Survivors of Commercial Sexual Exploitation Involved in the Justice System: Mental Health Outcomes, HIV/STI Risks, and Perceived Needs to Exit Exploitation and Facilitate Recovery

: This exploratory retrospective study analyzes the emotional and mental processes, risk behavior for HIV/STIs, and needed services to exit commercial sexual exploitation. Participants were court-referred to the local survivor-led program, Freedom from Exploitation, in southern California. Data were collected (N = 168) using an intake assessment form for a period of ﬁve years (2015–2020). Two groups were identiﬁed in the data, self-identiﬁed survivors of sex trafﬁcking (SST) and non-self-identiﬁed survivors of sex trafﬁcking (NSST). Bivariate and multivariate logistic regressions examined the associations of HIV/STI risks and emotional and mental processes with these two subgroups. Findings demonstrated that both groups experienced gender-based violence and similar emotional and mental processes as well as HIV/STIs risks. However, in adjusted models, the SST group had three times the odds of experiencing abuse by a sex buyer when asked to use a condom and eight times the odds of feeling hopeless or desperate and experiencing nightmares/ﬂashbacks among other negative mental health outcomes. Both SST and NSST said they needed assistance to obtain legal services and complete a high school equivalency credential, among other services. Findings may be used by social service and law enforcement agencies to better assist survivors of sex trafﬁcking and similar groups in supporting their rehabilitation and protection.


Introduction
According to the United Nations Global Report (2020), sex trafficking is the most common type of human trafficking followed by labor trafficking [1]. Human trafficking (HT) is "the recruitment, transport, transfer, harboring or receipt of a person by such means as threat or use of force or other forms of coercion, abduction, fraud or deception for the purpose of exploitation" [1]. Although men, women, and children of any age can become victims of human trafficking, women and girls continue to be the primary targets. Children's rates of exploitation continue to increase with girls mostly found within sex trafficking, and boys within labor trafficking [1]. Traffickers entrap their victims through a variety of control tactics that include threats, coercion, deception, and abuse of power. The most common ways victims are lured into sex trafficking are through the guise of a romantic relationship, fake offers of employment, survival sex, and kidnapping [2][3][4]. After an initial grooming period, the potential victim may be offered affection, flattery, a place to stay, or gifts. If these individuals do not break away from the traffickers' grooming period, they soon become victims of trafficking by being put in a position where she/he is forced to use her/his body as a commodity to earn financial gains for the trafficker [5]. Victims of trafficking are controlled Sexes 2023, 4 through false promises, psychological and physical abuse, social isolation, and other forms of manipulation. In several studies that interviewed survivors of trafficking, participants have shared the multiple strategies of their traffickers [2][3][4]6]. These strategies have included gang rape, beatings, torture, psychological manipulation, withholding of water, food, bathroom privileges, and forced use of addictive substances [6][7][8]. The extreme abuse associated with trafficking results in a range of negative health consequences that many times last a lifetime and are complex to address [9][10][11]. Additionally, even when sex trafficking victims attempt to escape traffickers, they face numerous challenges that keep them from being completely free from the consequences of abuse. Though there is ample research on the negative health consequences for survivors of sex trafficking, few studies have assessed their thoughts and feelings about their sex buyers during a commercial sex act, especially among those involved in the justice system. Furthermore, this retrospective analysis compares self-identified sex trafficking survivors (SST) with non-self-identified sex trafficking survivors (NSST). The NSST group consisted of individuals who traded sex in exchange for something else but who were not under the control of a sex trafficker. SST were self-identified participants who also exchanged or traded sex for something else but who had a sex trafficker who abused and controlled the participant. Thus, this study aimed to 1) better understand their vulnerabilities to sexual exploitation and their emotional and mental process during commercial sexual exploitation; 2) comprehend reasons that led them to their commercial sexual exploitation; 3) compare Human Immunodeficiency Virus and sexually transmitted infections (HIV/STIs) unsafe risk behaviors between SST and NSST participants; and 4) methodologically gather opinions from commercial sexually exploited survivors, who are part of the justice system, about what assistance and services are needed to exit their exploitation.

Risks and Vulnerabilities for Sex Trafficking Victimization
Risks for sex trafficking include homelessness, housing insecurity, poverty, childhood abuse, substance use issues, and involvement in the foster care and juvenile justice system, gender non-conforming groups or any sexual and ethnic minorities [8][9][10][11][12][13][14]. Adolescents who possess such vulnerabilities are particularly at risk of becoming a victim of sex trafficking as traffickers will exploit their developmentally appropriate need for identity formation, belonging, autonomy, risk-taking, and evolving problem-solving skills [2] Other risk factors include unlawful immigration status, limited English proficiency, disability status, and being a victim of intimate partner violence and other forms of domestic violence [13, [15][16][17][18][19][20].
Other factors known to increase the risk for sexual exploitation are adverse childhood events (ACEs) and childhood sexual abuse. Strong evidence links ACEs with a heightened risk for sexual exploitation and it is associated with many other negative outcomes such as low academic achievement, teen pregnancy, and chronic disease [14,[21][22][23]. ACEs may include abuse, neglect, violence, suicide or incarceration of a family member, housing and food instability, destitution, domestic violence, and parental substance misuse. Research suggests that early trauma undermines a child's safety, stability, and bonding with caregivers which has a destructive impact on self-esteem [14,21].
Several studies have found that childhood sexual abuse is a strong predictor of sexual trafficking [12,20,23,24]. When children are sexually abused, their personal boundaries are altered, which puts them at risk for further abuse and exploitation when they seek affection and connection with others. Research suggests that abuse is normalized and internalized to the extent that victims of abuse may lack the ability to distinguish between healthy versus unhealthy relationships and may lack the skills needed to advocate for themselves to stop mistreatment and abuse [3].

Needs of Survivors
SST have a complex range of needs following escape from traffickers. Research shows that safe housing is the most urgent need of an individual who attempts to leave their trafficker as well as acute medical and/or dental care, crisis mental health services, food, water, and clothes [10,[33][34][35]. Once safety has been established, survivors are likely to need continued medical and dental care, possibly for health conditions caused by captivity, assault, deprivation, or withdrawal symptoms related to alcohol and substance dependency. Intermediate needs may include transitional housing, case management for the coordination of care among service providers, assistance in obtaining health and housing benefits, and legal or advocacy assistance [10,33]. Survivors of trafficking likely require long-term services for the treatment of mental health conditions and/or substance misuse, transportation assistance, job training, safety planning, childcare, and support services to improve decision-making, life skills, and coping skills [10,35,36]. The evidence supports the need for service providers to equip survivors to eventually secure legal employment so they can support themselves, and thereby, reduce their risk of re-entry into trafficking and other forms of victimization [33,35,37].

Current Approaches to Address Survivors' Needs and Healing
While the number of programs and services aimed to combat HT has increased in recent years, there continues to be a gap in suitable services and assistance for SST. Nonetheless, several studies have highlighted the need for an overall framework of guiding principles for providing suitable services for SST and other similar populations. Such a framework uses a trauma-informed, human rights, victim-centered approach to provide compassionate care, facilitate collaboration among multiple service providers, and harness community resources. [38][39][40][41]. Though there is a robust discussion among researchers about approaches that may address the multiple needs of SST, there is very little input from SST about services that best fit their needs. Scant literature exists to understand their opinions, insights, and recommendations about the most effective ways to facilitate their recovery and reintegration into a life free from abuse and exploitation. Therefore, this retrospective analysis sought to understand the psychological interpersonal and intrapersonal processes experienced during their commercial sexual exploitation, compare the risk of abuse between SST and NSST participants, and methodologically compile their recommendations on the services needed to facilitate recovery reintegration.

Sampling and Data Collection
This exploratory retrospective study was based on data collected by the nonprofit organization, Freedom from Exploitation, over a five-year period (2015-2020). Freedom from Exploitation is located in southern California. This organization utilizes a survivor-centered curriculum and is also survivor-led. It focuses on educating and training survivors of sex trafficking and others who have experienced commercial sexual exploitation. The end goal of the curriculum is to build resiliency among participants and facilitate a successful transition from victimization to survivorship and reintegration back into society.
Program participants, prior to starting their program, filled out the intake assessment and were court-referred participants to this San Diego program. Participants of Freedom from Exploitation are court-referred; therefore, all participants in this study had some involvement with the justice system either through local law enforcement or the Federal Bureau of Investigation (FBI). Prior to participation in the program, clients completed an intake assessment, initially developed by the SAGE Project in San Francisco [42]. Data were de-identified prior to analysis and collaboration. Two groups were identified within the data analyzed in this study. Both groups were self-identified either as survivors of sex trafficking (SST) or non-survivors of sex trafficking (NSST). NSST also experienced commercial sexual exploitation but were not under the control of a trafficker. Out of the 225 participants who completed the intake assessment, 57 were excluded for being incomplete, resulting in a final sample size of N = 168 participants, with a subset sample of (N= 27) SST and (N = 79) NSST.

Measures
A 55-item intake assessment tool was administered to participants to evaluate the vulnerabilities that led them to be sexually exploited, HIV/STIs risk factors, emotional and mental processes during their commercial sexual exploitation act, victimization of sex trafficking, opinions on the types of assistance and services they needed to exit their exploitation sexual exploitation, and demographics. For example, participants were asked if they exchanged sex for money, a place to stay, clothes or jewelry, a pimp or violent partner, food or candy, or to get drugs for a partner. Questions on condom use asked participants if a john/sex buyer had refused to use a condom, gave extra money or drugs to have sex without using a condom, said they would find someone else who was willing to have sex without using a condom, or become abusive when asked to use a condom. These questions sought to measure the risk for HIV/STIs and the risk for increased abuse when participants asked to use a condom. Questions concerning mental health asked participants how they felt during a commercial sex act. They were asked if they felt depressed, hopeless, repulsed, humiliated, dirty, disgusted, hateful, or mistrustful towards men, or experienced symptoms of PTSD such as flashbacks, nightmares, difficulty concentrating, or disassociation. The next subsection of the questionnaire asked participants, "Are you a victim of human trafficking)?" and if they had exchanged sex to meet their needs in the past month or year. The remaining subsection of the questionnaire asked, "What kind of assistance do you need to escape being sexually exploited as a prostitute?" Participants could select as many types of assistance as they wished from a list that included housing, childcare, drug detoxification, methadone maintenance, emotional support, job training, high school equivalency credential (GED), therapy, and legal services.

Analysis
This exploratory retrospective study included univariate, bivariate, and multivariate analyses. StataCorp statistical software version 16.1 (StataCorp, College Station, TX, USA) was utilized to manage and analyze data [43]. Descriptive statistical analysis was performed on sociodemographic characteristics including mean, median, and standard deviation (SD) for age, and needed assistance to exit commercial sexual exploitation.
Statistical inference of categorical binary data (yes/no) was analyzed through Chisquared (Chi2) and binomial logistic regression. Chi2 was used to predict any non-random associations between categorical variables comparing SST and NSST in their emotional and mental state and processes as well as HIV/STI risk behavior. Additionally, the analysis utilized binomial and multivariate logistic regression to see the odds ratio and adjusted odds ratios when comparing the two groups identified in the data, SST and NSST. The statistical significance was set at a p-value < or = 0.05. Variables of comparison included HIV/STIs risk from unsafe sexual behavior when interacting with sex buyers as well as intra and interpersonal mental processes and trauma, adjusting for age and ethnicity. Lastly, descriptive analysis was performed on their perceived needs for rehabilitation and reintegration into society.

Safeguards of Participants
The dataset was de-identified prior to being shared with researchers for analysis. An IRB-exemption was granted by the University of New England's IRB case# 031221-10 to assure study protocols were reviewed and participant data were de-identified. Table 1 illustrates the sociodemographic characteristics of the study participants (N = 168) who were part of an educational and empowerment training conducted by Freedom from Exploitation in San Diego, California. Out of those who answered demographic questions (n = 152), most of the participants were female (86.30%), more than half (60%) were 18-24 years old, and their ages ranged from 18 to 55 (M = 26, SD = 8.7). Regarding their race and ethnicity, over half the participants self-identified as Mixed/Biracial (60%), one-fifth as Middle Eastern (14%), and one-tenth as Asian (Chinese, Korean, or Thai, 5%). More than half of the participants had experienced homelessness at some point in their lives (53%). Nearly a third were part of the foster care system (27%).  Table 2 demonstrates the diversity of risks and vulnerabilities that pushed both study groups, SST and NSST, to trade sex to meet their needs for necessities. Most participants exchanged sex or sexual contact for money (78%), a place to stay (31%), for clothes and jewelry (29%), forced by a violent trafficker (pimp) or partner (28%), and to meet their children's needs (28%) among other reasons. Out of those who responded to the question Are you a victim of Human Trafficking? (N = 103), 27% self-identified as being a survivor while two-thirds (74%) did not. The other two questions that denoted victimization were: Have you had sex to meet basic needs in the past month, and in the past year? Over half of the participants (57%) had sex to meet basic needs in the past year, and more than one-fifth (21%) had done so in the past month.

Sociodemographics
Most participants, SST and NSST, experienced abuse by a sex buyer when asked to use a condom (81%), followed by half of the participants reporting that a sex buyer threatened to find someone else when asked to use a condom (52%). In less than half of the participants, (41%), the sex buyer refused to use a condom and the participants were offered extra cash to have sex without using a condom (37%). The intake assessment tool also captured the psychological and emotional processes of participants while engaged in a commercial sexual act. Table 2 summarized participant feelings and mental processes during a commercial sex act. Participants cited feeling disgusted (74%); lying to the sex buyer about the sex buyer's physical attractiveness (66%); feeling dirty (65%); feeling depressed (58%); and feeling hatred towards men or having lost trust in men (56%). Table 3 represents bivariate and multiple regression analysis findings on HIV/STIs risk behavior and the emotional and mental processes of SST compared to their NSST counterparts during commercial sexual exploitation and when dealing with sex buyers. Statistical inference was based on both Pearson Chi-Square and Binary Logistic Regression which showed a statistically significant association between experiencing higher HIV/STIs risk behavior and gender-based violence among the SST as compared to the NSST group. However, there was no significant difference between SST and NSST when compared by self-reported rates of ever being homeless or in foster care.

HIV/STIs Risk Behavior, Emtional and Mental Processes during a Commercial Sexual Act, a Comparison between SST and NSST Participants
The risks for violence, HIV/STIs risk behavior, and negative mental health indicators were markedly higher for SST than NSST in bivariate analyses. The SST group had 10.62 times the odds of experiencing abuse when they asked a sex buyer to use a condom; and had 2.97 times the odds of a sex buyer refusing to use a condom when compared with the NSST. In terms of emotional and mental processes during a commercial sex act, the SST study group had 10.94 times the odds of lying to the sex buyer about his attractiveness; had 4.81 times the odds of feelings of repulsion towards the sex buyer; 4.95 times the odds of fantasizing harming the buyer. They felt significantly more disgusted, humiliated, dirty, dissociation, hatred towards men, loss of sexual pleasure, and wanted to quit being trafficked or prostituted. They were 15.07 times the odds of feeling depressed; and 12.22 times the odds of experiencing flashbacks/nightmares when compared with the NSST group. Lastly, the difference in risks for violence, HIV/STIs, and poor mental health was not greater for SST than NSST when they were compared by two known risks for sexual exploitation: homelessness and foster care involvement.

Participants' Opinions on Assistance Needed to Exit Commercial Sexual Exploitations
In an analysis of opinions of SST and NSST regarding the services they most needed to exit commercial sexual exploitation, the opinions of SST and NSST groups and pressing needs to support their exit from commercial sexual exploitation. Table 4 presents the findings of the participants who provided feedback in this area. The most needed assistance stated by those who provided a "yes" to the category was obtaining legal services (40%), followed by a GED (39%), followed by childcare services (35%). Other types of services and support included therapy, job training, and drug detoxification programs among others. Notes: * adjusting for age and ethnicity, ** p < 0.05, *** p < 0.01, **** p < 0.001. Note: 1. Total number of cases did not include "I don't know" or "Missing cases". 2. Responses here included only those who said "yes" for SST and NSST.

Discussion
Little is known about adults involved in the justice system who have experienced sex trafficking (SST) or commercial sexual exploitation without being under the control of a trafficker (NSST) in the context of their emotional and mental processes during victimization. This retrospective study begins to shed light on these processes during the victimization of these two groups. Additionally, to the authors' knowledge, there has been no study that has compared SST to NSST in the areas of HIV/STIs risk behavior, emotional and mental processes, gender-based violence, and sex trafficking vulnerabilities. This study also begins to narrow these current gaps. The findings of this study suggest that someone who is a survivor of sex trafficking and who is also involved in the justice system is more likely to face higher levels of condom refusal and violence by sex buyers when compared to their NSST counterpart. Although it has been established that those who engage in commercial sexual exploitation are more likely to engage in unsafe behaviors, putting them at greater risk for HIV/STIs, this study begins to demonstrate that those who are survivors of sex trafficking possess even higher risks than those who are not survivors of sex trafficking but experience similar exploitation [44][45][46]. Moreover, the emotional and mental processes and outcomes of SST are more severe when compared to NSST.
Additionally, the findings of this analysis corroborate the multiple reasons why individuals are pushed to engage in commercial sexual exploitation, as both SST and NSST are involved in the justice system. Basic needs such as financial stability, housing, and being able to meet their children's needs were the main push factors that led to their exploitation. Other reasons were to avoid sexual abuse by the trafficker and to obtain drugs. These findings affirm the literature about the vulnerabilities of individuals who find themselves having to use their bodies to survive to meet their daily needs [10,33]. Although housing seems to be a risk for commercial sexual exploitation, it did not seem to be a top priority for those in this study as a need to exit their exploitation. One potential reason could be that these participants are already part of a program or are justice system involved, which means they are either detained or housed by a local organization. Nonetheless, the top needed services by the participants of this study included legal services, GED, and childcare. Legal aid and job-training-related services among others here identified have also been found among homeless young adults who had experienced both sex and labor trafficking [47,48].

Recommendations
This analysis provides critical insights into the physical, mental, legal, social service support, and economic needs of those experiencing commercial sexual exploitation and who are part of the justice system. These findings may help both law enforcement agents and social service providers to identify and better serve survivors of sex trafficking and other similar groups to address their immediate and long-term mental health, legal, and offspring-related needs. Moreover, these findings may offer important information about survivors' emotional and psychological processes and extreme trauma as well as the high risk for violence and abuse they experience from their trafficker and sex buyers. The findings of this retrospective analysis also reinforce what is known about the resources needed to support SST and NSST to exit their current exploitation and the support needed to successfully reintegrate into society. Additionally, this study offers new information about the need for childcare among SST and NSST, a topic that has not been adequately investigated.
A key finding is that survivors identified a clear need for educational support to finish their high school education and gain job training skills for those who are involved in the justice system. This suggests the need to create pathways of collaboration to provide more educational opportunities, job training as well as employment opportunities for this population [41]. This study also points to the need for childcare, highlighting a critical need to support SST parents who must attempt to leave their traffickers, seek rehabilitative services, and find a way to support themselves and their children who are part of the justice system. Lastly, this study highlights an urgent need for therapy services tailored to the specific needs of survivors of sexual exploitation who often experience extreme, repeated, and prolonged forms of gender violence.

Limitations
This study has several notable limitations. One such limitation is the design of a retrospective analysis which introduces the possibility of selection bias, recall bias, and response bias. Participants may not have recalled events accurately or disclosed information that they thought researchers would find undesirable or information that could cause difficult memories to resurface. Another limitation was a significant amount of missing data concerning the assistance needed for transitioning and reintegrating successfully into society. Moreover, participants who self-identified as NSST could have been victims of sex trafficking who did not yet recognize themselves as such. We also acknowledge that some NSST did not feel forced or coerced into selling sex, therefore having better outcomes, and that there is a greater diversity within this subgroup that this study did not capture. The SST group (N = 27) is maybe too small; yet statistical significance was remarkably established in the majority of the analysis. Additionally, this analysis' sample was based on court-referred young adults who were part of the justice system, and whose experiences may be different from those who are not involved in the justice system. The statistical analysis controlled for age and ethnicity covariates, but with a bigger sample, more covariates could be included; therefore, more robust evaluations that include SST and NSST who are involved in the justice system are needed to better understand unsafe behaviors known to increase the risk for HIV/STIs, emotional and mental processes during exploitation, push factors that lead to exploitation, and services that are needed to facilitate recovery. Furthermore, when more human trafficking measures are developed, more validated measures can be used. Lastly, a mixed-method approach to inquiry could provide a deeper understanding of the complexities of their experience with traffickers and the justice system, commercial sexual exploitation differences between SSTs and NSSTs, and an in-depth understanding of the services needed to help those seeking a way out of exploitation.
A strength of the study was the data collection process spanning a five-year period, an adequate length of time to collect sufficient data for analysis. Perhaps the greatest strength of the study is that data were methodologically gathered and analyzed directly from sexually trafficked survivors and similar groups to gain their perspective on what types of assistance would most help them exit exploitation. This analysis may offer a better understanding of their lived experiences and what would be the most useful way to facilitate recovery and reintegration back into society for those who have experienced sexual violence and exploitation. These findings begin to uncover the psychological and emotional processes that survivors face during commercial sexual exploitation and may be used to inform policy and practice aimed at assisting SST. It also demonstrates the extreme risk for violence vulnerability, HIV/STIs, and emotional distress that SST experience when compared to NSSTs.

Conclusions
This analysis focused on discovering different components of the psychological processes of SSTs during acts of sexual exploitation. It also studied the behavioral risk factors for HIV/STIs of SST during interactions with their sex buyers. Lastly, it methodologically collected recommendations from SST on the types of services needed to help them successfully rehabilitate and reintegrate back into society. The findings of this study may potentially enhance efforts aimed at improving the lives of survivors of sexual trafficking in the U.S., as well as increasing awareness of the services needed to prevent such crime and exploitation [49]. Informed Consent Statement: Data analyzed in this retrospective study was de-identified prior to researchers conducting analysis.