Health Care Designed Specifically for Sex Workers
Terri Wilder: Congratulations on the launch of the new Callen-Lorde pop-up clinic.
You are a former sex worker. From your perspective, why was it important for this clinic to exist?
Cecilia Gentili: Before we keep going, I am going to give you an exclusive. I am going to come out. I’ve been saying former sex worker for a long time, and I don’t know why. I think it was because I was always scared to mention to people that I do still engage in sex work at times. It’s a very specific dynamic that has to do not only with what I get in terms of financial [remuneration], but it has a lot to do with validation that I get for being a sex worker.
So, scratch former. You can say, “Cecilia, a sex worker.” How’s that?
Cecilia, as a sex worker, why is it important for this clinic to exist?
Gentili: The importance of this clinic is the fact that it’s crafted for sex workers, and that it’s totally sized as a space that is for the community. Before, it was providers who were comprehensive and sensitive of sex workers in some cases. But as a sex worker, I never had an opportunity to go to a space I knew was crafted for me.
Sometimes I got to go to spaces where I knew that a provider may be comprehensive of my identity as a sex worker, but never had a space that was specifically crafted for me as a sex worker, in terms of my health. Does that make sense?
Wilder: Yes. What was your reaction when Callen-Lorde talked about naming the clinic in your honor?
Gentili: It is an honor. It is such an honor for me to have my name on a project that means so much to me. A part of my identity—one of the most important parts of my identity—is my history of sex work. My fight for the rights of sex workers defines pretty much who I am. So, by having my name on a clinic, it means so much to me.
If you look at my history, I am a trans woman and an undocumented sex worker with an addiction to every kind of drug that you can think of, who went to rectify that and was going to be deported. I was in deportation detention. If you think of me, you don’t think of a person whose name graces a clinic. And you know what? They made it happen, and it’s an incredible honor to have my name there.
Wilder: Thanks for sharing all that. Zil, you are a medical provider at Callen-Lorde and have an extensive background in providing community-based health care for sex workers. You helped design the care model to be affirming, sex positive, and inclusive. What is the philosophy of the clinic, and what services are offered?
Zil Goldstein: We want to have the clinic be as low a threshold as possible. We want to make it as easy as possible for people who are engaged in the sex industry to get care. So, we’ve been focusing largely on a walk-in model on Fridays. And, you know, there’s so much hullabaloo to get a medical appointment with anyone around filling out forms and printing and I.D. and calling.
One of the things that I’ve learned from my work with sex workers is that people need a phone. Making someone call ahead for an appointment is a barrier to care. Even for patients who are a little bit better resourced, it’s still a barrier to pick up the phone, make the phone call, and say, “Hello, I’m here for the sex worker clinic.” We just wanted to integrate this into as easy a process as possible.
That goes for everything that we do with our medications—which are free for patients—and with our medical visits, therapy visits, and our psychiatry visits. All of this is free. There’s no navigating with an insurance company to find out if Callen-Lorde is in-network. There’s no prior authorization for medication. That just gives us a lot more flexibility than any other more traditional part of the medical system, where there are all of these barriers that seem like they’re just the day-to-day part of doing business in medicine, but really keep people from feeling comfortable to get care.
We have pharmacy, medical providers, case managers, therapists, and psychiatrists. All of those services are available for free.
Wilder: For folks who may be interested in coming to COIN, how does Callen-Lorde define sex worker?
Goldstein: We use the Young Women’s Empowerment Project definition of sex work: Any form of being sexual, or the idea of being sexual, in exchange for money, gifts, safety, drugs, hormones, or survival needs, like housing, food, clothes, or immigration documentation, whether or not the individual gets to keep the money, goods, services, or someone else profits from those acts.
We really wanted to cast as wide a net as possible and make this so that people who are working on the streets can walk in and get care—people who are strippers, people who are doing phone sex, and anyone who needs it. We serve the range of different types of sex workers, doing different types of work, and at different income levels.
“We’ll Find Ways to Get People What They Need”
Wilder: The clinic officially launched on Transgender Day of Visibility. Cecilia, can you talk to me about the Transgender Day of Visibility, and why that day was picked for the launch?
Gentili: I’m going back to my experience because I can’t talk for a whole community. I’m going to talk about my experience.
Sex workers come in all kinds of genders and shapes and identities and sexualities and everything. Sex workers are a huge array of identities. We cannot overlook the fact that for trans people—especially for trans women, and especially for Black and brown trans women—sex work was actually the only way to provide for themselves, when it comes to financial sustainability.
For me, when I started my transition in the ’80s, as a trans person, there was nothing that I could work at in order to create my own financial wellness but sex work. So, for the trans community, sex work has been the only choice when it comes to work.
Through the years, we continue to see the community growing and moving into so many areas of the workforce, year by year. But this still continues to be a reality for many trans people. As I said before, for mostly trans women and trans women of color, sex work continues to be the closest choice to creating an idea of work.
And for many of us, it’s also a very empowering idea. When this whole world tells you that your body is a mistake and that you are worthless, you have a person who comes and gives you either money or whatever you’re exchanging sex for, for your time and for your body. For me, specifically, it was such an empowering interaction. It made sense to put them together—which doesn’t mean that this clinic is just for trans sex workers. This clinic and this project is for sex workers, in general, of all genders.
As long as they do understand themselves as sex workers, the services are there for them. But we wanted to recognize the impact that sex work has had in the transgender community as one of the only choices of work for many of us throughout history.
Wilder: When I saw the announcement about the clinic, I was thrilled to read that the services were going to be free. How did the funding for the clinic come about?
Goldstein: Cecilia is really the reason. Part of the reason we named the clinic after her is that she was really instrumental in making this happen. I’ve been trying to find a way to do this since 2012, and Cecilia came up to me one day and was like, “Do you want to make this happen?” I was like, “Cecilia, you know this is my dream, right?” She said, “Follow me.” And I said, “I will follow you anywhere.”
Gentili: I love you. I was one of the founders of Decrim NY, which was a coalition to decarcerate, decriminalize, and destigmatize sex work in the state of New York. We have had some wins in there, with the “Walking While Trans” ban [being overturned] and things like that. But, as part of our work, we were also thinking on a city level.
So, as part of my work with Decrim I started having conversations with the City Council, and we talked with many City Council members. We had a couple of roundtables, where people who work with folks who are in situations of trafficking and people like me who push for decriminalization of sex work had conversations and sometimes a little bit of fights and this and that. At the end of the day, the city created a pot of money for services for people who engage in the sex trade. It was not specifically for consensual sex workers, or for people who are in trafficking situations. So, we created opportunities to apply for money.
That’s when I went to Callen-Lorde and said, “Let’s apply for a clinic.” That’s what we did. And that’s how we got the funding, which—I don’t have the exact number—was enough to create this clinic and put it out there.
This sex worker, undocumented from Argentina, goes to the City Council to ask for money for a sex workers’ clinic and gets it. You know, isn’t that amazing?
Wilder: It is amazing. The release said it was $500,000. That’s a good chunk of change.
Gentili: It is. It is. It’s not nearly enough to cover all the things that we cover. When we talk about medical services, medication, mental health, and case managers, it’s going to dry out pretty soon. So, for any City Council member that is listening, remember that this is not enough. We need more money, darlings!
Wilder: What will happen when the money runs out? Are there other ways that the patients will be able to continue to get their services?
Gentili: That is a question that we are working on right now. I happen to be a very optimistic person, and I consider myself relentless. So, I am committed to going to the City Council, knocking on everybody’s doors, and making sure that this funding continues to be made available for the community. Because it is necessary.
We are experiencing an extreme success on how people are accessing these services, which shows that these services are necessary. People have contacted me privately, telling me, “Hey, thank you. I had my first checkup in 10 years.” “Hey, thank you. I have not seen a doctor in the last 15 years, and you are changing this.” After I finish crying after they tell me that, I realize that this is super important. I am committed. Callen-Lorde is committed to continue fighting for this funding, because we understand that this is a necessity for the community.
Goldstein: These services will always be available at Callen-Lorde. We’ve been able to make a lot of really amazing changes, in terms of training, not just our providers, but all our staff on working with people who are involved in the sex trade. We’ve permanently changed the organization at this point. So, these services are always going to be available. We’ll find ways to get people what they need.
This funding is essential. This funding means that people who haven’t been able to get care, like Cecilia said, in 15 or 20 years, are coming in. This funding means that people are having better access, not only to sexual health services like PEP [HIV post-exposure prophylaxis] and PrEP [HIV pre-exposure prophylaxis] and testing, but also treating diabetes and hypertension, and addressing all of these issues that people might have with their health that aren’t related to sex work.
And we’re here to stay. We’re here for this patient population. We just need the money to keep it going, because that’s what really enables people to come in: not having to worry about copays on their medication, not having to worry about finding documentation so they can apply to Medicaid, and not having to worry about other forms of insurance to pay for health care. This is about access, and we want to make sure that that stays around.
Wilder: Sex workers might have concerns about what’s being written in their medical chart. For example, what would happen if their medical chart was subpoenaed? Can you talk about confidentiality and the unique situation of being a sex worker, and having your medical chart and what’s documented in it?
Goldstein: That’s something that we discuss individually with every patient. We’ve never in the history of Callen-Lorde had medical records subpoenaed for a criminal investigation. We have had medical records subpoenaed for things like disability cases or malpractice suits—not against Callen-Lorde providers, but with other providers in the city.
We resist all subpoenas unless the patient wants their records released. We do that as much as we can. To a certain degree, we can’t. But, we check in with every patient about what they’re comfortable having documented. We’ve let everyone make that choice about what level of detail goes into their chart, versus, do you want to talk about the number of clients a person sees per week, and how they manage the stress of that? Or are we going to talk about it as the patient has had a number of sexual partners that they want to have testing for? Or do we just focus on other issues, like back pain, for the visit, and not make any mention that someone is a sex worker?
It really would be unusual for medical records to be subpoenaed in a criminal investigation. But we prepare for that eventuality and we let every person make the choice about what goes into their records.
Gentili: And it puts the power back on the sex worker, that they are able to disclose whatever they want to disclose, and also able to say, “Hey, I want to disclose this privately, and I don’t want it in my chart.”
Normalizing Health Care for Sex Workers
Wilder: You had mentioned that the clinic is open on Friday on a walk-in basis. Is there a particular team at Callen-Lorde that is assigned, or maybe even volunteered, to be part of the COIN clinic? And is this team made up of people who have a specific interest in working with sex workers?
Goldstein: We trained all of our providers on best practices when working with sex workers. With the Friday clinic, those are actually appointments to see me. So, we have a certain number of appointments reserved every Friday on my schedule for people to walk in. Then we have other volunteer providers who are seeing scheduled appointments.
Not only are they trained by Cecilia, but I am mentoring our providers who are working in the COIN clinic and working with people who are involved in the sex trades.
Sex work is a major component of the LGBT community. So many sex workers are LGBT. We’ve been seeing sex workers at Callen-Lorde for many, many years. So, while there are aspects of this that are new and that have required training, it’s something that most of our providers are familiar with. We’ve been able to enroll a lot of established patients at Callen-Lorde who didn’t have any pathway to cover their medical care and services through the COIN clinic—so they can stop paying hundreds of dollars a month out of pocket for their medications and so they can come in more frequently. We’re making this a part of our mission. Just having this funding from the City Council is what makes that possible.
Gentili: I don’t know how much people know me or don’t know me, so I don’t want to look full of myself. But I went last Friday with somebody that needed support, because she hadn’t seen a doctor in an incredible number of years. I went to support her, and I was able to shadow the whole process of this person. And it was seamless.
It brings tears to my eyes to think this person was able to navigate the medical system and, in a couple of hours, leave with seeing a medical provider, having a mental health appointment scheduled, getting all her blood work done, and the medicines that the provider prescribed for her—and spending zero dollars. If I ever felt tired, all of that tiredness went away, because I feel like I need to keep working to have this continue happening. That’s how it works.
Wilder: Were there other community members who are part of the sex worker community that are involved or have given input?
Gentili: Last year we conducted—I don’t even remember how many—focus groups. These focus groups were divided mostly by gender identity and sexual orientation. For example, we had focus groups with cis women—most of their clients are cis men. We had a focus group with cis men. We had a focus group with nonbinary people. We had a focus group with transgender women. We had a focus group with transgender men. We had a focus group with people who do not speak English as their first language. So, we had an extensive number of focus groups, where we asked these people questions like, “How does it look to have a successful experience with a medical provider?” “How does it look to be outreached in a way that is empowering?” “What are the things that you experience that you don’t want to experience anymore in a health care center?”
We asked all these questions. All these questions informed the work that we created for this clinic. And we created a very extensive report that Callen-Lorde took into account while creating this space.
Goldstein: We had a number of people at Callen-Lorde at the edges come to me in private to say that they are former sex workers, and to give feedback for the clinic, which has been really great. It’s just a very empowering experience for people who work at Callen-Lorde, too, who have been part of the sex trade in the past. Getting to give feedback and help grow a program that’s so personal has really been great for a lot of staff that have been at Callen-Lorde.
Wilder: At the end of the day, what is your big vision for the clinic, and what do you hope it will ultimately achieve?
Goldstein: I love it when people come in that haven’t been to—well, I don’t love that they haven’t been to the doctor in many years. But the fact that they feel comfortable and trust Callen-Lorde with their health, and trust us to not provide them with health care in a disrespectful manner is really wonderful. I want to keep that going. I want to expand our program. I want to be able to offer walk-in appointments more than just on Fridays. I want to have this be available at least five days a week. I really just want to reach as many people as we can.
Gentili: My goal is to normalize health care for communities that do not have the concept of seeing a medical provider as usual, as normal. We can talk about many communities that go through the same. But for me, as a sex worker, I happen to know how difficult, how abnormal the idea of seeing a medical provider was for me for so many years. I think having a space that from the get-go says, “This space is especially for people who do what you do for a living,” creates a sense of normalcy for the experience of seeing a medical provider.
When we see the medical experience as normal, we can have health care interactions with our providers and be able to disclose more in order to get better services.