Situating HIV risk in the lives of formerly trafficked female sex workers on the Mexico-US border

Abstract

Due to stigma and the psychosocial repercussions of past trauma and abuse, survivors of sex trafficking may experience increased susceptibility to violence, revictimization, and various harmful health outcomes, including HIV infection. Given the paucity of research characterizing the experiences of formerly trafficked female sex workers (FSWs), we set out to describe and contextualize perceptions of HIV risk among women who have experienced past episodes of sex trafficking and who are currently engaged in sex work in Tijuana, Mexico. Based on semi-structured interviews and ethnographic fieldwork, we describe the following interrelated themes as influencing formerly trafficked FSWs' perceptions and experiences of HIV risk: economic vulnerability; susceptibility to violence; and psychological trauma. Our findings highlight the need for HIV prevention efforts to incorporate broader structural and social interventions aimed at reducing vulnerability to violence and human rights abuses among this population and improving their general economic, psychological, and social well-being.

Introduction

The Mexico-US border is considered a major destination and transit point for human trafficking, a practice that may be contributing to the growing HIV epidemic in this region (US Department of State, 2011). The United Nations Palermo Protocols define human trafficking as, “the recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion…for the purpose of exploitation” and includes all commercial exploitation of children below age 18 (United Nations, 2000). Women and girls trafficked for sexual exploitation are exposed to serious health risks, including increased vulnerability to violence, HIV, and sexually transmitted infections (STIs) (Dharmadhikari, Gupta, Decker, Raj, & Silverman, 2009; Gupta, Raj, Decker, Reed, & Silverman, 2009; Silverman et al., 2008).

While research on sex trafficking is in its infancy, studies suggest that continued engagement in sex work is fairly common among survivors—who often face stigma and limited economic opportunities (Hennink & Simkhada, 2004; Oxman-Martinez, Lacroix, & Hanley, 2005). Considering that sex trafficking survivors have been found to exhibit high levels of psychological trauma (Ostrovschi et al., 2011; Tsutsumi et al., 2008; Zimmerman et al., 2003, 2008), and that mental illness is linked to increased HIV vulnerability (Hong, Li, Fang, & Zhao, 2007; Lang, Salazar, DiClemente, Markosyan, & Darbinyan, 2011; Surratt, Kurtz, Chen, & Mooss, 2011), it is likely that formerly trafficked female sex workers (FSWs) experience particularly elevated risks of HIV infection. Yet, few studies have investigated HIV risk among this population.

Tijuana, Mexico—located across the Mexico-US border from San Diego, California—is currently experiencing an emerging HIV epidemic (Strathdee & Magis-Rodriguez, 2008). FSWs have been disproportionately affected by this epidemic, with HIV prevalence among this population increasing from below 1% to 6% over the past decade (Patterson et al., 2008). While sex trafficking may be contributing to HIV vulnerability among FSWs in Tijuana, research describing the health impacts of sex trafficking is lacking in this setting. Recognizing the need for qualitative data documenting the lived experiences of sex trafficking survivors, and guided by studies highlighting the importance of understanding how individuals situate HIV within the larger context of their lives (Bourgois, 1998; Bourgois, Lettiere, & Quesada, 1997; Carballo-Diéguez & Dolezal, 1996; Carter, Harry, Jeune, & Nicholson, 1997; Connors, 1992; Maharaj & Cleland, 2005), we set out to describe and contextualize perceptions of HIV risk among a sub-sample of formerly trafficked FSWs participating in a larger study of HIV/STI vulnerability along the Mexico-US border.

Methods

Study setting

Sex work is quasi-legal and highly prevalent in Tijuana's Zona Norte district, where an estimated 9,000 FSWs operate in a variety of venues attracting clients from the US, Mexico, and internationally (Bucardo, Semple, Fraga-Vallejo, Davila, & Patterson, 2004; Goldenberg et al., 2011; Patterson et al., 2006). FSWs over the age of 18 are permitted to work within the Zona Norte, provided they purchase registration cards and undergo regular HIV/STI screening; however, it is believed that over half of Tijuana's FSWs operate without permits (Bucardo et al., 2004; Sirotin et al., 2010).

Although research describing human trafficking in the Americas remains scarce, the Mexico-US border is believed to function as a corridor for the trafficking of persons to the US and other countries (Seelke, 2011). While a growing number of governmental and non-governmental organizations in Tijuana offer support, including shelter, legal assistance, and health care, to survivors of sexual and gender-based violence, the dedication of resources to trafficked persons in this region remains low (US Department of State, 2011; Zhang, 2011).

Data Collection

Between November 2010 and June 2011, we conducted ethnographic fieldwork and in-depth interviews with formerly trafficked FSWs (n=24) in Tijuana, Mexico. Fieldwork included tours of local agencies that provide services to trafficked women, informal conversations and meetings with service providers, FSWs, and other key informants, and ethnographic observation within the Zona Norte. This data allowed us to contextualize the information obtained through in-depth interviews.

We recruited interview participants from a larger study examining HIV/STI risks among FSWs and their non-commercial partners in Tijuana and Ciudad Juarez, Mexico (Proyecto Parejas) (Syvertsen et al., 2012). Eligibility requirements to participate in the parent study included: being at least 18 years old and biologically female; residing in Tijuana or Ciudad Juarez; having sold or traded sex in the past month; having maintained a non-commercial male sexual partner for the past six months; having ever used heroin, cocaine, crack, or methamphetamine; and having no plans to leave either city within the next 24 months. We invited Tijuana residents to participate in qualitative interviews if they reported any of the following experiences: 1) entry into or continuation of sex work based on force, coercion, or deception (ForcedSW); 2) non-consensual movement for the purpose of sex work (TransportSW); 3) entry into sex work before the age of 18 (SW<18). These inclusion criteria were derived from the UN's definition of human trafficking (United Nations, 2000). We used a purposive sampling scheme (Corbin, 2008) with the aim of recruiting women representing a diverse range in age, migration status, and trafficking history.

Qualitative interviews lasted approximately 1.5 hours and were conducted in Spanish or English by trained female interviewers in private offices within Tijuana's Zona Norte. Interviews consisted of open-ended questions, in which participants were asked to describe their personal histories, including their reasons for beginning and continuing sex work, as well as related health concerns such as HIV/STI risk and prevention.

The research was approved by IRBs at the University of California, San Diego and El Colegio de la Frontera Norte, Mexico. Written informed consent was obtained from all participants. Each woman received $20 (USD) as compensation for time and travel expenses. Condoms, HIV/STI prevention information, psychological support, and referrals to services and care were made available to all participants.

Data Analysis

Interviews were transcribed and translated. All personal identifiers were removed. Narrative analysis was guided by the constant comparative method (Glaser, 1965). QSR NVivo 9 software was used to manage data coding. Each interview was read and coded for influences and perceptions related to post-trafficking HIV risk. As coding proceeded, themes were generated and compared across cases. Themes were continuously analyzed and revised to develop a comprehensive representation of women's experiences.

Results

Of 24 interviews conducted, one case was excluded from analysis because her trafficking experience had occurred over thirty years ago. The remaining women had a mean age of 33; their mean age of entry into sex work was 17 (Table 1). Eighteen women had been recruited into sex work as minors, 11 were forced, coerced, or deceived into sex work, and two had experienced forced movement for sex work. Six women met more than one of these criteria.

Table 1.

Socio-demographic characteristics and HIV/STI status among formerly trafficked FSW (n=23)

Variable	Category	Value
Age, in years (mean, range)		33 (20–53)
Place of birth (n, %)	Baja California, Mexico	10 (43.5%)
	Distrito Federal, Mexico	2 (8.7%)
	Other Mexican state	9 (39.1%)
	Central America	1 (4.3%)
	United States	1 (4.3%)
Children (n, %)	Has dependent children	13 (56.5%)
	Does not have dependent children	10 (43.5%)
Age at first engagement in sex		17 (12–28)
work, in years (mean, range)
Trafficking history (n, %)	Began sex work < 18 years old (SW<18)	18 (78.3%)
	Forced into sex work (ForcedSW)	11 (47.8%)
	Forced migration for sex work (TransportSW)	2 (8.7%)
	Met more than one of the three criteria described above	6 (26.1%)
HIV status (n, %)	HIV positive test result	1 (4.3%)
Other STI status (Syphilis, Gonorrhea, or Chlamydia) (n, %)	Other STI positive test result	1 (Chlamydia) (4.3%)

Participating women presented HIV as one of many competing risks and pressures that shaped their daily lives. We identified the following trafficking-related themes as strongly influencing how these women perceived, experienced, and responded to HIV risk: economic vulnerability; susceptibility to violence; and psychological trauma.

Overview of trafficking experiences

While participants' trafficking trajectories varied considerably, instances of childhood abuse, social isolation, and recurring violence were common. Many women spoke of being sexually and physically abused as children and subsequently recruited into sex work at a young age, some as young as 12 years old, after running away from or being kicked out of their homes. Others were trafficked later in life, often during a time of social vulnerability—such as after deportation from the US or release from jail. The degree of autonomy and personal safety experienced during episodes of sex trafficking ranged substantially. While some women were raped and beaten, others explained that they were sexually exploited as minors by older boyfriends or acquaintances, who primarily manipulated them through emotional intimacy.

Among women who were forced into sex work, most managed to escape on their own or were eventually released. For example, one woman who was forced into sexual servitude in migrant labor camps told of how her captors had allowed her to leave after she became pregnant. Despite seeking care at a hospital after her release, she ultimately miscarried as a result of beatings these men had inflicted upon her.

The majority of women who were recruited into the sex trade as minors continued engaging in sex work through adulthood due to economic necessity or drug addiction. While many women expressed desires to leave sex work, others spoke positively of the flexible hours, higher earning potential, and autonomy they experienced as independent sex workers.

Economic vulnerability

Most participants began sex work at a time in their lives marked by economic deprivation. Struggling with pressures of homelessness, food insecurity, and single teenage motherhood, many women were recruited into sex work by persons seeking to profit from their desperate circumstances.

Despite having reclaimed autonomy over many aspects of their lives, most women remained dependent on sex work due to poverty and the lack of decent paying jobs in Tijuana. Over half of participants had dependent children and most were the primary income earners within their households. As mothers, these women tended to frame sex work as a sacrifice:

What I earn is only for my son, not for me. That's why I'm doing all of this, because of him […] Sometimes I want to get out, but […] if I find a job at a restaurant […] how much would they pay me a week?

Here, I earn what I will need for the diapers very quickly [Age 34, ForcedSW; TransportSW; SW<18].

The relationship between participants' perceptions of HIV risk and their economic dependence on sex work became especially apparent as they discussed condom use. Many women acknowledged the risk of unprotected sex, but reported that economic desperation often led them to acquiesce to clients' demands:

There are guys who don't like it, and they say, “I'm going to give you a little more for not using a condom.” So you do it, you don't pay attention to the risks [Age 25, SW<18].

Susceptibility to violence

Although no longer held captive or physically forced into sex work, violence—perpetrated by clients, intimate partners, and police…remained pervasive in women's post-trafficking lives. Participants perceived their vulnerability to violence as limiting their ability to mitigate HIV risk. Many women had been raped and assaulted while working as independent FSWs and several women described recent instances in which clients had used violence, or the threat of violence, to force them into having unprotected sex or engaging in other unwanted behavior, such as drug use and anal sex, which carry increased risk of HIV infection:

I didn't want to have sex because I was on my period, and this guy pulled out a knife. I was forced, he made me have anal sex […] He said, “If not, you'll stay here, you won't get out of here,” I was scared and well, I had to do it [Age 46, SW<18].

One of them used a gun once […] He wanted to have sex from behind, and I don't like that, especially because he was drunk and high [Age 34, ForcedSW; TransportSW; SW<18].

In response to the risk of client violence, many women had adopted precautionary strategies, such as refusing to enter clients' cars, refraining from sex work outside the Zona Norte, and only engaging with regular clients, who they perceived as posing less of a threat:

I don't go with strangers - like the first time we meet and do that, no […] I always try to hang [out] with them first, just try and get to know them. I think I don't put myself in any [dangerous] situations [Age 29, ForcedSW].

While such measures exemplify these women's agency and resilience, women also reported that they were less likely to use condoms with regular clients, suggesting that in mitigating the threat of client violence they may be exposing themselves to increased HIV risk.

In most cases of violence, women were hesitant to involve local law enforcement, whom they felt lacked the willingness to protect them. Many women reported episodes of police abuse in which officers had extorted them for money or sex—constituting yet another source of risk in these women's lives.

Psychological trauma

Women often discussed their struggles with psychoemotional distress. Despite having survived severe trauma and abuse, few participants had ever received any form of mental health care. When asked what services they felt would benefit them and others survivors of abuse, several women appealed for greater access to psychological services:

Q: What kind of help would you of liked to have?

A: Well, psychological help, no? Psychological help to take away some of the trauma and fear [Age 46, SW<18].

I've been wanting to see a psychologist for a long time, but I haven't gone. I've been told that it's very expensive [Age 34, ForcedSW, SW<18].

Participants often described psychoemotional distress as driving substance abuse—which they perceived as exacerbating their risk of HIV infection. Most women had never received any rehabilitation or other trafficking-related services; the few women who had sought care at drug rehabilitation centers in or around Tijuana complained of mistreatment in these centers and noted that such programs lacked adequate mental health services to address the underlying causes of their substance abuse:

The ones that we have are [drug] rehabilitation centers and, and they talk about drugs and everything […] but they never talk about the problems that we have sometimes. Those same problems make us want to take drugs or get drunk, well, so we don't feel anything [Age 22, SW<18].

Participants' struggles with unresolved psychological trauma illustrated the degree to which HIV risk is deeply embedded among other biological and psychosocial concerns which may compromise trafficked women's capacity to prioritize their own health and safety:

I've never had any hope of what my life will be like, I've never had it and even less now, it's only to live every day […] It's been a long while since I've been scared, never, what more could happen to me that hadn't already? I wasn't scared of dying; many times what I wanted was to die [Age 32, SW<18].

Discussion

Our analysis describes perceptions of HIV risk among formerly trafficked FSWs as situated among an array of competing stressors which influence how they experience and respond to the risk of HIV infection.

Many of the economic pressures that precipitated participants' susceptibility to sex trafficking continued to act as drivers of sex work continuation and inconsistent condom use…an observation that supports prior research associating financial need with increased HIV vulnerability among FSWs (Castillo, Gómez, & Delgado, 1999; de la Torre, Havenner, Adams, & Ng, 2010; Dunkle et al., 2004; Vanwesenbeeck, 1994). Although increasing access to condoms, sterile injection equipment, and HIV/STI prevention information among FSWs is critical to reducing HIV transmission, our findings suggest that individualized interventions are likely to be of limited effectiveness unless combined with structural interventions addressing the inequities that perpetuate vulnerability to drug- and sex-related risks, including the risk of sex trafficking.

Our research uncovered strong linkages between vulnerability to violence and condom use. While violence has widely been described as a barrier to condom use among FSWs (Bucardo et al., 2004; Decker et al., 2010; Okal et al., 2011; Shannon et al., 2008; Shannon & Csete, 2010; Ulibarri, Strathdee, & Patterson, 2010), the persistent nature of violence experienced by women in our study suggests that formerly trafficked FSWs are particularly susceptible to revictimization. These findings demonstrate the need for interventions aimed at decreasing vulnerability to violence among FSWs, increasing condom use among clients, and confronting abusive police practices, especially within the Mexico-US border context.

Psychological trauma was a primary concern for many women. This is consistent with studies showing elevated levels of psychological distress among trafficking survivors in South Asia and Europe (Ostrovschi et al., 2011; Tsutsumi et al., 2008; Zimmerman et al., 2008; Zimmerman et al., 2003). Our analysis suggests that among trafficked FSWs, this high burden of psychological morbidity constitutes a driver of HIV vulnerability by fueling substance abuse and inhibiting risk mitigation. These findings highlight the need for improved access to psychological care and other rehabilitative services for survivors of sex trafficking and other forms of sexual violence. Reports of mistreatment in drug rehabilitation centers are supported by previous research in this context (Syvertsen et al., 2010).

Strengths and Limitations

We based our analysis on the UN Palermo Protocols definition of human trafficking (United Nations, 2000). This definition, like all existing definitions of human trafficking, is not universally agreed upon and is subject to criticism.

We recruited our sample from a parent study in which having a long-term noncommercial partner and having ever used heroin, cocaine, crack or methamphetamine were inclusion criteria. While prior HIV testing and counseling experiences may influence HIV risk perception, only 52% of women in a recent study of FSWs who inject drugs in Tijuana and Ciudad Juarez had ever been tested for HIV, suggesting that prior HIV testing and counseling is likely not a primary influence on HIV risk perception among our study participants (Strathdee et al., 2011). Although underage FSWs are particularly vulnerable to trafficking, we did not include them in our study for ethical and legal reasons, including the illegal status of youth sex work and the lack of health and social services for underage FSWs in Tijuana. By providing retrospective accounts of participants' entry into sex work and experiences as child sex workers, our research aims to inform the consideration and development of future studies of trafficking among underage sex workers in this context. As the topics we investigated can be socially stigmatizing, to minimize social desirability bias, we trained interviewers to conduct interviews in a non-judgmental manner, ensure confidentially, and openly discuss the purpose of our research with participants.

Conclusion

Our analysis suggests that persisting poverty, violence, and psychological trauma inhibit formerly trafficked FSWs' capacities to prioritize and respond to HIV risk. These findings highlight the need for HIV/STI prevention efforts to incorporate structural interventions aimed at preventing sex trafficking and other forms of violence against FSWs, and supporting their overall well being.