FVPF eJournal
Futures Without Violence eJournal
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Sex Trade, Violence, and Health

by Michele R. Decker, ScD and Elizabeth Miller, MD, PhD

Michele R. Decker, ScD MPH
Assistant Professor
Department of Population, Family and Reproductive Health
Johns Hopkins Bloomberg School of Public Health
mdecker@jhsph.edu

Elizabeth Miller, MD, PhD
Assistant Professor
Department of Pediatrics
UC Davis School of Medicine
elizabeth.miller@ucdmc.ucdavis.edu

Background
Young women and girls involved in sex trade are at extremely high risk for physical and sexual violence victimization as well as for a range of negative health outcomes.  Despite this growing body of evidence, this vulnerable population continues to be under-recognized and underserved by both the health care system and by violence victimization services.  Consideration of the intersections of sex trade, violence, and health holds implications for appropriate clinical care as well as violence prevention and service delivery.   This article will briefly describe the existing literature regarding health and violence among women involved in sex trade and will outline future directions for research and programmatic efforts.

Sex Trade: What’s in a name?
The exchange of sex for money, drugs, or other items of value has been defined by a myriad of terms spanning transactional sex, sex trade, commercial sex work, prostitution, and commercial sexual exploitation, to name a few.  Common to these definitions is the exchange of sex for material goods or value; distinguishing them are different levels of control and/or exploitation assumed to characterize these experiences (e.g., transactional sex vs. prostitution).  These assumptions have not been well tested, and little is known about (a) conditions of violence and coercion around entry, and (b) the ability to exit, both of which may differ among these various groupings.  Such research is needed to best reflect the experiences of those involved.  To the extent possible, this article integrates research spanning these sub-populations.

Health

Women involved in sex trade represent an extremely vulnerable population subject to severe health consequences spanning substance use (Ward & Day, 2006; el-Bassel et al., 2001), mental health issues (Ward & Day, 2006; el-Bassel et al., 2001; el-Bassel et al., 1997; Farley & Barkan, 1998; Farley et al., 2004; Burnette et al., 2008) and sexually transmitted infections (STI) including HIV (Ward & Day, 2006; el-Bassel et al., 2001; Brahme et al., 2006; Sarkar et al., 2005; Decker et al., 2010) as well as an age-adjusted mortality rate almost double that of the general population (Potterat et al., 2004).  Likely resulting from these threats, extensive health and safety needs have been documented that include medical care, housing, substance use treatment, job skills training, and other support services (Valera et al., 2001; Jeal & Salisbury, 2004; Jeal & Salisbury, 2007; Kurtz et al., 2005).

Sex Trade and Violence Victimization
The intersections of violence with sex trade are vast and complex.  Physical and sexual abuse during childhood is a common precursor for involvement in commercial sex (Wilson & Widom, 2010; Nixon et al., 2002; Stoltz et al., 2007).  Sex trade is also a common context for severe physical and sexual violence (el-Bassel et al., 2001) at the hands of clients and pimps (Nixon et al., 2002; Williamson & Cluse-Tolar, 2002).    Notably, intimate partner violence (IPV) is also common among those involved in sex trade (el-Bassel et al., 2001; Nixon et al., 2002; Raj et al., 2006; Decker et al., under review), though the nature of this relationship is not well understood.  For example, IPV victimization may make women vulnerable to sex trade if they have few alternate means of financial support while leaving abusive partners.  Moreover, for some women, pimp-like relationships may begin as boyfriend-like relationships that then progress into pressure into trading sex (Nixon et al., 2002; Kennedy et al., 2007).  This evidence suggests that perpetrators of partner violence and pimps may be the same individuals for some women.   These fluctuating relationship categories present challenges for clinicians and violence victim advocates, as abusive individuals identified as partners may also be involved in sexual exploitation.   Recognizing the potential links between partner violence and sex trade may help clinicians and violence support service providers better understand the experiences and risks faced by their patients and clients.

Violence and Coercion in the Context of Sex Trade Threatens Sexual and Reproductive Health

Violence and coercion have important roles in the dramatically elevated sexual risk for this group of women in comparison to the general population.  Indeed, many of the ways in which violence can compromise health among those involved in sex trade mirrors those identified in other violence-related research.  For example, experiences of forced sex and condom refusal by clients, as well as being offered more money for unprotected sex, are common in the US as well as elsewhere (Basuki et al., 2002; Buckingham et al., 2005; Decker et al., 2009; Decker et al., 2010; Decker et al., under review).  These data illustrate the role of coercion in compromising health and posing sexual risk in this vulnerable group.   Again, paralleling the links of IPV and STI/HIV observed in the general population (Silverman et al., 2008; Decker et al., 2005), violence victimization in the context of sex trade has been linked with greater STI and HIV risk among those involved (Decker et al., 2010; Sarkar et al., 2008). Physical trauma from violent sexual acts, client condom refusal, fear of condom negotiation with both clients and pimps, and lack of transportation or freedom (e.g., restrictions imposed by pimps) to seek clinical care, are all likely contributors to an increased risk for poor sexual and reproductive health among those involved in sex trade.   From a clinical perspective, understanding the connections among sex trade experiences, violence, and poor health is critical given the lack of control these women may face in protecting their own sexual and reproductive health (e.g., via condom use).

Future Directions

Given the severe risk for violence and resulting trauma on multiple levels across the lifecourse (e.g., childhood physical and sexual abuse, partner violence, and sexual assault within and outside the context of sex trade), women involved in sex trade likely require unique attention within violence victim advocacy services.  Despite clear indication of their elevated risk for violence, very little is known about the use of violence-related support services among women in sex trade, and unique barriers they may face in accessing such services.   While further research is needed to understand the prevalence of sex trade involvement among clients of domestic and sexual violence programs, targeted outreach and sensitivity training around sex trade experiences are likely needed to best guide those involved.

Similarly, understanding how this vulnerable population may intersect with more general health services is critical for designing assessment and strategies for intervention.   For example, 32% to 41% of women in substance use treatment settings report a history of  sex trade during the past year (el-Bassel et al., 2001; Burnette et al., 2008) and preliminary findings from our recent investigation of family planning clinic patients indicate an 8% lifetime prevalence of sex trade involvement (Decker et al., under review).  Evaluating the prevalence of sex trade experiences within clinical settings that serve patients at high risk for poor health is critical for providing trauma- informed care; moreover these access points may well serve an important role in identifying those involved in sex trade and referring them to support services.

Given the implications for violence and health based on sex trade involvement, clinical providers and violence-support services alike should work to raise awareness of sex trade, and facilitate identification and trauma-informed care for this at-risk group.  Qualitative investigation among women involved in street-based prostitution indicates a desire for providers to understand their situation (Jeal & Salisbury, 2004), yet few such women disclose their involvement (Cohan et al., 2006).  In light of the stigma associated with sex trade (Kurtz et al., 2005; Jeal & Salisbury 2004), addressing sex trade experiences must be conducted with the utmost sensitivity.   Several lessons from the IPV screening literature likely apply to addressing sex trade in the clinical and social service settings.  For example, normalizing experiences of sex trade and offering a reason for asking may reduce patient concerns about being judged. In addition, providers can offer support and referral to resources regardless of disclosure, and can create an atmosphere of safety to allow the patient to disclose at a later date (Chang et al., 2005).  Providers can be trained to ask sensitively about sex trade, to include this consideration in particular when confronted with a patient with poor health status, and to ensure that she receives the immediate service supports she needs.

Finally, a better understanding of the contexts by which women become involved in sex trade will greatly enhance our ability to meet the needs of those involved.   Recent international and domestic attention to sex trafficking and commercial sexual exploitation of youth is critically important given the high HIV prevalence documented among this group (Silverman et al., 2007).  Recent data illustrates that many enter sex work as adolescents and/or under conditions of force or coercion (i.e. sex trafficking; UN 2000); moreover, those entering through such mechanisms face greater levels of maltreatment and sexual risk (Decker et al., in press; Sarkar et al., 2008).   Young women and girls involved in sex trade often confront a vast range of circumstances that, in turn, likely influence their risks for poor health and violence and coercion.  Future research must attend to these patterns in order better understand and meet the needs of this vulnerable population.

Conclusion
The risks for negative health consequences and violence victimization among those involved in sex trade strongly indicate the need for greater attention to this population within the public health infrastructure.  Women’s clinical care and violence support services are particularly critical settings for outreach.   Moreover, evidence that many women involved in sex trade wish to escape it (Farley & Barkan, 1998) highlights the need for efforts to identify and assist women involved in sex trade in order to improve their overall health and well-being.

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