The Making of a Health Clinic for Sex Workers, by Sex Workers

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The Making of a Health Clinic for Sex Workers, by Sex Workers

The phone at Carol Stuart’s shared Potrero Hill home rang regularly in 1998—often from sex workers, often when they needed legal assistance. Usually, they called when someone needed to reach her roommate, activist Margo St. James, the founder of Call Off Your Old Tired Ethics, or COYOTE, a groundbreaking San Francisco-based sex workers’ rights organization. But when Stuart, who helped out with COYOTE, answered one morning, the caller’s request stood out to her.

“This woman said, ‘I was arrested last night and I just went to court and the judge dismissed the charges and let me go, but last night they took my blood,’” Stuart remembers. The woman on the phone said that the blood test had been done without her consent or an explanation of the nature of the test, and she wanted to know if that was legal.

“I said, ‘Hell no,’” Stuart remembers.

Stuart recalled that her response to the call was influenced by the knowledge that filled her shared home. In addition to St. James, the house was also occupied by St. James’s husband Paul Avery, known for his reporting on the Zodiac killer, and Carlton Smith, a journalist who wrote about the Green River Killer. There was a sense of outrage at the exploitation of vulnerable populations that united the housemates, evidenced by Stuart’s response to the sex worker who had reached out to her that day.

Stuart’s conversation with the woman didn’t end there. Shortly after getting off the call, she reached out to Carol Leigh, known as The Scarlot Harlot, a local artist and activist with a blaze of curly red hair, who is credited with coining the term “sex work.” The pair soon contacted Jeffrey Klausner, then head of the San Francisco Department of Public Health’s STI Prevention and Control Division, and told him that the city allegedly tested a jailed sex worker without her permission. “‘Hey dude, you can’t be doing this,’” Stuart recalled telling him. Klausner remembered that the city was routinely screening all inmates for syphilis and HIV, and argued that this was always done with permission, though he added, “What’s voluntary to bureaucrats may not appear to be voluntary to people who are incarcerated.”

Soon, Leigh and Stuart met with him in his office and, as Stuart recalled, Klausner mentioned his concern about sex workers and syphilis. “I basically lied to him and said, ‘Oh, we’ll get you syphilis.’” She was really interested in opening up a peer-run health clinic for sex workers as a way to effectively address their healthcare needs, as opposed to the medical establishment’s perception of their needs.

The idea of a sex worker-run clinic came from Priscilla Alexander, a former COYOTE secretary, who wrote a paper about just such a hypothetical organization while pursuing a graduate degree in public health. “I gave him Priscilla’s blueprint, right then and there,” said Stuart. “I said, ‘This is what we want to open.’” Klausner had already been looking into ways to reach the sex worker community and says he was “immediately intrigued” by the clinic concept. “The moment was fortuitous,” he said.

In June of 1999, St. James Infirmary, named after Margo St. James, opened as something of a “pop-up clinic” within the San Francisco City Clinic, as Johanna Breyer, its then-director, described it. One night a week, after the City Clinic closed its doors, St. James Infirmary used the same office space to provide primary care, STI testing, peer counseling, case management, free food, acupuncture, and massage therapy to its clients, all free of charge. It was the first peer-run non-profit health clinic for sex workers in the United States. Two decades later, it remains the only peer-run non-profit health clinic for sex workers in the United States.

St. James Infirmary seemed like a long-shot, even in San Francisco: a collaboration with the city government that prioritizes the interests and needs of sex workers over those of health officials and law enforcement. It might seem even more so if you consider that St. James Infirmary’s founders were all driven by the belief that, in Breyer’s words, “sex work, and the impact of sex work, should be a public health issue, not a criminal issue.” That this progressive mission managed to get any government backing is the result of an irreplicable alchemy of activist community, political momentum, and public opinion; and it was only made possible by years of sex worker activism.

The seeds were planted in 1993 when Breyer and Dawn Passar formed the Exotic Dancers Alliance to address the poor working conditions at the adult entertainment theaters in San Francisco. While performing at Market Street Cinemas, a historic downtown strip club, they objected to being classified as independent contractors and charged stage fees to perform; so they organized and lawsuits followed. In the process, they were connected with COYOTE, where they met Leigh, St. James, and Stuart.

The following year, when San Francisco convened its Taskforce on Prostitution, an attempt to address community complaints about sex work, they were all—Breyer, Leigh, Passar, St. James, and Stuart—included in the discussion. “We were really networking,” Stuart said. The Taskforce eventually recommended not only decriminalization, but also utilizing “the revenues made available by eliminating budgets to enforce prostitution laws” to “support current and develop new peer-guided programs and services” for sex workers, including “occupational and educational programs, health and other programs for those who continue working as prostitutes, as well as those who wish to transition into other occupations.”

Soon, St. James ran for a seat on San Francisco’s Board of Supervisors—both Stuart and Breyer worked on her campaign—and narrowly missed winning. “That was a big deal because a lot of people who otherwise were not aware of the issues were being informed on the issues,” said Stuart. Then in 1997, performers from The Lusty Lady, a North Beach peep show, famously unionized after revolting against unfair working conditions. By the time that meeting took place with Klausner in 1998, there had been years of influential activist collaboration, as well as public education and influence. In fact, Breyer and Passar had already been in conversation with Klausner himself about sex workers’ rights.

The political connections that St. James had gained, both through her years of activism and her supervisor run, also proved to be crucial to forming the clinic. “Margo knew all of those good old boys,” said Breyer, referring to the influential local politicians of the time. “We didn’t necessarily have anyone blocking us. Even if they disagreed with the [decriminalization] philosophies that we were all aligned with, no one was stopping us from doing this.” As Alexandra Lutnick wrote about St. James Infirmary’s founding, “If it were not for the relationships that Margo cultivated over the past 30 years, the creation of a peer-run occupational clinic for sex workers would have been a much more arduous task.” (St. James wasn’t available for an interview due to health concerns. Her friends have put out a call for a letter-writing campaign to express gratitude for her activist work.) Breyer puts the unique circumstances like so: “It’s a small city, we had those political allegiances, the time was right.”

After the meeting with Klausner, Breyer, then 28 years old, was tapped as the first executive director of St. James Infirmary, in part because she had just finished her master’s in social welfare at the University of California Berkeley. “We didn’t know how we were going to do it, necessarily, but the idea was there and we had really formed this community of advocates,” said Breyer. The unpaid job was made tenable when she settled years-old lawsuits that had been brought against strip club owners after the EDA was formed. “I had a little bit of money to be able to just do this for not very much money,” she explained. “We literally ran on less than ten thousand dollars for that first year.”

“None of us knew how to run a freaking health clinic,” Stuart said with a laugh. Breyer had relevant experience from her masters in social welfare, but that was, as she put it, “all theoretical.” She didn’t have on-the-ground experience incorporating as a non-profit organization, for starters. “We really learned along the way,” she said. They weren’t entirely on their own, they clinic recruited Deborah Cohan, then a third-year OBGYN resident at the University of California, San Francisco, as medical director, and Chuck Cloniger, a City Clinic nurse practitioner whose time was donated by the Department of Public Health. Cloniger gave the team a primer on everything from handling medical records to seeing patients.

When the clinic launched in June of 1999, “there were lines out the door,” Stuart said. Most of its clientele didn’t have health insurance and access to free health care brought sex workers to St. James’s door. But the clinic provided more than just free health care for sex workers, it also provided “a safe space where they were comfortable disclosing what was really going on and not feeling like they were going to be judged or turned away,” said Breyer.

Leigh, who was in that first meeting with Klausner, ended up visiting the clinic herself as a client. “It was great—because I was always afraid to talk to my doctors, and I’d always felt judged—to go to a place and honestly talk about your health situation and honestly talk about my concerns,” she said, explaining that she worried about outside doctors treating her through the lens of their prejudices against sex work.

Annie Sprinkle, a legendary sex worker, educator, and performance artist, was an early client and said that going to the clinic was “fun” and a “social atmosphere,” even though “they took care of serious shit.” Beyond creating a stronger sense of community, though, Sprinkle said that St. James Infirmary “felt like a beacon of hope, that amazing things were possible, and that there was a way, perhaps, to collaborate with the city government.” Sprinkle, who eventually joined the clinic’s board, continued, “It’s taken for granted now, but back then it was mind-blowing. ‘The city supporting a clinic for sex workers? How is this possible?’”

When the clinic first opened, the clientele was mostly fellow sex worker advocates. After the first couple months, though, Breyer recalled, “We really had a steady stream of folks coming in,” she said. “It gained notoriety by word of mouth.” In the first year, the clientele was mostly white cisgender women, but with time the clinic began to increasingly serve transgender women and cisgender men. But even in its early days, the clinic’s practices were forward-looking for the time: It ran a syringe exchange program and provided hormone therapy for transgender clients. According to Toni Newman, St. James Infirmary’s current executive director, the clinic had one of the earliest transgender health programs in San Francisco.

In 2002, shortly after moving to San Francisco, Scarlett Paradise, a trans woman, became a client at St. James Infirmary, where she was given clothing and access to shelter. Many therapists are ill-prepared to work with trans clients, Paradise said, but at St. James Infirmary she found a therapist with whom she was so comfortable that she still sees her to this day. “I owe everything to St. James Infirmary. If it hadn’t been for them, I wouldn’t have survived,” she said, referring to the emotional support, and broader sense of community that she found at the clinic.

After the first few years, the clinic moved to its own space: an independent office in the SOMA district given to then rent free because the health department no longer needed it. It was an improvement on the original City Clinic location, which was not only shared but also just a couple blocks away from the Hall of Justice, where, as Breyer put it, “folks might have to appear for their solicitation cases.” The new space meant the clinic was able to expand its hours and services. “That really helped us to stay afloat in times when our budget was just a shoestring,” said Cloniger, who is now St. James Infirmary’s clinical director.

The clinic was often on a shoestring budget, in large part because of its particular funding challenges: “It’s easy to give money to something that’s called Planned Parenthood,” he explained, “but something that’s unabashedly called a sex worker clinic, a lot of corporate and big money donors are leery.”

“Things have changed since 1999,” executive director Newman said. Now that St. James Infirmary is heading into its third decade, it’s reconsidering its raison d’être. This fall, St. James Infirmary will be undergoing a needs assessment, which involves surveying current and former clients, to determine how the clinic is most needed. “Are we really vitally needed as a clinic?” asked Newman. “My thinking is: I’m not really sure we should remain a clinic with medical personnel.” She added, “We need to figure out: What do sex workers need in 2019?”

The reassessment in part a reaction to the changing landscape of healthcare in this country, thanks to the Affordable Care Act. Currently, most of the clinic’s clients have some form of health insurance, according to Cloniger. “More and more people are insured or eligible to be insured, so they have choices,” he said. “It’s also 20 years later in terms of how people look at sex work. There’s been a generational change in that time. There are more places that are sex worker-friendly than perhaps there were when we opened.” St. James Infirmary has been a part of that change; numerous second-year OBGYN residents from UCSF are trained at the clinic, which Cloniger sees as one of its biggest accomplishments.

The clinic’s mental health services are especially in demand, with a “huge waiting list” for clients to enroll in its year-long therapy program. Twenty years ago, the clinic had peer counseling and limited access to a licensed therapist; now St. James has two licensed therapists on staff. “A lot of sex workers, they’re not getting a lot of support,” said O’Shea, St. James’s programs director, by way of explaining the demand. Finding a therapist who supports sex work can be challenging, even in San Francisco, she added. As Newman put it, “They can tell us anything. There’s no [gasps!]. You go other places and [gasps!]. There’s no judgment here and that makes us very special.”

Many of St. James’s most-needed services currently deal with the “intersection of sex work and poverty, and what’s driving that poverty,” Newman explained. Therapy can address some of those concerns, but so does counseling around things like managing a checking account or getting a G.E.D.

Already, Newman says the clinic has started to intentionally broaden its scope, expanding services for transgender clients. “Sex workers are our main priority, but now we’re trying to, let’s say, open the envelope,” she said. A 2015 survey of transgender adults found that 11 percent of respondents reported having engaged in sex work, and transgender women of color, in particular, are disproportionately targeted by police. According to Newman, St. James Infirmary currently has the highest number of trans women of color employed by any non-profit in the state. “We’re trying to build up the reputation that we’re an advocacy group for sex workers, trans women, and LGBTQ folk,” she said.

Newman is also considering a push toward more policy involvement. In August, California Governor Gavin Newsom signed into law SB 233, which provides sex workers with immunity from arrest under certain limited circumstances, and which was partly sponsored by St. James Infirmary. Now the clinic is partnering with dozens of non-profits in the state to work on a bill to decriminalize sex work in California. It’s a little surreal, given that the San Francisco Taskforce on Prostitution—the one that helped form St. James Infirmary—recommended decriminalization back in 1996.

In many ways, St. James Infirmary is a testament to the long game of broader political change, and not just because of the clinic’s enduringly anomalous status. The clinic’s founders “never strayed” or made “any concessions” around their fundamental belief in decriminalization, said Breyer. Decades later, the push to decriminalize sex work is gaining traction in New York. Breyer says it’s more important than ever to continue demonstrating “the need for care-based organizations,” as opposed to criminal enforcement.

“This is the oldest profession in the world,” she said, some 26 years after starting her work with the Exotic Dancer’s Alliance. “It’s time to get over it.”

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