Human sex trafficking (HST) is a public health concern that takes a significant toll on the health and well-being of its victims. Individuals who have been trafficked for sex are at a greater risk for physical, mental, and sexual health problems (Hossain, Zimmerman, Abas, Light, & Watts, 2010; Lederer & Wetzel, 2014; Oram, Stöckl, Busza, Howard, & Zimmerman, 2012; Zimmerman et al., 2008). Victims frequently report having been diagnosed with an infectious disease, sexually transmitted infections, and gynecological (Cwickel, Chudakov, Paikin, Agmon, & Belmaker, 2004; Decker, McCauley, Pheungszmran, Janyam, & Silverman, 2011; Zimmerman et al., 2008) and substance abuse (Lederer & Wetzel, 2014; Raymond & Hughes, 2001) problems. Women engaged in sex work are also more likely to be raped and experience violence (Kurtz, Surratt, Inciardi, & Kiley, 2004; Ottisova, Hemmings, Howard, Zimmerman, & Oram, 2016; Raymond & Hughes, 2001; Romans, Potter, Martin, & Herbison, 2001). Reports of poor health among this vulnerable population are not unexpected given that exposure to sexual violence and victimization have been associated with poor mental and physical health outcomes (Breiding, 2015; Chen et al., 2010; Hossain et al., 2010).
Research conducted primarily outside the United States has led to a better understanding of the common health consequences associated with HST (Decker et al., 2011; Hossain et al., 2010; Zimmerman et al., 2008). Findings of poor health outcomes, exposure to violence, and substance abuse for U.S.-born women have been consistent with the literature conducted on women internationally (Lederer & Wetzel, 2014; Raymond & Hughes, 2001), yet sample sizes of U.S. victims, specifically, are small (Raymond & Hughes, 2001). Globally, women comprise the largest number of victims of HST (Hossain et al., 2010; Zimmerman et al., 2008), and the United States is the second largest market for women trafficked for sex (Mizus, Moody, Privado, & Douglas, 2003). Considering the clear evidence of need for quality health care, it is worthwhile to explore what is known about the health needs of women who are trafficked for sex in the United States.
It is difficult to tease out what is known about women who are trafficked for sex in the United States. Service providers and law enforcement report difficulty identifying victims of HST, and victims are more likely to be arrested as offenders (Clawson, Small, Go, & Myles, 2003; Farrell, DeLateur, Owens, & Fahy, 2016). In addition, federal and state laws aimed to address U.S.-born minors trafficked in the United States do not necessarily extend to women (U.S. Department of State, 2006). Because of the criminalization and stigmatization of prostitution in the United States, women, specifically engaged in sex work, fear that they are outside the protection of the law (Kurtz et al., 2004) and/or that they will be further exploited by law enforcement (Kurtz et al., 2004; Raphael & Shapiro, 2002).
Moreover, HST manifests in many ways. There is overlap between confirmed cases of HST and intimate partner violence whereby a boyfriend or husband is abusive and engages his partner in commercial sex, thus meeting the criteria for a pimp (Raphael, Reichert, & Powers, 2010; Smith, Vardaman, & Snow, 2009). Women trapped in such coercive and abusive circumstances may not identify as a victim of trafficking, further complicating the accuracy on the prevalence and characteristics of women trafficked for sex in the United States, and subsequently, data do not consistently account for domestic victims (Hounmenou, 2012).
The purpose of this integrative review was to discover what is known about the characteristics and healthcare needs of women who are/have been trafficked for sex in the United States, including women born inside and outside the United States. In an effort to isolate the domain of inquiry, this review includes peer-reviewed research that draws a clear distinction between minor versus adult trafficking and sex work versus HST, focusing solely on articles that report the characteristics and health needs of the women. Synthesis of this knowledge is a first step toward designing care that is tailored to meet the complex health needs of this vulnerable group that is at risk for being medically underserved. The following research question guided this review: What are the reported healthcare needs of women who are trafficked for sex in the United States?
This review was conducted following the methodology outlined by Whittmore and Knafl (2005). This technique can accommodate a broad perspective of the phenomena under examination by synthesizing diverse study designs, including theoretical literature. The approach to this integrative review was composed of the following stages: (a) problem identification, (b) literature search, (c) data evaluation, (d) data analysis, and (e) presentation of results.
This review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Moher, Liberati, Tetzlaff, & Altman, 2009) criteria (see Figure 1) and with the assistance of a health sciences librarian. To isolate the social, political, economic, and cultural characteristics, eligibility criteria for this review included peer-reviewed quantitative, qualitative, and mixed methods studies, solely from the United States. The population of interest was women who have been/are currently trafficked for sex in the United States. To examine a phenomenon for which a paucity of research exists, no limits for years published were applied. The medical subject headings (MESH terms) used for HST were “human trafficking,” “transactional sex,” “sex worker,” “forced prostitution,” “sexual exploitation,” and “traffick.” Data collection was completed in September 2017 and again in April 2019 utilizing four electronic databases: Cumulative Index to Nursing & Allied Health, PsychInfo, PubMed, and Scopus.
The initial search yielded 1,340 articles. In an effort to include the most recent, relevant data, a second search was completed in April 2019, yielding an additional 219 articles, for a total of 1,559. After removing duplicates from both searches, 991 records were reviewed. Because of the broad search, numerous articles were retrieved that were not directly related to the research question. Subsequently, 594 articles were removed based on title alone. Articles were excluded if they were not conducted in the United States, not related to trafficking, and focused on intimate partner violence, a specific disease, drug/firearms trafficking, substance use disorder, men, or adolescents. Three hundred eighty-seven abstracts were reviewed, 372 from the initial search and 15 from the second search. Twenty full-text articles from the first search and four full-text articles from the second search were screened to determine relevance to this review. A search of the reference lists of these articles yielded an additional five full-text articles to review. Nine studies (eight from the initial search and one from the second search) met the inclusion criteria.
Selected articles were further assessed for the quality of research using a framework developed and trialed by Hawker, Payne, Kerr, Hardey, and Powell (2002). This systematic approach was designed to encompass many different types of materials while assessing the level to which the article under review's aims, methods, sampling, data, analysis, and reporting of results were rigorous. This methodology uses the criteria of “good,” “fair,” “poor,” and “very poor.” A summed score ranging from 0 to 27 was calculated for each study. Those with a total of at least 22 were rated as good. All nine studies included in this review were rated as good (see Table 1).
The nine articles included in this review were read multiple times to fully understand the overall content. Using a continuous comparative method, data across all articles were organized, categorized, and then synthesized (Whittmore & Knafl, 2005) to identify recurring themes reflecting the state of science on the characteristics and reported healthcare needs of women who are trafficked for sex in the United States (see Table 1).
The nine studies in this review were published between 2011 and 2018, with samples sizes ranging from 12 to 143 women, with one retrospective study (Dewan, 2014) of 136 case records from an antitrafficking program in New York. Two studies, guided by different research aims, extrapolated data from the same 12 study participants born outside the United States, residing in Los Angeles County (Baldwin et al., 2011, 2015), and data originally collected by Raymond and Hughes (2001Z) were used in two secondary analyses (Finn, Muftić, & Marsh, 2015; Muftić & Finn, 2013). Only three of the nine studies under review specifically explored the health of the women (Baldwin et al., 2011; Muftić & Finn, 2013; Ravi et al., 2017). However, one study (Rajaram & Tidball, 2018) explored the complex needs of survivors, which included healthcare needs.
Whereas only one study (Jani & Anstadt, 2013) targeted women born outside the United States who were trafficked for sex in the United States, samples in three additional studies were entirely composed of women born outside the United States yet trafficked in the United States (Baldwin et al., 2011, 2015; Dewan, 2014). Three studies included victims of both labor and sex trafficking (Baldwin et al., 2011, 2015; Dewan, 2014), whereas five studies explored sex work specifically (Finn et al., 2015; Jani & Anstadt, 2013; Muftić & Finn, 2013; Mumma et al., 2017; Ravi et al., 2017), and three of those had a primary focus of HST (Jani & Anstadt, 2013; Mumma et al., 2017; Ravi et al., 2017). While Dewan (2014) differentiated labor versus sex trafficking, a ratio of male versus female victims who were trafficked was not provided.
The age of subjects ranged from 18 to 60 years. Although this review yielded 392 study participants, race/ethnicity was only reported for 103 study participants. As a result, and because of inconsistencies in how researchers reported race/ethnicity, the results must be reported dichotomously as 64 non-White and 39 White. Survivors born outside the United States were likely to originate from small towns/villages, whereas U.S.-born women described their hometowns as urban (Jani & Anstadt, 2013; Muftić & Finn, 2013; Rajaram & Tidball, 2018). For data on additional characteristics of the women, study designs, and quality of studies, see Table 1.
Three themes emerged: (a) social structures significant to access to care and vulnerability, (b) abuse and maltreatment, and (c) health needs and inadequate response of the healthcare system.
Social Structures Significant to Access to Care and Vulnerability
Social structures, including immigration status and response of the legal system, are factors that affect access to care. Five studies reported on a connection between social structures and an increased risk for vulnerability and victimization (Dewan, 2014; Finn et al., 2015; Jani & Anstadt, 2013; Rajaram & Tidball, 2018; Ravi et al., 2017). Generally, victims of trafficking born both outside and within the United States had factors that placed them at an increased risk for exploitation. Women born outside the United States, yet trafficked within the United States, were likely to originate from cultures that do not have well-established antitrafficking laws (Dewan, 2014; Jani & Anstadt, 2013). Survivors explained how they were exploited when corrupt community leaders and local law enforcement from their places of origin colluded with local and international traffickers (Jani & Anstadt, 2013).
In addition, women born outside the United States reported feeling pressured to earn money and contribute to their families' income. Furthermore, in some cases, an education was subsequently denied (Jani & Anstadt, 2013). In a qualitative study exploring South Asian women's vulnerability to traffic-related migration, Jani and Anstadt (2013) reported that, because of the lack of opportunity in their homelands to secure financial independence, women migrated to large cities in their countries of origin and sought employment as dancers in dance bars. Dance bars, especially in places like Mumbai, are notorious venues where “deals” for prostitution are made. Subsequently, rejection by their families and villages after returning from the city postemployment in dance bars left women feeling abandoned (Jani & Anstadt, 2013). Originating from a culture of extreme shame and poverty combined with very limited options to sustain themselves financially contributed to the women's agreement to travel to the United States, take risks, and become further isolated from their families (Jani & Anstadt, 2013). Furthermore, while examining service utilization among victims of trafficking who originated from outside the United States, Dewan (2014) reported that 58.7% of victims were lured into entering the United States illegally. Information on how they were lured was not reported.
While examining the overlap between victimization and offending behavior among women in sex work in the United States, Finn et al. (2015) identified how inadequate responses by the legal justice system and corruption in law enforcement further victimized the women. According to Finn et al., almost 86% of the women trafficked in the United States received an injury because of a crime, yet among reports of assault made to police, only 25% of the cases were forwarded for prosecution, and a mere 22.2% secured an order of protection against her assailant. Moreover, 25% of the victims apprehended for prostitution or another crime in the United States were not informed of their rights upon arrest, and 20% were blackmailed by police to have sex with them in exchange for lenient treatment (Finn et al., 2015). Similarly, Rajaram and Tidball (2018) reported that the lack of a trauma-informed approach and poor interagency collaboration by both the criminal justice and police departments revictimized and caused further problems for the women who were subsequently left without any help.
Abuse and Maltreatment
Evidence of abuse and maltreatment was prevalent in seven of the studies reviewed (Baldwin et al., 2015; Finn et al., 2015; Jani & Anstadt, 2013; Muftić & Finn, 2013; Mumma et al., 2017; Rajaram & Tidball, 2018; Ravi et al., 2017). Rape was among the most frequently reported violent crimes to which the women were subjected to (Baldwin et al., 2015; Finn et al., 2015; Jani & Anstadt, 2013; Rajaram & Tidball, 2018; Ravi et al., 2017). Other examples from the qualitative work included women feeling humiliated when they were forced to have sex while menstruating (Baldwin et al., 2015) and punishment from their trafficker for both turning away buyers who did not agree to use a condom and unintended pregnancy (Ravi et al., 2017). Finally, while evaluating the feasibility of a screening tool to identify adult victims of HST, Mumma et al. (2017) found that 100% of the identified victims reported that they had, or someone they worked with had, been beaten, hit, yelled at, raped, threatened, or made to feel physical pain for working slowly or trying to leave.
Both women born outside and within the United States reported a history of childhood trauma (Finn et al., 2015; Muftić & Finn, 2013; Rajaram & Tidball, 2018; Ravi et al., 2017). However, in a study examining risk factors and health outcomes in U.S.-born and non-U.S.-born women trafficked for sex in the United States as well as nontrafficked sex workers in the United States, Muftić and Finn (2013) reported that U.S.-born women who were trafficked for sex were more than twice as likely to report a history of child abuse compared with non-U.S.-born women who were trafficked for sex (87.5% vs. 40%, respectively). Furthermore, victims born inside the United States fared worse and were statistically different than victims born outside the United States in the domains of history of abuse, duration in the sex trade, exposure to street prostitution, violence, and other problems (Muftić & Finn, 2013).
Health Needs and Inadequate Response of the Healthcare System
Frequently identified condition-specific needs were gynecological, including abortion (Baldwin et al., 2011; Muftić & Finn, 2013; Mumma et al., 2017; Ravi et al., 2017), infectious disease, and substance abuse (Baldwin et al., 2011; Muftić & Finn, 2013; Mumma et al., 2017; Ravi et al., 2017). Many women also reported seeking treatment for trauma-related injuries (Baldwin et al., 2011; Finn et al., 2015; Muftić & Finn, 2013; Mumma et al., 2017; Ravi et al., 2017).
Beyond specific diagnosis, the reviewed literature explored many facets contributing to health care such as not having insurance or inactive Medicaid (which are both associated with trafficking-ring-related trafficking and forced relocation), identification or transportation (Ravi et al., 2017), and a health system that was not responsive to their needs (Baldwin et al., 2011; Rajaram & Tidball, 2018; Ravi et al., 2017).
The qualitative studies reviewed provide additional insight into the experience of seeking care and highlight specific issues that are unique to this population. Two studies showed that, when women were allowed to seek treatment, the trafficker or another designated individual accompanied them to the appointment (Baldwin et al., 2011; Ravi et al., 2017), even speaking on their behalf and filling out the required paperwork (Baldwin et al., 2011). In addition, although many women reported feeling scared and nervous during their healthcare encounter, the participants in Baldwin et al.'s (2011) qualitative study reported they were not assessed for abuse.
Multiple studies reviewed also reported physicians' indifference to their overall health and well-being. While exploring the lived experience of trafficking survivors in the Midwest, Rajaram and Tidball (2018) reported that survivors felt hurt, further alienated, and feelings of distrust increased when healthcare agents and other frontline providers lacked sensitivity and subsequently blamed and judged victims. Other issues identified included concerns that the physician and trafficker knew each other (Baldwin et al., 2011), arranging for women to be seen in private locations, and fear of arrest if they were to seek treatment from a hospital (Ravi et al., 2017).
Comprehensive care also includes follow-up, but only one qualitative study spoke directly to the issue. Ravi et al. (2017) reported that follow-up care was hampered because of various factors such as forced relocation, unreliable and/or falsified contact information, and a lack of engagement because of substance use disorder. The ability to fill prescriptions was also inhibited because of insufficient finances and/or inaccessible transportation, and adherence to certain treatment, such as vaginal suppositories or abstinence, was compromised for fear of lost income.
The results of this review show that, despite the critical need for effective health care, existing social structures, a lack of resources, and an inadequate response by the health system result in care that does not meet the specific needs of women who are trafficked for sex in the United States. This could be not only because in part of providers having difficulty identifying victims of HST (Clawson et al., 2003) but also because what is known about the healthcare needs of the women is still in its nascent stage. This review yielded only five studies that reported on the health problems of the women (Baldwin et al., 2011; Muftić & Finn, 2013; Mumma et al., 2017; Rajaram & Tidball, 2018; Ravi et al., 2017), and only Ravi et al. (2017) had a primary focus on the health of U.S.-born women, specifically. Moreover, for understandable reasons, victims reported difficulties with adherence to the prescribed treatment, such as fear of lost income while practicing abstinence posttreatment for an sexually transmitted infection (Ravi et al., 2017). These findings warrant further evaluation.
It is important to note that Muftić and Finn (2013) described differences in several variables between victims born inside the United States and outside the United States. However, not all of the reported findings clearly or consistently drew a distinction between victims born in the United States, victims born outside the United States, and nontrafficked sex workers (Finn et al., 2015). As such, the effects of country of origin on overall health are not clear.
The results of this review highlight the lack of attention being paid to women who are trafficked in the United States. Despite the report that most of the victims trafficked for sex in the United States are born in the United States (Banks & Kyckelhahn, 2011), four studies in this review were solely composed of victims born outside the United States (Baldwin et al., 2011, 2015; Dewan, 2014; Jani & Anstadt, 2013). This could be because U.S.-born victims are more likely to be identified as offenders (Farrell et al., 2016). It may also be related to the availability of funding for research and intervention, as no federal dollars (U.S.) were allocated for U.S.-born victims for any kind of trafficking before 2014. From 2014 to 2019, however, $30 million went to the assistance of U.S.-born victims. Funding for victims born outside the United States has far outpaced funding for U.S.-born victims and, exceedingly, has been available dating back to 2011 with a total budget of almost $116 million from 2011 to 2019 (U.S. Department of Health and Human Services, 2019). This disproportionate response between U.S.-born and non-U.S.-born victims illustrates the need for additional research and assistance.
Although a broad search and an ancestry approach were utilized to locate as many relevant documents as possible, all available and pertinent documents may not have been discovered and included in this review. In addition, six of the studies used a convenience/purposive sample of women who participated in services for trafficked victims, and one study's subjects were incarcerated. It is likely that the healthcare needs of women who utilize services are different than women who do not. Another note of concern is the lack of information regarding the race and ethnicity of victims in the published reports. Those data are critical to understanding victims of trafficking experiences while navigating the healthcare system. In addition, two studies were secondary analyses of data that were collected almost two decades ago (Finn et al., 2015; Muftić & Finn, 2013), before the U.S. implementation of national awareness campaigns and programs targeting domestic victims, and thus may not reflect the current conditions.
Implications for Clinical Forensic Nursing Practice and Research
Despite limited data on the health of U.S.-born women, specifically, who are trafficked for sex in the United States, findings from this review indicate that care tailored to meet their health needs is grossly inadequate and lacked a trauma-informed approach. Providers face difficulty identifying victims of sex trafficking; however, initiatives to address under recognition are progressing (Hounmenou, 2012; Macy & Graham, 2012). Forensic nurses are uniquely trained to recognize and manage patients, using a trauma-informed approach, who present with a history of abuse and trauma, as is in the case of victims of HST. For example, women reported difficulty adhering to prescribed treatment such as vaginal suppositories for an sexually transmitted infection (Ravi et al., 2017). Forensic nurses are positioned to provide and advocate for treatment that is appropriate if the prescribed or standard treatment does not accommodate for the unique circumstances of women who are trafficked for sex.
In addition, a clear understanding of what the women want or need from the health system, in general, remains elusive, and further research is needed. Given their knowledge of how sexual and domestic violence impacts health and healthcare utilization, forensic nurses should lead research that explores the perspective of the women to discover how the experiences of trauma, abuse, and being trafficked for sex influence their health and health-seeking behaviors. A clearer understanding of these factors is needed to address the complex history of this vulnerable group and how it contributes to their healthcare needs so that an appropriate healthcare response can be designed and implemented.
Although research on the characteristics and health needs of women who are trafficked for sex in the United States is still in its nascent stage, the need for such work is apparent, and this review clearly identifies important areas for research and practice. Moreover, much of the literature on human trafficking has been conducted from the perspective of criminal justice, social services, psychology, and sociology, which may contribute to the lack of an evidence-based approach to health care for this vulnerable population. It does not appear that HST is declining or that a solution to thoroughly address the complexities of victims' health disparities has been discovered. As frontline providers of health care, forensic nurses must lead in the delivery of holistic care designed to address the unique needs of this vulnerable group.
The authors would like to thank Rick Zoucha, PhD, PMHCNS-BC, and Lara Gerassi, PhD, LCSW, for their assistance with preparation of the article.
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