Crossroads of Choice: A qualitative study of the factors influencing decisions to transition from sex work among women engaged in sex work in Southern Uganda

Background

Women Engaged in commercial Sex Work (WESW) are exposed to behavioral, biological, and structural factors that exacerbate their risk to HIV infection and other sexually transmitted infections. While commercial sex work may appear voluntary, WESW are more likely to be constrained to selling sex due to limited viable alternatives. To effectively support this vulnerable group of women, it is critical to understand factors that facilitate and impede their decisions to transition from sex work into other careers or jobs. The current study explored women's decision to transition from sex work into other careers or jobs.

Methods

Semi-structured in-depth interviews were conducted with 53 WESW aged 20-47 enrolled within a larger study-Kyaterekera study, a randomized clinical trial (N = 542) implemented in 19 HIV hotspots in the Southern region of Uganda. Participants were selected based on their intervention attendance (high/medium/low attendance). The interviews were conducted in Luganda the widely spoken language in the study area to explore the factors influencing women's decisions to from transition from sex work to other jobs or careers. The main interview question used for this study was, "What are some of the factors that may influence whether you would transition from sex work to other jobs or vocations?". All interviews were audio-recorded, transcribed verbatim and translated into English. Thematic analysis in Dedoose software was used to analyze the data.

Results

Participants reported three primary types of decisions, including considering leaving sex work, deciding to leave, and continuing sex work. The emerging themes from the interviews were categorized into individual and structural level facilitators and barriers to leave sex work. Individual level factors included issues of stigma, discrimination, and aging as factors that facilitated women's decision to leave sex work. At the structural level, factors which include interpersonal stigma and discrimination (from immediate family and community members), physical and sexual violence and income related factors were identified as facilitators and barriers to leaving sex work.

Conclusion

Our study highlights the complex decision-making processes among WESW as they navigate transitions to alternative jobs or careers. By advocating for multifaceted interventions and policies tailored to the diverse challenges faced by WESW, our study contributes to a more informed approach to supporting their transition out of sex work.

"I was already there once": Cumulative attempt capital of marginalized women exiting substance use and street prostitution contributes to their recovery capital

Despite a move to view substance use as a disease of the brain, relapse into drugs is still often viewed as a personal failure. Low recovery capital has been used to explain relapse among certain marginalized populations. Recovery capital is a recent framework that refers to the individual's sum of all internal and external assets that may assist in their recovery process. It includes four categories: physical, human, social, and cultural capital. However, this framework does not relate to the role of actual relapses in the recovery process, despite their common occurrence. To bridge this gap, in-depth interviews with 29 women formerly engaged in substance use and street prostitution in a large urban area were used to probe women about their relapse and recovery experiences. The current study demonstrates the value in repeat recovery setbacks, what I term "cumulative attempt capital": lessons learned from previous recovery attempts. I argue that previous attempts improve women's social and professional networks, help them learn from past mistakes, improve and maintain their health, and provide them with a sense of self-efficacy. This research expands our understanding of the positive role failed attempts play in one's recovery. Such reframing by service providers can alleviate a sense of shame and low self-worth for women in street prostitution and substance use and has implications for policy and program development.

Prostitution in the shadow of life-long sexual abuse: Arab women's retrospective experiences

The present study uses the life-course and intersectionality perspectives to explore the meaning that aging Arab women attribute to their lived experiences of life-long sexual abuse in the shadow of engaging in prostitution. Interpretive phenomenological analysis was used to analyze the narratives of 10 older Arab women in Israel who were engaged in prostitution. Four themes emerged: experiencing childhood in the shadow of sexual abuse, becoming a prostitute, being entrapped in prostitution, and settling accounts with the native culture. Women aging in prostitution experience a harsh reality of abuse and loss. The present study points to multiple channels of abuse throughout the life course, from childhood until old age.

Coping self-efficacy and social support as predictors of adolescent sex trafficking exit: Results of a secondary analysis

INTRODUCTION

Social work case management services are increasingly available to youth who want to exit commercial sexual exploitation (CSE). However, few empirical studies investigate the efficacy of such services, particularly whether these services promote an exit from CSE. Guided by ecological systems theory and the Intentions to Exit Prostitution (IEP) model, this study investigates the efficacy of social work case management services for youth CSE survivors.

METHODS

Youth survivors of CSE (n = 95) participated in a one-group, quasi-experimental double pre/posttest design study. Measures included the Multidimensional Scale of Perceived Social Support (MSPSS), Coping Self-Efficacy Scale (Cop-SE), and a modified version of the University of Rhode Island Change Assessment (URICA) surveys at zero- and six-months following study commencement. The research team also collected demographic and victimization data, the number and type of social work case management services received, and goal plan data. Analyses included repeated measures tests and linear and multinomial logistic regressions to determine if doses of social work case management are predictive of the positive short-term outcomes that are linked to increased readiness to exit CSE.

RESULTS

Youth CSE survivors experienced upward trends in perceived social support and coping self-efficacy scores between zero- and six-months following study commencement. Linear and logistic regressions demonstrated that variables like months of service time, trafficking classification, goal counts, race, and age can predict outcomes like survivor social support, coping self-efficacy, and intention to change behaviors that can lead to revictimization.

IMPLICATIONS

Results suggest social work case management services that improve coping self-efficacy and perceived social support can lead to cognitive changes that promote an exit from CSE. Practitioners should target services that adhere to dimensions of the IEP as these improvements are likely to support positive outcomes for youth survivors of CSE.

Sex Trafficking in New York City and Vulnerabilities to Re-Trafficking

Human trafficking occurs in a cycle of coercion and exploitation of vulnerable people; yet, little is known about those who are trafficked more than one time (re-trafficked). Our study sought to describe the trafficking experiences and explore vulnerabilities to re-trafficking in an urban, majority immigrant, population. This study is part of a parent cohort study that enrolls patients at the EMPOWER Center in New York City, which provides trauma-informed obstetric and gynecologic services to victims of sexual- and gender-based violence. Retrospective chart review was conducted on patients with a history of sex trafficking who were evaluated at the EMPOWER Center from February 2013 to January 2021. A total of 87 patients were enrolled in this study, 23 (26.4%) of whom had been re-trafficked. All were women. Most (88.5%) were victims of international trafficking, most often from Mexico or the Caribbean/Central America. Nine (10.3%) reported contraceptive use and six (6.9%) experienced forced substance use while trafficked. The most reported barriers that women faced in escaping trafficking were threat of violence (28.7%) and financial dependence (19.5%). Re-trafficked patients were more likely to have a history of being undocumented (odds ratio [OR] = 5.29; 95% confidence intervals [CI] [1.34, 20.94]) and experienced childhood sexual abuse (OR = 2.99; 95% CI [1.10, 8.16]), experienced childhood physical abuse (OR = 3.33; 95% CI [1.18, 9.39]), and lived with a non-parent family member (OR = 6.56; 95% CI [1.71, 25.23]). Although these vulnerabilities were no longer significant when analyzed in a parsimonious multivariate logistic regression model adjusting for the other significant variables, likely due to the limited sample size. Almost half (46.0%) reported ongoing emotional effects from being trafficked, which did not vary by re-trafficking status. Our study highlights potential pre-trafficking vulnerabilities, illustrates the complexity of the trafficking experience, and presents potential risk factors for being re-trafficked.

Understanding the longitudinal relationship between substance use and violent victimization among street-based women who exchange sex in Baltimore, Maryland

BACKGROUND

Women who exchange sex (WES) experience extensive interpersonal violence from multiple perpetrators. Violence towards WES contributes to poor mental and behavioral health outcomes, including high rates of drug use. However, it is difficult to disentangle the temporal relationship between drug use and violence among WES.

METHODS

We used data from 251 WES, who completed baseline and 6-month follow up surveys. WES reported baseline sociodemographic characteristics, including homelessness and hunger. Participants reported their drug use by type and violent experiences by perpetrator at each time point. We conducted a path analysis examining the associations between drug use and violent victimization over time.

RESULTS

Participants were on average 37.8 years old, non-Hispanic White (57.4%) and experiencing high levels of structural vulnerability (59.4% homelessness; 58.6% weekly hunger). Drug use and violence were significantly correlated within each time point. Prospectively, baseline violent victimization was significantly associated with drug use (ß (SE) = 0.13 (0.06)) and violence (ß (SE) = 0.47 (0.05)) at follow up. Baseline drug use was associated with drug use at follow up (ß (SE) = 0.45 (0.05)) but was not significantly associated with violence at follow up (ß (SE) = 0.10 (0.06)).

CONCLUSIONS

Violence and drug use are closely linked in this population; and violence appears to facilitate sustained drug use. Interventions to address the dual epidemics of violence and substance use in this population should address underlying trauma as well as socio-structural drivers of violence as well as tailored harm reduction services for this population.

Beaten but not down! Exploring resilience among female sex workers (FSWs) in Nairobi, Kenya

BACKGROUND

In Kenya sex work is illegal and those engaged in the trade are stigmatized and marginalized. We explored how female sex workers in Nairobi, Kenya, utilize different resources to navigate the negative consequences of the work they do.

METHODS

Qualitative data were collected in October 2019 from 40 FSWs who were randomly sampled from 1003 women enrolled in the Maisha Fiti study, a 3-year longitudinal mixed-methods study exploring the relationship between HIV risk and violence and mental health. All interviews were audio-recorded, transcribed and translated. Data were thematically coded and analyzed using Nvivo 12.

RESULTS

Participants' age range was 18-45 years. Before entry into sex work, all but one had at least one child. Providing for the children was expressed as the main reason the women joined sex work. All the women grew up in adverse circumstances such as poor financial backgrounds and some reported sexual and physical abuse as children. They also continued to experience adversity in their adulthood including intimate partner violence as well as violence at the workplace. All the participants were noted to have utilised the resources they have to build resilience and cope with these adversities while remaining hopeful for the future. Motherhood was mentioned by most as the reason they have remained resilient. Coming together in groups and engaging with HIV prevention and treatment services were noted as important factors too in building resilience.

CONCLUSION

Despite the adverse experiences throughout the lives of FSWs, resilience was a key theme that emerged from this study. A holistic approach is needed in addressing the health needs of female sex workers. Encouraging FSWs to come together and advocating together for their needs is a key resource from which resilience and forbearance can grow. Upstream prevention through strengthening of education systems and supporting girls to stay in school and complete their secondary and/or tertiary education would help them gain training and skills, providing them with options for income generation during their adult lives.

Double Jeopardy: Maintaining Livelihoods or Preserving Health? The Tough Choices Sex Workers Faced during the COVID-19 Pandemic

The COVID-19 pandemic and associated public health preventive measures such as lockdown and home confinement have posed unique challenges to female sex workers (FSW) globally, including in Canada where the sex trade is not formally recognized. In this commentary, we discuss the unintended consequences the pandemic has had on various social determinants of health among FSW. We draw on a review of scholarly and grey literature, complemented by our experience with the Exit Doors Here program, a sex work exiting program implemented in Toronto, Canada. Due to COVID-19, many FSW suddenly lost their main source of income, work conditions became riskier, and sheltering-in-place presented challenges for women with no safe housing. The slowdown of social and health care services also meant FSW were not receiving the required attention. We make recommendations for intersectoral mitigation strategies to limit the short- and long-term impacts of COVID-19 on FSW health and livelihoods. Recommendations focus on addressing women’s marginalizing circumstances and speak to a gender transformative approach to the COVID-19 recovery. Our recommendations are relevant to FSW and other marginalized groups, in the current context and in the context of future health, social, and economic crises.

The hopelessness effect: Counsellors' perceptions of their female clients involved in sex work in Canada

This qualitative study explored how counsellors who work with women currently or formerly involved in sex work perceive these women's future. From May to July 2016, we conducted semi-structured interviews with 21 counsellors providing psychosocial services in Canadian agencies with recognized mandates to support such women. The interview protocol was based on the Possible Selves Mapping Interview, adapted to explore the counsellors' hopes and fears for these clients. We subjected the interview transcripts to an interpretive descriptive analysis. Our findings centred on three themes: the counsellors' hopes for their clients' future, in light of their personal and social resources; the counsellors' fears about the cumulative devastating effects that their clients' work environment might have on them; and the counsellors' fears that these women would lose hope for the future. This study clearly demonstrates the importance of addressing the safety and well-being of women involved in sex work and of recognizing the impacts of social inequalities and structural barriers on these women's life paths. The implications of these findings for policies and practices are discussed at the end of this paper.

Court-Affiliated Diversion Programs for Prostitution-Related Crimes: A Comprehensive Review of Program Components and Impact

OBJECTIVE

Court diversion programs offer alternative treatment interventions in lieu of punitive sanctions. Programs have recently been developed for women arrested for prostitution, with a recognition that many of these individuals frequently experience multiple forms of violence and experience multiple barriers to exiting sex work. This review aims to (a) examine programmatic components used across programs, and (b) identify the diversionary programs' impact on participants.

METHODS

Studies were identified by entering key search words into three electronic databases and by conducting a citation search.

RESULTS

Nine articles were included in the review. Although programs varied in structure, services, and length of time, studies indicated a range of positive outcomes for participants.

CONCLUSIONS

Results help to illuminate future directions for criminal justice practice, policy, and research.

Short-term interruptions to sex work among a prospective cohort of street-based cisgender female sex workers in Baltimore

BACKGROUND

Street-based female sex workers (FSW) often cycle in and out of sex work engagement. For many FSW, substance use plays a critical role in sex work entry, continuation, and interruptions. We examined individual, interpersonal, and structural correlates of short-term interruptions of sex work among street-based FSW in an urban environment.

METHODS

Data were from 205 FSW in Baltimore, MD, USA followed as part of an observational prospective cohort study between April 2016-Februrary 2018. The primary outcome was short-term interruptions of sex work (stopping sex work) over the past 3 months, asked every 3 months over a 12-month follow-up. We assessed the relationship between individual, structural, and interpersonal factors for each woman's prior visit and current visit with short-term sex work interruptions. We employed modified Poisson regression with Generalized Estimating Equations to identify correlates of short-term interruptions of sex work.

RESULTS

Eighty-two women (40%) reported stopping sex work over the past 3 months at least once during follow-up. Past drug treatment (adjusted incidence rate ratio [aIRR] 1.40; 95% CI: 1.06-1.86) and not having used drugs in the past 3 months (aIRR 2.70; 95% CI: 1.96-3.71) were positively associated with short-term interruption to sex work. Past intimate partner violence (IPV) (aIRR 0.52; 95% CI: 0.31-0.86) and current homelessness (aIRR 0.61; 95% CI: 0.41-0.91) were negatively associated with short-term interruption. Results were inconclusive for the association between recent prostitution arrest and short-term interruptions to sex work (IRR 0.86; 95% CI: 0.40-1.86).

CONCLUSION

The study suggests that similar to other professions, women leave sex work for numerous reasons. Substance use cessation and participation in drug treatment programs may contribute to short-term interruptions of sex work by reducing reliance on sex work for income among street-based FSW. Structural vulnerabilities including homelessness and IPV are driving continued street-based sex work, speaking to the need for holistic structural interventions.

Rethinking Role Residual: Retired Police Officers and the Inertia of Habitus

In this paper, we bring conceptual clarity to the literature on "role residual." Based on the extant literature and our own research involving police retirees, we first delineate three empirical variants of role residual: emotional, cognitive, and behavioral. We then make the case that a comprehensive understanding of the phenomenon requires a theoretical framework capable of conceptualizing role residual in a way that is consistent with a broader theory of practice. To that end, we use Bourdieu's work to argue that role residual comprises states of being or behavior that occur at the intersection of (a) schemas and dispositions inscribed in the habitus as a result of one's prior role-specific orientation to the field, and (b) a configuration of proximate conditions in the present that is sufficiently similar to what one would have experienced while in one's prior role.

Examining Recidivism in a Prostitution Diversion Program

Street-based sex work is criminalized throughout much of the U.S. Diversion programs have shown mixed results. This study examined the effect a quasi-experimental intervention (prostitution diversion program, n = 149) had on prostitution rearrest compared with a waitlist control group (n = 77) among N = 226 individuals arrested for prostitution in Baltimore. In both groups, n = 64 (28.32%) were rearrested for prostitution over 30 months. Tests of differences compared groups with a significant difference in gender only. A Cox proportional hazard model examined differences in survival time (to recidivist prostitution arrest) between individuals in the control and intervention groups at 6, 12, 18, 24, and 30 months. Results indicate that participation in the intervention did not have a significant effect on decreasing prostitution arrests over time. History of prior prostitution arrest was a significant predictor (hazard ration [HR] = 1.12, p = .02) of rearrest.Lack of program success suggests that barriers to exiting prostitution are substantial, despite availability of supportive services, and that diversion programs may not be the best intervention strategy for all sex workers. Future research should identify motivators for exiting and how to reduce exiting barriers.

Uncharted Waters: Developing Mental Health Services for Survivors of Domestic Human Sex Trafficking

In recent years, heightened attention has been paid to commercial sexual exploitation, including domestic human sex trafficking (HST), with mental health concerns named the most dominant health concern among survivors. Human sex trafficking is associated with significant and long-term mental health consequences. Research to date has emphasized ways to identify survivors in health care settings. Once identified, however, few specialized services are available to help survivors exit and recover. The current services infrastructure for HST has been compared to the disjointed social response to intimate partner violence before the women's movement helped develop a system of battered women's shelters. Although research has highlighted the need for a multidisciplinary and interagency response to HST, including mental health care, best practices have not yet been formulated. Furthermore, available services are fragmented across sectors. With psychology and psychiatry taking tentative steps to develop services for HST survivors, this article identifies six principles to help avoid a fragmented and potentially retraumatizing clinical and systemic response. The overarching goal is to design services that are flexible, accessible, trauma informed, survivor driven, responsive to stages of change, multidisciplinary, and enduring, especially given the centrality of healthy attachments and community in trauma recovery. Principles are derived from the limited available research on HST services and from examples of efficacious interventions for patient groups with similar characteristics. The discussion is also informed by composite clinical vignettes from a specialized clinic for adult survivors of HST, housed in a major teaching hospital. Finally, practice recommendations and strategies for building interdisciplinary collaborations are discussed.

"I am still negative": Female sex workers' perspectives on uptake and use of daily pre-exposure prophylaxis for HIV prevention in South Africa

Women remain highly vulnerable to HIV infection in sub-Saharan Africa, with female sex workers (FSWs) facing some of the highest rates of HIV. Oral pre-exposure prophylaxis (PrEP) has the potential to reduce new infections among populations at highest risk and end-user perspectives of actual use in ‘real-world’ settings are critical to informing PrEP implementation. This paper presents findings from serial in-depth interviews (IDIs) conducted with FSW participants during the course of the Treatment And Prevention for Sex workers (TAPS) Demonstration Project in South Africa, exploring the lived experiences and perceptions of taking up and using PrEP. This research provides insight into risks and responsibilities facing FSWs perceived as prominent drivers in taking up and using PrEP, how PrEP was adopted to mitigate risk or ameliorate realities, and the characteristics of PrEP most valued, all of which are critical to consider in scale-up. Overall, distrust in the existence and/or efficacy of PrEP affected the motivation of women to come to the clinic and to maintain use. As one of the first reports of PrEP use among FSWs outside of a clinical trial setting, this research shows that it will be important to ensure accurate, relevant, and widespread messaging in communities to generate demand and support for PrEP.

"It's All about Breaking down Those Barriers…": Exploring Survivors' Perspectives on Services and Treatment Needs following Commercial Sexual Exploitation during Childhood

Purpose: In recent years, there has been an increase in funds and services available to address the needs of commercially sexually exploited children (CSEC). While previous studies have explored the mental, behavioral, and physical needs of CSEC victims and survivors, few studies have focused on the service needs CSEC victims and survivors themselves deem most important. The current study seeks to bridge this gap by garnering American CSEC victims' and survivors' perspectives regarding CSEC service strengths, weaknesses, and gaps.Method: Semi-structured, in-depth interviews were conducted with 13 adult survivors of CSEC to examine their perceptions of current CSEC services in the United States. All interviews were recorded, transcribed verbatim, and imported into a qualitative data analysis program. Using an inductive approach, two major themes emerged: short-term needs and long-term needs.Results: Short-term needs included victim identification, housing, and emergency medical care. Long-term needs included life-skills, community building, legal assistance, and medical care. The results point to the complex needs of CSEC victims/survivors.Discussion: While CSEC services continue to develop, there remain many gaps in care in the services available. Study findings provide valuable insight to practitioners and researchers alike and identify the most critical needs of CSEC victims and survivors. Implications for practice and research are discussed.

The Complexity of Adaptation to Childhood Polyvictimization in Youth and Young Adults: Recommendations for Multidisciplinary Responders

Exposure to violence is pervasive in our society. An abundance of research has demonstrated that individuals who experience polyvictimization (PV)-prolonged or multiple forms of traumatic victimizations-are at heightened risk for continuing to experience repeated victimizations throughout their lifetimes. The current article reviews several overlapping constructs of traumatic victimizations with the ultimate goal of providing a unifying framework for conceptualizing prolonged and multiple victimization (defined in this article as PV) as a precursor to complex post-traumatic biopsychosocial adaptations, revictimization, and in some instances reenactment as a perpetrator (defined as complex trauma [CT]). This model is then applied to three socially disadvantaged victim populations-lesbian, gay, bisexual, transgender, queer, or questioning; commercially sexually exploited individuals; and urban communities of color-who are at heightened risk for PV and for exhibiting complex clinical presentations to demonstrate how the PV-CT framework can destigmatize, reframe, and ultimately reduce health disparities experienced by these populations. Trauma-informed recommendations are provided to aid researchers and multidisciplinary providers working to reduce harm and improve the quality of life for polyvictims.

Providing trauma-informed care to women exiting prostitution: assessing programmatic responses to severe trauma

Women in prostitution (WIP) experience extremely high levels of sexual, physical, and emotional abuse and are significantly more likely to experience mental health issues and trauma than the general population. Research that addresses the mental health needs of WIP emphasizes treating trauma, both trauma that predated entry into prostitution and trauma experienced during prostitution. Very little research is available on services for WIP, thus providers have limited guidance on providing effective services, particularly trauma-informed care. Although programs exist exclusively to assist women leaving prostitution, little is known about services they offer or if services are trauma-informed. Given this dearth, this study consisted of exploratory program evaluations of eight agencies that focus primarily on serving WIP to understand how trauma is addressed in their services.

Survivors’ Perspectives on Recovery From Commercial Sexual Exploitation Beginning in Childhood

This study explored the process of exiting and recovery from commercial sexual exploitation beginning in childhood, utilizing semistructured interviews with 11 adult female survivors who had been out of the commercial sex industry for at least six months. The narratives were analyzed using consensual qualitative research. Participants described a complex interface of internal motivation and external resources in the exiting process. They identified a need for comprehensive, nonjudgmental services across all stages of change, in order to support a profound reconstruction of identity and community. Subgroup comparisons revealed that women who were exploited at younger ages were more vulnerable to coercive and dehumanizing exploitation and required especially intensive services. These results support the methods of many survivor-led programs for sexually exploited youth. Implications of survivors’ perspectives for counseling, research, and advocacy are discussed.

Entrapment and Enmeshment Schemes Used by Sex Traffickers

Emerging research suggests that sex traffickers/pimps control the majority of trafficked girls in the United States. The youthfulness of these victims and their lack of psychosocial maturity severely diminish their ability to detect exploitative motives or withstand manipulation of traffickers. A review of 43 cases of sexually exploited girls involving non-relative traffickers and 10 semi-structured interviews with social service providers revealed numerous scripts and schemes used by sex traffickers to entrap and entangle victims including boyfriend/lover scripts, ruses involving debt bondage, friendship or faux-family scripts, threats of forced abortion or to take away children, and coerced co-offending. These findings inform potential prevention efforts and highlight the need for multi-systemic, victim-centered approaches to intervention.

The Girl Is Mine

Intimate partner violence (IPV) and sex work have been primarily constructed as mutually exclusive phenomena within scholarly literature, though both can be situated under the umbrella of gender-based violence and traced to male sexual proprietariness. Specialized research has resulted in deeper understanding of nuanced categorizations of sub-phenomena within both IPV and sex work, with parallel constructions along a spectrum of increasing danger. However, the scholarly construction of these continua as parallel—and thus unrelated—disguises the systemic nature of each form of violence and potentially pits victims against each other in the struggle for legitimacy. We propose a more systemic approach to understanding and researching IPV and sex work and provide examples of research already moving in this direction.

A Heated Debate: Theoretical Perspectives of Sexual Exploitation and Sex Work

The theoretical and often political framework of sexual exploitation and sex work among women is widely and enthusiastically debated among academic and legal scholars alike. The majority of theoretical literature in this area focuses on the macro perspective, while the micro-level perspective as to theory and causation remains sparse. This article provides a comprehensive overview of the philosophical, legal, and political perspectives pertaining to sexual exploitation of women and girls while addressing the subsequent controversies in the field.

Squaring Up: Experiences of Transition from Off-Street Sex Work to Square Work and Duality--Concurrent Involvement in Both--in Vancouver, BC

Many studies of exit from sex work are inspired by role theory, where people experience a lack of attachment to a role; are faced with individual, interactional, and structural challenges; contemplate transition and exit a role; and then struggle to establish postrole identities and new lives. This framework has been used to explicate the factors and experiences of those who leave or attempt to leave the sex industry; however, it is limited because studies present sex work as a harmful and dangerous profession that people are trapped in, escaping, or have survived. In this paper, I discuss Vancouver's history of violence against sex workers and I review research on sex work exiting and bring forward recommendations for the design of exit program based on the experiences of 22 active and former off-street sex workers from Vancouver, British Columbia. I describe study participants who include Sex-Work-No-More participants who would not return to the industry, Sex-Work-Maybe participants who consider reinvolvement, and Dual-Life participants who are employed in sex work and conventional work simultaneously. These participants uniquely challenge narrow, binary understandings of involvement and transition because they discuss their use of deception to obtain resources needed to make change; the support that clients have provided; their strategic engagement in sex work as a means to exit; their considerations of reentry; and for some, their dual employment. In light of new legislation that criminalizes activities related to sex work-the Protection of Communities and Exploited Persons Act-and the Federal government announcement of $20 million dollars for the creation of exit services nationwide, hearing from sex workers is essential to advancing agendas in this area.

Sex Trading Among Hazardously Drinking Jailed Women

For women involved in sex trading, both alcohol problems and passage through the criminal justice system are highly prevalent. This study is the first to conduct a focused examination of factors associated with sex trading among hazardously drinking, pretrial, jailed women. Cocaine use, social support for alcohol abstinence, and more days incarcerated in the 90 days leading up to the index incarceration were significantly associated with sex trading involvement among alcoholic women. Helping incarcerated alcoholic women reduce cocaine use and improve sober support networks during and following an incarceration may minimize sex trading after release.

Assessing exploitation experiences of girls and boys seen at a Child Advocacy Center

The primary aim of this study was to describe the abuse experiences of sexually exploited runaway adolescents seen at a Child Advocacy Center (N=62). We also sought to identify risk behaviors, attributes of resiliency, laboratory results for sexually transmitted infection (STI) screens, and genital injuries from colposcopic exams. We used retrospective mixed-methods with in-depth forensic interviews, together with self-report survey responses, physical exams and chart data. Forensic interviews were analyzed using interpretive description analytical methods along domains of experience and meaning of sexual exploitation events. Univariate descriptive statistics characterized trauma responses and health risks. The first sexual exploitation events for many victims occurred as part of seemingly random encounters with procurers. Older adolescent or adult women recruited some youth working for a pimp. However, half the youth did not report a trafficker involved in setting up their exchange of sex for money, substances, or other types of consideration. 78% scored positive on the UCLA PTSD tool; 57% reported DSM IV criteria for problem substance use; 71% reported cutting behaviors, 75% suicidal ideation, and 50% had attempted suicide. Contrary to common depictions, youth may be solicited relatively quickly as runaways, yet exploitation is not always linked to having a pimp. Avoidant coping does not appear effective, as most patients exhibited significant symptoms of trauma. Awareness of variations in youth's sexual exploitation experiences may help researchers and clinicians understand potential differences in sequelae, design effective treatment plans, and develop community prevention programs.

Short-term cessation of sex work and injection drug use: evidence from a recurrent event survival analysis

OBJECTIVE

This study quantitatively examined the prevalence and correlates of short-term sex work cessation among female sex workers who inject drugs (FSW-IDUs) and determined whether injection drug use was independently associated with cessation.

METHODS

We used data from FSW-IDUs (n=467) enrolled into an intervention designed to increase condom use and decrease sharing of injection equipment but was not designed to promote sex work cessation. We applied a survival analysis that accounted for quit-re-entry patterns of sex work over 1-year stratified by city, Tijuana and Ciudad Juarez, Mexico.

RESULTS

Overall, 55% of participants stopped sex work at least once during follow-up. Controlling for other characteristics and intervention assignment, injection drug use was inversely associated with short-term sex work cessation in both cities. In Ciudad Juarez, women receiving drug treatment during follow-up had a 2-fold increase in the hazard of stopping sex work. In both cities, income from sources other than sex work, police interactions and healthcare access were independently and significantly associated with shorter-term cessation.

CONCLUSIONS

Short-term sex work cessation was significantly affected by injection drug use. Expanded drug treatment and counseling coupled with supportive services such as relapse prevention, job training, and provision of alternate employment opportunities may promote longer-term cessation among women motivated to leave the sex industry.

Young women selling sex online - narratives on regulating feelings

The current study concerns young women's life stories of their experiences selling sex online before the age of 18. The aim was to gain an understanding of young women's perceptions of the reasons they started, continued, and stopped selling sex. The study included interviews with 15 young women between the ages of 15 and 25 (M=18.9). Thematic analysis was used to identify similarities and differences in the narratives. Three themes and eight sub-themes were identified in relation to different stages in their lives in the sex trade. The themes were organized into three parts, each with its own storyline: "Entering - adverse life experiences"; traumatic events: feeling different and being excluded. "Immersion - using the body as a tool for regulating feelings"; being seen: being touched: being in control: affect regulation and self-harming. "Exiting - change or die"; living close to death: the process of quitting. The informants all had stable social lives in the sense that they had roofs over their heads, food to eat, and no substance-abuse issues. None had a third party who arranged the sexual contacts and none were currently trafficked. They described how their experiences of traumatic events and of feeling different and excluded had led them into the sex trade. Selling sex functioned as a way to be seen, to handle traumatic events, and to regulate feelings. Professionals working with young people who sell sex online need to understand the complex web of mixed feelings and emotional needs that can play a role in selling sex. Young people selling sex might need guidance in relationship building as well as help processing traumatic experiences and ending self-harming behavior. Further studies are needed on the functions of online sex selling and on the exit process for young people, in order to prevent entrance and facilitate exiting.

Risk and resiliency factors influencing onset and adolescence-limited commercial sexual exploitation of disadvantaged girls

BACKGROUND

Previous research into age-related variables relevant to girls and young women being involved in commercial sexual exploitation (including prostitution) has not distinguished between its onset and limitation to adolescence and its early onset and persistence into adult life.

AIMS

The aims of this study were to examine variables associated with adolescent versus adult onset of commercial sexual exploitation and identify potential risk and resiliency factors differentiating adolescence-limited sexual exploitation and early-onset-adult persistent exploitation.

METHOD

Interviews with 174 vulnerable mostly African-American women, 23% of whom reported commercial sexual exploitation in adolescence and/or adulthood, yielded data, which were analysed using multinomial logistic regressions.

RESULTS

Adolescent sexual victimisation, younger age at first alcohol/drug use, being a victim of intimate partner violence and sense of stigmatisation of sexual self/others were all variables associated with adolescent onset of commercial sexual exploitation. Educational attainment differentiated adolescence limited from adolescent-adult persistent exploitation; exploitation had ceased by adulthood among over two-thirds of those who completed at least high school education, but only 13% of those exploited into adult life had finished high school.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

As level of education was linked to cessation of exploitation by adulthood, support for vulnerable girls to complete education at least to high school level may be protective.The link between early onset of substance misuse and persistent exploitation suggests that education and support specifically targeted within this field could reduce likelihood of persistent abuse.Work directed at improvement of self-image may also reduce risk of persistent exploitation.

On the relationships between commercial sexual exploitation/prostitution, substance dependency, and delinquency in youthful offenders

Researchers have consistently linked commercial sexual exploitation (CSE) of youth and involvement in prostitution with substance dependency and delinquency. Yet, important questions remain regarding the directionality and mechanisms driving this association. Utilizing a sample of 114 CSE/prostituted youth participating in the Pathways to Desistance study-a longitudinal investigation of the transition from adolescence to adulthood among serious adolescent offenders-the current study examined key criminal career parameters of CSE/prostitution including age of onset and rate of recurrence. Additionally, structural equation modeling (SEM) was used to explore concurrent associations and causal links between CSE/prostitution and drug involvement. Findings show a general sequential pattern of the ages of onset with substance use and selling drugs occurring prior to CSE/prostitution, evidence that a small group with chronic CSE/prostitution account for the majority of CSE/prostitution occurrences, and high rates of repeated CSE/prostitution. SEM results suggest CSE/prostituted youth persist in drug involvement from year to year but infrequently experience perpetuation of CSE/prostitution from year to year. Concurrent associations between CSE/prostitution and drug involvement were found across the length of the study. Additionally, drug involvement at one year was linked to CSE/prostitution during the subsequent year during early years of the study.

Age-graded risks for commercial sexual exploitation of male and female youth

Emerging evidence indicates male youth are affected by commercial sexual exploitation (CSE). However, most studies investigating risk markers influencing age of onset of CSE have focused on vulnerabilities of girls and women. Using a sample of 1,354 serious youthful offenders (of whom approximately 8% of males and females reported being paid for sex), the current study assessed whether risks associated with age of onset of CSE for girls and young women operated similarly in boys and young men. Findings showed that African American male youth were at heightened risk for CSE, while female youth of all races/ethnicities were at similar risk. For all youth, maternal substance use and earlier age of first sex were associated with early age of onset of CSE. For male youth, experiencing rape and substance use dependency were associated with early age of onset. Psychotic symptoms, likely experienced as social alienation, were associated with both early and late age of onset. For all youth, lower educational attainment was associated with CSE beginning in later adolescence or young adulthood. In addition, substance use dependency was linked to late age of onset for female youth. Implications of the study findings for theory development and application to CSE are noted.

Qualitative perspectives toward prostitution's perceived lifestyle addictiveness

BACKGROUND AND AIMS

The aim of the present study was to provide a phenomenological perspective of individuals who actively engage in street-level prostitution and identified a lifestyle addiction associated with their activities.

METHODS

We interviewed 25 women who were incarcerated in American county jails (at the time of interviews) for prostitution crimes. The transcripts were analyzed for themes that represented the shared consensus of the research participants.

RESULTS

Four negative psychological dynamics related to prostitution. First, participants described accounts of physical and emotional violence which they experienced at the hand of clients and others involved in the lifestyle. Second, interviewees explained an extreme dislike for their actions relating to and involving prostitution. These individuals did not describe themselves as being sexually addicted; sex was means to a desired end. Third, participants described how prostitution's lifestyle had evolved into something which they conceptualized as an addiction. As such, they did not describe themselves as feeling addicted to sex acts - but to lifestyle elements that accompanied prostitution behaviors. Finally, participants believed that freedom from prostitution's lifestyle would require social service assistance in order to overcome their lifestyle addiction.

CONCLUSIONS

The results show that, although the prostitutes repeatedly and consistently used the term "addiction" when describing their lifestyles, they did not meet the DSM-IV-TR criteria for addiction. Rather, they shared many of the same psychological constructs as do addicts (e.g., feeling trapped, desiring escape, needing help to change), but they did not meet medical criteria for addictive dependence (e.g., tolerance or withdrawal).

The illusions and juxtapositions of commercial sexual exploitation among youth: identifying effective street-outreach strategies

To explore sexually exploited youths' perspectives of how street outreach workers can effectively provide outreach and connections to services, we conducted qualitative interviews with 13 female participants, ages 14 to 22, in a Midwest U.S. city. Participants reported multiple types of exploitation, most first exploited by age 13, plus substance use and recurrent homelessness. Nearly all had a pimp, and all used the internet as a venue for sexual exploitation. Participants wanted outreach workers to use "soft words" to refer to exploitation. They expressed contradictory images of their "boyfriend" pimps and their exploitation. They wanted outreach workers to "provide resources," "be nonjudgmental," "listen," and "care." Street outreach can be one way to support sexually exploited youth but should occur in multiple settings.

A Predictive Theory of Intentions to Exit Street-Level Prostitution

Street-level prostitution is notoriously difficult to escape and rarely do women exit prostitution on their first attempt or without experiencing serious negative consequences to their physical or mental health. Unfortunately, few theories exist that explain the exiting process and those that do exist are difficult to test quantitatively. This article applies the integrative model of behavioral prediction to examine intentions to exit prostitution through attitudes, norms, and self-efficacy beliefs that underlie a woman’s intention to exit prostitution. Constructs unique prostitution—agency and societal context—enhance the model. This theory may explain and predict an exit from street-level prostitution.

Understanding the social and economic contexts surrounding women engaged in street-level prostitution

Prostitution involves the exchange of sexual services for economic compensation. Due to the sexual promiscuity surrounding prostitution, women involved in prostitution constitute a high-risk group for contracting and transmitting STDs, including HIV. Prostitution is not only a public health concern, but also an economic one. Cities throughout the United States spent an average of $7.5 to $16 million per year enforcing prostitution laws and addressing negative outcomes associated with prostitution. Thus, women involved in prostitution are a cause for concern from both public health and economic perspectives. However, little is known about why women remain in this type of behavior given the risks prostitution presents, and even less is known about how to intervene and interrupt the complex cycle of prostitution. Thus, the purpose of this study was to understand what factors contribute to a woman's decision to remain in prostitution. A series of interviews were conducted with 12 women engaged in street-level prostitution. Results of the study revealed that drug use not only spurs entry into prostitution, but also contributes to the tenure of prostitution. Further, social support and economic stability are plausible reasons for women remaining in prostitution. These findings lead us to recommendations for policy and program development. Women involved in prostitution are a highly marginalized population, rarely recognized as individuals with life histories. Understanding why women remain in prostitution is important, because until these determinants are known, intervention programs designed to interrupt the cycle, and ultimately prevent prostitution, cannot be formulated.