered by Sex Workers

This section discusses a few drugs sometimes encountered by sex workers. You can find out more about other types of drugs here.

Cocaine

There are three types of cocaine: coke, crack and freebase.

• Coke looks like a fine white powder • Crack looks like small lumps or rocks • Freebase looks like a crystallised powder

Cocaine powder has a bitter ‘chemical’ taste and smell, while crack cocaine can smell like burnt plastic or rubber.

People can take cocaine in a number of different ways, such as by: • snorting it as a powder. Most people snort cocaine • smoking it as crack or freebase • injecting it

Taking cocaine could make you feel: • happy • excited • wide awake • confident • anxious and panicky • paranoid

Cocaine can also: • make your heart beat faster • raise your body temperature – so you feel hot • stop you feeling hungry • make you feel sick • make you need to poo • make you so confident that you take risks you wouldn’t normally do – which can be more dangerous for sex workers.

The initial high from cocaine doesn’t last that long, around 20 to 30 minutes. The effects of smoking crack are even shorter lasting, around 10 minutes, with the peak lasting for about two minutes after smoking it. Some people find that cocaine makes them feel down, anxious and paranoid the next day, or longer.

Physical Health Risks • Cocaine is risky for anyone with high blood pressure or a heart condition, but even healthy young people can have a fit or a heart attack after taking it.

• The risk of overdose increases if you mix cocaine with other drugs or alcohol.

• Over time, snorting cocaine damages the cartilage in your nose that separates your nostrils. Heavy users can lose this cartilage and end up with a misshapen nose.

• Taking cocaine when pregnant can damage your baby, cause miscarriage, premature labour and low birth weight.

• Regularly smoking crack can cause breathing problems and pains in the chest.

• Injecting cocaine can damage veins and cause ulcers and infections.

• Sharing needles and syringes is also very dangerous as you could catch HIV, hepatitis B or hepatitis C.

• It's also easier to overdose from injecting cocaine.

• Speed-balling (injecting a mixture of cocaine and heroin) is more dangerous than taking cocaine alone and can be fatal.

• When heroin is pure, it is a white powder. This can easily be mistaken for cocaine, and people have died or been hospitalised after snorting it thinking it was cocaine.

Mental Health Risks Regular use of cocaine can make people feel:

• depressed • run-down • anxious • paranoid

If you are experiencing any of these symptoms, or you are concerned about your cocaine use, see your GP or find your local drug recovery service.