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

Trends in US Emergency Department Use After Sexual Assault, 2006-2019

IMPORTANCE

Adult sexual assault (SA) survivors experience numerous emergent health problems, yet few seek emergency medical care. Quantifying the number and types of survivors presenting to US emergency departments (EDs) after SA can inform health care delivery strategies to reduce survivor morbidity and mortality.

OBJECTIVE

To quantify ED use and factors that influenced seeking ED care for adult SA from 2006 through 2019.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used SA data from the Nationwide Emergency Department Sample from 2006 through 2019, which includes more than 35.8 million observations of US ED visits from 989 hospitals, a 20% stratified sample of hospital-based EDs. The study also used the Federal Bureau of Investigation's Uniform Crime Reporting Program, which includes annual crime data from more than 18 000 law enforcement agencies representing more than 300 million US inhabitants. The study sample included any adult aged 18 to 65 years with an ED visit in the Nationwide Emergency Department Sample coded as SA. The data were analyzed between January 2020 and June 2022.

MAIN OUTCOMES AND MEASURES

Annual SA-related ED visits, subsequent hospital admissions, and associated patient-related factors (age, sex, race and ethnicity, income quartile, and insurance) were analyzed using descriptive statistics.

RESULTS

Data were from 120 to 143 million weighted ED visits reported annually from 2006 through 2019. Sexual assault-related ED visits increased more than 1533.0% from 3607 in 2006 to 55 296 in 2019. Concurrently, admission rates for these visits declined from 12.6% to 4.3%. Female, younger, and lower-income individuals were more likely to present to the ED after SA. Older and Medicaid-insured patients were more likely to be admitted. Overall, the rate of ED visits for SA outpaced law enforcement reporting.

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that US adult SA ED visits increased from 2006 through 2019 and highlighted the populations who access emergency care most frequently and who more likely need inpatient care. These data can inform policies and the programming needed to support this vulnerable population.

Sexual Assault Survivors Who Exchange Sex: Identity, Stigma, and Informal Responses from Support Providers

It is well established in the literature that individuals who engage in sex work are more likely to experience sexual trauma/violence, but little research has examined experiences of sexual assault survivors who exchange sex from the survivor's perspective. Sexual assault survivors and their informal support providers (SP; e.g., family, friends, romantic partners) were interviewed separately about disclosure, social reactions, and help-seeking following assault. Sixteen survivors mentioned experiences exchanging sex, which comprises the sample for the current study, as well as comments from twelve SPs. Qualitative analysis revealed several themes including violence experienced engaging in sex work, navigating stigma and the identity of both sexual assault survivor and sex worker, and how survivors' social supports impact their recovery. Survivors endorsed their sex worker identities at varying levels, and others used their identity as a sexual assault survivor to explain why they engaged in sex work. Social work implications regarding service provision and advocacy work are discussed.

Risk Factors for Domestic Child Sex Trafficking in the United States

Despite increased effort to respond to human trafficking at national and state levels, very little empirical research has been conducted on domestic child sex trafficking. This study retrospectively examines associations between multiple risk factors and domestic child sex trafficking (i.e., entry into the commercial sex industry under the age of 18) in a sample of individuals aged 16 and older currently involved in the commercial sex industry ( N = 273). Two primary research questions are addressed: (1) What set of risk factors, prior to entering the commercial sex industry, are associated with domestic child sex trafficking and (2) what group differences, if any, exist in risk factors between current or former domestic child sex-trafficking victims and non-trafficked adults engaged in the commercial sex industry? A cross-sectional survey was administered using Respondent-Driven Sampling (RDS) in five cities in one Midwestern state. Overall, 115 participants (48.3%) were identified as current or former domestic child sex-trafficking victims. Bivariate results suggest that childhood emotional and sexual abuse, rape, ever running away from home, having family members in sex work, and having friends who purchased sex were significantly associated with domestic child sex trafficking. Multivariate results indicate that domestic child sex trafficking victims were significantly more likely to have ever run away and to be a racial/ethnic minority than non-trafficked adults engaged in the commercial sex industry. Findings can inform state-level policies on human trafficking and assist child protection and juvenile justice agencies in developing prevention and intervention responses to commercial sexual exploitation.

Culturally Competent Health Care for Sex Workers: An Examination of Myths That Stigmatize Sex-Work and Hinder Access to Care

Sex workers are individuals who offer sexual services in exchange for compensation (i.e., money, goods, or other services). Within the United States the full-service sex work (FSSW) industry generates 14 billion dollars annually there are estimated to be 1-2 million FSSWers, though experts believe this number to be an underestimate. Many FSSWers face the possibility of violence, legal involvement, and social stigmatization. As a result, this population experiences increased risk for mental health disorders. Given these risks and vulnerabilities, FSSWers stand to benefit from receiving mental health care however a constellation of individual, organizational, and systemic barriers limit care utilization. Destigmatization of FSSW and offering of culturally competent mental health care can help empower this traditionally marginalized population. The objective of the current review is to (1) educate clinicians on sex work and describe the unique struggles faced by FSSW and vulnerability factors clinicians must consider, (2) address 5 common myths about FSSW that perpetuate stigma, and (3) advance a research and culturally competent clinical training agenda that can optimize mental health care engagement and utilization within the sex work community.

“She Is NOT a Genuine Client”: Exploring Health Practitioner’s Mistrust of Rape Survivors in Nairobi, Kenya

Sexual violence is one of the most common forms of violence against women in Kenya. Recognizing this, the Kenyan government introduced health care sector guidelines for survivors of sexual violence. This study explores the care of rape survivors from the perspective of health-care practitioners and identifies a number of recommendations for improving the quality of care. Qualitative interviews were conducted with 28 health practitioners from eight post-rape care facilities located in Nairobi, Kenya. Data were analyzed using the Colaizzi’s 1978 analytical model. The study uncovered a troubling tendency of health practitioners questioning the authenticity of a woman’s claim, deeming some not to be genuine rape survivors. Doubts about the veracity of the client’s story led to additional emotional drain on health practitioners. This judgment negatively impacted the quality of care for rape survivors and in some cases, leading practitioners to deny services and exposing survivors to secondary victimization.

Attrition and Rape Case Characteristics: A Profile and Comparison of Female Sex Workers and Non-Sex Workers

The attrition of rape cases from the criminal justice system (CJS) remains high and there is a paucity of research in relation to marginalized groups. Sex workers (SWs) are vulnerable to sexual violence due to the nature of their work. They are also unlikely to report such violence to police for a range of reasons. Two stages of research sought to describe the victim, perpetrator, and offense characteristics of SW rape and to examine the attrition of these cases. All rapes and attempted rapes (N = 1,146) reported to police in a large city in the South West of England over a 21-year period were examined; 67 cases involved SWs. Data were extracted from police files in line with the variables of interest. Secondary analysis of the total number of SW rapes (n = 67) resulted in a profile of these cases. A matched pairs study revealed significant differences in victim, perpetrator, and assault characteristics between SW (n = 62) and non-sex-worker (NSW) samples (n = 62). Although no significant difference was found in terms of attrition from the CJS, SW cases were observed to secure more convictions for rape than NSW cases. The implications of the findings for practice and future research are discussed.

Prevalence and Correlates of Client-Perpetrated Violence against Female Sex Workers in 13 Mexican Cities

BACKGROUND

Globally, client-perpetrated violence against female sex workers (FSWs) has been associated with multiple health-related harms, including high-risk sexual behavior and increased exposure to HIV/STIs. This study examined correlates of client-perpetrated sexual, physical, and economic violence (e.g., robbery) against FSWs in 13 cities throughout Mexico.

METHODS

FSWs (N = 1,089) who were enrolled in a brief, evidence-based, sexual risk reduction intervention for FSWs (Mujer Segura) were interviewed about their work context, including experiences of violence perpetrated by clients, sexual risk and substance use practices, financial need, and social supports. Three broad categories of factors (sociodemographic, work context, behavioral and social characteristics of FSWs) were examined as correlates of sexual, physical, and economic violence.

RESULTS

The prevalence of different types of client-perpetrated violence against FSWs in the past 6 months was: sexual (11.7%), physical (11.8%), economic (16.9%), and any violence (22.6%). Greater financial need, self-identification as a street worker, and lower perceived emotional support were independently associated with all three types of violence. Alcohol use before or during sex with clients in the past month was associated with physical and sexual violence. Using drugs before or during sex with clients, injection drug use in the past month, and population size of city were associated with sexual violence only, and FSWs' alcohol use score (AUDIT-C) was associated with economic violence only.

CONCLUSIONS

Correlates of client-perpetrated violence encompassed sociodemographic, work context, and behavioral and social factors, suggesting that approaches to violence prevention for FSWs must be multi-dimensional. Prevention could involve teaching FSWs strategies for risk avoidance in the workplace (e.g., avoiding use of alcohol with clients), enhancement of FSWs' community-based supports, development of interventions that deliver an anti-violence curriculum to clients, and programs to address FSWs' financial need by increasing their economic opportunities outside of the sex trade.

Health outcomes among women trafficked for sex in the United States: a closer look

Human trafficking is recognized as a major public health problem and a tragic transnational crime. Little is known about the health outcomes of victims of human trafficking. This study identifies the relationship of risk factors to physical, sexual, and mental health outcomes in three groups of women (N = 38) exploited for sex in the United States: international trafficking victims, domestic trafficking victims, and nontrafficked sex workers. To date this is the first study to examine the impact of risk factors on health outcomes using a sample of women trafficked for sex in the United States that includes both domestic and international victims. Overall, findings suggest that the experiences in sex work of domestic trafficking victims were dissimilar to those of international trafficking victims. Moreover, domestic trafficking victims displayed poorer health outcomes compared to international trafficking victims. In terms of risk factors, a higher percentage of women involved in street prostitution reported sexual health problems, co-occurring health issues, and addiction. Childhood physical/sexual victimization was related to poor physical health.

A comparative analysis of victims of sexual assault with and without mental health histories: acute and follow-up care characteristics

Sexual assault is a common and serious health issue that is underreported and has low follow-up rates. The myriad of psychological sequelae of sexual assault are well documented; however, there is a dearth of literature on the prevalence of preexisting mental health issues in survivors of sexual assault. This exploratory study compares victims seen at a sexual assault treatment center with and without preexisting self-reported mental health histories. The rates of preexisting mental illness in sexual assault victims are significant. Implications for clinical practice and research are discussed.

Alcohol use and client-perpetrated sexual violence against female sex workers in China

The global literature suggests that female sex workers (FSWs) experience high rates of sexual violence perpetrated by their clients, especially when FSWs are under the influence of alcohol. However, such data are limited in China. The current study is aimed to fill in the literature gap by examining the association between alcohol use by FSWs and client-perpetrated sexual violence against FSWs in China. A total of 1022 FSWs were recruited through community outreach in Guangxi, China. Female sex workers completed a self-administered survey on their demographic information, alcohol use, and sexual violence perpetrated by clients. Multivariable regression was employed to assess the relationship between alcohol use and client-perpetrated sexual violence among FSWs while controlling for possible confounders. Results indicated that alcohol use was positively associated with the experience of sexual violence in both bivariate and multivariable analyses. Women who were at a higher risk level of alcohol use were more likely to experience sexual violence perpetrated by clients even after controlling confounders (e.g., demographics and alcohol-serving practice). Given the association between alcohol use and client-perpetrated sexual violence, preventing or reducing alcohol use among FSWs could be an effective strategy to protect these women from sexual violence perpetrated by their clients. Alternatively, psychological counseling and other support should be available to these women so they can reduce their alcohol use as a maladaptive coping strategy. We call for culturally appropriate alcohol use reduction components, incorporated with sexual violence reduction strategies including adaptive coping skills training as well as empowerment, and targeting both FSWs and their clients.

High prevalence of forced sex among non-brothel based, wine shop centered sex workers in Chennai, India

Sexual violence has been shown to increase women's risk of HIV infection. India is a country where the HIV epidemic is growing among women and intimate partner violence (IPV) is pervasive. This study examined prevalence of and factors associated with forced sex among female sex workers (FSWs) in Chennai, India. We conducted a probability survey among FSWs in 24 slum venues and identified predictive factors for recent forced sex using univariate and multivariable proportional odds models. Among 522 FSWs, 28% reported having forced sex with one partner and 35% with 2+ partners. In the final multivariable model, women who had a high number of partners who had a strong tendency to drink alcohol before sex were more likely to have experienced forced sex, and women who had both unprotected sex with a nonspousal partner and > 20 days of alcohol consumption in the last 30 days were more likely to have experienced forced sex. Discussion about family violence with larger social networks was independently associated with lower odds of forced sex among FSWs. HIV interventions for FSWs and their clients aimed at reducing alcohol consumption and encouraging condom use could be enhanced by violence prevention interventions to facilitate discourse about sexual violence.

Factors associated with the perpetration of sexual violence among wine-shop patrons in Chennai, India

With an estimated 2.5 million people living with HIV/AIDS, India has the third highest number of HIV-infected people in the world. Despite reductions in prevalence among the general population, the percentage of all infections occurring among Indian women is continuing to rise. Women's risk of HIV infection from their partner and observed associations between sexual violence and HIV infection in India underscore the importance of understanding determinants of forced sex. A probability survey was conducted from June 2003 to August 2007 in Chennai, India, among alcohol venue ("wine shops") patrons to estimate the prevalence of sexual violence and to identify risk factors associated with perpetrating forced sex. Among 1499 men, 28.5% reported forced sex with at least one partner in the past 3 months. In multivariate analysis, earning income for less than 12 months a year, visiting the wine shop with friends, STD symptoms, perpetration of physical violence, and number of sexual partners were statistically significantly associated with perpetrating forced sex. Men who reported having 3 or more close friends were less likely to perpetrate violence. HIV interventions that facilitate formal groups that foster positive social support and address a range of HIV risk behaviors including sexually and physically abusive behaviors are recommended to reduce sexual violence.

Alcohol use among female sex workers and male clients: an integrative review of global literature

AIMS

To review the patterns, contexts and impacts of alcohol use associated with commercial sex reported in the global literature.

METHODS

We identified peer-reviewed English-language articles from 1980 to 2008 reporting alcohol consumption among female sex workers (FSWs) or male clients. We retrieved 70 articles describing 76 studies, in which 64 were quantitative (52 for FSWs, 12 for male clients) and 12 qualitative.

RESULTS

Studies increased over the past three decades, with geographic concentration of the research in Asia and North America. Alcohol use was prevalent among FSWs and clients. Integrating quantitative and qualitative studies, multilevel contexts of alcohol use in the sex work environment were identified, including workplace and occupation-related use, the use of alcohol to facilitate the transition into and practice of commercial sex among both FSWs and male clients, and self-medication among FSWs. Alcohol use was associated with adverse physical health, illicit drug use, mental health problems, and victimization of sexual violence, although its associations with HIV/sexually transmitted infections and unprotected sex among FSWs were inconclusive.

CONCLUSIONS

Alcohol use in the context of commercial sex is prevalent, harmful among FSWs and male clients, but under-researched. Research in this area in more diverse settings and with standardized measures is required. The review underscores the importance of integrated intervention for alcohol use and related problems in multilevel contexts and with multiple components in order to effectively reduce alcohol use and its harmful effects among FSWs and their clients.

Examination for sexual assault: evaluating the literature for indicators of women-centered care

This study aimed to assess the extent to which recent peer-reviewed published literature on the acute management of sexual assault was women-centered. We developed indicators and a framework that operationalized women-centered care provision in the context of sexual assault. We then reviewed and evaluated the literature in relation to these indicators. A systematic search identified a total of 20 relevant articles for inclusion in the analysis. These were published in medical journals (65%, 13/20), nursing journals (20%, 4/20), and journals targeted toward other health care practitioners (15%, 3/20), and originated from the United States (65%, 13/20), the United Kingdom (15%, 3/20), Australia (10%, 2/20), Spain (5%, 1/20), and Canada (5%, 1/20) between January 2000 and August 2005. We found little acknowledgment of the inherent tensions faced by sexual assault examiners in providing women-centered care. Moreover, absent from most articles were discussions of the complexities of consent in sexual assault examinations, social justice issues, the need for gender-sensitive training for health care providers, and a critical appraisal of colposcopic and DNA technologies. Indicators of respect, safety and restoring control, and connections to community were present in the majority of articles.

Migration, sexual exploitation, and women's health: a case report from a community health center

An estimated 50,000 women and children are annually trafficked into the United States, resulting in complex health and social consequences and significant risk for violence. This article presents a case of a trafficked woman identified in the U.S. health system and describes the vulnerabilities to forced prostitution as a result of trafficking and the challenges in providing an effective and comprehensive response to meet safety and health care needs. Health care providers are in a unique position to identify and support U.S. sex trafficking victims; thus, education and training for health care professionals on trafficking is needed.

The relationship between HIV/Sexually Transmitted Infection risk and alcohol use during commercial sex episodes: results from the study of female commercial sex workers in the Philippines

The HIV/Sexually Transmitted Infection (STI) risk associated with alcohol use between female commercial sex workers (FCSWs) and their customers has been understudied. We examined this relationship for 1,114 FCSWs aged 15-54 with data collected during the baseline study period (1994 to 1998) in four southern provinces of the Philippines. Two alcohol-related risk situations during commercial sex episodes were examined: prior alcohol use by an FCSW and perceived intoxication in a customer. The influence of sociodemographic variables on sexual risk behaviors was also studied. Multiple sexual risk behaviors were observed with more frequency for FCSWs if alcohol was used before commercial sex or if the episode involved a customer perceived to be intoxicated. Forty-two percent of FCSWs who had sex with an intoxicated customer were STI positive, significantly more than FCSWs who did not have sex with an intoxicated customer (28%, p < .01). Similar significant differences were found for FCSWs who did not consume alcohol before having sex and were STI positive (29%) versus FCSW who did consume alcohol before sex and were STI positive (33%, p < .01). Our analyses reinforce accumulating evidence in the field that sexual risk reduction interventions need to go beyond the behaviors of individual FCSWs to meet the layering of risks such as observed in this study. Multilevel strategies targeting customer substance use and other situational and structural factors have proven to be pivotal mediators in our other research with this population. These experiences and the limitations of this study are discussed.

Sexual assault in Virginia: A population-based study

PURPOSE

Sexual assault is a serious social problem that affects the lives of many women, men, and children. Most sexual assaults are not reported to authorities and most victims do not seek services. As a result, accurate statistics on the prevalence and incidence of this problem are difficult to obtain. As in many states, the magnitude of sexual assault in Virginia is not known. This study was conducted to estimate the prevalence and determine the correlates of sexual assault among women in Virginia.

METHODS

A cross-sectional telephone survey was conducted among adult female residents of Virginia between November 2002 and February 2003. A total of 1,769 women aged 18 and older were interviewed using a random digit dialing method.

RESULTS

The lifetime prevalence of sexual assault in Virginia was 27.6%. The majority (65%) were rape victims with a prevalence of 17.8%. Approximately 78% of the victims reported that the sexual assault occurred for the first time when they were children or adolescents. Women who reported sexual assault were more likely to be between 35 and 44 years old (OR = 3.57; 95% CI = 2.06-6.15), divorced/separated/widowed (OR = 1.61; 95% CI = 1.13-2.30), consume alcohol four or more times a week (OR = 1.80; 95% CI = 1.01-3.21), ideate suicide (OR = 4.48; 95% CI = 3.23-6.23), and perceive their health status to be poorer (OR = 2.74; 95% CI = 1.30-5.83).

CONCLUSION

Sexual assault is a major public health problem in the Commonwealth of Virginia and children are disproportionately affected by the problem. Interventions and prevention programs should focus on children and adolescents.