Exploring the experiences of wellbeing, health, and healthcare among women who have been domestically sex trafficked in Ontario, Canada: A qualitative study protocol

INTRODUCTION

Although there is a growing body of evidence to suggest that persons who have been sex trafficked can suffer devastating health consequences and often face challenges accessing suitable care that addresses their health and overall well-being, little existing research has adopted a survivor-informed approach. Centering the voices of sex-trafficked women in this research will provide valuable insights into their health-related experiences and can help lay the foundation for survivor-centric healthcare responses.

METHODS AND ANALYSIS

Using a semi-structured interview guide, we will interview women who have been domestically sex trafficked in Ontario; recruitment will continue until data saturation is reached. Interview questions and prompts will elicit information about women's experiences prior to, during, and after their trafficking ordeal, with particular attention paid to their encounters with healthcare providers. Intersectionality theory will inform strategies for recruitment, data collection, and data analysis. Data will be analyzed deductively as well as inductively using Braun and Clarke's six phases of reflexive thematic analysis. The study's design was informed by the consolidated criteria for reporting qualitative research (COREQ), which ensures a comprehensive and robust reporting of interview data. We will continue to adhere to the COREQ checklist throughout the data collection, analysis, and findings write-up phases, helping to ensure methodological accuracy and transparency.

DISCUSSION

To our knowledge, this will be the first Canada-specific investigation to apply intersectionality theory to explore the experiences of well-being, health, and healthcare from the perspectives of women who have been domestically sex trafficked. The results of this study hold the potential to improve responses to trafficking within the healthcare sector. Specifically, the findings could be used to inform the development of education materials and curricula for medical students and continuing professional education for health and allied healthcare providers. They could also inform the creation of patient experience surveys and intake forms for sex trafficked patients.

Including the issue of receiving payment for sex in intervention for substance use disorder: Professionals' intentions and interventions

BACKGROUND

Studies have shown that a high percentage of individuals with substance use disorder (SUD) are involved in receiving payment for sex (RPS). The stigma associated with RPS may lead to non-disclosure of RPS in drug treatment services thus preventing fully benefitting from SUD treatment. Research on RPS in the context of SUD interventions is scarce. The current study examined the extent to which social workers believe they should attend to the issue of RPS as part of the treatment of addictions and the extent of their self-reported work with RPS, as associated with comfort in discussing sexual issues in treatment (CDSIT), professional self-efficacy, attitudes towards people who engage in RPS, and attitudes towards social justice.

METHOD

A sample of 171 social workers who had worked with individuals with SUD in addiction treatment centers completed an online questionnaire. The main analyses were only conducted on participants who completed the full questionnaire (n = 124).

RESULTS

Most social workers believe in the importance of addressing RPS issues in treatment of individuals with SUD, but mostly did not translate their beliefs into practice. Attitudes toward social justice and toward people who engage in RPS, and the interaction between self-efficacy and CDSIT were associated with the belief in the importance of addressing RPS in treatment. The main factor that contributed to the self-reported work with RPS was CDSIT.

CONCLUSION

Policy-makers should promote specific training for professionals in the addiction field to address the issue of RPS when working with individuals with SUD, and increase levels of CDSIT.

Violence Against Prostitutes and Non-prostitutes: An Analysis of Frequency, Variety and Severity

Violence against women is a form of gender violence, and the lethal aspect of it, defined as femicide, is a global health and human rights problem.This study looked at 330 cases of femicide that occurred in North West Italy, between 1970 and 2020, committed by 303 male perpetrators. The victims included women who were prostitutes and those who were not.Findings show that only a small proportion of femicide occurs within an anonymous setting: Victims were mostly killed by a man they knew. The type and intensity of the relationship was likely to affect how the violence occurred. In those cases in which victims and perpetrators had an intimate relationship, the risk of overkill, that is, an excessive use of violence that goes further than what is necessary to cause death, was four times higher in comparison with the murder of unknown victims. As with non-prostitutes, the risk of overkill was almost fourfold for those prostitutes who knew their perpetrators. Furthermore, when comparing prostitutes with any unknown victims, the risk of being overkilled was almost five times higher for the former, suggesting that prostitutes are more at risk of being murdered with excessive violence. In addition, prostitutes were more likely to be victims of sexual murder, postmortem mutilation, and being killed by men who had previous criminal records.Women who are victims of violence are not a homogeneous group, although some of the psychosocial correlates are the same and relevance should be given to the features behind the type, intensity, and nature of the relationship between prostitutes and non-prostitutes and their perpetrators. These variables are what make violence against women a preventable problem.

Sub-Saharan women trafficked for sexual exploitation: A transdisciplinary approach from the paradigm of resilience

Introduction. Human trafficking for the purpose of sexual exploitation is a growing social problem in today’s democratic societies, affecting mainly girls and women (Eurostat, 2018). It is also a crime (Palermo protocol [UN, 2000]), a violation of human rights, and a manifestation of gender-based violence (UN’s Declaration on the Elimination of Violence against Women [UN, 1993]), and a type of slavery (Correa, 2011) against the most impoverished women. Purpose. In this article, we focus on the sub-Saharan trafficked women who come to southern Europe via the human trafficking routes that cross northern Africa going through places such as Lagos, Tinzaouaten (Mali), Tamanrrasset (Argelia), the Sahara Desert, and different Moroccan cities, before reaching Europe over the Southern Spanish coastline. Ew show the resources used by these women when going through the said contexts of exploitation and forced prostitution. Methodology. Our research reviews the existing literature taking resilience as a pivotal point that is present in various areas of knowledge, including psychology and literature, among others. It allows us to show a change of perspective in this matter, by making these women visible in terms of their capacities. Results. We show examples, from different fields of knowledge and disciplines, of women who, having lived in these contexts, have carried out processes of fortitude, recovery, and personal growth. A new glimpse of this phenomenon and of these processes is studied, from a scarcely researched perspective to this day. Contribution. The originality of this analysis contributes a new understanding of the capacity of resilience of this population, despite the adverse conditions of their migratory experience

Violence in Commercial Sex Work: A Case Study on the Impact of Violence Among Commercial Female Sex Workers in India and Strategies to Combat Violence

Violence is one of the primary contextual factors that significantly raise sex workers' sexually transmitted infection risk. The current study examines how violence affects sexual health behavior among commercial female sex workers in a red light district in Calcutta, India. The study which employs in-depth interviews of 37 commercial female sex workers also discusses an innovative multilayered strategy devised by the sex workers to combat violence through a community mobilization drive. The current study shows that the sex workers can confront the system that precipitates violence and actively engage with it to mitigate the impact of structural barriers to empowerment.

Psychological Distress Among Orphaned Youth and Youth Reporting Sexual Exploitation in Kampala, Uganda

Psychological distress is a priority health issue in low- and middle-income countries; however, it is inadequately addressed among vulnerable youth living in extremely underserved communities (i.e., on the streets and in the slums) who are at a high risk of experiencing adversity. The purpose of this study was to compute the prevalence of self-reported psychological distress among youth living in the slums of Kampala, Uganda, and examine how orphan status and commercial sexual exploitation (CSE) are related to youth psychological distress. Analyses are based on a 2014 cross-sectional survey of service-seeking youth (N = 1134) in Kampala, Uganda. Bivariate and multivariable multinomial regression analyses were used to determine associations between orphan status, sexual exploitation, and psychological distress (defined as experiencing the following proxy variables for more complex psychopathology: hopelessness and/or worry). Among all youth participants, 83.2% (n = 937) reported at least one type of psychological distress; 51.3% (n = 578) reported experiencing both types. The reported prevalence of any type of psychological distress was highest among youth who reported experiencing sexual exploitation (91.2%), double orphans (90.0%), and single orphans (83.8%); however, a high prevalence (76.7%) of any type of distress was also found among youth who reported both parents alive. Experiencing both types of distress was associated with being a double orphan (adjusted odds ratio [AOR] = 2.92, 95% confidence interval [CI] = [1.77, 4.81]), reporting CSE (AOR = 2.71, 95% CI = [1.67, 4.41]), and increased age (AOR = 1.31, 95% CI = [1.20, 1.44]). Psychological distress is prevalent among all youth living in the slums of Kampala and is independently associated with being a double orphan and experiencing CSE. These findings underscore the urgent need to intervene with all youth who reside in this particular underserved community, especially those who have lost both parents, and to prevent CSE among this vulnerable, underserved population.

Using Peer Education to Promote Psychosocial and Occupational Health and Empowerment Among Female Sex Workers in Nepal

Female sex workers (FSWs) in Nepal are vulnerable to an array of occupational risks, which may compromise their psychosocial health and ability to engage in protective behaviors. A peer education (PE) intervention designed to empower and promote the psychosocial health of FSWs was pilot tested in Kathmandu, Nepal. FSWs who were exposed to the PE intervention (n = 96) had significantly higher scores on psychosocial health knowledge, perceived self-efficacy and ability to access resources, happiness, and job control compared with those who were not (n = 64). PE may be a promising way to promote psychosocial health and empowerment among FSWs.

A Systematic Review of Dissociation in Female Sex Workers

We analyze the empirical evidence for the association between the occurrence of dissociation and acting as a female sex worker (FSW). The ten screened databases included original research papers looking at the association between various abusive relationships and dissociation. From the initial 5942 records, we screened 554 full-text articles from which eleven studies met the inclusion criteria. Dissociation was mainly described as a strategy to cope with work related experiences, persisting from an early age in cases affected by childhood sexual abuse (CSA). Only one study investigated the occurrence of dissociative disorders. The other studies showed that the FSW population frequently exhibits dissociative symptoms. Most study participants were street FSW characterized by high rates of revictimization, a history of childhood sexual abuse, and of trauma-related and substance use disorders. Due to the selectivity of the study samples, conclusions cannot be generalized. Our findings disclose an important research gap. Further research on mental health among FSW should cover all fields of the sex industry in order to understand the roots of sex work (SW) and its sequelae. This could help develop and implement targeted interventions.

Sex Work and Mental Health: A Study of Women in the Netherlands

This study examined how characteristics of prostitution and quality-of-life factors related to symptoms of depression and post-traumatic stress among 88 women engaged in prostitution in the Netherlands. Numerous factors were associated with elevated mental health concerns, including the experience of violence in prostitution, engaging in street prostitution, being motivated to engage in prostitution for financial reasons, having less confidence in one's ability to find alternative work, desiring to leave prostitution, and sense of self-transcendence. In contrast, focusing on achievement, having a sense of fair treatment from others and society, and self-acceptance were associated with better mental health outcomes. Finally, mediation analyses indicated that post-traumatic stress associated with engaging in prostitution against one's deeper desire to exit prostitution was, in part, the result of a lack of self-acceptance. The analyses controlled for relevant demographic factors, including age and level of education. The effect sizes for each of the findings ranged from medium to large. Implications for mental health care and public policy are included.

Violence against Prostitutes

Violence has long been assumed to be an intrinsic trait of female prostitution. However, it has been mostly associated with the locale in which the activity is exercised, i.e. with working time and space. In this article, based on data gathered by direct observations, in-depth interviews and the compilation of so-called time-budgets, the authors demonstrate that violence is as pervasive and omnipresent a feature of prostitutes’ ostensibly private ‘off-duty’ (non-working) time and space, though it takes on varied and distinct forms and configurations, compared to violence in the workplace.

“Bad for the Body, Bad for the Heart”: Prostitution Harms Women Even if Legalized or Decriminalized

With examples from a 2003 New Zealand prostitution law, this article discusses the logical inconsistencies in laws sponsoring prostitution and includes evidence for the physical, emotional, and social harms of prostitution. These harms are not decreased by legalization or decriminalization. The article addresses the confusion caused by organizations that oppose trafficking but at the same time promote prostitution as a justifiable form of labor for poor women. The failure of condom distribution/harm reduction programs to protect women in prostitution from rape, sexually transmitted diseases (STDs), and HIV is discussed. The success of such programs in obtaining funding and in promoting prostitution as sex work is also discussed.

Female Prostitution, Customers, and Violence

Through a critical review of existing research, this article argues that (a) customers have been excluded from many debates surrounding prostitution, and including them will create a more robust dialogue regarding prostitution; (b) though prostitution seeking is often treated as a natural part of masculine sexual experience, most men do not pursue prostitutes, and very few are regular users; (c) many commonsense understandings of men’s motivations for seeking prostitutes are consistent with existing research; (d) a series of attitudinal orientations may help explain why some men meet their desires through prostitution and others do not, and may also help to explain some of the violence experienced by prostitutes; and (e) customers actively construct their encounters with prostitutes in ways that support their understandings of prostitution and their sexual desires, often working to maintain a sense of mutuality and consent. Incorporating customers into academic scholarship on prostitution can lead to more balanced research that better informs public policy.

The Everyday Occurrence

This article reports the results of qualitative interviews with 47 women involved in prostitution from three western Canadian provinces. More than two thirds of the women had become involved at age 15 or younger. The respondents described high rates of violence perpetrated against them. They reported considerable childhood sexual abuse, most often by a family member or by caretakers while they were living in foster care or group homes. The young women continued to experience violence as prostitutes so commonplace that it almost seemed “normal.” They were victimized by pimps, johns, other prostituted women, intimate partners, and representatives from mainstream society and members of the police. This article describes their experiences of violence, the associated health problems, the protective strategies they used, and their attempts to leave the streets. The conclusion suggests ways in which agencies and policies could better address the violence experienced by these young women.

The Trauma of Commercial Sexual Exploitation of Youth: A Comparison of CSE Victims to Sexual Abuse Victims in a Clinical Sample

This study examined the demographic features, trauma profiles, clinical severity indicators, problem behaviors, and service utilization characteristics of youth victims of commercial sexual exploitation (CSE) compared with a matched sample of sexually abused/assaulted youth who were not exploited in commercial sex. Secondary data analysis and propensity score matching were used to select a sample of 215 help-seeking youth who were exploited in prostitution (n = 43) or who were sexually abused/assaulted but not exploited in prostitution (n = 172) from the National Child Traumatic Stress Network Core Data Set (NCTSN CDS). Propensity Score Matching was used to select a comparison sample based on age, race, ethnicity, and primary residence. Statistically significant differences were noted between the groups on standardized (e.g., UCLA Posttraumatic Stress Disorder Reaction Index [PTSD-RI], Child Behavior Checklist [CBCL]) and other measures of emotional and behavioral problems (e.g., avoidance and hyperarousal symptoms, dissociation, truancy, running away, conduct disorder, sexualized behaviors, and substance abuse). This study provides useful insight into the symptom and service utilization profiles of youth exploited in commercial sex as compared with youth with other types of sexually exploitive experiences. Targeted screening and event-sensitive measures are recommended to more accurately identify youth exploited in commercial sex. More research is needed to determine if and what modifications to trauma therapies may be required to address the more severe symptomatology and behavior problems associated with youth exploited in commercial sex.

Materialistic Desires or Childhood Adversities as Explanations for Girls' Trading Sex for Benefits

This study investigates whether high school and younger South Korean girls trade sex with middle-aged men for benefits due to cultural emphasis on materialism/consumerism, childhood adversities, or both. This form of prostitution, referred to as "compensated dating," is common in economically developed East Asian Countries, where there is debate about its causes. Purposeful sampling was used to select a diverse group of 25 girls who described involvement in compensated dating, and a life calendar method was used to guide the interview. The rich data were subjected to thematic analysis to show the nature of prostitution involvement, precursors, and motivations. Data analysis revealed that sole reliance on materialistic desire as an explanation of prostitution obscures the influence of peer pressure and family dysfunction. Findings suggest the need for social services rather than punitive responses to girls involved in compensated dating.

Examining the associations between sex trade involvement, rape, and symptomatology of sexual abuse trauma

The high prevalence of rape and sexual trauma symptomatology among women involved in street-based sex trades is well-established. Because prior research has lacked appropriate, non-sex trade involved comparison groups, it is unknown whether differences exist among similarly situated women who do and do not trade sex. This article explores experiences of childhood and adult rape and symptomatology of sexual abuse trauma among a community-based sample of 322 women who use methamphetamine in San Francisco, California, 61% of whom were involved in the sex trade. Study participants were recruited via respondent-driven sampling and eligible if they were cisgender women, aged 18 or older, current methamphetamine users, and sexually active with at least one cisgender man in the past 6 months. The dependent variable was sexual abuse trauma symptomatology, as measured by the Sexual Abuse Trauma Index (SATI) subscale of the Trauma Symptom Checklist-40 (TSC-40), and the explanatory variable was sex trade involvement. Potential covariates were age, current homelessness, methamphetamine dependence, and experiences of childhood and adult rape. Sixty-one percent of participants had a SATI subscale score suggestive of sexual abuse trauma. The overall prevalence of rape in childhood and adulthood was 52% and 73%, respectively. In bivariate analysis, sex trade involvement and all of the potential covariates except for homelessness and age were associated with a SATI score suggestive of sexual abuse trauma. In multivariate models controlling for significant covariates, there was no longer a statistically significant association between sex trade involvement or childhood rape and an elevated SATI score. Elevated levels of psychological dependence on methamphetamine and experiences of rape as an adult were still associated with a high SATI score. These findings highlight that urban poor women, regardless of sex trade involvement, suffer high levels of rape and related trauma symptomatology.

"Amar te Duele" ("love hurts"): sexual relationship power, intimate partner violence, depression symptoms and HIV risk among female sex workers who use drugs and their non-commercial, steady partners in Mexico

A significant body of research among female sex workers (FSWs) has focused on individual-level HIV risk factors. Comparatively little is known about their non-commercial, steady partners who may heavily influence their behavior and HIV risk. This cross-sectional study of 214 FSWs who use drugs and their male steady partners aged ≥18 in two Mexico-U.S. border cities utilized a path-analytic model for dyadic data based upon the Actor-Partner Interdependence Model to examine relationships between sexual relationship power, intimate partner violence (IPV), depression symptoms, and unprotected sex. FSWs' relationship power, IPV perpetration and victimization were significantly associated with unprotected sex within the relationship. Male partners' depression symptoms were significantly associated with unprotected sex within the relationship. Future HIV prevention interventions for FSWs and their male partners should address issues of sexual relationship power, IPV, and mental health both individually and in the context of their relationship.

A border context of violence: Mexican female sex workers on the U.S.-Mexico border

Female sex workers (FSW) represent a population confronted with an array of intersecting social problems. We explore the case of FSW in Nuevo Laredo and Ciudad Juarez to understand the everyday violence associated with sex work within the unique context of Mexico. Life history interviews were conducted with 109 FSW revealing violent acts by clients and other sex industry employees (bar owners, police, other FSW). The risk of violence by different types of persons associated with the sex work industry varied by venue and geographic area. Moreover, the violence was shaped by the social structural constraints of dominant gender ideologies.

Prevalence and correlates of client-perpetrated abuse among female sex workers in two Mexico-U.S. border cities

History of abuse has been associated with greater HIV risk among women. This study examined client-perpetrated abuse among female sex workers (FSWs) in two Mexico-U.S. border cities where HIV prevalence is rising. Among 924 FSWs, prevalence of client-perpetrated abuse was 31%. In multivariate logistic regression models, intimate partner violence (IPV), psychological distress, and having drug-using clients were associated with experiencing client-perpetrated abuse. FSWs along the Mexico-U.S. border report frequently experiencing abuse from both clients and intimate partners, which may have serious mental health consequences. Our findings suggest the need for screening and gender-based violence prevention services for Mexican FSWs.

Why the Treatment of Mental Disorders Is an Important Component of HIV Prevention among People Who Inject Drugs

People who inject drugs are more likely to be HIV positive and to have a mental disorder than the general population. We explore how the detection and treatment of mental illness among people who are injecting drugs are essential to primary and secondary prevention of HIV infection in this population. Aside from opioid addiction, few studies have been conducted on the links between mental disorders and injection-drug use. However, independent of the injection-drug use literature, a growing number of studies demonstrate that untreated mental illness, especially depression and alcohol/substance use disorders, is associated with HIV-related risk behaviors, acquiring HIV infection, failure to access HIV care and treatment, failure to adhere to HIV care and treatment, and increased morbidity and mortality from HIV-related diseases and comorbidities. In our review of both the published literature and gray literature we found a dearth of information on models for providing care for both opioid addiction and other mental illnesses regardless of HIV status, particularly in low- and middle-income countries. We therefore make recommendations on how to address the mental health needs of HIV-positive people who inject drugs, which include the provision of opioid substitution therapy and integrated mental health, substance abuse, and HIV services.

Violence as a barrier for HIV prevention among female sex workers in Argentina

BACKGROUND

Violence against female sex workers (FSWs) has been increasingly reported as an important determinant of HIV infection risk. This study explores the frequency of different violent experiences (sexual abuse, rejection, beating and imprisonment) among FSWs in Argentina and its association with condom use and HIV and T. pallidum prevalence.

METHODS

A convenience sample of 1255 FSWs was included in a cross-sectional study conducted between October 2006 and November 2009.

RESULTS

Sexual abuse was reported by 24.1% (219/907) of women. A total of 34.7% (42/1234) reported rejection experiences, 21.9% (267/1215) reported having been beaten and 45.4% (561/1236) stated having been arrested because of their sex work activity. There was a higher frequency of inconsistent condom use with clients among FSWs who had experienced sexual abuse, rejection, and police detention. A higher frequency of HIV and T. pallidum infection was detected among FSWs who reported having been arrested by the police.

CONCLUSION

The study shows for the first time the frequency of different violent situations among FSWs in Argentina. The association between violence against sex workers, condom use and STI prevalence demonstrated here calls for measures to reduce stigma and violence against FSWs. Such violent experiences may increase vulnerability to STI through coerced unprotected sex.

Sex worker victimization, modes of working, and location in New South Wales, Australia: a geography of victimization

This article examines the association among victimization, modes of sex working, and the locations used by sex workers through an analysis of "Ugly Mug" reports detailing 528 crime acts in 333 reported incidents in New South Wales (NSW), Australia. These forms, voluntarily lodged between 2000 and 2008 by members of NSW's estimated 10,000 sex worker population, suggest that street-based work has a higher victimization rate than other modes of working, including escort work, work in commercial premises, and private work. Although this ostensibly supports the commonly held view that "outdoor" working is more dangerous than "indoor" work, this analysis suggests that most instances of victimization actually occur in private spaces. Hence, it is argued that risks of victimization in sex work are influenced by a variety of environmental characteristics relating to concealment, control, and isolation, suggesting that not all off-street locations are equally safe. We conclude with recommendations for policy regarding sex work.

Sex, price and preferences: accounting for unsafe sexual practices in prostitution markets

Unsafe sexual practices are persistent in prostitution interactions: one in four contacts can be called unsafe. The determinants of this are still matter for debate. We account for the roles played by clients' preferences and the hypothetical price premium of unsafe sexual practices with the help of a large dataset of clients' self-reported commercial sexual transactions in Belgium and The Netherlands. Almost 25,000 reports were collected, representing the whole gamut of prostitution market segments. The first set of explanations consists of an analysis of the price-fixing elements of paid sex. With the help of the so-called hedonic pricing method we test for the existence of a price incentive for unsafe sex. In accordance with the results from studies in some prostitution markets in the developing world, the study replicates a significant wage penalty for condom use of an estimated 7.2 per cent, confirmed in both multilevel and fixed-effects regressions. The second part of the analysis reconstructs the demand side basis of this wage penalty: the consistent preference of clients of prostitution for unsafe sex. This study is the first to document empirically clients' preference for intercourse without a condom, with the help of a multilevel ordinal regression.

Commercial sexual exploitation of children and the school nurse

As trusted health professionals in the school setting, school nurses are well positioned to identify students who may be victims of commercial sexual exploitation of children (CSEC). However, until recently this issue has been clouded by lack of awareness, stigma, and/or denial. Since nationally the average age of entry for girls into the commercial sex industry (specifically prostitution) is 12-15 years old, many of these young people continue to attend school although attendance may be sporadic. Additional continuing education is needed to increase school nurses' awareness that these young victims might be in their practices, whether they are located in urban, rural, or suburban communities. As primary sources of health care for children throughout the United States, school nurses have a pivotal role in helping an exploited girl move beyond invisibility to a path of safety and support-and a new life.

Transactional relationships and sex with a woman in prostitution: prevalence and patterns in a representative sample of South African men

Background

Sex motivated by economic exchange is a public health concern as a driver of the Sub-Saharan African HIV epidemic. We describe patterns of engagement in transactional sexual relationships and sex with women in prostitution of South African men, and suggest interpretations that advance our understanding of the phenomenon.

Methods

Cross-sectional study with a randomly-selected sample of 1645 sexually active men aged 18–49 years who completed interviews in a household study and were asked whether they had had sex with a woman in prostitution, or had had a relationship or sex they took to be motivated by the expectation of material gain (transactional sex).

Results

18% of men had ever had sex with a woman in prostitution, 66% at least one type of transactional sexual relationship, only 30% of men had done neither. Most men had had a transactional relationship/sex with a main partner (58% of all men), 42% with a concurrent partner (or makhwapheni) and 44% with a once off partner, and there was almost no difference in reports of what was provided to women of different partner types. The majority of men distinguished the two types of sexual relationships and even among men who had once-off transactional sex and gave cash (n = 314), few (34%) reported that they had had sex with a ‘prostitute’. Transactional sex was more common among men aged 25–34 years, less educated men and low income earners rather than those with none or higher income. Having had sex with a woman in prostitution varied little between social and demographic categories, but was less common among the unwaged or very low earners.

Conclusions

The notion of ‘transactional sex’ developed through research with women does not translate easily to men. Many perceive expectations that they fulfil a provider role, with quid pro quo entitlement to sex. Men distinguished these circumstances of sex from having sex with a woman in prostitution. Whilst there may be similarities, when viewed relationally, these are quite distinct practices. Conflating them is sociologically inappropriate. Efforts to work with men to reduce transactional sex should focus on addressing sexual entitlement and promoting gender inequity.

Posttraumatic Stress Disorder (PTSD) and Disorders of Extreme Stress (DESNOS) Symptoms Following Prostitution and Childhood Abuse

With the participation of 46 prostituted women in Korea, this study investigates the relationship between prostitution experiences, a history of childhood sexual abuse (CSA), and symptoms of posttraumatic stress disorder (PTSD) and disorders of extreme stress not otherwise specified (DESNOS). Prostituted women showed higher levels of PTSD and DESNOS symptoms compared to a control group. Women who had experienced both CSA by a significant other and prostitution showed the highest levels of traumatic stress. However, posttraumatic reexperiencing and avoidance and identity, relational, and affect regulation problems were significant for prostitution experiences even when the effects of CSA were controlled.

This body which is not mine

This paper explores women's accounts of prostitution in terms of the lived experience of the body, drawing on life story narratives and arts images created by women in the sex industry. These narratives show that women's experiences of prostitution constitute a spectrum of (dis)embodiment that is inflected, not determined, by settings and contexts. Theoretical approaches to embodiment were sought that acknowledged tensions between violation and a sense of empowerment. Therefore, the ontology of selling sex, and associated experiences such as violence, drug use and self-harm are explored using feminist applications of Merleau-Ponty's notion of the `habit body'. A key focus is how the body is constituted by embodied experiences of abuse (e.g. the work of Parkins and of Weiss), and how women negotiate ownership of the body within commercial sex transactions. This highlights the process of repositioning the body by selling sex, in accordance with the accumulated experiences of the habit body. Thus, to borrow from Wendy Parkins, women perceive that they are acting meaningfully through the body, even when reproducing dynamics of objectification and dissociation.

Prostitute homicides: a descriptive study

It has been estimated that women involved in street prostitution are 60 to 100 times more likely to be murdered than are nonprostitute females. In addition, homicides of prostitutes are notoriously difficult to investigate and, as such, many cases remain unsolved. Despite this large risk factor, little literature exists on homicides of prostitutes, and there is a lack of basic statistics and knowledge regarding this very specific victim group that could possibly help investigators. The aim of the current study is to conduct an exploratory study to explore the key characteristics of this group and how they differ from other subgroups of homicide. Forty-six cases of U.K. prostitute homicides are analyzed and compared to 59 male offender-female victim nonsexual homicide cases and 17 male offender-female victim sexual homicide cases.

Female street sex workers in Hong Kong: moving beyond sexual health

BACKGROUND

For many years, the sex industry in Hong Kong has appeared to be an integral and ever-expanding component of the city's sociocultural and economic structure. Accordingly, the physical and psychological health of sex workers is becoming an increasing concern for the workers themselves, the public, and government policy.

METHODS

A cross-sectional survey on the quality of life (World Health Organization Quality of Life [WHOQOL]) of female sex workers (FSWs) in Hong Kong was used to investigate the physical and psychological well-being of street FSWs, and the results were compared with those of non-sex-working Hong Kong women after adjusting for age, educational level, marital status, and health status.

RESULTS

The 89 FSWs surveyed scored significantly lower on QOL--WHOQOL-BREF (HK)--measures compared with the non-sex-working women. One common aspect among these sex workers was their negative view of themselves and of life. Many sex workers were at risk of being abused while at work, and many women worked without legal protection. Most of the women surveyed engaged in sex work to support their families. Because their income was often insufficient, some of their needs, especially those concerning health, were often neglected.

CONCLUSIONS

The low WHOQOL-BREF (HK) scores in FSWs indicate feelings of helplessness and entrapment, which may well result in detrimental effects on sex workers' health, self-esteem, and confidence when asserting their basic rights, such as access to healthcare and safety. The conclusion highlights the vulnerability of this population to apparent weaknesses in Hong Kong's current healthcare system.

Extent, Trends, and Perpetrators of Prostitution-Related Homicide in the United States

Prostitute women have the highest homicide victimization rate of any set of women ever studied. We analyzed nine diverse homicide data sets to examine the extent, trends, and perpetrators of prostitution-related homicide in the United States. Most data sources substantially under-ascertained prostitute homicides. As estimated from a conservative capture-recapture analysis, 2.7% of female homicide victims in the United States between 1982 and 2000 were prostitutes. Frequencies of recorded prostitute and client homicides increased substantially in the late 1980s and early 1990s; nearly all of the few observed pimp homicides occurred before the late 1980s. These trends may be linked to the rise of crack cocaine use. Prostitutes were killed primarily by clients, clients were killed mainly by prostitutes, and pimps were killed predominantly by pimps. Another conservative estimate suggests that serial killers accounted for 35% of prostitute homicides. Proactive surveillance of, and evidence collection from, clients and prostitutes might enhance the investigation of prostitution-related homicide.

Resilience Among Young Men Who Have Sex With Men in New York City

This article describes a study of resilience among young men who have sex with men (YMSM). Resilience is defined as positive adaptation in the context of hardship. Using targeted sampling to capture the diversity and range of this hidden population, we recruited 569 YMSM ages 17-28 years old and examined a subset of 134 YMSM who had experienced severe childhood adversity, as indicated by placement in foster care. Most of the YMSM in this subset were from racial or ethnic minority backgrounds and fewer than half identified as gay or homosexual (46.3 percent). More than half (58.3 percent) exhibited positive outcomes on four of seven indicators of adaptive functioning. YMSM who identified as either bisexual or heterosexual exhibited lower rates of resilience. Structural- as well as individual-level factors appear to be implicated in resilience among YMSM. Findings underscore the importance of fostering stable sexual identity as a means of building resilience.

Burnout among female indoor sex workers

This study examined levels of "burnout" and associated factors among a sample of female indoor sex workers in the Netherlands (N=96). Levels of burnout on 3 dimensions (emotional exhaustion, depersonalization, and personal competence) were assessed. Only sex workers' mean score on depersonalization was significantly higher than that of a comparison group of female nurses and comparable to those of another comparison group of patients with work-related psychological problems. Evidence was provided for the importance of experiential and context-related factors in burnout among indoor sex workers. For instance, 42% of the variance in depersonalization was explained by not working by choice, negative social reactions, experiences of violence, and lack of control in interaction with clients. Depersonalization may be a strategy to cope with negative conditions and experiences in sex work, but was significantly related to indicators of stress and emotional exhaustion. More than half (53%) of the variance in emotional exhaustion was explained by lack of management support, negative social reactions, not working by choice, and negative working motivation. Personal competence was highest among sex workers with a professional attitude, who started sex work at a relatively older age, and who were well supported by colleagues and management. It is concluded that burnout is not as much associated with sex work per se, but with sex work under certain conditions, among which stigma (notably negative social reactions) and stigma-related experiences (such as role conflict, experiences with violence, and lack of a worker-supportive organizational context) are important.

Prostitution in Vancouver: violence and the colonization of First Nations women

We interviewed 100 women prostituting in Vancouver, Canada. We found an extremely high prevalence of lifetime violence and post-traumatic stress disorder (PTSD). Fifty-two percent of our interviewees were women from Canada's First Nations, a significant overrepresentation in prostitution compared with their representation in Vancouver generally (1.7-7%). Eighty-two percent reported a history of childhood sexual abuse, by an average of four perpetrators. Seventy-two percent reported childhood physical abuse, 90% had been physically assaulted in prostitution, 78% had been raped in prostitution. Seventy-two percent met DSM-IV criteria for PTSD. Ninety-five percent said that they wanted to leave prostitution. Eighty-six percent reported current or past homelessness with housing as one of their most urgent needs. Eighty-two percent expressed a need for treatment for drug or alcohol addictions. Findings are discussed in terms of the legacy of colonialism, the intrinsically traumatizing nature of prostitution and prostitution's violations of basic human rights.

Sex work research: methodological and ethical challenges

The challenges involved in the design of ethical, nonexploitative research projects with sex workers or any other marginalized population are significant. First, the size and boundaries of the population are unknown, making it extremely difficult to get a representative sample. Second, because membership in hidden populations often involves stigmatized or illegal behavior, concerns regarding privacy and confidentiality are paramount and difficult to resolve. In addition, they often result in challenges to the validity of the data. Third, in spite of evidence to the contrary, associations between sex work and victimization are still strong, dichotomies remain prevalent, and sex workers are often represented as a homogeneous population. Drawing on three research projects in which the author has been involved-all grounded in a sex-as-work approach-as well as the work of others, this article provides several strategies for overcoming these challenges. Clear guidelines for ethical, nonexploitive methodologies are embedded in the solutions provided.

Sexual assault in the lives of urban sex workers: a descriptive and comparative analysis

This exploratory study contributes to the sparse literature on sexually assaulted sex workers. We examined 462 sexual assault cases seen at an emergency department-based sexual assault service and reported to the police between 1993 and 1997. More than one fifth of victims were sex workers. We compared them to other victims on victim characteristics, assault characteristics, and medical-legal findings. Relative to other victims, sex workers were younger, had lower incomes, and were more likely to be heroin and/or cocaine users. They suffered a greater number of injuries and forensic samples collected from their bodies were more likely to test positive for sperm and/or semen. These victims were also less likely to have been using alcohol and/or marijuana prior to the assault and to be emotionally expressed during the medical- legal examination. The substantial proportion of sex workers in the study population suggests that attention to their particular needs should be an important part of hospital-based sexual assault services. Clinical implications and directions for future research are discussed.

A continuum of risk? The management of health, physical and emotional risks by female sex workers

This paper describes the findings from a 10-month ethnographic study of the female sex industry in a large British city. I argue that sex workers construct a continuum of risk which prioritizes certain types of dangers depending on the perceived consequences and the degree of control individuals consider they have over minimising the likelihood of a risk occurring. Although health-related matters are a real concern to many women, because they generally have comprehensive strategies to manage health risks at work, this risk category is given a low priority compared with other risks. The risk of violence is considered a greater anxiety because of the prevalence of incidents in the sex work community. However, because of comprehensive screening and protection strategies to minimise violence, this type of harm is not given the same level of attention that emotional risks receive. By using a continuum of risk to understand how sex workers perceive occupational hazards in prostitution, further understanding can be gained about the nature of risk in prostitution, sex workers' routines and the organisational features of the sex industry. In addition, the implications for health policy are discussed, suggesting that the emotional consequences of selling sex should be considered as much as the tangible, physical risks of prostitution.

The relationship between adult sexual assault and prostitution: an exploratory analysis

Previous research has established a link between childhood sexual abuse and engaging in prostitution as an adult. The purpose of this study was to extend this literature by exploring whether being raped as an adult is associated with exchanging sex for money. Interviews with 102 rape survivors in a major metropolitan area revealed that 23.5% had engaged in prostitution post-rape. Those who had exchanged sex for money were more likely to be women of color, to have a high school education or less, to be unemployed, and to have children to support, than those who had not engaged in prostitution post-assault. The prostitution subsample also had significantly higher levels of psychological distress, physical health symptomatology, and substance use. Survivors were asked whether and how the rape was associated with engaging in prostitution: most (75%) stated that they felt it was related to the assault. The most commonly cited reason for engaging in prostitution by these survivors was that they were trying to regain some control over their lives and their bodies; exchanging sex for money was seen as one way to control men's access to them. Implications for future research on victimization and prostitution are discussed.

Precursors and pathways to adolescent prostitution in Taiwan

This paper identifies the major precursors and pathways to prostitution for contemporary Taiwanese girls and the socioeconomic and cultural changes that have facilitated the shift in pathways over the past 10 years. Special attention is paid to the case of Taiwanese aborigines, who have particularly suffered systemic disruption due to prostitution. Analysis of case files and interviews provide quantitative and qualitative data that highlight the role of filial piety and the shift from indenture to runaway as the major pathway in Taiwan. Discussion includes relation of these findings to juvenile entry into prostitution in other countries, directions for future research, and policy recommendations for Taiwan's government.