Where’s the Harm in Harm Reduction?

2016-01-15 18.00.54
Photo credit: Josephine Ensign/2016

Harm reduction, properly applied, is a good public health and individual health strategy. Its focus is on reducing or minimizing harms to the individual, their partners, families, and communities–harms stemming from a whole range of ‘risky’ behaviors. This focus includes providing care in a non-shaming, empowering way, including through the use of motivational interviewing. Harm reduction principles and practices are most well-known for people using drugs and/or alcohol. There is the successful public health practice such as needle exchange in terms of reducing HIV and other blood-borne infections in communities–the lack of which was highlighted recently by the HIV-surge in Indiana. (See the May 16, 2015 NYT article by Carl Hulse, “Surge in cases of HIV tests US policy on needle exchanges.”)  But harm reduction has been applied to other ‘risky’ behaviors, including tobacco adolescent sexual activity, and even for tattoos and body piercings.

I am all for harm reduction and have actively used this approach in my own work as a nurse practitioner for over twenty years. I am proud to live in Seattle-King County that is fairly enlightened in its public health approach utilizing at least some level of harm reduction.

But I have come to see the harm in harm reduction as applied to prostitution. What follows is the story of the evolution of my thinking about this topic, based on my work providing health care to homeless teens and young adults. It is an excerpt of my forthcoming medical memoir, Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net (SWP, August 2016):

“A large number of our youth clinic patients worked in the sex industry as exotic dancers and prostitutes. Most came to clinic by themselves, some were brought in by their pimps, and a few young females came in with their male high school teachers who were fleeing other states on criminal sex charges. I was never sure which I found more despicable: the pimps or the teachers. The prostitutes were mostly young women, although there were also young men and transgender youth. We called it survival sex or just plain sex work, and erred on the side of nonintervention, harm reduction, trying to keep the young people as safe as possible until they could exit “the life.” This was a laudable goal and one I believed in. But in effect there were times we were supporting their lifestyle, enabling it, and becoming part of the problem. We mostly used the neutral term “sex worker” instead of “prostitute,” thinking it was more politically correct, more respectful of the young people involved.

I often asked myself: Is it possible for someone to be involved in commercial sex work and have healthy self-esteem? Is there such a thing as a happy, healthy hooker? Is the character Julia Roberts plays in Pretty Woman based on any sort of reality, or is she just part of a twisted fairy tale? I know prostitutes who call it a profession, who say they freely choose their work. I’d like to believe them because it would make my work easier. But their statements have the off-key clang of the false bravado I know so well, having used it myself over the years. So many young prostitutes have histories of previous sexual abuse as children. Their bodies are not their own; their bodies have been stolen from them. In such situations, free choice is not possible.”

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