St. James Infirmary: A Safe Medical Haven for Sex Workers by Chris Hall Founded in June, 1999, the St. James Infirmary is both a result of San Francisco's legacy of sexual politics, and a practical and unique approach to difficult problems that may ultimately create new traditions. The Infirmary is the only occupational health and safety clinic in the country run by and for sex workers. For three years now, the St. James Infirmary has provided free, confidential health services for the city's prostitutes, nude models, adult actors, and exotic dancers ranging from STD prevention to acupuncture therapy, counseling, and support groups.

In 1911 San Francisco established the Municipal Clinic in order to deal with high rates of STD transmission within the Barbary Coast, San Francisco's legendary red-light district. However, the clinic was at least as devoted to controlling the city's prostitutes as much as its disease. Its programs were entirely coercive in application: any woman entering a brothel was required to present a certificate of health as a condition of employment, and all working prostitutes were required to appear at the Municipal Clinic every four days, where they would be examined for diseases. If a woman was found to be disease-free, the staff stamped a booklet which she was required to keep on her person and show to any policeman upon demand.

The idea of targeting sex workers with public health services is not in itself a new one. On the contrary, as long as there have been social reform efforts and "anti-vice" campaigns, there have been attempts to address the medical issues of prostitution. These efforts have usually been defined solely as STD treatment and prevention. Historically such efforts have played a much higher emphasis on protecting the mores of society and their public representatives from the prostitutes than in serving the interests of the workers themselves. The Municipal Clinic was closed in 1913, under pressure from San Francisco's clergy and other moral reformers who considered syphilis and gonorrhea a means to play a vital role in discouraging vice. Father Terence Caraher, one of San Francisco's most dedicated crusaders against vice, went so far as to condemn the Clinic itself as "a blow at marriage."

Sex Workers Band Together

In contrast, today's St. James Infirmary is the result of sex workers organizing for their own interests. The clinic was founded by a coalition between the prostitutes rights group Call Off Your Old Tired Ethics (COYOTE), the Exotic Dancers Alliance (EDA), and the San Francisco Department of Health, STD Prevention and Control Services. The alliance between city government and sex workers seems odd at first glance, even in San Francisco, but it's one that's been beneficial for all involved. For the clinic itself, the partnership gives them office space, use of the City Clinic for three hours twice a week, and a certain degree of legitimacy in the eyes of those who might otherwise look askance at such a venture. 

Johanna Breyer, a former exotic dancer, one of the original founders of EDA, and the Social Services Director for St. James Infirmary, says, "Overall, the Health Department has been supportive of the program and they realize that it actually is one of their most successful collaborations."

Two things at the core of the St. James Infirmary's philosophy make it unique from other programs. First, it's a peer-based clinic, founded and run mostly by people who have worked in the sex industry themselves, and are thus very familiar with the day-to-day realities of sex work. Second, the Infirmary operates from the viewpoint of providing occupational health and safety services resources to its clients, rather than trying to "save the workers from themselves". The Municipal Clinic's idea of working with "fallen women" is one that resonates in most public-health programs today, but Breyer says, "We really believe that this is legitimate work. We believe that the people we serve provide a valuable service to the community". Where we're coming from is that sex workers deserve the same level of respect as any other worker.

That statement is radical, and denotes a major point of departure in the guiding philosophy of the St. James Infirmary as opposed to more traditional programs. Historically, public health programs aimed at prostitutes have overtly campaigned to get their clients to change occupations, projecting a message that sex work is either sinful or pathological. In contrast, Breyer says that at St. James, a non-judgmental attitude is key: "We aren't here to rescue people from sex work, we're here simply to provide services, no matter what stage they are in sex work, so we see current sex workers, former sex workers, and transitioning sex workers."

But neither does the fact that St. James Infirmary isn't trying to convince sex workers to leave the life mean that they neglect those who decide that they do want to change to something more mainstream. On the contrary, the clinic provides a number of services for transitioning sex workers, including two monthly support groups-- one for women and one for men. Individual counseling is also available. 

"I've watched a lot of people go in and out of the sex industry," Breyer says. "When they are ready to get out of the industry, it can sometimes be challenging, because oftentimes you are isolated and you don't necessarily know people who are going through the same thing."

Finding Support Amongst Peers

This situation arises from the fact that the people who make up the regular support networks for workers-- friends, families, and so on-- may be unaware of their status in the sex industry. The support groups combat that sense of isolation by providing a space where transitioning sex workers can openly talk about the steps they need to take to stop working and to get reinforcement for the steps they have already been able to take. Support groups like these do fit relatively comfortably into the concept most people have of what health services targeted towards strippers and prostitutes should be. But the services that the St. James Infirmary provides to its clients go far beyond the popular idea of what the medical needs are within the sex industry. 

The clinic does, of course, provide STD and HIV testing, the staples of all such programs, but their services also include legal referrals, gynecological and urological care, immunizations, clothing and food donations, acupuncture, and massage therapy. After a recent survey showed that 45% of their clients were using tobacco, the Infirmary recently began a smoking cessation program. At first glance, things like acupuncture and anti-smoking programs might seem like general services, only tangentially linked to the specific needs of sex workers, but in reality they show how important the themes of occupational safety and peer-based services are in determining how St. James Infirmary serves its clients. 

One of the biggest obstacles for sex workers in obtaining health care, regardless of their financial situation, is establishing a trusting relationship with a doctor. Doctors often know little about the risks and realities of the sex industry, and often stereotype workers, treating them with discomfort or outright hostility, and sometimes giving them inappropriate treatment. Dr. Carol Queen, a sexologist and retired prostitute, says, "When I was seeing clients, the minute I mentioned it to a doc, he or she would triage me into the AIDS lecture-- which I could have delivered to them. And that was in San Francisco, where docs have a bit of a clue."

The common scapegoating of prostitutes as vectors of disease is one thing that most public-health programs have had in common; historically, most of these programs have emphasized the risks that sex workers present to their clients and society at large, rather than vice-versa. This was true of the Victorian Era, when the Municipal Clinic was operating, during World War II, when wartime propaganda portrayed prostitutes as dangers to the war effort, and in the 1980s and 90s, during the AIDS epidemic hysteria. Open, non-judgmental communication represents the St. James Infirmary's split with this tradition, and is their greatest asset in addressing the realities of sex workers, rather than acting as enforcers of public morality.

Lisa Montanarelli, co-author of The First Year: Hepatitis C, says, "Standard health-care workers often ask how many partners you've had in the last year, and if you answer in multiples of 10 or 100, they treat you as a vector of disease and only treat you for STDs." Montanarelli, herself a patient for hepatitis C, has gone to the St. James Infirmary for acupuncture, STD checks, and pap smears and vouches for the staff, explaining, "the volunteers are nonjudgmental and treat all their patients with respect."

Hope for the Future 

For now, the St. James Infirmary is a one-of-a-kind entity. Even in San Francisco, three years after its founding, the staff have only six hours a week in a facility borrowed from the city, plus outreach programs during their off-hours, to provide all their services. As Breyer says wryly, "The dream continues for a space the St. James Infirmary can call its own and use to maintain longer, more regular hours."

There are other instances of sex workers organizing to provide health services; the closest parallel is probably the Adult Industry Medical Health Care Foundation, in Sherman Oaks, California, which adult movie star Sharon Mitchell founded in 1998 to address rising HIV infection in the adult movie industry. Danzine, an advocacy group for sex workers in Portland, Oregon, also maintains their own thrift store and a needle exchange. But the wide variety of services and clientele of St. James Infirmary are unique.

A quote from Richard Enrico, a fundamentalist Christian who leads the Foundation for Moral Restoration, about Mitchell's clinic shows how little things have changed since the days of Father Caraher's crusade against the Municipal Clinic: "Porn stars pervert teenagers," Enrico said to the L.A. Times in 2001, "They shouldn't be surprised if they get STDs. You do something wrong, you deserve what you get."

This is one of the great burdens that Breyer, the staff of St. James Infirmary, and anyone else providing health care to sex workers without moral strings attached must deal with. Even in San Francisco, Breyer says, "We had to convince people for the first year or so that what we were doing was really rewarding to the community."

Despite long-standing obstacles Breyer does have hopes for the St. James Infirmary to do even more in the future. She wants to create satellite clinics throughout the city, as well as to expand the outreach programs that now exist. "The philosophy is that there would be a St. James Infirmary in every area where sex workers reside and work, even in areas outside of San Francisco," she says. As St. James Infirmary expands and grows, it's inevitable that it will provide a lot of education about sex, health, and the politics of both for both those inside and outside the sex industry.

Copyright © 2002 Chris Hall. All Rights Reserved. Do not copy or post in whole or in part. 

Visit St. James Infirmary's Web site to learn more about the clinic, and how you can help with its efforts.

Learn about COYOTE, an organization which "works for the rights of all sex workers: strippers, phone operators, prostitutes, porn actresses etc. of all genders and persuasions.

The San Francisco Coalition on Prostitution "began as a network of prostitutes, dancers and performers in the sex industry, political advocates, health workers, service providers and legal advocates organized to support the rights and needs of sex trade workers." Visit their Web site to learn more about their community building and public education efforts. 

Chris Hall is a self-described cynic who lives in San Francisco, the perfect city for anyone in love with sex. He writes and edits book reviews for Maximum RockNRoll, and has been published in the anthologies Male Lust and Young Blood. He works as a volunteer at the California AIDS Hotline, trying to promote sexual health. Hall is a skeptic and a godless atheist, but in the right circumstances he can display a sentimentality that would give Frank Capra diabetes. His girlfriend is a zaftig sex goddess with very large breasts who lives in New York, a fact which inspires his one frustration with San Francisco. He is a regular features contributor to Mind Caviar. Email Chris Hall.

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