Categories
Education Homelessness Policy Reflection

Commercial Sexual Exploitation.

I recently attended a presentation given by one of the founders of The Organization for Prostitution Survivors (OPS).

If you or your organization want to hear a compelling, educational, and thoughtful talk about commercial sexual exploitation, I encourage you to contact OPS.

The talk did not necessarily alter the way I go about my work as a psychiatrist, but it did challenge my assumptions about prostitution, highlight the different perspectives men and women have about sex (to be clear, the talk was not at all “anti-male”), and encourage me to reconsider the influences of our culture on commercial sexual exploitation.

I’ve included my notes and reactions from the presentation below. Any errors and lack of clarity are entirely mine.


The speaker (a man) began with a discussion about the social construction of gender. What does it mean to “act like a man”? The stereotype is that a “man” excels at sports, fights well, doesn’t show emotions (particularly sadness, fear, etc.), is dominant, and is skilled at and knows a lot about (heterosexual) sex.

Boys learn these stereotypes throughout their youth. Boys are eventually introduced to pornography, which may actually serve a means of male bonding (passing around a copy of Playboy, sharing links to online pornography, etc.). Pornography doesn’t teach boys how about sexual relationships, but instead offers flat, two-dimensional representations of women solely in the context of sex. Masturbation leads to orgasm, which is a potent reward for viewing women as sexual objects (instead of actual people).

The speaker then asked the audience for adjectives attributed to “good girls” and “bad girls”. The assumptions about “bad girls” are often the same for prostituted women[1. The speaker used the phrase “prostituted woman” instead of “prostitute” for the same reason that I use “man with a diagnosis of schizophrenia” instead of “schizophrenic”. Let’s please remember that we are talking about actual people here.] (they have multiple sex partners; they drink alcohol and use drugs; etc.). The words we use to denigrate women are synonyms for prostituted women: whore, slut, etc.

As a consequence, prostituted women become a legitimate target group for male violence. We somehow come to believe that it is okay for men to hurt prostituted women. They are, after all, “bad girls”.

The speaker discussed Gary Ridgway (the “Green River Killer”), who sought out prostituted women and murdered them. Nearly half of the women he killed were under the age of 18. The speaker asked why the media consistently describes these women as “prostitutes” and omits that nearly half of them were, in fact, “children”? What if we described Gary Ridgway as the “most prolific killer of children” in American history?

The speaker then described how a former pimp would find and select women (girls). His strategy was essentially this: If he spoke to a woman and she responded with any direct eye contact (even if she was flattered), he would walk away and end the “grooming” process right there.

Why? Because he knew that those women who made no eye contact with him already had life experiences that would make the pimp’s job easier. “Someone else has already beaten her down so I don’t need to do as much to make her work.”

The speaker then noted that researchers often wonder about the mental health of prostituted women… but why hasn’t anyone examined the mental health of buyers and pimps (mostly men)? Prostituted women often develop PTSD, which is unsurprising given the chronic trauma they endure while working. What is wrong with us as a society that we haven’t shown the same interest in what is “wrong” with the johns?

A discussion followed about the words we use to describe men viewing women. In the US, we often say that men “ogle” or “leer at” women. Those words have a “hubba hubba hubba!” quality to them; men who want an interactive, romantic relationship don’t “ogle” or “leer at” women. When was the last time you heard of a man “beholding” a woman?

One of the most striking points the speaker made was when he asked, “To the men in the audience: What do you do to protect yourself from rape?”

Silence ensued. Some men in the audience were perplexed.

“To the women in the audience: What do you do to protect yourself from rape?”

Many women answered immediately: “Travel in pairs.” “Keep my drinks with me at all times when I’m out.” etc.

Both men and women in the audience were stunned at the disparity of responses.

The speaker then discussed the issue of consent: Consent for sex should be an “enthusiastic yes!”, not something that requires negotiation. In prostitution, the exchange of money for sex is coercion. Economic coercion is never true consent.

The speaker also commented that buyers aren’t paying to learn the reality of the prostituted woman. If the girl is 16 years old and the buying man asks her age, of course she is going to say that she is 18. If he asks her if she has a pimp, of course she will deny it.

The speaker then challenged the audience to speak up even when someone tells a sexist joke against women. Doing so helps to construct a world of equality where women aren’t reduced to sexual objects. He commented that a sexist joke is on a continuum that also includes a man forcing his wife to have with him (“why did I get married if I couldn’t have sex with her whenever I wanted?”), paying a prostituted woman for sex, rape, and murdering women.

The speaker shared that prostitution “is like domestic violence on crack”. The cycle of abuse applies to both. He reported that prostituted women leave and return to their pimps between seven and ten times before leaving for good. It is often difficult for the women to leave because they often identify with their pimps due to something like Stockholm syndrome, though “trauma-bonding” is probably more precise. Prostituted women also frequently develop drug and alcohol problems as a means of coping with the ongoing trauma associated with the work. (Imagine getting into the cars of buyers multiple times a night without knowing if you will get hurt; imagine a pimp beating you because you did not bring back sufficient earnings; etc.)

The speaker also discussed the “bad date list”, which has historically been a paper list that prostituted women have passed around with names and identifying information of buyers who don’t pay, hurt the women, etc. He said that they hope to develop a “bad date” app because of the ubiquity of smart phones.

The speaker closed by discussing different models of managing prostitution in societies. He said that he is strongly opposed to legalized prostitution. He cited some data where states and countries with legalized prostitution often results in more sex trafficking and prostitution. He gave the example of Germany: The demand for prostitution has gone up since it has become legal, so Eastern European women are often lured and trafficked into Germany to work as prostitutes.

He expressed hope in the “Swedish model“: Sweden has taken the approach that women working in prostitution are victims and, thus, the selling of sex is not considered a crime. However, buyers, pimps, and traffickers are prosecuted to the fullest extent of the law. Some data suggests that, as a consequence, there is less visible prostitution and fewer women working in prostitution.


Categories
Education Homelessness Lessons Medicine NYC Policy

Involuntary Commitment (V).

Recall that the first scenario described a homeless woman who did not seem inclined to move to shelter despite the forecast of a heavy snowstorm. How would you apply involuntary commitment criteria?

1. Does this person want to harm himself or someone else?

There was no evidence at that time to suggest that she was considering suicide or homicide. One might wonder about grave disability, as her behavior in that context was not consistent with most other homeless people at that time. (Because of the pending snowstorm, most of the homeless encampments were empty that morning.)

2. How imminent is this risk of harm to self or others?

Imminent. The snowstorm had already started and six inches were forecasted to cover the ground in the next few hours. If the snowstorm occurred as predicted and she did not move, she would be at significant risk of developing hypothermia, frostbite, or complications from both.

3. Are these behaviors due to a psychiatric condition?

Maybe.

She had mentioned one thing (“The government secrets are safe with me”) that might suggest a delusion, though we don’t really know what she meant when she said that. Her behavior suggests paranoia, though it is also understandable if people don’t want to talk to strangers.

Just because someone is homeless does not automatically mean that mental illness is present, though individuals who are chronically homeless are more likely to have a mental illness. Given what we knew about her, it seemed more likely than not that she has a psychiatric condition.

Related: Will hospitalization help treat the underlying psychiatric condition?

Maybe.

If it isn’t clear if she has a psychiatric condition, then it isn’t clear if hospitalization would help.

So what actually happened?


The outreach workers working with me wanted to send her to the hospital for evaluation and treatment. I wasn’t confident that she would actually be hospitalized. If I was working in an psychiatric emergency room, I probably would have released her. Her presentation did not seem to meet a minimum threshold for dangerousness, though she did not appear well.

The snow continued to fall. No one said anything. I excused myself to step away and consider the options.

I was worried about her. She had reported that she had been homeless for decades in New York; this wasn’t the first major snowstorm to hit the area. However, she was now older and just because she survived past snowstorms did not mean that she would survive this one. Furthermore, other individuals with comparable experience with homelessness had abandoned their campsites that morning—why hadn’t she?

In New York State, two physicians are required to detain a person against her will. If I began the process in the street, the emergency room psychiatrist could either complete the process or reject my proposal and release the individual.

With reluctance, I ultimately began the process for involuntary commitment. I was not convinced that she needed hospitalization, though I knew that the process would take several hours. Hopefully, the snow storm would blow through in that time.


She wasn’t pleased when the ambulance arrived (“I’m fine… I’m fine…”), though she did not resist the paramedics. I sat in the back of the ambulance with her. She was shivering. Neither one of us said anything; what could we talk about?

“So… what do you think of this weather we’re having?”

Upon arrival at the emergency room, I gave a brief report and the commitment paperwork to the psychiatrist on duty. The psychiatrist commented that he had never seen her before, which did not surprise me: Sometimes the most vulnerable and ill individuals never interact with the health care system.

“From what you’re telling me, I don’t think we’re going to detain her,” the emergency room psychiatrist said.

“I understand.”

A guard and a nurse asked her to empty out her pockets and remove her parka. She did not balk. Though I knew she was thin, I was taken aback with just how slender her frame was.


The snowstorm blew through. Close to eight inches collected on the ground. The rare pedestrian dashed across the empty streets through the blurry grey air.

I got a phone call as the storm was ending.

“We’re not going to hospitalize her; there’s not enough.”

“That’s fine. Thanks for letting me know.”


The next time I saw her she was standing on a corner, her hands in the pockets of that same parka. When I greeted her, she turned around and walked away quickly. She spurned my greetings for nearly three months.

I understood and could not blame her.

Only after three months did she finally agree to talk with me. One brisk morning, while she was still tucked under the plastic bags filled with paper, she finally told me her story. She probably demonstrated significant psychiatric symptoms in the past (and was probably diagnosed with schizophrenia), though she experienced less symptoms now. She still didn’t want housing because she believed that she didn’t deserve housing.

I left New York and she remained. I still think about her occasionally and wonder if she is still alive.

Categories
Education Homelessness Lessons Medicine NYC Policy

Involuntary Commitment (I).

It’s winter in New York City. The temperature is hovering around 32 degrees Fahrenheit. Large, slushy snowflakes are falling from the pewter sky.

You are already familiar with this woman; you had met her the previous Spring. No one is sure of her age, but she looks over 65 years old. She had said that she had immigrated to the US when she was in her 20s because she had a scholarship to a prestigious university. Something interrupted her schooling. She ultimately stopped attending classes and hitchhiked here. She’s been homeless on the streets of New York ever since.

She has never shared her date of birth for fear that the government would use that information against her. It’s not clear if her stated name is really her name. She’s a familiar figure in the neighborhood; people regularly give her styrofoam bowls steaming with hot soup, sandwiches wrapped in white butcher paper, shiny cans of soda, and cups of coffee. Some people have been giving her food for the past ten years. Upon receipt she murmurs, “Thank you,” and nods her head on her slender neck.

She never makes eye contact. The irises of her eyes have grey halos and her gaze is usually over your right shoulder. You’ve tried to learn more about her past, what led to her homelessness, and her interest in housing, but she usually ends the conversation and walks away. One time before bidding you good-bye she did comment, “The government secrets are safe with me.”

People in New York walk past her everyday while she sleeps and never realize it: She buries herself underneath black garbage bags stuffed with paper. What looks like a mountain of trash on the curb or underneath scaffolding is actually her private fort.

“The paper keeps me warm,” she has said. To prove her point while the autumn winds sent the dying leaves swirling through the air, she rolled up a sleeve of her parka to reveal wads of newspaper crumpled in her clothing. At times she donned a hat made out of a paper bag and stuffed it with newspaper to warm her head.

It is not yet 10am on this snowy morning and the weather forecasters predict that the storm will worsen as the day goes on. The snow is already sticking to the sidewalk. Over six inches are predicted to fall in the next few hours.

Today, the woman’s camp is underneath the short awning of the back door of a clothing boutique. Underneath her is a flattened cardboard box, the corners already beginning to darken and soften from the snow. On top of her are only four or five garbage bags, fewer than what usually covers her. Upon hearing you, she sits up and her face, as expected, does not show any expression.

Her parka is unbuttoned and underneath is a thin white shirt with a tattered collar. The skin of her neck is mottled and red.

“There’s a snowstorm coming through, it’s supposed to be pretty bad. Would you be willing to stay in a shelter until it’s done?” you ask.

“No, I’ll be fine.”

“It looks like you’re cold; you don’t have as many bags as you usually do and your skin is turning red. We don’t want you to be outside when it is this cold out,” you try again.

“I’m fine.”

“We worry that if you stay out here, you might get frostbite.”

“I’m fine.”

“Where have you gone in the past when there were big snowstorms?”

“I’m fine.”

Meanwhile, snow is beginning to collect on her coat, her bags, and in her hair. She makes no motion to move.


Does this woman have a mental illness? Does she need to be sent to the hospital for psychiatric evaluation? If she doesn’t want to go to the hospital, should she be forced to go to the hospital against her will?

Categories
Education Homelessness Lessons Medicine Observations

When I Grow Up…

When I grow up, I want to be a drunk.

I want to wake up feeling restless and uncomfortable. It’ll be neat to drag myself out of bed to open that first bottle of wine. I’ll drink all of it within an hour. Then I’ll go to the liquor store. The guy behind the counter will know that, everyday, I will buy a pint of vodka from him. He will look at me with stony eyes, which will make me feel even more restless and uncomfortable. What he doesn’t know is that I will also get two more bottles of wine and a case of beer from the grocery store before I return home. As an adult, I want my sole coping skill to consist of getting drunk.

When I grow up, I want to get fired from all of my jobs because I am frequently drunk. I can’t wait for my boss to call me into his office because my coworkers smell alcohol on my breath. It’ll be fun to make an a$$ of myself while working because I just can’t stop myself from drinking that bottle of wine in the morning.

When I grow up, I want strangers to see me doubled over a tree planter with vomit on my shirt. I look forward to police officers shouting at me to get the f-ck up and move along. I am eager to see the disdain and disgust of the firemen and paramedics when they realize that the 911 call was, yet again, for me. I can’t wait to hear the doctors and nurses in the emergency rooms say things like, “Oh, not him again. I’m so tired of seeing him. He’s taking up a bed that could be used for someone who is really having an emergency.”

When I grow up, I want to ruin all of my relationships because I am a drunk. I look forward to destroying property and scaring my girlfriends. I can’t wait for my wife to request a restraining order against me because I’ve threatened to kill her one too many times. It’ll be great when my parents and siblings never invite me over to their houses because they think my behavior is out of control. I can’t wait to achieve that level of isolation and notoriety.

When I grow up, I want to spend a lot of time in jail. I look forward to receiving charges of public intoxication, disorderly conduct, assault, and battery. I can’t wait to collect warrants because I was too drunk to show up for my court dates. It’ll be fun to bounce in and out of jail and frequently apologize to of all of my probation officers. It’ll be neat to lose my housing because I couldn’t pay my rent while I was in jail. Homelessness will be a delight!

When I grow up, I want people to judge me because of my alcohol problem. I look forward to people hating me because they believe that I choose to drink alcohol to the point that I can’t function. It’ll be exciting to realize that people believe I am useless and a waste of a human being.

When I grow up, I want to hate myself because I am a drunk. It’ll be fun to feel constant shame and complete lack of control over myself or anything else. I can’t wait to experience unending self-loathing and disappointment. And how thrilled I will feel when I realize that the only thing that makes me feel better in the moment is drinking more alcohol.

Categories
Homelessness Lessons Medicine Observations

Saying Good-Bye.

I originally wrote the post below over five years ago. It’s about a teenager I worked with for about six months at a residential treatment center. I still think about him from time to time; I hope that he was able to exit the mental health system.

A few months later, I learned that, less than 24 hours after we said good-bye, he injured himself while destroying property. He apparently threw chairs, punched walls, and tried to knock over bookcases and other pieces of furniture. There was no obvious trigger. It took four adults to subdue him. Staff commented that he had not behaved this way in over two years.

“That’s how he dealt with termination,” a staff psychiatrist murmured.

I’m still not sure if I agree with him.


I’m still not completely sure of the optimal way to proceed with termination.

Termination refers to the end of the therapeutic relationship between patient and physician (or, more specifically, psychiatrist). There are essentially three ways termination can occur:

  • Patient exits the relationship (patient stops attending appointments; physician fires patient; s/he dies)
  • Physician exits the relationship (s/he dies; patient fires the physician; physician disappears)
  • Patient and physician mutually agree on a final appointment date and time and complete the session

Ideally—for both parties—the last option occurs. This allows “closure”. And, no, I’m not entirely sure what comprises “closure”, but the lack of “closure” is why many break-ups suck. Think about it: Break-ups are uncommonly mutually agreed upon events; usually one party decides to unilaterally bail, resulting in negative emotions all around.

In therapy, we do not want to recreate break-ups; instead, we want to model and engage in the graceful end of effective and meaningful relationships. (Psychobabble.)

Saying good-bye is difficult. The white coat-wearing medical doctor within the psychiatrist bristles at the idea of termination; there is something about our medical training that promotes the idea (“virtue”?) of emotional distance and independence from our patients. So many things about our profession (both intentionally and unintentionally) facilitate this: Doctors wear white coats. Doctors wear gloves. Doctors ask a lot of questions, but rarely answer any. Doctors aim for objectivity and evidence.

So when we psychiatrists terminate with patients, the experience is weird and we are often surprised with how difficult it can be.

It’s never too early to initiate termination, so I had informed the adolescent male three months prior to our last appointment together that our time was drawing to a close. At the time, Andrew said nothing.

It’s not that he didn’t have anything to say about it; I had learned by this time that he heard practically everything I said, even though his behavior often purposely suggested that he was ignoring me.

A month prior to last our last appointment together, I reminded him again of my departure.

“Have you seen that Geico commercial? You know, the one with the little kid imitating a monster?” he replied.

As the days passed, he spontaneously mentioned the limited time we had together, though he tossed his remark within a smokescreen:

“I can’t believe that happened; it kinda makes me sad. You and I have three sessions left; we have to make the most of them. So I think I am going to try asking her again, maybe when she’s not so depressed, but it’s hard to tell….”

And that’s the way it had been the entire time we spent together; he would share bits of himself—often only a sentence here, another one there—at random intervals. Sometimes he would acquiesce if I asked a few questions to clarify his remark; most times, he simply changed the subject. One day, I called him on it.

“You’re really good at changing the subject when I ask you questions.”

“Yeah, I know,” he nonchalantly conceded, “I don’t like it when people care about me. It makes me feel weird.”

And when I tried to ask him more about that, he promptly commented on the weather. I smiled—sadly—at him.

The last time I saw him, he greeted me warmly.

We learn in the course of our training that therapeutic termination includes reviewing the time spent together and commenting on progress and goals attained. It’s like a summary statement, an opportunity to reflect upon how the patient has changed and how the patient can continue to effectively pursue his goals.

I already anticipated that, though he would hear my monologue of the above, he would not respond. My hypothesis bore true.

I commented on our very first meeting and what he stated were his goals at that time.

“Did I tell you the joke about the buffalo?”

I continued to commend him for the significant progress he had made in several spheres.

“What did the mother buffalo say to her kid as he left for school?”

I then reiterated his strengths—he had so many: he was so good with people; his integrity was admirable; he was intelligent and thoughtful; he was fiercely independent and more than capable of taking care of himself.

“Bi-son!”

I expressed my hope to him that he would continue to pursue his dreams—I was (and still am) confident that he could reach all of them.

“How about the one about the cowboys?”

I looked at him, willing him to participate in the conversation—but I knew saying good-bye was not his strong suit. His parents had abandoned him when he was young; there was no such thing as a “healthy” good-bye in his experience.

“Because they are too heavy to carry! HA!”

“Take care of yourself,” I said, patting his shoulder. “Good-bye, Andrew.”

He had already started to walk away when he answered, “All right.”

I watched his lanky figure amble down the hallway. I then quickly turned to go.