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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.


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Observations Reflection

12 Hours.

He sat in the chair and swung his legs out every few minutes, though he never stood up. He had not stood up for over 12 hours.

His calloused fingers picked at the hems of his jeans. He dug a thumbnail near the outseam and tried to scratch out a loose thread. Unsuccessful, his fingers travelled farther down his pant leg.

His left hand tugged on his earlobe. The size of his pupils fluctuated as his eyes darted around the room.

“Do you want anything to drink?”

“In a minute.”

When presented with a sealed water bottle, he laughed. It was a fearful laugh, quivering and choking.

“Someone could’ve poked a hole in that water bottle,” he said, waving it away. “No, I don’t want any of that.”

Then came a can of soda.

“It’s metal. There might be something wrong with the metal.”

His head swiveled on his neck, his eyes searching the ceiling.

“Can you tell them that I want to surrender?” he blurted.

“Who?”

“The police. Tell them that I will surrender. I don’t want them to fire a taser at me or shoot me with their guns.”

“There are no police here. No one will shoot you.”

“Uh huh. Right.” His eyes glimmered with tears as he sucked in a breath.

“I’m really scared, I’m so stressed out,” he said, rubbing his face. His legs twitched as he kicked them back under himself.

When we made any move to leave, he’d beg us to stay. When we offered him anything, he’d implore us to leave him alone.

What happened over the past 12 hours? Was his paranoia there all along, but he had enough “cognitive reserve” to mask his symptoms when we first met? Was it the lack of sleep? the lack of food and drink? Or was it something someone said? the way someone looked at him?

What happened that broke his mind? How was he fine one day—anxious, but smiling, talking, eating, resting—and not the next? How did reality walk away from him while he remained rooted in the chair?

Categories
Education Lessons Medicine Observations Reflection

On Being a Person.

Upon looking at me, there’s no doubt about it: I am Asian.

My ethnicity occasionally becomes a topic of conversation with patients. Some immediately ask me, “Yang… that’s Chinese, right?”

Others take a different approach:

“Where are you from?”

“Where am I from?” (This is meant to clarify the question, as it can mean different things….)

“I mean, where did your family come from? What part of Asia?”

Patients with significant psychotic symptoms occasionally start conversations with me like this:

“Konnichiwa! Ichiban? Teriyaki?”

or they might say things like this:

“God has a good recipe for kim chi. Do you want to know what it is?”

For the most part, it is completely clear that these conversations arise from benign intentions: Patients are trying to make a connection.

Even if I speak English with a perfect California accent or wear clothes that blend in with the fashion of Seattle, I cannot mask that I am Asian. It is a significant part of my identity and I bring it with me wherever I go.

While in training psychiatrists are often encouraged to present oneself as a “blank slate”. This psychodynaimc argument states that the more neutral you are—in speech, attire, manner etc.—the more you can analyze the “transference”, or what reactions (emotions, thoughts, behaviors) patients have upon interacting with you. These reactions are the grist for the therapeutic mill.

We, however, can never present ourselves as blank slates. Patients—people!—notice both what we bring to an interaction and what is absent. People might have opinions about my ethnicity, my facial expressions, the tone of my voice, or the scribbles I make during the conversation. They might also have opinions if I make few utterances, maintain an expressionless face, and answer questions only with questions (as demonstrated above).

Instead of being a “blank slate”, sometimes the best thing we can do as psychiatrists is to be a person.[1. To be clear, a psychiatrist should be a professional person; this is no time for sloppiness or disregard for a patient’s wellbeing and dignity. Being the best professional person you can be is still being a person.]

If people have relationship difficulties, we can be an actual person so that the patient can learn how relationships with people can be different. If people come to treatment because they have challenging relationships with themselves, we can be an actual person so the patient can learn how these views of self affect not only them, but also other people. If people have tenuous connections with reality, we can be an actual person who provides accurate feedback about “reality” (and make very clear that we’re not trying to steal their internal organs, etc.).

Being an actual person can be scary. We might worry what people (colleagues, patients, others) think of us. However, that vulnerability and authenticity we bring as people to the clinical interaction might be the most healing and inspiring to our patients.


Categories
Lessons Medicine Nonfiction Reflection

A Dream.

A few days before I learned what happened, I had a dream about you. When I awoke, my heart felt like a bird flapping its wings inside the cage of my ribs.

The details had vanished. Only anxiety remained.

I gasped when I learned what happened. I suddenly remembered the little details, the things that never made it into the clinical notes: You liked your coffee black. You read the Wall Street Journal. You missed driving your sports car.

Where did you kill yourself? Did you get a motel room? Were you outside? What time of day was it?

You certainly planned this. When did you make the final decision? Did you waver? Did you want to waver?

They say that there are two kinds of psychiatrists: The kind who have never had a patient commit suicide, and the kind who have had patients kill themselves.

I now belong to the second group. We all join the second group at some point.

I wish you hadn’t killed yourself.

I thank you for what you have taught me, both in life and in death.

I wish you had the peace in life that you thought was only available in death.

May peace be with you now.