TRAFFICKING IN WOMEN AND PROSTITUTION – LEGISLATIVE MODELS, INSTITUTIONAL PRACTICES AND RISK FACTORS

Maria-Miana DINA (1), Cornelia RADA (2)
Keywords: prostitution, human trafficking, legislative model, risk.

DOI: https://doi.org/10.26758/14.1.16   

Both authors have contributed equally to the article.

(1) National Administration of Penitentiaries, Directorate of Social Reintegration, Calea Floreasca, No.39, 1th Distinct, Bucharest, 023761, Romania; School of Advanced Studies of the Romanian Academy, “Constantin Rădulescu-Motru” Institute of Philosophy and Psychology, Department of Psychology, Romanian Academy, Bucharest, Romania.

(2) “Francisc I. Rainer” Institute of Anthropology, Romanian Academy, E-mail: corneliarada@yahoo.com; School of Advanced Studies of the Romanian Academy, “Constantin Rădulescu-Motru” Institute of Philosophy and Psychology, Department of Psychology, Romanian Academy, Bucharest, Romania. E-mail: corneliarada@yahoo.com

Address correspondence to: Maria – Miana Dina, National Administration of Penitentiaries, Directorate of Social Reintegration, Calea Floreasca, No.39, 1st Distinct, Bucharest, 023761. Ph.: +40744869005; E-mail: grebenar.miana@yahoo.com

Abstract

Objective. The objective was to analyze the impact of institutional practices on the physical and mental health of women victims of human trafficking and prostitution, as well as to highlight the main risk factors for them.

Material and methods. By using several databases, the number of studies included in this meta-analysis was 25. Scientific articles, doctoral theses, dissertations, presentations at conferences, book chapters, or reports were taken into account. There were longitudinal or cross-sectional studies. The meta-analysis totaled 455,406 subjects, the heterogeneity being a significant one (Q = 5062,288, df = 24, p = 0.000), and we increase the average effect, 38% of the variance of the results being due to the studied variables (95%: 1.08 % – 0.31%).

Results. The hostile attitude of the authorities towards sex workers and the refusal to offer protection were identified as the most widespread consequences of institutional practices. Other consequences that arise as a result of the direct interaction of sex workers with the authorities are risky behaviors such as drug use, violent sexual acts, or discontinuation of drug treatment. The key risk factors for women in this category are psychological difficulties, gender and economic inequalities and an inadequate sexual history.

Conclusions.  There is a continuous interaction between the legislative model, institutional practices, and the physical and mental health of sex workers. Awareness and understanding of the problems that these women face when they practice prostitution would facilitate the improvement of the management capacity of this phenomenon.

Keywords: prostitution, human trafficking, legislative model, risk.

Introduction

Concepts and theories

Although they represent widespread phenomena at the global level, prostitution and human trafficking are minor topics in academic circles. In the few debates, the academic environment concluded that gender inequalities, migration, and the effects of globalization are the main elements in their development. One of the concerns of society refers to the question of whether this type of sexual practice should be legalized or not (Liberato & Ratajczak, 2017).

In the literature, there are two schools of thought that argue for the reconsideration of prostitution, with women prostitutes being seen as “victims of coercion in a society that serves men by objectifying and subordinating women” (Freeman, 1989). Thus, if the abolitionist movement takes steps to put an end to this phenomenon by criminalizing the men who pay for such services and who traffic women (Farley et al., 2004), the liberal movement considers prostitution as an occupation that should be legalized, a job like any other (Freeman, 1989).

The followers of the liberal movement see this legalization of prostitution as a real challenge; the problem consists in finding an argument that can legally cover the fact that the purchased product is the human body itself (Jeffreys, 2009). They characterize the liberal feminist position as an expression of choice and progress against sexual violence (Jeffreys, 2009). Since the 1980s, when liberals promoted the notion that pornography was not an abusive factor for women, this idea of prostitution has undergone major changes. Vanwesenbeeck (2013) considered that prostitution is a “rational, financially motivated choice by adult women in a context of limited (other) career possibilities”, a “natural” choice based on a rationale that refers to financial profit. Another follower of this perspective is Dorfman (2011), who suggests that prostitution should be seen as a way to combat poverty, with the woman offering sexual services in exchange for sums of money. Thus, prostitutes are not victims but rather women who work for money.

Among the arguments of this school of thought is the fact that the sale of sex must be associated with any type of work, being compared to dancing or another form of art, while women who practice prostitution show considerable techniques and skills (Campbell, Smith, Leacy, Ryan, & Stoica, 2020).

The other category, the radical feminist perspective, brings to attention the avoidance of a key question, both at the political and societal level, namely, “How could women choose?” (Bromberg, 1997). Regarding this ability to choose, the radicalists bring another vision, specifying that the woman does not choose whether or not she wants to prostitute herself but only has the perception of the fact that she has chosen the “lesser evil” (Kesler, 2002).

Researcher Melissa Farley claims that prostitution is one of the deadliest forms of organized crime, with women being constantly harassed and beaten (Farley, 2004). She believes that prostitutes cannot exercise their autonomy over the situation, in front of the one who pays (Farley, 2017). Also, she thought that the type of sex practiced in the framework of prostitution is a coercive one (Moran & Farley, 2019).

Another element brought to the attention of public opinion by the radical perspective is the history of black women in the United States of America, namely a deeply patriarchal society in which African-American women were subjected to sexual abuse. Hursh (2007) describes this vulnerability as “gender captivity”, determined by both race and sex. In this context, although prostitution existed due to the demand for sex from men, black women became vulnerable through the prism of their identity.

At the same time, the trafficking of women is seen in close connection with the phenomenon of globalization and the migration of populations from one region to another. Jeffreys (2009) sees this as a process of “externalization of women’s subordination”, considering that along with globalization, the trafficking of poor women in much richer countries has also increased. A counterargument of the liberal perspective to this opinion is the idea that some women “follow the money”, so they travel or migrate to other states (Vanwesenbeeck, 2013; Beegan & Moran, 2017).

 Legislative models for the management of human trafficking and prostitution

According to specialized literature, there are five major legislative models implemented at the level of society and intended to control the crimes of human trafficking and prostitution (Vanwesenbeeck, 2013; Vanwesenbeeck, 2017).

The first model, that of complete criminality, stands against these crimes and prohibits any form of sex work, including selling or buying sex. It is very well-developed in certain regions of the USA, South Africa, and Sri Lanka (Duff et al., 2017).

The partial model penalizes only certain aspects of sex work, such as organizing sex work, running a brothel, or involving third parties in such businesses. This principle has been observed in Canada, since 2014, in India, and England, except for the northern part of Ireland (Argento, Chettiar, Nguyen, Montaner, & Shannon, 2015).

The third model, that of the criminalization of the purchase of sex, accuses and supports the punishment of participation in the sex trade, being very well represented in countries such as France, Northern Ireland, Norway, and Serbia (Scoular & Carline, 2014).

The regulation model supports the sale of sex, even giving it legal status, but under certain conditions, such as licensed brothels, where HIV testing is carried out. This principle has been observed since 1999, when Sweden banned the purchase of sex but not the sale of sex. Other states that support this legislation are Germany, Mexico, Senegal, and certain regions of Australia (Levy & Jakobsson, 2014).

The model of full acceptance appeared in 2003 when New Zealand removed criminal sanctions for adult sex workers. This model aims to regulate the industry of women’s trafficking and prostitution by establishing work safety standards (Abel, 2014).

As can be seen, all five prohibit the presence of minors in this type of activity, as well as the use of coercion or other types of violence. In reality, the implementation of these legislative measures differs, even in the case of the same state, from one region to another (Campbell, 2015).

Sweden was the first country to ban the purchase of sexual services, defining prostitution as “a serious form of male violence against women” (Hinde, 2008). According to the Swedish model, the prostitute should not be penalized, as she should be given specific assistance in order to get out of this vicious circle. Norway also adopted this legislation in 2009, and in 2014, the Canadian Parliament accepted the Nordic model (Government of Canada, 2014).

In Romania, the crime of human trafficking has been regulated since 2001, after the signing of the Protocol on the Prevention, Suppression, and Punishment of Human Trafficking, especially of Women and Children, executed in Palermo on December 13, 2000. Later, Romanian legislation underwent certain changes, and the New Penal Code of 2014 included the offenses of the special law (Alexandroiu, 2019). According to Horhogea (2020), “Romania could be considered one of the main sources of victims who fall prey to human trafficking”, taking into account that in 2020 alone, more than 596 victims of human trafficking were identified, of which 255 were former minors (Ministry of Internal Affairs, 2022).

As far as prostitution in Romania is concerned, this is an illegal activity, being prohibited by Law No. 61/1991, the normative text specifying as follows: “It is a contravention to commit any of the following acts, if they are not committed in such conditions that, according to the criminal law, they are considered crimes: attracting people, in any form, committed in premises, parks, on the streets, or in other public places in order to practice sexual relations with them in order to obtain material benefits, as well as urging or determining, for the same purpose, a person to commit such acts”. Therefore, prostitution is a misdemeanor punishable by a fine.

Toader (2022), through his attempt to transpose the legal truth into social reality, believes that due to the “mild” sanction with which prostitution is treated in Romania, it becomes a legal activity but unregulated from a legal point of view. Another argument he brings in support of his opinion is that the use of sexual services does not bear any sanction, so the consumer of sexual services is encouraged to return to benefit from them.

According to official data provided by the National Agency Against Trafficking in Persons, at least 100,000 Romanian women work as prostitutes in Europe, with several thousand being registered with a work permit by the Swiss authorities (Ministry of Internal Affairs, 2022).

As can be seen, the legalization of sex work facilitated the existence of areas where prostitution is accepted, being seen as a normal practice. Although the authorities try to control the phenomenon of prostitution and human trafficking for sexual exploitation, organized crime groups manage to collect many victims (Farley et al., 2011).

Material and methods

Purpose

The purpose of this study was to explore the existing research on the topic of the health of sex workers from the perspective of the consequences of the application of legislative models as well as the risk factors.

The general objective of the study

The general objective of this study was to analyze the impact of legislative implications and institutional practices on the health of women victims of human trafficking and prostitution and to highlight the main risk factors in this regard.

Specific objectives

This literature review has two specific objectives:

O1. To elaborate an analysis of the existing information in the specialized literature regarding the consequences of the application of the legislative models related to prostitution and human trafficking by the authorities for the victims of the two phenomena.

O2. To carry out an analysis of the existing data in the specialized literature regarding the factors associated with high-risk situations regarding the health of sex workers.

The analysis of the studies and their results focused on the following research questions:

  1. What is the impact of institutional practices on the health of sex workers?
  2. What are the risk factors for mental and physical health problems in the case of sex workers?

Search strategy

Fifteen databases were explored, not only by means of keywords but also by combining them. The key terms were trafficking, people, prostitution, sex workers, and mental health. The combinations of words consisted of: human trafficking; human trafficking and prostitution; mental health of sex workers; prostitution and health; human trafficking and mental health.

Scientific articles, presentations at conferences, book chapters, or reports, as well as three doctoral theses and a dissertation, were considered. Among the databases used are ProQuest, Social Since Database, Elsevier, PubMed, Web of Science, Academic Search Complete, PsychInfo, and Science Direct.

In order to expand this search, the bibliographic references of each identified study were analyzed, which led to other materials. The main search engine in this case was Google Scholar. The search covered the period 2015–2021.

Data extraction and study selection

The data were extracted in two distinct stages, taking into account studies in Romanian and English. All the identified materials were analyzed based on the previously established selection criteria.

In the first stage of the selection of the studies, the period of publication was taken into account, and research was selected only from the interval 2015–2021, with the aim of analyzing the most recent data. At the same time, it was sought to indicate significant information regarding the design of the study, its methodology, and its results in the abstract. In this first stage, 133 studies were selected.

The second stage involved an analysis that included the scientific background part, the presentation of the objectives, the research design, the sample size and its average age, the study population, and the location. After applying these inclusion criteria, 87 studies were excluded.

The third stage of selection focused on the description of the statistical methods used, reporting the results according to the methods used, and summarizing the results. At the end of this stage, the number of studies included in this meta-analysis was 25.

These were longitudinal or cross-sectional studies. The sample size varied from 66 to 5,792 participants. Most of the time, the results were obtained by using regression or correlation statistical techniques.

Publishing error

Considering the risk determined by the publication error, namely the impossibility of access to certain studies due to the presentation of only positive results and therefore the lack of data on the ineffectiveness of certain techniques or, on the contrary, the presentation of only the negative ones, in addition to the fact that a wide range of materials were taken into account, the search stage was extended, including the examination of bibliographic references. Thus, reports, book chapters, newspaper articles, manuscripts, scientific articles, works presented at conferences, and unpublishable works were analyzed.

Also, for this purpose, the studies included in the meta-analysis were tested for publication error using the “Comprehensive Meta Analysis” program.

Results

The studies included in this meta-analysis were 25 in number and covered the period 2015–2021. Of these, 15 had a cross-sectional design and 10 had a longitudinal design.

The regions where these studies were carried out are the USA, Africa, India, China, Iran, Belgium, Norway, and Brazil. Out of the 25, only one research study analyzes (research is an uncountable noun) a male sample; the remaining 24 have female participants.

The meta-analysis totaled 455,406 subjects, the heterogeneity being significant (Q = 5062,288, df = 24, p = 0.000), and an average effect size of 38% of the variance of the results being due to the studied variables (95%: 1, 08%–0.31%).

Considering the first question, What is the impact of institutional practices on the health of sex workers?, out of the 25 studies, 10 analyzed these implications. According to them, approximately 60% of the victims of human trafficking and prostitution affirmed the hostile attitude of the authorities towards sex workers and the refusal to offer protection. Other consequences that come from the interaction of sex workers with the authorities are risky behaviors, such as drug consumption reported in approximately 55% of sex workers, violent sexual acts with a frequency of 6 out of 10 cases, or the interruption of drug treatment in approximately 45% of victims.

Figure 1

The impact of institutional practices on sex workers (to see Figure 1, please click here).

For the second question, What are the risk factors regarding mental and physical health problems in the case of sex workers?, the main dimensions evaluated referred to the predisposition towards a depressive state of people involved in prostitution or human trafficking. According to the analyzed studies, the key risk factors for women in this category are psychological difficulties (depression, post-traumatic stress disorder, addictive behavior—alcohol consumption) found in more than half of them, gender and economic inequalities (support low social status, stigma), about 70% reporting these elements, and an inadequate sexual history (sexual violence, history of unprotected sex, multiple sexual partners, HIV infection) in about half of them. Regarding psychological difficulties, severe depression was correlated both with sex without a condom and with the availability of moving to another city. Also, the state of emotional vulnerability was associated with the number of sexual partners and with the harmful consumption of alcohol. The existence of a history with traumatic potential was linked to the lack of a stable home and the process of stigmatization.

From the point of view of physical health, HIV was associated with the lack of condoms, suicidal ideation, depression, and alcohol consumption.

Figure 2

Risk factors regarding the physical and mental health of sex workers (to see Figure 2, please click here).

Discussion

Institutional practices and their consequences

Several authors talk about the attitude of the authorities towards women, who, although they are victims of human trafficking, are labeled as sex workers and therefore marginalized (Socias et al., 2015; Lyons et al., 2017). Whether it is a lack of involvement or support, or aggressive behavior on the part of the authorities, has been documented, particularly in arrest situations, with a history of arrest being linked to physical violence (Lyons et al., 2017).

This harassing behavior of the authorities has a higher probability of manifestation in situations where the person has a prison history (Socias et al., 2015). In this context, the inappropriate behavior of the authorities also manifests itself even in the case of people facing health problems, even if this fact constitutes a vulnerability factor (Sou et al., 2017). In this sense, the specialized literature highlights correlations between the non-compliant institutional practices of the authorities (transfer from pre-trial detention to a detention unit or transfer between detention units) and the limitation of access to drug treatment, in the case of people infected with HIV (Goldenberg et al., 2017; Beattie et al., 2015).

Negative police interaction with women who practice prostitution has implications even in terms of sexual health safety measures, namely the use of condoms on a regular basis (Erausquin, Reed, & Blankenship, 2015). Also, among these consequences are the use of non-injectable drugs, especially in situations with increased stress, such as police checks (Duff et al., 2017), the application of extortion techniques to police officers in order to obtain information from women who practice prostitution (Wirtz et al., 2015), as well as with an increase in violent behavior during sexual intercourse by clients (Muldoon et al., 2017).

From the point of view of the adopted legislative model, it seems that the implementation of laws that completely criminalize the buying and selling of sex leads to a decrease in the prevalence of sexually transmitted infections (Jung, 2017). However, according to American researchers, the health of sex workers is put at risk since they enter prostitution, which occurs through a series of predisposing factors involving family neglect and sexual abuse (Dodsworth, 2012; Wilson & Widom, 2015). Farley (2017) states that “familial sexual abuse functions as a training ground for prostitution” (p. 98). At the same time, Raphael et al. (2015) found that 71% of the participants in their study reported being recruited into prostitution, with 21% describing acts of violence committed against them by their pimp during the initial period of recruitment. Moreover, in their study, Raphael et al. (2015) identified that, from the time of recruitment to the time of interview, participants who experienced medium or high levels of coercive control from their pimp experienced progressively higher levels of violence.

Also, the Swedish model uses policies that are similarly predominantly repressive, considering the problem of Swedish prostitution as a harmful practice of gender inequality and one that should be eradicated (Östergren, 2017). However, evidence that repressive laws have eliminated prostitution remains weak. Furthermore, it has been noted that the law has had the effect of displacing sex work into less visible spaces that serve to increase the alienation between protective and health services and sex workers (Östergren, 2017; Hinde, 2008).

Even the partial model, which penalizes only certain aspects of sex work, does not fully manage to supervise the health of sex workers. For example, Canada, which supports men’s right to sex on demand by accepting street prostitution but banning brothels, faces the impossibility of stopping the trafficking of women and maintaining control of prostitution. The concentration of Canadian policies on the perfect victim, i.e., the immature teenager with family or financial difficulties, determined a weak control over adult victims, assaulted by pimps (Lowman, 2016).

Regarding the model of criminalizing the purchase of sex, difficulties arise from the perspective of the rule of law, the safety and well-being of victims of trafficking. Such a situation is present in Norway, where, although the authorities offer sex workers temporary residence permits in exchange for providing valuable information to the police, the victims often refuse to testify in a legal process because of the fear they face of pimps. Thus, by refusing to declare the truth, they continue to be hidden victims without being able to benefit from the support of the authorities (Jahnsen & Skilbrei, 2018).

Regarding the model of complete acceptance, Radačić (2017) points out that, despite state policies and organizations that contribute to building a community of sex workers, their stigmatization leaves a strong mark on their mental health. At the same time, while there are relatively privileged sex workers because they work in an indoor setting, the less privileged come from disadvantaged backgrounds and live in precarious conditions.

Risk factors

Psychological difficulties

Patel, Ganju, Prabhakar, & Adhikary (2016) found that more than a quarter of the sample of participants representing women who practice prostitution (n=2400) manifests major depression. The differences regarding the probability of occurrence are given by the availability of travel to another city and the experience of violence in the last 12 months. Therefore, those who exhibited mobile behavior regarding the practice of prostitution by moving to other regions or were assaulted presented a higher probability of major depression. Also, Coetzee et al. (2018) bring to attention the symptoms of severe depression in the case of women who were involved in crimes of human trafficking and prostitution, with 68.7% of the total sample reporting this fact (n = 508). Ortblad et al. (2020) talk about the link between depression and physical health, considering that they are in a direct relationship. In addition to depression, suicidal ideation is reported by over 10% of sex workers (Grosso et al., 2019), as is the state of emotional vulnerability. Roberts et al. (2018) recorded associations between the state of emotional vulnerability and involvement in sexual intercourse.

Post-traumatic stress disorder belongs to the category of psychological difficulties. The existence of a potentially traumatic history facilitates the appearance of characteristic symptoms, especially for these people (Jain et al., 2020). Dependent behavior stands out as another aspect, with the prevalence of alcohol consumption among sex workers being 45.5%. It therefore appears that harmful alcohol consumption was three times more likely to occur in this context (Abelson et al., 2019; Bitty-Anderson et al., 2019).

Gender and economic inequalities

Barnhart et al. (2019) draw attention to the financial difficulties that sex workers face. For reasons of poverty, they can either become victims of human trafficking or choose to have sex for certain amounts of money. At the same time, they talk about the impact of the environment of origin, the support group, and the examples from the entourage, but also about the social vulnerability determined by gender, especially when these people end up being involved in human trafficking. A low level of education and the lack of a job are factors that complete these inequalities. Another risk factor identified was the stigmatization process, which increases the probability of involvement in these actions (Coetzee et al., 2018).

Inadequate sexual history

One of the main risk factors regarding the sexual activity of sex workers is HIV infection (Marra et al., 2018; Rhead et al., 2018; Vorsters et al., 2016). According to da Costa et al. (2018), the risk of HIV is found especially in the 17–21 age group, with the prevalence estimates being: HIV 5.3%; active syphilis 8.5%. In turn, Bitty-Anderson et al. (2019) found that the existence of HIV had an estimated prevalence of 12.5% in this context. According to several authors, HIV is correlated not only with alcohol consumption but also with emotional vulnerability (Bitty-Anderson et al., 2019; Grosso et al., 2019; Ortblad et al., 2020). At the same time, it seems that there are links between HIV and condom use (Shen et al., 2016; Ortblad et al., 2020; Jain et al., 2020).

Shokoohi et al. (2018) draw attention to the number of sexual partners in the case of sex workers, finding positive correlations between the large number of partners and the lack of stable housing. Also, Roberts et al. (2018) found that people who have emotional problems can have up to five times more partners in a month, unlike those who do not show these symptoms (p = 0.002). At the same time, a potentially traumatic sexual history is a risk factor for victims of human trafficking or sex workers, as this is directly related to sexual behavior (Coetzee et al., 2018).

Conclusion

It cannot be said that there is a perfect legislative model to control prostitution and maintain the health of sex workers at an optimal level. Although there are various attempts for this purpose, social-cultural factors tend to influence the behavior of the authorities in their interactions with sex workers, and therefore, the institutional practices are not in absolute compliance with the legislative model. Taking into account this aspect, we consider that for a legislative model to be successful, it must take into account the cultural particularities of the respective region, and more than that, it must be built according to the social image that the prostituted person represents at the level of the population. Most of the time, the impact of their social image not only disfavors them but also facilitates a decrease in their chances of getting out of this context. By expressing hostile behavior by the authorities, sex workers tend to be even more engaged in this lifestyle.

The lack of viable work alternatives and poor sex education turn sex workers into safe victims. This habit of using condoms only with new clients raises a strong alarm signal regarding not only the education of the population regarding sexual protection but also the meaning of the concept of health itself. The consumption of alcohol, drugs, psychological difficulties, and infection with HIV represent factors that require special attention, as they can become triggers both in the prevention and in the spread of the phenomenon.

As can be seen, there is a continuous interaction between the legislative model, institutional practices, and the physical and mental health of sex workers. A complex understanding of the needs of these people and the provision of personalized assistance, depending on the history of each one, would facilitate the control of this social phenomenon. Awareness and understanding of the problems these women face when they practice prostitution would facilitate the improvement of their capacity to manage this phenomenon.

The psychological difficulties, major depression, and emotional vulnerabilities that most sex workers face are aspects that point to the fact that these people are part of a category that needs specialized support, and simply incarcerating them cannot ensure the solution to the problem.

Future studies should use validated instruments and consistent time intervals to allow more rigorous comparisons between them.

Tabel 1

Studies included in the meta-analysis (to see Table 1, please click here).

Tabel 2

Confidence interval for meta-analysis studies (to see Table 2, please click here).

Acknowledgments

This study is part of the doctoral research project entitled “Dimensions of personality, emotions and cognitions in people deprived of freedom”, PhD. Student Maria – Miana DINA, coordinated by PhD. Cornelia Rada, carried out at the School of Advanced Studies of the Romanian Academy, “Constantin Rădulescu-Motru” Institute of Philosophy and Psychology, Department of Psychology, Romanian Academy, Bucharest, Romania.

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