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Published in final edited form as: Violence Against Women. 2015 Feb 3;21(4):478–499. doi: 10.1177/1077801215569079

Exploring the Context of Trafficking and Adolescent Sex Industry Involvement in Tijuana, Mexico: Consequences for HIV Risk and Prevention

Shira M Goldenberg, Jay G Silverman, David Engstrom, Ietza Bojorquez-Chapela, Paula Usita, María Luisa Rolón, Steffanie A Strathdee
PMCID: PMC4703414  NIHMSID: NIHMS741937  PMID: 25648946

Abstract

Coerced and adolescent sex industry involvement are linked to serious health and social consequences, including enhanced risk of HIV infection. Using ethnographic fieldwork, including interviews with 30 female sex workers with a history of coerced or adolescent sex industry involvement, we describe contextual factors influencing vulnerability to coerced and adolescent sex industry entry and their impacts on HIV risk and prevention. Early gender-based violence and economic vulnerabilities perpetuated subsequent vulnerability to coercion and adolescent sex exchange, while HIV risk mitigation capacities improved with increased age, control over working conditions, and experience. Structural interventions addressing gender-based violence, economic factors, and HIV prevention among all females who exchange sex are needed.

Keywords: Sex trafficking, adolescent sex exchange, HIV risk

Introduction

Involuntary and adolescent involvement in the sex industry have been linked to serious health and social consequences, including HIV and sexually transmitted infections (STIs). In 2001, the U.N. Protocol to Prevent, Suppress, and Punish Trafficking in Persons, Especially Women and Children (Palermo Protocol) constituted the first international effort to criminalize sexual exploitation (Gozdziak & Collett, 2005). This study was informed by the Palermo Protocol definition, in which involuntary and adolescent sex industry entry are considered to be two major facets of “trafficking in persons”:

any act of recruitment, transportation, transfer, harbouring or receipt of persons, by means of threat, force, coercion, abduction, fraud, or deception, for the purpose of prostitution or other forms of sexual exploitation … including the recruitment, transportation, transfer, harbouring or receipt of a child for the purpose of exploitation, even when this does not involve the above means. (United Nations, 2000, pp.32)

Latin America is believed to be one of the largest sources of persons moved across international borders for the purposes of exploitation, yet is among the most under-researched regions on human trafficking (Langberg, 2005). Mexico is a large source, transit, and destination country for trafficked persons (U.S. Department of State, 2012). Most individuals trafficked to the United States are trafficked from or through Mexico (Cicero-Domínguez, 2005; Gozdziak & Collett, 2005).

Although empirical data regarding the prevalence or health impacts of involuntary and adolescent sex exchange are lacking in Mexico–U.S. border cities, exploitation within the sex industry is believed to be rife in this context, which is characterized by intense population mobility and overlapping sex and drug trades. Large numbers of women and children from Central America and southern and central Mexico are reportedly exploited in sex tourism locations such as border areas, tourist destinations, ports, and areas hosting migrant workers (Langberg, 2005; U.S. Department of State, 2009). Child sex tourism is often found in Mexican border and tourist areas, including Tijuana (U.S. Department of State, 2012), where media reports have recently drawn attention to numerous cases of child sexual exploitation (Agencia Fronteriza de Noticias, 2012a, 2012b).

Involuntary and Adolescent Sex Industry Involvement: Linkages to HIV Vulnerability

Evidence from South and South East Asia suggests that women and girls who begin to exchange sex involuntarily or during adolescence experience greatly heightened vulnerability to HIV and STI, in addition to other sexual and reproductive health consequences (Cohen, 2005; Decker, McCauley, Phuengsamran, Janyam, & Silverman, 2011; Gupta, Raj, Decker, Reed, & Silverman, 2009; Miller, Decker, Silverman, & Raj, 2007; Poudel & Carryer, 2000; Sarkar et al., 2008; Silverman et al., 2006; Silverman et al., 2007). Globally, those involved in the sex industry involuntarily or as adolescents experience disproportionately high rates of gender-based violence (Decker et al., 2011; Zimmerman et al., 2008), which is associated with HIV infection (Sarkar et al., 2008). Elevated HIV vulnerability among adolescents and those coerced to exchange sex has also been linked to trauma to an immature genital tract, which increases risk of HIV transmission among younger girls; unprotected sex as a result of limited autonomy and power over sexual transactions; and poor access to HIV prevention (e.g., condoms, information) and medical care (Decker et al., 2011; Sarkar et al., 2008; Silverman et al., 2007).

Vulnerability to involuntary and adolescent sex exchange ultimately results from structural factors, including poverty, gender inequalities, stigma, and laws and policies surrounding immigration and sex work (Adams, 2003; Cicero-Domínguez, 2005; Gozdziak & Collett, 2005; Langberg, 2005; Poudel & Carryer, 2000; Sex Workers Project, 2009; Vijeyarasa, 2009; Vijeyarasa & Stein, 2010). In Mexico, gender inequalities and norms (e.g., machismo) often limit economic opportunities for females and foster acceptance of gender-based violence among women and girls (Sowell, Holtz, & Velasquez, 2008). Among adolescents and those coerced to exchange sex, stigma, and ostracism increase susceptibility to future abuse, and pose barriers to accessing care (Gupta et al., 2009; Hennink, Simkhada, & Scotland, 2004). As a result of immigration policies and laws criminalizing sex work, fear of arrest, police harassment, or deportation may often increase marginalized women's susceptibility to exploitation and coercion (Sex Workers Project, 2009).

To inform our understanding of involuntary and adolescent sex industry involvement and their health consequences, gathering data from the perspectives of those who have directly experienced these circumstances is critical (Brennan, 2005; Gozdziak & Collett, 2005). Although both adolescent sex industry entry and coerced sex exchange have been shown to confer elevated risk of HIV infection in Asia, few empirical data contextualizing these experiences and their relationship to HIV risk are available, especially in Latin America. Since data regarding both the context and impacts of adolescent and coerced sex industry entry on HIV are needed to inform appropriate interventions for this vulnerable population, this study aimed to explore the context and impacts of adolescent and coerced sex industry entry on HIV risk. Specific objectives of this study were to (a) describe factors influencing vulnerability to coerced or adolescent sex exchange and (b) explore how contexts of adolescent and coerced sex exchange shape HIV risk among female sex workers who previously reported such experiences in Tijuana, Mexico.

Method

Study Setting

Located along the Mexico–U.S. border, Tijuana, Mexico is a popular sex tourism destination. The city's sex work and injection drug use scenes are concentrated in the Zona Norte [North Zone], a red light district in which thousands of women and girls sell or trade sex to clients from the United States, Mexico, and international locations (Goldenberg et al., 2011). The sex industry in the Zona Norte is quasi-legal; to avoid persecution by police, adults who exchange sex are required to undergo routine STI/HIV testing to maintain health permits, which are unavailable to minors.

The Mexico–U.S. border region is also experiencing an emerging HIV epidemic. As many as 1 in 116 persons aged 15 to 49 were estimated to be infected in Tijuana in 2006 (Iniguez-Stevens et al., 2009). Female sex workers are disproportionately exposed to HIV and STIs; HIV prevalence has increased from <1% to 6% among female sex workers in Mexico–U.S. border cities in the past decade (Strathdee & Magis-Rodriguez, 2008), and is >12% among those who also inject drugs (Strathdee et al., 2008).

Data Collection

From November 2010 to July 2011, we conducted ethnographic fieldwork in Tijuana, Mexico and San Diego, USA. Fieldwork included observations (e.g., physical characteristics of service provision agencies, border crossing dynamics), as well as in-depth interviews with current female sex workers who previously experienced involuntary or adolescent sex exchange (n = 31) and their service providers (n = 7). As this analysis aimed to understand involuntary and adolescent sex industry entry and their health impacts from the perspectives of women who directly experienced these vulnerabilities, analyses were restricted to these interviews only. During fieldwork, field notes were recorded during and following in-depth interviews to contextualize the data; we drew upon field notes during periodic team debriefings, in which staff discussed particularly impactful interviews, and during data analysis. Fieldwork also provided opportunities to better understand the influence of contextual factors (e.g., accessibility of services) on the health of trafficked women and facilitated reflexivity (e.g., assessing participants' comfort level with us). The study was approved by institutional review boards at University of California, San Diego (UCSD) and El Colegio de la Frontera Norte. Women received US$20 for their time and travel costs.

Eligibility Criteria

Female sex workers with a history of involuntary or adolescent sex exchange (n = 31) were recruited from a study of 420 female sex workers and their male partners in Tijuana and Cd. Juarez (Proyecto Parejas; PI: Strathdee). Eligible women for Proyecto Parejas were ≥18 years old; had traded sex in the past month; reported lifetime use of heroin, cocaine, crack, or methamphetamine; had a stable partner for at least 6 months; had sex with that partner in the last month; and were willing to recruit their partner for the study. As previously described (Syvertsen et al., 2012), participants were recruited by outreach workers through targeted sampling in areas where sex work and drug use occur (e.g., street, bars). All Proyecto Parejas participants completed a questionnaire and biological testing for HIV, syphilis, gonorrhea, and Chlamydia.

From this sampling frame, we conducted interviews with Tijuana-based participants who reported a history of involuntary or adolescent sex exchange. Based on the Palermo Protocol (United Nations, 2000) definition of trafficking in persons,1 we operationalized this as having been <18 years old the first time they exchanged sex (e.g., How old were you when you first traded sex for money, drugs, goods, food, shelter, or anything else?); forced, coerced, or deceived into exchanging sex (e.g., Have you ever been (a) forced to exchange sex; (b) sold or traded for sexual purposes; (c) held captive; (d) promised a job that turned out to be sex work?); and/or transported (e.g., Have you ever been moved between cities as a sex worker?) and forced to exchange sex. These experiences were assessed via the Projecto Parejas questionnaire, which identified 51 potentially eligible women with a history of involuntary or adolescent sex industry involvement in Tijuana. We subsequently developed a purposive sample (Strauss & Corbin, 1998) of women whose survey responses met one or more of these trafficking criteria and who represented a range in age, nationality (e.g., Mexican vs. foreign-born), trafficking experiences (e.g., underage vs. forced), and migration experience (e.g., deportee, internal migrant). These women were invited to complete a qualitative interview regarding their sex industry history. Thirty-two women were invited to participate in an interview, of whom one declined participation; 31 women were interviewed.

Interviews

In-depth interviews were conducted in private offices by female interviewers from UCSD and a community-based organization. Interviewers were trained according to WHO guidelines for research with this population (Zimmerman & Watts, 2003). All participants were explained the purpose of the study, the voluntary nature of participation, and risks and benefits of participating, and provided written informed consent prior to commencing an interview. Interviews were conducted in Spanish or English, audio-taped, and lasted approximately 1.5 hours. Informed by ethnographic methods (Fetterman, 2009) and WHO safety and ethical guidelines for conducting research with trafficked women (Zimmerman & Watts, 2003), interviews loosely followed an open-ended guide, which was iteratively revised as data collection and analysis progressed. Questions elicited women's narratives regarding circumstances surrounding their entry into and continuation of sex industry involvement and perceived HIV risk, including structural (e.g., gender inequities, poverty) and individual-level (e.g., HIV/STI prevention, substance use) factors. Member-checking was conducted with a sub-group of women (n = 6), which provided opportunities for deeper exploration and elaboration of concepts described during initial interviews, as well as to gather participants' feedback on our preliminary findings and their interpretation. Participants who reported different contexts of sex industry entry (e.g., involuntary vs. adolescent) and expressed particularly strong and/or diverse perspectives during their initial interviews were purposively sampled for member-checking interviews.

Given the sensitive nature of the interviews, we undertook substantial efforts to ensure participants' comfort with the research process prior to, during, and following in-depth interviews. For example, prior to initiating an interview, interviewers were trained to assure participants of the confidentiality of the data and to ensure that each participant felt comfortable and safe conducting the interview by asking questions such as, “Do you have any concerns about carrying out this interview with me?” and “Do you think that talking to me could pose any problems for you, for example, with people who may have abused you?” (Zimmerman & Watts, 2003). In addition, interviewers were trained to maintain a nonjudgmental stance; emphasize listening, rather than asking a multitude of questions; and to close the interview on a positive note (Zimmerman & Watts, 2003). The existence of long-term relationships between study staff and participants, who were recruited from a longitudinal study, likely also facilitated rapport with our research team. For example, women often cited trust and positive experiences with our studies (e.g., improved HIV-related knowledge resulting from contact with our projects, staff assistance in accessing health services) as the reason they felt comfortable disclosing highly personal information, and explained that sharing their histories represented a key part of their healing process.

Participant Characteristics

Characteristics of the study sample (as presented in Tables 1 and 2) were derived from Proyecto Parejas. These included biological testing for HIV and other STIs (e.g., Chlamydia, gonorrhea, syphilis) and measures of socio-demographic characteristics (e.g., age, education, birth city/country), substance use (e.g., drugs used in past 6 months), and pathways into exchanging sex (e.g., began to exchange sex <18 years old; forced, coerced, or deceived into exchanging sex; transported and forced to exchange sex).

Table 1. Socio-demographic characteristics of participants (n=30), Tijuana, Mexico, 2011.

Variable (n = 30)
Age, yearsa 33 (19-54)
Education, yearsa 6 (1-15)
Birthplace
 Tijuana, Mexico 12 (40.0%)
 Other Mexican city 16 (53.3%)
 Foreign-born 2 (6.7%)
Number of childrena 2 (0-7)
Positive for any STI/HIV 5 (16.7%)
Frequency of alcohol use
 None 21 (70.0%)
 ≤ 2-4 times/month 4 (13.3%)
 ≥ 2-3 times/week 5 (16.7%)
Drugs used, past 6 months*
 Heroin 19 (63.3%)
 Crack 2 (6.7%)
 Cocaine 6 (20.0%)
 Methamphetamine 22 (73.3%)
Injected drugs, past 6 months 18 (60.0%)
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*

Categories not exclusive

NOTE: Data are N (%) of women, unless otherwise indicated.

a

Median (range)

Table 2. Experiences of involuntary and adolescent sex exchange and violence among participants (n=30), Tijuana, Mexico, 2011.

Variable (n = 30)
Pathway into sex industry*
 Began to exchange sex<18 years old 25 (83.3%)
 Forced, deceived, or coerced to exchange sex 10 (33.3%)
 Transported and forced to exchange sex 2 (6.7%)
Age when first began to exchange sex, yearsa 16 (12-28)
Age when began to work regularly trading sex, yearsa 17 (12-30)
Ever experienced a traumatic event 9 (30.0%)
Ever raped 11 (36.7%)
 Age at first rape, yearsa 14 (3-18)
Ever physically abused 7 (23.3%)
 Age at first abuse, yearsa 18.5 (9-27)
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*

Categories not exclusive

NOTE: Data are N (%) of women, unless otherwise indicated.

a

Median (range)

Data Analysis

All interviews were transcribed verbatim and translated by trained research staff. All personal identifiers were removed, and each participant was identified by a unique pseudonym. The first author supervised transcription and translation and reviewed all of the transcripts for accuracy. Data were coded using NVivo 9.0. Underpinned by ethnographic methods, qualitative analysis was led by the first author in conjunction with co-authors, who provided input regarding the identification and interpretation of themes. The constant comparative method was used to describe the content and structure of the data (Crabtree & Miller, 1999). The analysis adopted an inductive perspective in which we used participants' language and experiences to (a) understand factors influencing vulnerability to involuntary and adolescent sex exchange and (b) explore how contexts of adolescent and involuntary sex industry involvement shape HIV risk. Analyses were restricted to interviews with 30 women; one participant was excluded from the analysis, given that she had begun to exchange sex over 40 years prior and her interview reflected a sufficiently different context to warrant exclusion.

Results

Participant Characteristics

Participants' median age was 33 (range = 19-54). Women completed a median of 6 years of education, and the median number of children participants had was 2. Drug use was highly prevalent, as was to be expected (eligibility criteria included a history of drug use), whereas alcohol use was fairly low. Eighteen women had recently injected drugs, and five (16.7%) tested positive for any STI/HIV (Table 1).

By design, 25 women began to exchange sex as adolescents, 11 reported being forced, coerced, or deceived to exchange sex, and 2 were transported and forced to exchange sex. The median age of sex industry entry was 16 (range = 12-28), 11 women reported a history of rape (median age = 14; Table 2).

Findings

Gender-based violence (“I left because of the hitting”) and economic vulnerabilities (“my kids had to eat”) were key themes found to perpetuate vulnerability to adolescent and involuntary sex industry entry. However, women's narratives also included descriptions of agency related to their sex industry entry, illustrating that pathways into exchanging sex are often complex and manifold. The theme HIV risk within the context of adolescent and coerced sex exchange (“I lived with that fear”) illustrates participants' initially low HIV prevention capacities during their initial experiences in the sex industry, whereas the theme, evolving HIV risk mitigation capacities (“Learning the business”) highlights how women's abilities to negotiate safer sex and reduce the risk of HIV infection improved with increased autonomy and time in the sex industry.

“I left because of the hitting”: Early gender-based violence

Gender-based violence, including sexual abuse and rape, was common throughout participants' childhood and adolescence and directly shaped many participants' pathways into the sex industry. Neglect, abuse, and instability during childhood had led many participants to drop out of school and begin using drugs at a young age. Most women linked early sexual abuse to subsequent homelessness (11 participants ran away from home as youth), and adolescent sex trade. For some, third parties such as padrotes [a Spanish term for pimp] and boyfriends were involved in this process; however, even under such circumstances, women often framed themselves as participants in this process, highlighting the nuanced interplay between their victimization and personal agency. For example, as the following stories indicate,

A: I started that stage [exchanging sex] when my dad raped me when I was 14…. I left my house, [I went] to the streets with the drug addicts…. [I met] my pimp when I was about 16 years old … he got me into a bar that was high-ranked.

Q: What did you do there?

A: I drank, sold myself and went to the room. (Luisa, age 40, entry at age 17)

I left my house when I was 13 years old because of the hitting…. I was on the streets; I stayed at an abandoned house by myself…. Sometimes the gangsters would go there to chemear [use inhalants]. One time I was sleeping … that's when I lost it [my virginity]. It was about 15 guys in the group and they all did it. The good thing is that I was left alive, right? I started walking along that neighborhood [exchanging sex]. (Sabina, age 45, entry at age 14)

The combination of being marginalized, inexperienced, and lacking social support often rendered young women vulnerable to exploitation by individuals who sought to profit from their circumstances. Numerous participants were forced, coerced, or tricked into exchanging sex for the first time as street youth. Many described their early years in the sex industry as a time of naiveté, in which they had trusted strangers, friends, and intimate partners who initially concealed their intentions of exploiting them. Concomitantly, many women also perceived their initial exchanging of sex to be a decision that they had participated in due to the lack of alternatives available to them at the time:

I left my home, and went to live with a friend…. Everything was fine for a while, but later I had to start having sex in exchange for getting to live there…. I didn't want to and I guess she took advantage of me, because I was drunk at the time… For me to be here and be able to eat, I guess … I had to do that. (Esperanza, age 25, entry at age 14)

Everything happened because I was desperate … I was hungry, I didn't know what to do…. This chick told me, “Let's go meet a friend, he has a lot of money and he's American….” But she went with the intention of selling me…. She didn't tell me that she was going to take me to a client. Obviously, if she had told me what I had to do, I wouldn't have gone, but she tricked me. (Isabel, age 19, entry at age 15)

Despite their efforts to leave their abusive circumstances behind, participants often experienced violence from clients, traffickers, pimps, and intimate partners upon leaving home and beginning to exchange sex. Rape, beatings, physical confinement, and threats were most severe among women who had experienced overt force or coercion related to their entry into the sex industry. For instance, some women were raped as a form of initiation:

He did force me to do it…. He used force to make me do it and left bruises on my hands. Honestly, I couldn't take it … I'm never going to forget about it, because he assaulted me. (Esperanza, age 25, entry at age 14)

Other women described the reasons surrounding their entry into and continuation in the sex industry in more nuanced ways. For instance, at the age of 17, Norma felt deceived by a friend who had “sent” her to a bar to exchange sex under the pretense of working as a waitress, but she voluntarily chose to remain there since this provided an important means of income to support her family obligations:

She told me [I'd be working] as a waitress…. I know what it is to be a waitress; serve liquor and that, but when we got there … she explained it to me [sex work]. I needed money to pay for my daughter's medication, I wasn't going to let her die. (Norma, age 29, entry at age 17)

Women often explained that although their entry into the sex industry may have initially been coerced or otherwise influenced by third parties, upon becoming aware of this, they sought ways to assert their independence and mitigate such exploitation. These findings indicate that women's initial pathways into the sex industry may often be quite different than their current reasons for exchanging sex. The following quote illustrates the process through which Marisol transitioned from working under the influence of a pimp during adolescence to a more autonomous role:

He brainwashed me and started telling me things…. He was about 30 and I was 15 or 16 … I was very young, you know how people can be ignorant…. My eyes looked like money signs to him [laughs]…. He wanted to deceive me, to be my pimp…. He would take my money, so I would keep working, but he treated me well … I didn't let him and I left. I started doing it on my own. I said, “Instead of giving someone else money, I'd rather keep it. If I'm doing something bad, it should at least be worth it.” I opened my eyes. I didn't want to keep giving money to people who wanted to take advantage of me. (Marisol, age 34, entry at age 15)

Despite the important role of coercion in many participants' histories, some of those who began to exchange sex as youth often did not describe evidence of coercion or force by others. For example, less than one third of women who began to exchange sex as adolescents (n = 7) described having been exploited by a third party, such as by a pimp or trafficker. These women generally did not frame themselves as naïve or exploited. Rather, after fleeing abusive circumstances at home, they explained that they began to exchange sex as a means of survival that they perceived to be forced by contexts of homelessness, marginalization, and drug addiction:

I did it for money, not because I wanted to. Once I didn't have a place to stay, I didn't have money and it was nighttime. I was hungry and I was using crystal [meth] … [I began] by myself … I've never had a pimp or anything…. I do know girls like that, but I've always been on my own. (Juliana, age 36, entry at age 12)

I came to the Centro [downtown] … I was on the streets, I started doing prostitution at a bar when I was 16 years old…. At 16, I went to the corner … that's where I used to prostitute myself…. I started using heroin and doing prostitution when I got here, to get money for drugs. (Sabina, age 45, entry at 14 years old)

“My kids had to eat”: Economic vulnerabilities

Economic needs, including shelter, food, and money to support young children, parents, and intimate partners, were primary factors shaping vulnerability to sexual exploitation. All but two women had at least one child (median number of children = 2). These women had typically given birth to their children as adolescents. These women perceived that the need to support dependents placed them in a situation in which they were vulnerable to being coerced to exchange sex during adolescence:

I started before I was 15 years old … because of the need for money, right? I became a mom at a very, very young age; I was already pregnant at 15. I started prostitution after I had my daughter, well, because of a person that I met on the streets, well, he initiated me. He wanted to trick me…. I started going out with him, then he started taking me to the bars. (Marisol, age 34, entry at 15 years old)

I had to find ways of getting some money, because my kids had to eat. (Ana, age 52, entry at age 19)

The need to support intimate partners was also linked to vulnerability to coercion within the sex industry. Some participants described having had dependent male partners who acted as padrotes (pimps) during their initial years in the sex industry. This was often attributed to gender inequalities, especially community perceptions that it is “easier” for a female to sell her body than for a male (especially a drug user) to find employment. Women were often highly critical of these norms and relationships:

I have friends that have partners and the men don't work. I met a friend, she had a husband, and she went out to work every day…. You could say that he did exploit her, he didn't use violence or force, she paid his rent, she paid this, that, everything. The man was just in the house, but I call that a padrote [pimp]. (Araceli, age 23, entry at age 16)

Some women cast former intimate partners who had previously coerced them into trading sex in this light, although others acknowledged their partners' efforts to support and provide for them:

My former partner basically sent me to do prostitution…. He was like what they refer to as padrotes [pimps] here. Since I didn't bring back the amount that he wanted … he told me that I had to go out because we owed rent, and we started to argue…. He grabbed a piece of glass from a Coca-Cola bottle, and he got [cut] me. He said, “That's so you'll learn, and so that you remember what you have to bring home, that's why.” And then he locked me up for 2 days. (Esmeralda, age 38, entry at age 17)

In other cases, women discussed ways in which they perceived themselves as having rejected their partners' attempts to exercise control over their sex industry activities. For example, the following quote from Isabel illustrates her perceived resistance toward her partner's efforts to control her earnings:

If I come late and I don't have any money, what does he [her partner] do? He hits me … [but] he wasn't able to change me the way he wanted to. He wanted to be my padrote [pimp]. He hit me and everything if I didn't come home with money, and he would say a lot of things. But I told him, “Look, I'm not stupid” … (Isabel, age 19, entry at 15 years old)

“I lived with that fear”: HIV risk within the context of adolescent and involuntary sex exchange

During participants' initial experiences of adolescent and coerced sex industry involvement, forced sex, other forms of physical and sexual violence (i.e., by clients, traffickers, and padrotes), poor access to HIV prevention resources, and lack of experience with clients generally resulted in limited condom use. A common factor limiting participants' HIV prevention capacities during this time was poor access to preventive information and services. For example, almost all women lacked access to HIV testing, free condoms, or related care when they first began to exchange sex, and often perceived that they had been at greatly elevated risk of HIV during this time, in comparison with their current circumstances.

Many women reported that they were unfamiliar with HIV/AIDS or how to use condoms when they first began having sex with clients, which often began as early as 12 or 13 years old—a highly concerning finding, given the increased biological susceptibility experienced by youth in the sex industry (Sarkar et al., 2006; Silverman, 2011). Women often reflected upon their initiation into the sex industry as a period that was characterized by limited control in terms of protecting their health and well-being. This was often linked to their young age, coercion by third parties, and limited HIV prevention capacities during their initial entry; for instance, the threat of violence, limited awareness of the risks posed by unprotected sex, and constraints on agency left most participants poorly equipped to negotiate condom use with clients, pimps, and other partners as recent sex industry initiates, especially during their first few commercial sex transactions. Adriana, who began exchanging sex at age 15, had a fatalistic perspective, sharing how she had felt forced to accept the threat of HIV infection as an adolescent facing the risks posed by an unsafe work environment, gender-based violence, and street entrenchment:

There was a time when I lived with that fear…. I didn't have a way to protect myself. I simply put myself at risk, I would leave with them and I would leave everything up to God, and see how things would turn out. (Adriana, age 21, entry at age 15)

Among women who had been forced or coerced to service clients, the influence of sexual exploitation on HIV risk was particularly evident. For example, Esperanza's story demonstrates the connection between gender-based violence, economic factors, and trafficking-related HIV risk. As a young woman who had fled her home to escape sexual abuse, her economic desperation had led her to seek refuge with a friend. While staying with this friend, Esperanza was raped and forced to have sex with clients in exchange for room and board. She explained the circumstances surrounding her condom use during her first forced encounter with a client during adolescence:

Q: That first time you had sex with a client … did you know you had to use a condom?

A: Well honestly, I don't remember, I think probably … not, because I remember when he pulled out … I got scared, I started to cry, I was all wet down there, and so I don't think he used one. Later on, the other girls explained, “Listen, you have to take these precautions. Don't even think about doing it without a condom.” … And so then that was when I started to know about using condoms. (Esperanza, age 25, entry at age 14)

In some cases, women's narratives indicated that third parties such as traffickers and padrotes directly influenced their condom use. Melissa, a woman who had also been abused as a young girl, met her traffickers after being released from prison. Her desperate circumstances had left her by the roadside, seeking shelter and transportation, when she met her traffickers. While being forced into sexual servitude across multiple U.S. states, her trafficker required that condoms be consistently used with paying clients. However, the persistent risk of violence posed barriers to her using condoms with her captor:

He always told us, “Condom, with a condom.” I ended up pregnant from the first 2 weeks [in sexual servitude]…. Pretty much the only ones we didn't use protection with was with him or his friends, but they would also get us in the room at night, the first time I said, “No, that that's not how the business went, that that's not how we did it.” He hit me, too. (Melissa, age 32, entry at age 28)

Although Melissa was eventually allowed to leave after becoming pregnant, her pregnancy ended in a miscarriage as a result of the violence inflicted upon her. At the time of her interview, Melissa was HIV-positive. The extensive health and social harms Melissa suffered provide a lens into the ways in which gender-based violence and economic marginalization can perpetuate vulnerability to sexual exploitation and shape health-related outcomes such as HIV infection.

“Learning the business”: Evolving HIV risk mitigation capacities

In comparison with the immense risk of HIV infection posed by participants' early years in the sex industry, most women's narratives suggested that their HIV prevention capacities had substantially improved over time. Key to this transition were changes in women's working conditions, enabled by increased control over their working conditions and experience with clients. Women often distinguished between their past and present circumstances through an improved sense of control over their lives and work, including keeping their earnings from exchanging sex, setting their schedule, and deciding upon clients. These changes were shown to reduce women's economic vulnerability, mitigate the risk of gender-based violence, and improve their overall well-being. For example, Esperanza went on to explain how her life had changed since she had been forced to exchange sex as a young woman:

My life was calmer because I was earning my own money; the money I earned belonged to me. I rented a hotel room and lived there on my own. Nobody told me what to do. (Esperanza, age 25, entry at age 14)

Such changes in working conditions facilitated the development of HIV risk mitigation strategies, often acquired through experience and advice from peers. Such strategies included separating work and intimate relationships, maintaining control over one's earnings, working in familiar areas, and preferring known clients. Rather than portraying themselves as victims, women's descriptions of their current lives frequently included accounts of resilience and adaptation in the face of ongoing HIV risk. Women often discussed how these strategies helped them reduce their vulnerability to rape, forced or coerced unprotected sex, and other forms of gender-based violence:

I suffered a lot in the beginning…. I got into cars, I went to other places … one time a drunk man … raped me and didn't want to pay. Later, I started being more careful by not getting into cars or leaving with strangers. (Marisol, age 34, entry at age 15)

I don't go with any strangers. If I have a preferred client I'll go in my hotel, I go out, I stand outside of the hotel…. You're never safe, but you can always take precautions. (Araceli, age 23, entry at age 16)

Discussion

The findings of this study illustrate that early gender-based violence and economic insecurity are key factors shaping young women's vulnerability to adolescent and involuntary sex industry involvement in Tijuana, Mexico. Most women reported the highest risk of HIV (e.g., unprotected sex within the context of gender-based violence) during their early years in the sex industry, especially among participants who experienced overt coercion to exchange sex, highlighting the ways in which coerced and early entry into the sex industry may elevate HIV-related vulnerabilities. Although participants' HIV prevention capacities were extremely minimal during their early years in the sex industry (e.g., as adolescents or within the context of forced entry), this often improved with age, control over their working conditions and experience. Despite the clear need for interventions to reduce these vulnerabilities and prevent HIV infection among this population, to the best of our knowledge, no evidence-based HIV prevention interventions for females who begin to exchange sex as adolescents or due to coercion exist.

Whereas prior studies have often linked youth sex trade and sexual exploitation to factors such as low education and poverty (Vaddiparti et al., 2006), our findings also illustrate the ways in which early gender-based violence can directly shape future vulnerability to adolescent sex exchange and coerced initiation into the sex industry (Roe-Sepowitz, 2012). Furthermore, findings suggest that economic factors may be key to understanding the relationship between prior gender-based violence and involuntary and adolescent sex industry entry. For example, among our participants, consequences of early abuse (e.g., homelessness, teenage pregnancy) often gave rise to economic needs such as shelter and child support, which subsequently rendered them vulnerable to coerced sex industry involvement. These findings complement prior work indicating the role of limited opportunities for women as drivers of trafficking (Langberg, 2005; Okonofua, Ogbomwan, Alutu, Kufre, & Eghosa, 2004; Rieger, 2007; Vindhya & Dev, 2011), the role of family obligations in involuntarily drawing women into the sex industry (Vijeyarasa, 2009), and the linkages between sexual exploitation and structural factors such as human rights abuses and gender inequalities (Poudel & Carryer, 2000; Vindhya &Dev, 2011). These findings illustrate how wider social and economic processes are connected to the distribution of health and HIV-related harms (Farmer, 2003; Galtung, 1969), situating HIV risk as co-produced by individuals and the contexts in which they are embedded (Rhodes et al., 2012).

The Complexity of Pathways Into the Sex Industry

The definition of trafficking hinges upon the use of coercion or force for the purpose of exploitation, whereas sex work is a term that refers to selling or trading sex, not necessarily involving any coercion (Butcher, 2003). However, our findings support previous research indicating that pathways into the sex industry are more complex and manifold than legalistic definitions may accurately capture (Chapkis, 2003; Goldenberg, 2011; Goldenberg et al., 2013; Goldenberg, Silverman, Engstrom, Bojorquez-Chapela, & Strathdee, 2014; Pauw & Brener, 2001; Urada, Goldenberg, Shannon, & Strathdee, in press).

In this study, participants' reasons for initiating and continuing to exchange sex were frequently characterized by the interplay of individual choice and constraints on agency, including coercion and related structural factors (e.g., gender inequalities, poor employment opportunities). Women sometimes described subtle influences of third parties on their decision to begin exchanging sex, and occasionally described seemingly incongruous realities; for instance, some perceived that they had been coerced into the sex industry, but also stated that they had decided that it was in their best interest (e.g., as a means of meeting family obligations). In many cases, participants who initially experienced trafficking subsequently continued selling sex in the absence of coercion, albeit constrained by a lack of alternative options. These findings are supported by previous observations that current trafficking definitions may oversimplify women's choices and realities, and do not necessarily reflect all individual women's experiences (Busza, 2004). These data suggest a need for increased attention to the complex relationship between agency and victimization in research on the public health impacts of sexual exploitation and adolescent sex exchange (Bungay, Halpin, Atchison, & Johnston, 2010; Hoyle, Bosworth, & Dempsey, 2011). Future intervention efforts should be conscious of these nuances given their potential implications. The dichotomization of voluntary versus forced involvement in the sex industry may fail to capture the complexities associated with sex industry entry, such as the roles of violence and trauma shaping such pathways. Furthermore, the effort to promote the well-being of trafficked individuals may inadvertently stigmatize “voluntary” sex workers as deserving of harm, while framing those who “involuntarily” exchange sex as worthy of attention (Peng, 2005).

Owing largely to its criminal justice underpinnings, the Palermo Protocol definition of sex trafficking is sufficiently broad that it lends itself to diverse interpretations. In epidemiological research, sex trafficking has been defined as adolescent sex exchange (i.e., exchanging sex prior to age 18), involuntary entry (i.e., being forced or deceived to exchange sex), or a combination of these (Decker et al., 2011; Sarkar et al., 2008). Although participants in the current study who began to exchange sex as adolescents often did not describe experiences of coercion/force, a review of research on adolescents in the sex industry found consistency in the increased risk of HIV and violence they face relative to older counterparts (Silverman, 2011). While adolescent and involuntary sex exchange may often overlap, as they did in many of the cases described in this study, future research aimed at disentangling the experiences of these potentially unique groups is needed. Future scholarship and debate aimed at clarifying and suggesting new ways of identifying and assisting victims of sexual exploitation are necessary to develop definitions that can be more easily operationalized in public health research. Efforts to engage sex workers and those who may be coerced into the sex industry in this process are needed. For example, a sex workers' organization defines trafficking not in terms of a particular process or job, instead arguing that “the outcome of that process that is instrumental in leaving the trafficked person with little or no option to leave the place or position in which they find themselves” (Jana, Bandyopadhyay, Dutta, & Saha, 2002, pp. 141-142).

This study aimed to provide an in-depth account of the experiences of current sex workers who reported historical adolescent or involuntary sex industry involvement, which represented the safest and most feasible way to gather empirical data on this topic in Mexico. Since our sample was restricted to current sex workers with noncommercial partners who were enrolled in a larger study, research among more generalizable populations is also needed. To identify eligible participants for in-depth interviews, we relied upon women's survey responses to ascertain their pathways into the sex industry. However, their qualitative interviews suggested that these pathways were far more nuanced than indicated by survey measures alone. Given that different query techniques (e.g., survey vs. in-depth interview) may yield distinct findings regarding the prevalence and nature of different modes of sex industry entry (Devine, Bowen, Dzuvichu, Rungsung, & Kermode, 2010), future mixed-methods research is needed to triangulate these and assess the most appropriate methods for identifying sexually exploited persons. Moreover, our participants' pathways into the sex industry (e.g., adolescent vs. forced/coerced) should be understood as a reflection of our purposive study design, rather than the prevalence of different entry mechanisms.

Implications for Public Health Interventions and Future Research

The linkages documented between involuntary and adolescent sex exchange and HIV complement previous quantitative studies documenting these relationships. For instance, research among women and girls in South and South East Asia (Decker et al., 2011; Poudel & Carryer, 2000; Silverman, 2011; Silverman et al., 2006; Silverman et al., 2007), Canada (Chettiar, Shannon, Wood, Zhang, & Kerr, 2010), and Mexico (Goldenberg, Rangel, et al., 2012; Loza et al., 2010) has demonstrated associations between involuntary and early sex trade, HIV, gender-based violence, and structural risks (e.g., poor working conditions, police arrest). This evidence suggests the need for HIV prevention interventions tailored to the needs of this highly marginalized population. Given the trauma and immense HIV risks reported by participants within the context of involuntary and early sex industry involvement, increasing access to HIV prevention resources (e.g., condoms, HIV testing) and providing psychosocial support for survivors of gender-based violence are recommended. Although participants often reported initially low HIV prevention capacity, as their autonomy and experience increased, they increasingly described themselves as active agents in relation to their health; for example, implementing strategies to reduce the risk of violence and condom negotiation, which was often enabled by working with peers and in safer spaces. These findings echo previous research suggesting the need to incorporate the positive role of individual agency (as well as peer support) into HIV interventions with this population (Jana et al., 2002).

Current approaches to prevent sex trafficking have often deflected attention away from structural inequalities that give rise to exploitation and related opportunities for prevention and, instead, often focus on the criminalization of sex workers (Vijeyarasa, 2009). Findings of this study suggest the critical need to shift toward interventions addressing the root causes that facilitate trafficking and exploitation (Jana et al., 2002; Sex Workers Project, 2009; Silverman, 2011). Structural interventions addressing wider factors contributing to sexual exploitation, such as early gender-based violence and economic vulnerabilities, while providing women and girls with the tools and resources needed to protect themselves from HIV infection, are recommended.

In light of the fact that many of those initially coerced into the sex industry may transition to exchange sex as sex workers (i.e., consensual exchange of sexual services for money or other goods), more nuanced approaches that recognize the agency as well as historical vulnerabilities, where present, of women and adolescents who exchange sex are recommended. As most participants substantially improved their HIV prevention capacities as their autonomy increased, non-victimizing interventions that build upon their resilience and skills and promote empowerment are needed. However, limited empirical data exist regarding effective interventions to promote the health and well-being of trafficked women and girls (Crawford & Kaufman, 2008; Kaufman & Crawford, 2011; Silverman, 2011). Evidence-based interventions to reduce exploitation and HIV infection are needed to promote the health and human rights of all women and girls in the sex industry. Engaging sex workers as well as trafficked women in future research is recommended to inform public health interventions that respond to their health and social needs in a sensitive, informed manner.

Acknowledgments

The authors would like to thank the women who courageously provided their stories and time, as well as study staff for field and research assistance. The authors wish to acknowledge Teresita Rocha, Irina Artamonova, Alicia Vera, Dr. Jennifer Syversten, Dr. Thomas Patterson, and Dr. Thomas Novotny. This study was supported by the Berkeley Health Initiative of the Americas' Programa de Investigación en Migración y Salud (Research Program on Migration and Health) and the National Institutes of Health (NIDA R01 DA027772). Goldenberg is supported by a Canadian Institutes of Health Research Fellowship.

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