Sex trafficking in the United States involves the forced sexual exploitation of adults or the sale of commercial sex by minors, and does not require transportation across borders into or inside of the country, as is commonly perceived.1 Victims experience significant physical, sexual, and psychological trauma while sex-trafficked, resulting in short and long-term complex health issues.2–5 However, trafficking survivors may choose not disclose their trafficking-related experience, in part due to concerns regarding safety and stigma.6
Current research and policy efforts have focused on training health care providers to identify sex-trafficking survivors in clinical settings and to connect them with care.7,8 Although there are currently no standardized guidelines for victim screening and health care delivery for those who are identified, incorporating trauma-informed care (TIC) practices are consistently recommended in existing protocols.9–11 TIC by health care providers involves recognizing signs and symptoms of trauma and avoiding retraumatization when providing clinical care.12
As best practices for health care delivery for sex-trafficking survivors develop, incorporating the perspectives of survivors is critical. However, survivor-based insight on health care for this population is sparse in the medical literature, due in part to challenges in identifying this largely hidden population. As a result, our study was designed to interview survivors of domestic sex trafficking who were incarcerated in the New York City jail system regarding experiences with trauma while being trafficked, and advice they have for health care delivery to this population.
This qualitative study was conducted from July to September 2015 in New York City’s women’s jail (Rose M. Singer Center) on Rikers Island. We chose to conduct this study in a correctional setting because women with experiences in trafficking may be overrepresented in a jail population13 and the setting provides a controlled environment in which they may freely share their stories. For logistical reasons, study participants were recruited from a housing area dedicated to counseling and therapeutic programming for persons with substance use disorders. The Institutional Review Boards (IRB) of the NYC Department of Health and Mental Hygiene (NYC DOHMH) and the University of Pennsylvania approved this study. Because of changes in the structure of the jail health system, the IRB oversight of this project was transferred from the NYC DOHMH to the Biomedical Research Association of New York in January 2016.14
Women age 18 and older, who were comfortable completing interviews in English and who answered “yes” to the screening question “Were you ever forced into prostitution or made to turn tricks by family members, boyfriends, friends, pimps, or other people you met?” were eligible to participate.
Study recruitment occurred through announcements made during a weekly, volunteer-led health education program conducted by one of the investigators (A.R.). Therapeutic programming coordinators on the unit were also briefed about the study and notified the team if they met potentially interested participants.
Interviewees participated in a single, audio-recorded interview ∼60 minutes in length, which were conducted by either A.R. or M.R.P (both of whom are women) in private office spaces on the unit. Interviewees were asked to choose a name other than their own to facilitate anonymity. A jail-approved package of undergarments was provided as compensation for study participation.
The interview covered multiple domains, including the context of survivors’ trafficking experience. The circumstances of the participants’ trafficking experiences were also elicited, in order to provide context for the health-related experiences described and the health care delivery advice that was provided.
Domains pertinent to trauma included interpersonal violence, behavioral health, and advice for the health care system. With regard to interpersonal violence, interviewees were asked to describe a situation where they experienced violence perpetrated by a trafficker and by a buyer of sex. With regard to behavioral health, interviewees were asked about their experiences with substance use, and how they felt experiencing trafficking impacted their mental health. With regard to health care delivery, interviewees were asked about their thoughts on disclosing their trafficking histories to health care providers, ways in which they would feel comfortable talking about the experiences, and suggestions they had for health care delivery for persons with similar experiences. The script was piloted with volunteers meeting study inclusion criteria for feedback before utilization.
Following completion of the interview, recordings were transcribed by an independent transcription agency. Members of the research team (A.R., M.R.P., J.A.S.) independently read through a subset of transcripts, reviewed the transcripts for accuracy, identified themes that emerged from the content, and designed and applied a coding scheme through an iterative revision process that ultimately resulted in a final coding scheme that was applied to all interviews. The interviews were (re)coded by 2 authors (A.R., M.R.P.), each completing a subset of the total transcripts. Seven of 26 transcripts were coded by both of these authors for quality assurance. Discrepancies were resolved through discussion until consensus was achieved. Qualitative data analysis software, NVivo version 11 (QSR International, Doncaster, Victoria, Australia), was used to assist in this process.
In total, 26 interviewees answered “yes” to the screening question and completed interviews. Five interviews were later excluded from analysis because the narrative provided did not ultimately meet the legal definition of sex trafficking. Interviewees ranged in age from 19 to 60 years, and 71% self-identified as a racial or ethnic minority (Table 1). The majority of interviewees (57.1%) had not completed high school.
Interviewees varied as to the last time participants were trafficked, ranging from immediately before their incarceration, to as far back as 20 years before the time of interview. All interviewees had histories of substance use at various points in their life, ranging from substance use that started while being trafficked, worsened while trafficked, or started after being trafficked. Heroin, cocaine (including crack-cocaine), and marijuana were the most commonly cited substances used. Of note, although not interview questions, 86% of interviewees disclosed experiencing sexual violence as a minor, often preceding their being trafficked.
Results relevant to our focus on trauma-related experiences and health care delivery are presented below in 3 sections: interpersonal violence, behavioral health, and health care delivery advice.
Of the 21 interviewees, 19 had traffickers, whereas 2 engaged in selling sex as minors without the involvement of a trafficker. Types of traffickers varied. The most common experience in this cohort was with exploiters who ran trafficking rings (42.9%, n=9), involving groups of trafficked women housed together, self-referred to as a “family” and the trafficker expecting to be called “daddy.” Other traffickers included drug dealers (23.8%, n=5), mothers (9.5%, n=2), intimate partners (9.5%, n=2), and a stranger (4.8%, n=1). Interviewees described varying locations where they were trafficked, spanning from only within their local neighborhoods, to multiple states across the country. Interviewees varied in their time course with a trafficker, ranging from a single experience with 1 trafficker, to being trafficked by multiple traffickers throughout different times in their life.
Survivors described experiencing physical, sexual, and psychological violence while trafficked. Violence was perpetrated by both traffickers and the buyers (sometimes referred to as “tricks”) who purchased sex (all of whom were men). Examples of violence included being beaten to unconsciousness, gang raped, choked, burned, imprisoned, threatened with weapons, threatened to harm loved ones, deprived of sleep, food, and clothing, and witnessed violence perpetrated against other trafficked women and girls. Those in trafficking rings described “quotas” for the amount of money they were expected to generate daily, and violent repercussions if these expectations were not met. Survivors also described incurring additional trauma when attempting to escape dangerous situations during encounters with buyers, such as jumping out of moving cars or off of rooftops.
Substance use tended to be the most common method of coping with trauma-related experiences (13 of 21 interviewees shared this perspective). Those who used substances before experiencing trafficking also consistently stated that sex trafficking worsened their addiction. Approximately 25% of survivors described using substances to address other trafficking-related stresses, including using cocaine for the purposes of staying awake for multiple days to meet quotas, and heroin to numb physical pain during sexual encounters:
… It was much more difficult to work sober because I was dealing with the emotions or the pain that I was feeling during intercourse, because when you have sex with people 8, 9, 10 times a day, even more than that, it starts to hurt a lot. And being high made it easier to deal with that and also it made it easier for me to get away from my body while it was happening, place my brain somewhere else. (Corey)
When asked about how being trafficked affected their mental health, interviewees discussed mental health diagnoses they had received since being trafficked [depression, anxiety, and posttraumatic stress disorder (PTSD)] as well as disruptive symptoms they were experiencing in their daily lives, such as feeling unsafe at night, feeling easily startled, and having increased suspicion with normal interactions:
… It’s a lot to deal with, period, having sex with all these men, doing things you wouldn’t really do… like now, I’m diagnosed with PTSD. I have that really bad from being hit and… yelling and stuff. (Phoenix)
The complex interplay of trafficking and nontrafficking-related abuse, negative self-views, concerns regarding intimacy, and strained relationships with partners or family members were also consistent themes that emerged when discussing mental health:
It made me feel worthless and disgusting. It made me feel like I wasn’t good enough to be somebody’s wife. Not a good mother, either. If I had to see my son the next day, I wouldn’t want to touch him because I felt like I had the cooties type… It’s just very downgrading… I could never find the joy in it. No. (Vicky)
… I think because I was abused as a kid, sexually abused, that I didn’t have the love for my body and myself as a young woman was supposed to … in fact, I don’t even like sex. To this day, I still don’t even care for it … Like if I never had sex again, I’m fine. And so, that’s not good… “sex can’t be for free”: that’s the type of mentality I have… And I know it’s wrong. But if I’m in a relationship, how long is it going to be? Is it over yet? Are we there yet? … Or it has to be some type of rough sex. It’s like “you can’t caress me because I don’t feel like I deserve that” … “Don't cuddle me … I’m not into all that. Don’t touch me.” So I know there’s some issues there. (Angie)
… I’m not interested in being with men, even though I love my husband, like I want to be with him. But I just don’t want to be judged. Like I have flashbacks or whatever. And I blame more man, because it’s never happened with a woman. So it’s like it’s very hard. It’s very hard because he don’t know what happened. I can’t tell him what happened. (M)
Approximately 25% of interviewees also discussed that jail was an initial site where they began processing their trafficking-related trauma, as they found themselves in a situation free of substance use and the presence of traffickers:
So I had all of that, that I had never dealt with before, that I was still dealing with, plus my uncle’s sexual abuse towards me, the emotional abuse from my ex-husband and my 2 other kids’ father, and never dealing with any of own of stuff. Just bottling it in, bottling it in, taking care of everybody else, not worrying about it. So that was kind of my mental health. And I’m just now kind of starting to work on it here [at Rikers]. (Candace)
Health Care Delivery Advice
When interviewees were asked about their thoughts on discussing their histories of trafficking with health care providers and suggestions they had for improving health care delivery their responses centered on the themes of addressing provider-patient communication, concerns regarding sexual assault examinations, and improving direct-services and prevention programming.
Survivors shared their general perceptions with regard to the health care system, providing context for their recommendations regarding patient-provider interactions. Themes of feeling intimated by health care providers and concern that health systems prioritized a person’s ability to pay over provision of care consistently emerged. Interviewees also shared advice on characteristics that would make them feel more comfortable in a health care setting, including having rapport with front desk and support staff (eg, receptionists, social workers) and with providers who communicate compassion, empathy, and are not judgmental:
Allow the person to be themselves. Don’t undermine who’s sitting in front of you … Doctors have a tendency to make people feel dumb when they walk into the room. Take off that white coat. Become more personable with your patients, because 9 times out of 10, you make them comfortable, they will be comfortable enough to express things that you might need to know. (Lady Moet)
Interviewees also shared their thoughts about discussing trafficking histories in health care settings, including ways to approach the topic that would potentially make survivors feel more comfortable, reasons why people may choose not to disclose, and ways to respond to those who do disclose. Most commonly, interviewees felt the issue should be approached directly:
… Some people are embarrassed. Some people are shy. Some people are afraid of being judged … But I think the way you ask about birth control, I think it should be a question that all doctors should ask … I think you should ask “have you ever been forced into prostitution” … I think it just should be simple, straight to the point … I feel that that should be a mandated thing to do … Whether you get a straight-up answer or you don’t—at least you did your job as a doctor. At least you have that out there. (God’s Child)
… You have to read the person … their posture, their body language. See if they’re somebody that you think that could open up to you … It’s just like bringing up the topic would probably trigger something in them, but you just got to bring it up in a certain way that … you’re not letting them think that you’re … aiming at them to say something … be gentle, because it’s a tough topic to bring up with somebody, especially somebody you don’t know … Some girls might get offended. You never know. They might come back next time and tell you the truth. (Vicky)
Recommendations to facilitate discussion also included: normalizing the question so people don’t feel targeted, not pressuring people to respond, and emphasizing safety and confidentiality in the screening process. Being asked sensitive questions, such as number of sexual partners (a standard Centers for Disease Control and Prevention Human Immunodeficiency Virus prevention question)15 was also mentioned as a source of unease during office visits:
… When so much money is coming in, you have clients waiting, and you need to go to a doctor, you know you have to make that money. So really, your health is being put to the back. And then by the time you do finally go, you have just so many problems … I never felt comfortable letting anyone know what type of lifestyle I was in. They would ask me how many partners have I had. I’d tell them 1 … I was getting infection after infection … And … I just didn’t feel comfortable telling them what kind of lifestyle I was in. (Star)
Survivors also discussed the importance of providers being self-aware of their reaction when a disclosure is made:
When I told my primary care provider about it (being trafficked) … she gave me this … raised the eyebrows, distanced look. And she was like, “oh, okay.” I was like, “all right, what does that mean, are you judging me?” … that’s really big for me … not to show adverse reactions and just having the same general demeanor, being very friendly and nice and open, and showing that “no matter what you’ve been through, it’s okay, it doesn’t mean anything to how I feel about you … I’m still gonna give you the help that you need without showing judgment…” (Corey)
Addressing negative experiences when seeking and undergoing sexual assault examinations was another issue that emerged when interviewees discussed ways that the health care system could better serve sex-trafficking survivors. Women described feeling judged when answering routine questions such as “What were you doing at the time” of the event and feeling coerced out of reporting. Some women were unable to endure long waits for examinations, sometimes leaving during the process or not initiating it altogether. When kits were completed, interviewees also expressed a desire for providers to contact survivors about rape-kit–related test results, even if they were negative, as not having a definitive result furthered their stress about the consequences of the rape. Two interviewees suggested having sexual assault forensic kits that could be completed at home, so that they would not need to come into health care settings for evaluation.
Survivors discussed direct-service logistical issues, including addressing barriers to engaging in mental health and substance use rehabilitation services:
I think if … people would take advantage of what they have here (jail), that would be good. But you shouldn’t have to come here to get it. I think there should be more mental health in the clinics, the public clinics. (Jennifer)
… Stop turning everybody away because they got no Medicaid … they don’t got Medicaid, and you’re not going to treat them or you don’t even think about talking to them? … everybody don’t know how to go to free doctors. Everybody don’t know about Medicaid … I feel everybody deserve 1 chance, especially when it comes to their health … Because when you don’t, that’s how a lot of germs and diseases go back out. It goes right back out, that’s how everybody is getting sick … Because it’s spreadable. (Knight)
… I tried to get on methadone so many times, but … they basically told me that they couldn’t take me because my habit was too small and they needed to save room for people that had bigger habits. I always think about that, because I feel like if I could have just gotten on methadone then … I wouldn’t be where I’m at right now … I feel like there should be more funding for public counseling … even just group meetings … for … addicts, for people that have been sexually abused, emotionally abused. (Alice)
Approximately 1 in 4 participants (n=5) suggested wrap-around services in clinical settings, such as a social worker or a drop-in center with food and shelter resources. Having nonmedicinal alternatives to mental health care including women’s support groups was also commonly suggested:
… [S]top thinking everything is a magic pill, because addiction is not—there’s no magic pill for that … Help us in areas like … meditation. Maybe some yoga whenever we get outside. How about look in the mirror, give themselves affirmations … How about changing the company that you keep? … How about ‘being with that family member may not be healthy for you, so stay away from that family member, in addition to the regimen that we’re giving to you?’ … We’re human here … Everything is not with a script… (Angie)
The importance of trafficking prevention programs was also raised by 20% of participants, including initiatives such as groups for parents in the clinic and trafficking-related education outside of the clinic through outreach, including in jails and schools.
The narratives of these survivors highlight the severity and chronicity of trauma that occurs in sex trafficking as well as its impact on behavioral health and the ways in which these experiences shape survivors’ reflections on health care delivery. Our study provides an important opportunity to have guidance directly from a subset of trafficked people during a period when they are substance-free and removed from traffickers’ influence.
As noted in prior studies,16,17 our results also show that the traumas that people experience while trafficked frequently coexist with nontrafficking-related traumas and abuses, and recognizing the chronicity of these traumas and their intersection with substance use and mental health is critical in designing effective delivery systems. Our results also offer several avenues for future studies with regard to ways in which providers and health care systems can sensitively address trafficking in health care settings.
Although TIC practices such as communicating empathy and being nonjudgmental are frequently emphasized in care delivery for trafficked people, the results of our study also illustrate that a survivor’s decision to disclose a history of trafficking is complex. Thus, incorporating “universal” TIC practices into routine care of all patients may address a survivor’s concerns in a patient-centered way without necessitating disclosure.18 Implementation and evaluation of TIC practices for sex-trafficking survivors warrants further investigation, and the suggested language and approaches that survivors offer in this paper can provide a framework within which to design future studies.
Our findings also support integrating TIC practices for nonclinical stakeholders, such as in correctional settings and substance use treatment programs. Existing studies among incarcerated populations highlight the importance of TIC due to high rates of trauma and mental health conditions.19–21 That sex-trafficking survivors experience incarceration and substance use secondary to their being trafficked provides additional impetus for these sectors to integrate TIC frameworks, further benefiting survivors.
Finally, our study offers multiple programmatic suggestions from survivors that could be helpful for stakeholders such as policymakers, funders, and community-based organizations to consider when developing and allocating resources for survivors and trafficking prevention efforts. For example, the Office for Victims of Crime provides grants for trafficking victim-serving organizations for services including health care and mental health services.22 Suggestions made by survivors in this study, such as having support groups, improved access to mental health and substance use treatment, and working with community-health liaisons offer potential areas to further explore program development, evaluation, and funding.
We recognize that while we had the important opportunity to collaborate with survivors of domestic sex trafficking for this research, our study also has limitations. Given the logistical constraints of the jail setting, not all participants had the opportunity to be asked all questions within the time allotted (eg, 4 participants were not asked the time frame of their last trafficking experience). The site of our study recruitment (the unit for persons with substance use disorders) may have also resulted in overrepresentation of substance use among survivors. In addition, recall bias must also be factored into these findings, particularly given peoples’ varied and intermittent experiences with trafficking and substance use. Finally, we are cognizant that the experiences and advice shared in this study are not representative of all sex-trafficked persons in the United States. However, these limitations do not diminish the saliency of findings with regard to this cohort’s experience on health and sex trafficking.
This study draws attention to the complex and chronic trauma that sex-trafficked women in the United States may experience that make TIC practices integral to providing health care for these individuals. At a time when addressing the intersection of health and sex trafficking is gaining increased attention in the medical and public health fields, our findings offer an opportunity for multiple stakeholders to incorporate survivor-based input to improve health care delivery for this population.
The authors thank Loretta Young of the Robert Wood Johnson Foundation Clinical Scholars Program for her time and feedback regarding study design, and Virginia Shephard (Corizon Health), Cecilia Flaherty and Carmen Gonzalez (both formerly affiliated with the NYC DOHMH) for their generous collaboration in implementing this study.