Cisgender and Transgender Sex Workers from Colombia: The Relation Between Burnout Syndrome and Working Conditions in a Prohibitionist-Regulatory Law

Burnout syndrome has been recently included in the 11th revision of the International Classification of Diseases (ICD-11) as an occupational phenomenon. This syndrome has often been studied in the occupational context, but very little research has been conducted on sex workers. The present study examined the prevalence of burnout in cisgender and transgender women from Colombia for whom no laws regulate their job. It also analyzed the relation of burnout with sociodemographic variables and working conditions: number of working hours/week, monthly income, number of clients, experience as sex workers, and clients’ sex. We examined data from 98 sex workers using non probabilistic sampling. Self-reported measures of burnout syndrome were administered. Our results indicated that a considerable amount of women experience high burnout levels. However, 43.9% of the transgender women reported considerable personal accomplishment. Lower level of education and less income were related to more burnout, while the women who worked fewer years as sex workers reported less personal accomplishment. These findings shed light on sex workers’ burnout to raise awareness, improve their protection, and move toward regulatory laws that increase their safety and protection. Some implications may emerge which comprehends (1) security and safety, (2) whether performing sex work is deliberate or pressured, and (3) protective working conditions.

the occupational context and should not be applied to describe experiences in other areas of life" (p. 347). Therefore, individuals who perform a job in certain circumstances may be vulnerable and suffer this syndrome.
To date, burnout syndrome has been explored among several jobs, mainly related to health, education, and those caring for others (see García-Carmona, Marín, & Aguayo, 2019;Kim, Jörg, & Klassen, 2019;López-López et al., 2019;Tawfik et al., 2019). Overall, this syndrome is often found in jobs involving coming into close contact with others (Schaufeli & van Dierendonck, 1995). However, research on burnout is lacking for some other jobs, such as sex work, for which the analysis of this phenomenon may have relevant implications for regulatory laws and the policy framework within which it takes place.
In the present study, sex work is conceptualized as the interchange between sexual activity and money, carried out by an adult with full mental capacities and without coercion from a third party (Network for the Recognition of Sexual Work, 2012). Research suggests using the term "sex work" instead of prostitution as the latter is associated with negative aspects and leads to stigmatization (McMillan, Worth, & Rawstorne, 2018), which also depends based on the dominant cultural stigmatizing perceptions of sex workers (Rule & Twinley, 2020). Within a conceptual framework, sex work, as other job types, should be legally regulated (International Amnesty, 2016).
There are three regulatory models of sex work: prohibitionist, which prohibits sexual work and penalizes sex workers, clients, and procurers; abolitionist, which does not prohibit sex work, but penalizes clients and procurers; and regulatory, which provides laws and occupational obligations to all the individuals who perform this activity (Mccarthy, Benoit, Jansson, & Kolar, 2012). In Colombia, sex work can be conducted, but there is no normative regulation to deal with this job from the occupational, social, and economic points of view. However, this activity is neither illegal nor forbidden as it is approved by the Penal Code from the Republic of Colombia (2004). Therefore, we can affirm that a mixed model exists, with some norms referring to the prohibitionist model (e.g., prohibition of children's sexual work, procuring, or induction to prostitution) and others referring to the regulatory model as a previous landmark ruling exists (STC T-629/2010, of 13 August) that guarantees occupational rights.
Previous research has reported several negative consequences due to the criminalization of sexual work, such as increased stigmatization and violence, abuse from police, and difficulties gaining access to health services (Baratosy & Wendt, 2017;International Amnesty, 2016;Levy & Jakobsson, 2014). Nevertheless, criminalization, or merely the depenalization of sex work, may not be enough as sex work that lacks legalization spells vulnerability for one of the most basic human rights: that related to jobs (International Amnesty, 2015). The fact that no law exists to regulate this job implies several problems. First is the lack of knowledge on the number of individuals performing this job; for example, there are no official statistical data in Colombia about the number of sex workers. Only the data reported by the District of Bogotá, the capital of Colombia, indicate a number of 23,426 sex workers, that is, 293 sex workers in every 100,000 inhabitants (District Secretary of Women, 2017). Moreover, lack of knowledge on numbers also means lack of knowledge about people forced to work as sex workers (Weitzer, 2009). Second is being a victim of violence; about 15% or the surveyed women (N = 2758) reported having suffered violence, and this prevalence doubled (29.5%) when women were transgenders (District Secretary of Women, 2017). Third is the lack of protection and stigmatization from health services to sex workers (Baratosy & Wendt, 2017;van Stapele, Nencel, & Sabelis, 2019;Zehnder, Mutschler, Rössler, Rufer, & Rüsch, 2019). Hence, it is necessary to highlight the lack of attention paid to occupational hazards, occupational illness, or other job-related situations.
To date, one study can be found which evaluated burnout syndrome in sex workers in the Netherlands, where a law has regulated sex work since 2000. Yet in spite of that law, which guarantees sex workers certain working rights, the results showed that some of these workers still report certain burnout syndrome levels, albeit low ones (Vanwesenbeeck, 2005). With the proposal to increase knowledge about this syndrome, and given the few research works interested in studying mental impairment related to sex workers' working conditions that often may lead sex workers to segregation and isolation (Curtis, D'Aniello, Twist, Brents, & Eddy, 2019), the main goal of the present study was to evaluate burnout syndrome in sex workers in Colombia, a country where sex work is neither forbidden nor regulated.
The goals of the present study were (1) to know the level of burnout in sex workers, (2) to examine whether there were significant differences between cisgender and transgender women's burnout syndrome levels; (3) examine whether a relation existed between burnout syndrome and sociodemographic variables, such as age, level of education, and socioeconomic level; and (4) study the relation between burnout syndrome and some aspects of working conditions, such as number of hours worked/week, monthly income, number of clients, experience (number of months as sex worker), and clients' sex.
We tested the following hypotheses, except for the first objective, as it is of an exploratory nature: H1. We expected lower personal accomplishment levels in the cisgender than the transgender participants. One previous research work showed that transgender sex workers reported positive experiences in the sex work industry (Nadal, Vargas, Meterko, Hamit, & McLean, 2012). Therefore, cisgender women could report more depersonalization and emotional exhaustion than transgenders. However, no previous studies have indicated this likely relation. H2. For the sociodemographic variables, we expected to find a negative relation between burnout and level education/socioeconomic level. Those individuals with a higher level of education and a higher socioeconomic level may be less likely to report burnout (Maslach, Schaufeli, & Leiter, 2001). No previous research has indicated robust findings for age and, therefore, no hypotheses are posed. H3. For working conditions, we expected to find a positive relation to link burnout, number of hours, number of clients, and experience as sex worker, and a negative relation between burnout and monthly income. No hypothesis is posed about clients' sex because no previous findings were obtained on this matter. Research on burnout in relation to other jobs has indicated that the number of hours negatively affects workers (Frajerman et al., 2019;Suleiman-Martos et al., 2020). A bigger number of clients are also a predictor of higher burnout levels (Maslach, 2017). With other jobs, more monthly income indicates lower burnout levels (Jiang & Probst, 2017).

Participants
The sample consisted of 173 participants. Of these, the following were eliminated: 32 because they did not answer 25% or the items or more; 41 because they did not meet the inclusion criteria that were the following: (a) being 18 or older, (b) a sex worker, and (c) having Colombian nationality. Therefore, those who did not meet those criteria were excluded. In our particular case, only two responded that they were cisgender men. We decided to remove these two participants to comprise a homogeneous sample. Thus, the final sample comprised 98 participants (58.2% cisgender, 41.8% transgender women) aged from 18 to 56 (M = 27.38, SD = 7.67). Table 1 provides their sociodemographic characteristics. There were no statistically significant differences between the cisgender and transgender participants in relation to the sociodemographic characteristics, except for monthly income because the cisgender women reported earning more money.
Overall, the number of weekly hours they worked oscillated between 20 and 27 h, they had around 200 clients, and they had worked as sex workers for 5-6 years. Most indicated having finished secondary education and belonging to stratum 1 from Colombia, which refers to the lowest socioeconomic stratum.

Sociodemographic Information
We recruited information about sex, gender, education, socioeconomic stratification, which is distributed across in Colombia strata, and nationality. Socioeconomic stratification refers to a classification that homes receive. Citizens living in strata 5 and 6 subsidize the public services from strata 1, 2, and 3. Therefore, strata 1 to 3 are considered low socioeconomic strata, stratum 4 is intermediate, and strata 5 to 6 are high. We also requested information about their sex work conditions, such as number of hours worked per week, monthly income, number of clients, experience of sex workers, and their clients' sex (1 = men, 2 = women, 3 = both).
Maslach Burnout Inventory (MBI-HSS) (Maslach, Jackson, & Leiter, 1996) We used the Spanish validated version by Gil-Monte (2005), which consists of 20 items distributed across three subscales: emotional exhaustion, depersonalization, and personal accomplishment. Emotional exhaustion refers to feelings of having overextended or depleted one's emotional recourses. Depersonalization is characterized by a negative, cynical, and detached response to other people, including colleagues and patients. Low personal accomplishment is a decline in feeling competent to perform tasks and accept responsibility (Maslach et al., 1996). Their items are answered on a 7-point Likert scale (0 = never to 6 = always). The possible range for emotional exhaustion is 0 to 48, 0 to 30 for depersonalization, and 0 to 42 for personal accomplishment. Higher scores indicate greater emotional exhaustion, depersonalization, and personal accomplishment, respectively. A previous study (Schaufeli & van Dierendonck, 1995) took the rated scores of female healthcare workers, between the 25th and 75th percentiles, as a severity level. If we consider that no previous research in Colombia has established a cut-off based on the direct scores from this scale independently of the cisgender and transgender sample in the present study, we considered the scores above the 75th percentile to be high, and our reliability values were adequate. Cronbach's alpha values were α = .90 for emotional exhaustion, α = .87 for depersonalization, and α = .85 for low personal accomplishment. Evidences of validity have been provided for the MBI in Latin America, showing adequate factorial and construct validity (see Kulakova et al., 2017).

Procedure
We used non probabilistic sampling with the snowball method. One of the researchers contacted some sex workers, invited them to take part in the study, and asked them to invite other colleagues. This contact was made either personally or by telephone to set appointments and to provide them with information about the study. Two researchers were responsible for recruiting the sample. They used a meeting point at the BLINDED for some hours that were adapted for the attending participants. Appointments were individual. The participants were informed about the main study goal (analyze aspects related to their working conditions and burnout) and their participation consisted in anonymously completing some questionnaires. The sex workers who accepted to volunteer in the study were handed out the questionnaires and the consent form; participants did not receive any compensation for taking part in the research. After signing consent, the participants completed the questionnaires with no researcher present. All participants were required to complete and informed consent document prior to fulfill the research survey. All procedures performed in the present study were in accordance with the ethical standards.

Results
First, the descriptive statistics for all the burnout subscales were independently obtained for both cisgender and transgender sex workers. Second, we obtained the percentage of sex workers who scored high (above the 75th percentile). Table 2 shows both the cisgender and transgender participants reporting high burnout levels, especially for emotional exhaustion and personal accomplishment, as scores were above the theoretical midpoint of the possible range. Significant differences were found between cisgender and transgender when conducting a t-student for the means comparison. In particular, the cisgender workers reported perceiving more personal accomplishment compared with the transgender workers. Consistently based on the scores cut-off by the 75th percentile, which indicates high scores, the highest scores were obtained by the personal accomplishment subscale for the transgender sex workers (43.9%), which significantly differed from the scores for the cisgender workers (15.85% had scores higher than the 75th percentile). Both cisgender and transgender sex workers were independently considered for further analyses. Z-order correlations were used to examine the associations between the sociodemographic variables and working conditions with all three burnout subscales. For the cisgender women, Table 3 shows the following significant correlations; in particular, lower monthly income was significantly correlated with greater emotional exhaustion, while greater income, more number of clients, more experience as sex worker, and having sex with more diverse clients (both men and women) were associated with more personal accomplishment. None of the remaining examined sociodemographic variables was statistically related to the burnout subscales.
Regarding transgender participants, only the emotional exhaustion and depersonalization subscales were positively associated (see Table 3). Regarding the sociodemographic variables, a lower level of education was related to greater emotional exhaustion. From the working conditions, no significant association appeared, except for working more months as sex workers, which was associated with more personal accomplishment (Table 3).

Discussion
This research attempts to contribute to the previous literature by focusing on how policies and workplaces affect sex workers' well-being (Crowhurst, Vuolajärvi, & Korgan, 2019). The goal of the present study was to acquire in-depth knowledge about burnout syndrome in sex workers from Colombia. Our findings highlighted high levels of emotional exhaustion and depersonalization among female sex workers. They also confirmed some of the posed hypotheses. Therefore, this population is vulnerable to suffer not only burnout syndrome, but also some of its related mental health impairments. For this reason, prevention and intervention programs should also address sex workers, who have often been neglected. We, therefore, discuss some of the implications of these findings for legal and policy regulations.  The dominant legal model that regulates sex work in Colombia could be considered a mixed model because it includes norms contemplated by the prohibitionist model and others that refer to the legalization or "regulationist" model as tolerance zones have been established Code of Police and Coexistence from the Republic of Colombia (2016a, 2016b and 2016c). The prohibitionist or abolition models are based on women's victimization and vulnerability (Munro & Scoular, 2012), and also consider that sex work is a clear example of gender inequality and the equivalent to violence against women (Scoular & Carline, 2014), which implies considering sex workers devoid of reasonableness. Therefore, this approach hurts sex workers (Levy & Jakobsson, 2014) and can reinforce victimization and coercion stereotypes (Carline, 2011). Along these lines, theories of misrecognition, misrepresentation, and social justice are also interesting (Fraser, 2009), which refer to the importance of sex workers being taken into account when making policies, who are thus subjects of rights because job satisfaction and well-being would otherwise be harmed.
Our findings generally indicate low-to-moderate levels of emotional exhaustion and depersonalization, with high levels in some cases; for example, 17.3% of the cisgender women reported scores above the 75th percentile. Sex work involves emotional exertion, and making more efforts than other clientfocused work, which explain why our participants reported high emotional exhaustion levels. In a recent study conducted with a sample of sex workers, the participants reported suffering high emotional stress during sexual encounters (Pitcher, 2019). Another study evaluated burnout syndrome, in which sex workers reported medium-to-low burnout levels (Vanwesenbeeck, 2005). It is likely that part of these results can be explained by working conditions and the regulation of this job. The study by Vanwesenbeeck (2005) was conducted in the Netherlands, where sex work has been allowed and regulated since 2000. Thus, working conditions differ in this country, unlike for our participants, whose job is not regulated by Colombian laws.
Some differences between transgender and cisgender women appear for their personal accomplishment levels, but not for their emotional exhaustion or depersonalization, which partially supports H1. In particular, the cisgender women reported lower personal accomplishment levels than the transgender women, with 15.85% vs. 43.9% respectively. Some women may have chosen sex work as a pragmatic solution to particular problems, while others have done so for other reasons that they consider positive, such as more monthly income (Pitcher, 2019). A majority of the transwomen have experienced widespread discrimination at work (National Center for Transgender Equality and the National Gay and Lesbian Task Force, 2009), so they consider sex work a positive alternative because they feel that their male clients consider them real women (Nadal et al., 2012). In addition, it is likely that transgender women feel more personal accomplishment as their monthly income can help them to pay cosmetic surgery. Therefore, they can achieve things that are valuable for them (e.g., breast augmentation, sex change); in other words, as some participants in a previous study (Pitcher, 2019) declare, sex work can be an instrumentalist provisional route that therefore allows them to achieve aspirations or opportunities that with other employment would be more difficult. Another possible explanation could be that transgender women feel more empowered as they may have reflected more on themselves and their identity. A previous study from South Africa concluded that many transgender female sex workers described their identities using positive and empowered language, while cisgender male sex workers expressed shame and internalized stigma in relation to identities (Samudzi & Mannell, 2016).
Regarding the sociodemographic variables, only lower level of education was relevant for the transgender women to explain their emotional exhaustion at a low-to-moderate level. Therefore, no robust findings are shown. However, considering this result as a trend, it is likely that these women believe that, due to their low level of education, sex work is one of the scarce job opportunities they have, which is linked to sadness and hopelessness. Previous studies have concluded that the few job opportunities are associated with hopelessness, sadness, guilt, anxiety, and etc. (Drapeau, Marchand, & Beaulieu-Prévost, 2012). In other words, burnout syndrome may be better explained by some specific aspects relating to the work environment or conditions rather than by other individual factors (Maslach & Leiter, 2016). Therefore, H2 is partially supported as education only plays a role in burnout and not their socioeconomic level, which is probably due to the sample's homogeneity.
Some variables related to working conditions seemed relevant for burnout syndrome in the expected direction, while others did not. However, again, correlations are low to moderate; therefore, the following interpretations should be considered within this limitation. So, H3 is partially supported. First, the number of hours was not associated with burnout syndrome, probably because the more hours they work, the more money they earn. Money could be a factor that reduced their stress (Jiang & Probst, 2017) and was related to job satisfaction (Phrasisombath, Faxelid, Sychareun, & Thomsen, 2012). Second, and similarly to Vanwesenbeeck (2005), the number of clients was not related to either emotional exhaustion or depersonalization. However, having more clients was related to more personal accomplishment for the cisgender sex workers, but not for the transgender ones. One possible explanation for this could be that a bigger number of clients would be related to earning more monthly income. However, more research is needed to better clarify this finding. Third, lower income was related to more emotional exhaustion and less personal accomplishment. These findings are coherent with previous studies (Saijo, Yoshioka, Hanley, Kitaoka, & Yoshida, 2018;Vidotti, Ribeiro, Galdino, & Martins, 2018). Fourth, both the cisgender and transgender women who worked fewer years as sex workers reported less personal accomplishment. Perhaps these women were engaged in sex work as a solution to their personal circumstances, which would imply less self-esteem and, therefore, less personal achievement. As working conditions are related to job satisfaction (Bernstein, 2007;Perkins & Lovejoy, 2007;Sanders, Scoular, Campbell, Pitcher, & Cunningham, 2018), future research is necessary to analyze burnout syndrome and working conditions in different countries.
This study has several limitations. First, we recruited the sample through a convenient method and, therefore, the results cannot be generalized to other sex workers from other regions or countries. Nonetheless, when considering the specific characteristics of our sample, no other method sampling could have been used because updated official data on sex workers in this country are lacking. Further research should extend this analysis to other samples, including individuals with diverse gender identities and orientations as less research on sexual minorities is available (Calvillo et al., 2020). This would also help to obtain more heterogeneous samples. Second, we recommend including questions about sex worker's job affiliation (independent or dependent), and other issues like occupational hazards and previous accidents at work, to obtain a better picture of the role that their job conditions really play in their subjective well-being. Finally, we recommend more research on sex workers' burnout syndrome in other countries and regions.
The legalization of sex work can be seen as an economics and moral interaction. However, abolitionist or prohibitionist models lead to sex workers being more unprotected (Crowhurst et al., 2019). With the present research, the authors attempt to make the reality of cisgender and transgender women sex workers suffering burnout syndrome visible, that is, stress directly related to their work. Therefore, and according to Wagenaar and Altink (2012), the law should not prohibit what morality rejects because public policies are necessary so that sex workers' fundamental rights are protected from a comprehensive perspective, including psychological health, among many other aspects.
Therefore, some implications may emerge in the present study for the development of effective policies which comprehends the following aspects: (1) security and safety to develop their work in which both physical and mental health are guaranteed, (2) consider whether sex work is deliberate and their choice for living or they are pressured to perform this work, and (3) how working conditions may affect their lives and regulatory and specific conciliatory rules for sex workers. The lack of a specific regulation that neither prohibits nor allows sex work leads to the lack of protection of the people who are involved in it.

Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of interest.
Ethical Approval All procedures performed in the present study were in accordance with the ethical standards.
Informed Consent All participants were required to complete and informed consent document prior to fulfill the research survey.