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Journal of Trauma Practice
ISSN: 1536-2922 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/wztp20
Prostitution and Trafficking in Nine Countries
Melissa Farley PhD , Ann Cotton PsyD , Jacqueline Lynne MSW , Sybille
Zumbeck PhD , Frida Spiwak PhD , Maria E. Reyes PhD , Dinorah Alvarez BA
& Ufuk Sezgin PhD
To cite this article: Melissa Farley PhD , Ann Cotton PsyD , Jacqueline Lynne MSW , Sybille
Zumbeck PhD , Frida Spiwak PhD , Maria E. Reyes PhD , Dinorah Alvarez BA & Ufuk Sezgin PhD
(2004) Prostitution and Trafficking in Nine Countries, Journal of Trauma Practice, 2:3-4, 33-74,
To link to this article: http://dx.doi.org/10.1300/J189v02n03_03
Published online: 15 Oct 2008.
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Citing articles: 26 View citing articles
Prostitution and Trafficking in Nine Countries:
An Update on Violence
and Posttraumatic Stress Disorder
Maria E. Reyes
SUMMARY. We interviewed 854 people currently or recently in prosti-
tution in 9 countries (Canada, Colombia, Germany, Mexico, South Af-
Melissa Farley, PhD, is at Prostitution Research & Education, Box 16254, San
Francisco, CA 94116-0254 USA (Email: firstname.lastname@example.org).
Ann Cotton, PsyD, is at University of Washington School of Medicine and VA Puget
Sound Health Care System, Seattle, WA USA (Email: ann.cotton2@ med.va.gov).
Jacqueline Lynne, MSW, is at Vancouver Coastal Health, Vancouver, Canada.
Sybille Zumbeck, PhD, is at Psychological Institute III, University of Hamburg, Germany.
Frida Spiwak, PhD, is in Bogota, Colombia (Email: email@example.com).
Maria E. Reyes, PhD, is at Instituto Colombiano de Bienestar Familiar (ICBF) in
Dinorah Alvarez, BA, is at San Francisco State University, CA USA.
Ufuk Sezgin, PhD, is at the Psychiatry Department of Istanbul Medical University,
Istanbul, Turkey (Email: firstname.lastname@example.org).
The authors express their appreciation to Steven N. Gold, PhD, and to Harvey L.
Schwartz, PhD, for their helpful editing suggestions.
Printed with permission.
[Haworth co-indexing entry note]: “Prostitution and Trafficking in Nine Countries: An Update on Vio-
lence and Posttraumatic Stress Disorder.” Farley et al. Co-published simultaneously in Journal of Trauma
Practice (The Haworth Maltreatment & Trauma Press, an imprint of The Haworth Press, Inc.) Vol. 2, No. 3/4,
2003, pp. 33-74; and: Prostitution, Trafficking, and Traumatic Stress (ed: Melissa Farley) The Haworth Mal-
treatment & Trauma Press, an imprint of The Haworth Press, Inc., 2003, pp. 33-74. Single or multiple copies
of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00
a.m. - 5:00 p.m. (EST). E-mail address: email@example.com].
rica, Thailand, Turkey, United States, and Zambia), inquiring about
current and lifetime history of sexual and physical violence. We found
that prostitution was multitraumatic: 71% were physically assaulted in
prostitution; 63% were raped; 89% of these respondents wanted to es-
cape prostitution, but did not have other options for survival. A total of
75% had been homeless at some point in their lives; 68% met criteria for
PTSD. Severity of PTSD symptoms was strongly associated with the
number of different types of lifetime sexual and physical violence.
Our findings contradict common myths about prostitution: the as-
sumption that street prostitution is the worst type of prostitution, that
prostitution of men and boys is different from prostitution of women and
girls, that most of those in prostitution freely consent to it, that most peo-
ple are in prostitution because of drug addiction, that prostitution is qual-
itatively different from trafficking, and that legalizing or decriminalizing
prostitution would decrease its harm.
Commercial sex businesses include street prostitution, massage brothels,
escort services, outcall services, strip clubs, lap dancing, phone sex, adult and
child pornography (including the sexual assault of children by organized
groups of pedophiles as well as non-pedophile rapists), child prostitution,
video and Internet pornography, trafficking, and prostitution tourism. Most
people who are in prostitution for longer than a few months drift among these
various permutations of the commercial sex businesses (Dalla, 2000; Kramer,
Prostitution dehumanizes, commodifies and fetishizes women, in contrast
to non-commercial casual sex where both people act on the basis of sexual de-
sire and both people are free to retract without economic consequence. In pros-
titution, there is always a power imbalance, where the john1has the social and
economic power to hire her/him to act like a sexualized puppet. Prostitution
excludes any mutuality of privilege or pleasure: its goal is to ensure that one
person does not use her personal desire to determine which sexual acts do and
do not occur–while the other person acts on the basis of his personal desire
The account of a woman from the United States who prostituted primarily
in strip clubs but also in massage, escort, and street prostitution is typical in
that it encompasses the following types of violence. In strip club prostitution
she was sexually harassed and assaulted. The job required her to tolerate verbal
abuse (with a coerced smile), being grabbed and pinched on the legs, buttocks,
34 PROSTITUTION, TRAFFICKING, AND TRAUMATIC STRESS
breasts, and crotch. Sometimes this resulted in bruises and scratches on her
thighs and arms and breasts. Her breasts were squeezed until she was in severe
pain. She was humiliated by customers ejaculating on her face. She was physi-
cally brutalized, and her hair was pulled as a means of control and torture. She
was severely bruised from beatings and frequently had black eyes. She was re-
peatedly beaten on the head with closed fists, sometimes causing concussions
and unconsciousness. From these beatings, her jaw was dislocated and her ear-
drum was damaged. Many years later her jaw is still dislocated. She was cut
with knives. She was burned with cigarettes by customers who smoked while
raping her. She was gang raped. She was raped individually by at least twenty
men at different times in her life. Rapes by johns and pimps sometimes re-
sulted in internal bleeding.
Seventy percent of women in prostitution in San Francisco, California were
raped (Silbert & Pines, 1982). A study in Portland, Oregon found that prosti-
tuted women were raped on average once a week (Hunter, 1994). Eighty-five
percent of women in Minneapolis, Minnesota had been raped in prostitution
(Parriott, 1994). Ninety-four percent of those in street prostitution experienced
sexual assault and 75% were raped by one or more johns (Miller, 1995). In the
Netherlands (where prostitution is legal) 60% of prostituted women suffered
physical assaults; 70% experienced verbal threats of assault, 40% experienced
sexual violence and 40% were forced into prostitution and/or sexual abuse by
acquaintances (Vanwesenbeeck, de Graaf, van Zessen, Straver, & Visser, 1995;
Prolonged and repeated trauma usually precedes entry into prostitution.
From 55% to 90% of prostitutes report a childhood sexual abuse history
(James & Meyerding, 1977; Silbert & Pines, 1981; Harlan et al., 1981; Silbert &
Pines, 1983; Bagley & Young, 1987; Simons & Whitbeck, 1991; Belton, 1992;
Farley & Barkan, 1998). Silbert and Pines (1981, 1983) noted that 70% of their
interviewees said that childhood sexual abuse had an influence on their entry
into prostitution. A conservative estimate of the average age of recruitment
into prostitution in U.S.A. is 13-14 years. (Silbert & Pines, 1982; Weisberg,
Clearly, violence is the norm for women in prostitution. Incest, sexual ha-
rassment, verbal abuse, stalking, rape, battering, and torture–are points on a
continuum of violence, all of which occur regularly in prostitution. In fact,
prostitution itself is a form of sexual violence that results in economic profit
for those who sell women, men, and children. Though often denied or mini-
mized, other types of gender violence (while epidemic) are not sources of mass
Farley et al. 35
Prostituted women are unrecognized victims of intimate partner violence
by pimps as well as johns (Stark & Hodgson, 2003). Although there are little
research data available, agencies serving prostituted women observe that a ma-
jority of prostitution is pimp-controlled.2Giobbe described similar methods of
coercion and control used by pimps and non-pimp batterers to control women:
minimization and denial of physical violence and abuse, economic exploita-
tion, social isolation, verbal abuse, threats, intimidation, physical violence,
sexual assault, and captivity (Giobbe, 1991; Giobbe, 1993; Giobbe, Harrigan,
Ryan, & Gamache, 1990). The systematic violence of pimps against prosti-
tuted women is aimed not only at control, but also emphasizes the victim’s
powerlessness, worthlessness and invisibility except in her role as prostitute.
A qualitative distinction between prostitution of children and prostitution of
adults is arbitrary and it obscures the lengthy and extensive history of trauma
that is commonplace in prostitution. For example the 5-year-old incested by
her father and used in child prostitution and pornography may become par-
tially amnesic for these traumas and at adolescence may find herself drifting
into prostitution and other savage relationships. The 14-year-old in prostitu-
tion eventually turns 18 but she has not suddenly made a new “vocational
choice.” The abuse and reenactment of abuse simply continue. Women who be-
gan prostituting as adolescents may have parts of themselves that are
dissociatively compartmentalized into a much younger child’s time and place.3
Posttraumatic stress disorder (PTSD) can result when people have experi-
. . . extreme traumatic stressors involving direct personal experience of
an event that involves actual or threatened death or serious injury; threat
to one’s personal integrity; witnessing an event that involves death, in-
jury or a threat to the physical integrity of another person; learning about
unexpected or violent death, serious harm, or threat of death or injury ex-
perienced by a family member or other close associate. (American Psy-
chiatric Association, 1994)
In fact most prostitution, most of the time includes these traumatic stressors. In
response to these events, the person with PTSD experiences fear and power-
lessness, oscillating between emotional numbing and emotional/physiologic
hyperarousal. PTSD is likely to be especially severe or long lasting when the
stressor is planned and implemented by humans (as in war, rape, incest, batter-
ing, torture, or prostitution) rather than being a natural catastrophe.
Exposure to paid or unpaid sexual violence may result in symptoms of
PTSD. Symptoms are grouped into three categories: (1) traumatic re-experi-
encing of events, or flashbacks; (2) avoidance of situations which are remi-
36 PROSTITUTION, TRAFFICKING, AND TRAUMATIC STRESS
niscent of the traumatic events, and a protective emotional numbing of
responsiveness; and (3) autonomic nervous system hyperarousal (e.g., jittery
irritability, being super-alert, insomnia). The symptoms of PTSD may accu-
mulate over one’s lifetime. Many studies report a positive correlation between
a history of childhood sexual assault and symptoms of PTSD in adult women
(Friedman & Schnurr, 1995; Rodriguez, Ryan, Van de Kemp, & Foy, 1997).
Since almost all prostituted women have histories of childhood sexual abuse,
this undoubtedly contributes to their symptoms of posttraumatic stress. PTSD
is not only related to the overall number of traumatic events, but it is also di-
rectly related to the severity of that violence (Houskamp & Foy, 1991). The in-
cidence of PTSD has been investigated among battered women and ranges
from 45% to as high as 84% (Houskamp and Foy, 1991; Saunders, 1994;
Kemp, Rawlings, & Green 1991). The prevalence of PTSD among prostituted
women from 5 countries was 67% (Farley, Baral, Kiremire, & Sezgin, 1998),
which is in the same range as that of combat veterans (Weathers, Litz, Herman,
Huska, & Keane, 1993).
Following publication of an article which discussed the violence preceding
and intrinsic to prostitution, and the symptoms of posttraumatic stress disorder
resulting from prostitution in 5 countries–(South Africa, Thailand, Turkey,
United States, and Zambia)–the authors were contacted by other researchers
and advocates from around the world who were interested in collaborating in
further study of prostitution. Consequently, the present study expands the orig-
inal through the inclusion of four additional countries: Canada, Colombia,
Germany, and Mexico.
Brief structured interviews of people in prostitution were conducted in Van-
couver, Canada; Bogota, Colombia; Hamburg, Germany; Mexico City and
Puebla, Mexico; San Francisco, CA, U.S.A.; two cities in Thailand; Lusaka,
Zambia; Istanbul, Turkey; Johannesburg and Capetown, South Africa. These
countries were included in the study because investigators in those states
shared a commitment to documenting the experiences of women in prostitu-
tion, and in some instances to providing alternatives to prostitution.
In Canada, we interviewed 100 women prostituting in or near Vancouver’s
Downtown Eastside, one of the most economically destitute regions in North
America. The effects of colonization of First Nations people were evident
Farley et al. 37
from their overrepresentation in Canadian prostitution. Fifty-two percent were
First Nations (in a community where 1.7-7% are the official estimates of the
First Nations population), 38% were white European-Canadian, 5% were Afri-
can Canadian, and 5% left the question blank. The majority of the 52 First Na-
tions women described themselves as Native. Next most often, they described
themselves as Metis, a French word that translates to English as “mixed blood”
and is used to describe people who are of both First Nations and European an-
cestries. The two major colonizers of First Nations of Canada were the British
and the French; therefore, the majority of those called Metis were First Na-
tions/French or First Nations/British. The First Nations women also catego-
rized themselves as Native Indian, Cree, Cree Native, First Nations, Cree
Metis, Ojibwa, Blackfoot/Cree, Aboriginal, and Interior Salish.
In Mexico, we interviewed 123 women prostituting in street, brothel,
stripclub and massage prostitution in Mexico City and in Puebla.
Fifty-four women were interviewed in Hamburg, Germany where prostitu-
tion is legal. The German women were from a drop-in shelter for drug addicted
women, from a program which offered vocational rehabilitation for those
prostituted, and were also referred by peers, and by advertisement in a local
newspaper. With respect to country of origin, 82% were German and 11%
were trafficked into Germany from Thailand or the former Soviet Union.
Seven percent were raised in Germany and described themselves as ethnically
Polish, Chilean, or Turkish. Two found the experience of answering questions
about traumatic events too painful to continue, and a third woman was too in-
toxicated to participate.
In San Francisco we interviewed 130 respondents on the street who verbally
confirmed that they were prostituting. We interviewed respondents in four dif-
ferent areas in San Francisco where people worked as prostitutes. Thirty-nine
percent of the 130 interviewees were white European/American, 33% were
African American, 18% were Latina, 6% were Asian or Pacific Islander, and
5% described themselves as of mixed race or left the question blank.
In Thailand we interviewed several of the 110 respondents on the street, but
found that pimps did not allow the prostitutes to answer our questions. We in-
terviewed some respondents at a beauty parlor that provided a supportive at-
mosphere. The majority of the Thai respondents were interviewed at an agency
in northern Thailand that offered nonjudgmental support and job training.
We interviewed 68 prostituted people in Johannesburg and Capetown,
South Africa in brothels, on the street and at a drop-in center for prostitutes.
Respondents were racially diverse: 50% were white European; 29% were Afri-
can or Black; 12% described themselves as Coloured or Brown or of mixed
race; 3% were Indian; and 6% left the question blank.
38 PROSTITUTION, TRAFFICKING, AND TRAUMATIC STRESS
We interviewed 117 current and former prostitutes at TASINTHA in
Lusaka, Zambia. TASINTHA is a non-governmental organization that offered
food, vocational training, and community to approximately 600 prostituted
women a week.
In Turkey some prostitutes work legally in brothels which are privately
owned and controlled by local commissions composed of physicians, police,
and others who are “in charge of public morality.” We were not permitted to
interview women in brothels, so we interviewed 50 prostituted women who
were brought to a hospital in Istanbul by police for the purpose of STD control.
In Bogota we interviewed 96 women and children at agencies that offered
services to them. Prostitution in Colombia starts at a young age, often by ado-
lescence, and is accompanied by unwanted pregnancy (Spiwak & Reyes,
1999; UNICEF, 2000; UNICEF Colombia, 2001; Rodriguez & Cabrera, 1991,
Fundación Renacer, 2000, 2001; ICBF, 1999; Cárdenas and Rivera, 2000;
DABS, 2002). Spiwak & Reyes (1999) found that 72% of the women and chil-
dren prostituting in Colombia were from families that had been internally dis-
placed by political violence. Civil wars and internal displacement are known to
be risk factors for sexual exploitation (UNICEF Colombia, 2001; Fundacion
Renacer, 2000; 2001; Fundación Esperanza, 1998, 2000; CATW, 2002; U.S.
Report of Trafficking in Persons, 2001; NCMEC, 1992; ICBF, 2000; Leech,
2001). Prostitution is legal in Colombia, with thousands of brothels in urban
areas, as well as in paramilitary and guerilla-controlled rural regions. It is legal
to prostitute a 14-year-old girl or boy (Código Penal de Colombia, 2002), al-
though that act of sexual abuse violates the Convention on the Rights of the
Child endorsed by Colombia in 1999 (UNICEF, 2000; UNICEF Colombia,
2001; Seitles, 1997; ICBF-UNESCO, 1997; Motta et al., 1998; Morgan &
In six of the nine countries, we interviewed women and girls. In South Af-
rica we interviewed 10 men (14% of the South African sample) and one
transgendered person. In Thailand we interviewed 28 transgendered people
(25% of the Thai sample). In the United States we interviewed 18 men (13%)
and 15 transgendered people (12%) in addition to women and girls.
Transgendered people represent a significant minority of those in prostitution. A
previous study (Farley & Barkan, 1998) found that transgendered people
(male-to-female) in prostitution experienced the same frequency of physical
assaults and rapes as did women.
Mean age, age ranges and mean age of entry into prostitution, percentages
under age 18 at time of entry into prostitution, and mean number of years in
prostitution by country are shown in Table 1. Across 9 countries, ages of re-
spondents ranged from 12 to 68 with a mean age of 28 years (N = 779, SD = 8)
The average age of entry into prostitution was 19 years (SD = 6). Forty-seven
Farley et al. 39
TABLE 1. Age, Age of Entry, and Length of Time in Prostitution
(N = 854)
n = 100)
(n = 96)
(n = 54)
(n = 123)
(n = 68)
(n = 166)
(n = 50)
(n = 130)
(n = 117)
Mean age (SD) 28 (8) 28 (8) 31 (10) 26 (10) 27 (7) 24 (5) 26 (7) 29 31 (9) 27 (7)
Age range 12-68 13-49 14-58 15-68 18-60 17-38 14-46 16-55 14-61 12-53
Mean age entered
19 (6) 18 (6) 17 (4) 19 (6) 20 (4) 20 (5) 21 (5) Unknown 20 (8) 17 (4)
Years in prostitution (SD) 9 (8) 10 (8) 14 (8) 7 (8) 7 (8) 4 (4) 5 (4) Unknown 11 (9) 10 (7)
Percent younger than
47% (353) 54% (54) 59% (56) 41% (22) 32% (38) 40% (27) 32% (28) Unknown 42% (53) 68% (75)
percent reported that they were under 18 years of age at the time of entry into
prostitution. Based on respondents’ current age and age of entry into prosti-
tution we calculated the average length of time in prostitution to be 9 years
(SD = 8) across countries. This calculation was based on the assumption that
from the age at first prostitution to the time of the interview, there was no
period of time during which they did not prostitute. Since people seize the op-
portunity to interrupt or escape from prostitution, this number probably over-
estimates the amount of time spent in prostitution.
The Prostitution Questionnaire inquired about lifetime history of physical
and sexual violence and the use of or making of pornography during prostitu-
tion. We asked whether respondents wished to leave prostitution and what they
needed in order to leave. We asked if they had been homeless; if they had phys-
ical health problems; and if they used drugs or alcohol or both. Three questions
assessed rape: “Have you been raped?” “Who raped you?” and “How many
times have you been raped since you were in prostitution?” Some respondents
answered “no” when asked if they were raped, but then identified who had
raped them and/or how many times they had been raped. Therefore to assess
rape in prostitution, if a respondent identified “pimp” or “customer” in re-
sponse to “Who raped you?” or if the respondent reported one or more rapes
since being in prostitution then that respondent was identified as having been
raped in prostitution.
Respondents also completed the PTSD Checklist (PCL), a self-report in-
ventory for assessing the 17 DSM-IV symptoms of PTSD (Weathers, Litz,
Herman, Huska, & Keane, 1993; Blanchard, Jones-Alexander, Buckley, &
Forneris, 1996). Respondents were asked to rate symptoms of PTSD on a
scale with (1 =) not at all; (2 =) a little bit; (3 =) moderately; (4 =) quite a bit;
and (5 =) extremely. PCL test-retest reliability was .96. Internal consistency,
as measured by an alpha coefficient was .97. Validity of the scale was reflected
in its strong correlations with the Mississippi Scale (.93); the PK scale of the
MMPI-2 (.77); and the Impact of Events Scale (.90) (Weathers et al., 1993).
The PCL has functioned comparably across ethnic subcultures in U.S.A.
(Keane et al., 1996).
We measured symptoms of PTSD in two ways. First, using a procedure es-
tablished by the scale’s authors, we generated a measure of overall PTSD
symptom severity by summing respondents’ ratings across all 17 items. If a re-
spondent filled out less than half of the PCL (more than 8 blank items) it was
not included in the analysis. For those omitting one to eight items, the PCL
Farley et al. 41
sum was estimated by using the respondent’s mean PCL score in place of the
Second, using Weathers’ (1993) scoring suggestion, we considered a score
of 3 or above on a given PCL item to be a symptom of PTSD. Using those
scores, we then noted whether each respondent met criteria for a diagnosis of
PTSD. We report the numbers and percentages of respondents who qualified
for a diagnosis of PTSD in each country.
In Canada and United States, we administered a Chronic Health Problem
Questionnaire that included items developed from responses to an earlier
open-ended item which inquired about health problems of women in prostitu-
tion. Unanswered items were considered to indicate the absence of the health
problem. Therefore, percentages reported below are percentages of the entire
sample endorsing that item.
In Canada, Colombia, Mexico, South Africa, and United States, if inter-
viewees indicated that they were prostituting, they were asked to fill out the
Prostitution Questionnaire (PQ), the Post Traumatic Stress Disorder Checklist
(PCL), and the Chronic Health Problem Questionnaire (CHPQ). We inter-
viewed respondents in street, brothel, strip clubs, and massage prostitution. In
Germany and Turkey, respondents were administered interviews in medical
clinics. In Zambia and in Thailand, most respondents were interviewed in
agencies offering services to women in prostitution. The questionnaires were
administered in English, German, Spanish, Thai and Turkish. In Zambia, inter-
viewers translated as needed–most participants spoke some English. The au-
thors either administered or directly supervised the administration of all
questionnaires. If respondents could not read, the questions were read to them
by the researchers.
A range of sexual and other physical violence was reported by a majority of
these prostituted people in all nine countries (see Table 2). Listed in the follow-
ing tables are the percentages of respondents endorsing each item out of the to-
tal number of respondents who answered that item. The number of participants
endorsing each item is in parentheses.
Across countries, 59% of these interviewees reported that as children they
were beaten by a caregiver to the point of injury. Sixty-three percent were sex-
ually abused as children, with an average of four perpetrators against each
42 PROSTITUTION, TRAFFICKING, AND TRAUMATIC STRESS
TABLE 2. Violence in Prostitution
(N = 854)
(n = 100)
(n = 96)
(n = 54)
(n = 123)
(n = 68)
(n = 166)
(n = 50)
(n = 130)
(n = 117)
Threatened with a weapon
64% (503) 67% (66) 59% (57) 52% (28) 48% (46) 68% (45) 39% (33) 68% (34) 78% (100) 86% (94)
73% (595) 91% (91) 70% (67) 61% (33) 59% (72) 66% (45) 56% (50) 80% (40) 82% (106) 82% (91)
Raped in prostitution 57% (483) 76% (76) 47% (45) 63% (34) 46% (57) 56% (38) 38% (45) 50% (25) 73% (95) 79% (93)
(Of those raped) raped
more than five times
59% (286) 67% (51) 64% (29) 50% (17) 44% (25) 58% (22) 56% (25) 36% (9) 59% (56) 52% (48)
Current or past
75% (571) 86% (84) 76% (73) 74% (40) 55% (65) 73% (49) 57% (53) 58% (29) 84% (108) 89% (99)
As a child, was hit or
beaten by caregiver until
injured or bruised
59% (448) 73% (72) 66% (63) 48% (26) 57% (69) 56% (38) 39% (35) 56% (28) 49% (37) 71% (80)
Sexually abused as a child 63% (508) 84% (82) 67% (64) 48% (26) 54% (64) 66% (45) 47% (41) 34% (17) 57% (73) 84% (93)
Mean number of childhood
sexual abuse perpetrators
4 5 2 17 2 2 1 unknown 2 6
of childhood sexual abuse
unknown 1 3
child. As adults in prostitution, 64% of these respondents had been threatened
with a weapon, 71% had experienced physical assault, and 63% had been
raped. Current or past homelessness averaged 75% across countries and
ranged from 55% (Mexico) to 89% (Zambia).
From this range of violent events, we categorized four types of violence in
these people’s lives: (1) childhood sexual abuse, (2) childhood physical abuse,
(3) rape in prostitution as an adult and (4) physical assault in prostitution as an
adult. Respondents might have experienced none, one, two, three, or all four
types of violence (see Table 3). Fifty-one percent of the interviewees had expe-
rienced three or four different types of lifetime violence, 36% reported one to
two types of lifetime violence, and only 13% had not experienced any of these
types of violence. Since those who left items blank were assumed not to have
experienced the violence, this is a conservative estimate of lifetime violence.
We asked 315 respondents in Canada, Colombia, and Mexico about their ex-
perience of verbal abuse in prostitution. Eighty-eight percent reported having
been verbally abused.
The responses of our participants suggest that pornography is integral to
prostitution. Table 4 shows rates by country of those in prostitution who re-
ported that they were upset by attempts to coerce them into imitating pornogra-
phy and who had pornography made of them in prostitution. Across countries,
47% were upset by attempts to make them do what others had seen in pornog-
raphy and 49% reported pornography was made of them.
Posttraumatic Stress Disorder
To meet criteria for a diagnosis of posttraumatic stress disorder (PTSD) a
person must have at least one of five symptoms of intrusive re-experiencing of
trauma symptoms (criterion B), at least three of six symptoms of numbing and
avoidance of trauma (criterion C), and at least two of four symptoms of physio-
logic hyperarousal (criterion D). Given the extremely high rates of interper-
sonal violence reported by these respondents (stressors which meet criterion
A), we made the assumption that the 13% of respondents who had not directly
experienced violence themselves–had witnessed it. Thus we assumed that all
respondents met criterion A for a diagnosis of PTSD. Eight hundred
twenty-six of our respondents answered at least 8 of the 17 items on the Post
Traumatic Disorder Check List (PCL) and were included in the following
analysis. Across 9 countries, 68% of these respondents met criteria for a diag-
nosis of PTSD (see Table 5).
Mean PCL score was 53.5 (SD = 16.2) across the 9 countries, a reflec-
tion of the severity of the symptoms of PTSD in this sample (see Table 6).
Mean PTSD severities in the 9 countries ranged from 49 (Mexico) to 58
44 PROSTITUTION, TRAFFICKING, AND TRAUMATIC STRESS
TABLE 3. Number of Types of Lifetime Violence
Number of Types
of Lifetime Violence
(N = 854)
(n = 100)
(n = 96)
(n = 54)
(n = 123)
(n = 68)
(n = 166)
(n = 50)
(n = 130)
(n = 117)
No violence reported 13% (110) 2% (2) 12% (11) 6% (3) 22% (27) 12% (8) 28% (33) 20% (10) 6% (8) 7% (8)
1 Type of violence 16% (133) 12% (12) 16% (15) 17% (9) 15% (19) 19% (13) 28% (33) 24% (12) 12% (15) 4% (5)
2 Types of violence 20% (171) 7% (7) 22% (21) 37% (20) 16% (20) 16% (11) 21% (24) 22% (11) 34% (44) 11% (13)
3 Types of violence 26% (222) 24% (24) 16% (15) 33% (18) 25% (31) 19% (13) 17% (20) 34% (17) 34% (44) 34% (40)
4 Types of violence 25% (218) 55% (55) 35% (34) 7% (4) 21% (26) 34% (23) 5% (6) 0% (0) 15% (19) 44% (51)
TABLE 4. Prostitution and Pornography
(N = 854)
(n = 100)
(n = 96)
(n = 54)
(n = 123)
(n = 68)
(n = 166)
(n = 50)
(n = 130)
(n = 117)
Upset by an attempt to make
them do what had been seen
47% (377) 64% (63) 62% (60) 44% (24) 35% (42) 56% (37) 48% (43) 20% (10) 32% (41) 47% (51)
of her in prostitution 49% (371) 67% (64) 50% (48) 52% (28) 44% (53) 40% (26) 45% (39) N/A 49% (63) 47% (52)
TABLE 5. Posttraumatic Stress Disorder of Prostituted Respondents in 9 Countries
(N = 854)
(n = 100)
(n = 96)
(n = 54)
(n = 123)
(n = 68)
(n = 116)
(n = 50)
(n = 130)
(n = 117)
PTSD DIAGNOSIS (DSM-IV) 68% (562) 74% (72) 86% (83) 60% (32) 54% (67) 75% (51) 58% (59) 66% (33) 69% (87) 71% (78)
(Columbia). PTSD severity was significantly positively correlated with the
number of types of lifetime violence experienced (r = .33, p = .001). For com-
parison, Table 6 includes mean PCL scores from two other studies of PTSD se-
verity–Vietnam and Persian Gulf veterans (Weathers et al., 1993) and samples
of women from a health maintenance plan who had and had not experienced
physical and sexual abuse (Farley & Patsalides, 2001).
We asked interviewees in the 9 countries about their use of drugs and alco-
hol. Table 7 lists substance use by country. Across countries, 48% of those re-
sponding to this item reported drug use, and 52% reported alcohol use.
Colombia and Zambia reported the lowest use of drugs. Drugs were probably
not available due to the poverty of respondents. We did not inquire specifically
about glue sniffing which is common in Colombia. Colombia and Zambia,
along with Mexico, had the highest rates of alcohol use (71%-100%). Canada,
USA, and Germany reported the highest rates of drug use (70% to 95%).
We asked respondents what they needed by offering them a checklist of op-
tions that included an open-ended question for write-in responses (see Table
8). Eighty-nine percent told us that they desired to leave prostitution. A total of
75% needed a home or safe place, 76% needed job training, 61% needed health
care, 56% needed individual counseling, 51% needed peer support, 51%
needed legal assistance, 47% needed drug/alcohol treatment, 45% wanted
48 PROSTITUTION, TRAFFICKING, AND TRAUMATIC STRESS
TABLE 6. PTSD Checklist (PCL) Means from Three Studies
Mean PCLC Sum
1 Current study
99 women in prostitution (Canada)
96 women in prostitution (Colombia)
53 women in prostitution (Germany)
123 women in prostitution (Mexico)
68 people in prostitution (South Africa)
111 people in prostitution (Thailand)
50 women in prostitution (Turkey)
128 people in prostitution (USA)
112 women in prostitution (Zambia)
2 Weathers et al. (1993)
123 Vietnam veterans requesting treatment
1006 Persian Gulf War veterans
3 Farley & Patsalides, (2001)
25 w/ childhood physical abuse history
27 w/ childhood physical and sexual abuse history
*PTSD sum is an indicator of PTSD severity.
self-defense training, 44% needed childcare, 34% wanted prostitution to be le-
galized, and 23% wanted physical protection from a pimp.
We asked those we interviewed in six countries (Canada, Colombia, Ger-
many, Mexico, South Africa, and Zambia) whether they thought that legaliz-
ing prostitution would make them physically safer. Across countries 46%
stated that prostitution would be no safer if it were legalized (see Table 9). It is
noteworthy that in Germany where brothel prostitution is legal, 59% of re-
spondents told us that they did not think that legal prostitution made them any
safer from rape and physical assault.
In Mexico we were able to compare several different types of prostitution: 54
women in strip clubs, 44 women in brothels and massage parlors, and 25 women
who were prostituting on the street. We inquired about age of entry into prostitu-
tion, length of time in prostitution, PTSD severity, number of types of lifetime
violence and whether or not women in these different types of prostitution
wanted to escape from it. Age of entry into prostitution differentiated strip club
from other types of prostitution. Compared to brothel, massage and street prosti-
tution, significantly more women in strip clubs entered prostitution when they
were younger than 18 (F = 3.5; df = 2,113; p = .03). There were no statistically
significant differences between brothel/massage, street, and strip club prostitu-
tion with respect to PTSD severity, length of time in prostitution, childhood sex-
ual abuse, childhood physical abuse, rape in prostitution, number of types of
lifetime violence experienced, and percentages of respondents who told us that
they wanted escape from prostitution.
We investigated differences in PTSD associated with gender and gender
identity. In U.S. differences in PTSD incidence among women, men and
transgendered prostitutes were not statistically significant. In Thailand, differ-
ences between women and transgendered prostitutes were not statistically sig-
nificant. In South Africa, differences between women and men prostitutes
were not significant.
Previously, we found that 61% of those in prostitution in 5 countries re-
ported a current physical health problem, 52% reported alcohol use, and 45%
reported drug use (Farley et al., 1998). We are now able to report in more detail
the acute and chronic health problems experienced by those in prostitution in 7
of the 9 countries (Colombia, Mexico, South Africa, Thailand, Turkey, USA,
and Zambia). Half of these people reported symptoms that were associated
with violence, overwhelming stress, poverty, and homelessness.
Common medical problems of these 700 people in prostitution included tu-
berculosis, HIV, diabetes, cancer, arthritis, tachycardia, syphilis, malaria,
asthma, anemia, and hepatitis. Twenty-four percent reported reproductive
symptoms including sexually transmitted diseases (STD), uterine infections,
Farley et al. 49
TABLE 7. Use of Drugs and Alcohol Among People in Prostitution in 9 Countries
(N = 854)
(n = 100)
(n = 96)
(n = 54)
(n = 123)
(n = 68)
(n = 166)
(n = 50)
(n = 130)
(n = 117)
Used drugs 48% (383) 95% (94) 4% (3) 70% (38) 34% (40) 49% (33) 39% (40) 46% (23) 75% (94) 16% (18)
Used alcohol 52% (416) 47% (44) 100% (29) 54% (29) 71% (84) 43% (29) 56% (57) 64% (32) 26% (33) 72% (79)
TABLE 8. Responses to “What Do You Need?” Asked of 854 People in Prostitution
(N = 854)
(n = 100)
(n = 96)
(n = 54)
(n = 123)
(n = 68)
(n = 116)
(n = 50)
(n = 130)
(n = 117)
Leave prostitution 89% (699) 95% (89) 97% (93) 85% (33) 68% (81) 89% (58) 92% (82) 90% (45) 87% (111) 99% (107)
Home or safe place 75% (618) 66% (63) 74% (71) 61% (33) 87% (107) 72% (46) 59% (64) 60% (30) 78% (99) 94% (105)
Job training 76% (600) 67% (64) 57% (55) 63% (34) 92% (113) 75% (48) 56% (61) 46% (23) 73% (93) 97% (109)
Drug/alcohol treatment 47% (356) 82% (78) 15% (14) 48% (26) 38% (47) 46% (29) 44% (33) 6% (3) 67% (85) 37% (41)
Health care 61% (480) 41% (39) 56% (54) 46% (25) 67% (82) 69% (44) 41% (45) 38% (19) 58% (74) 88% (98)
Peer support 51% (393) 41% (38) 41% (39) 65% (35) 36% (44) 58% (37) 49% (53) 24% (12) 50% (64) 63% (71)
Individual counseling 56% (431) 58% (54) 34% (33) 69% (37) 43% (53) 61% (39) 66% (72) 46% (23) 48% (61) 53% (59)
Self-defense training 45% (340) 49% (47) 29% (28) 46% (25) 35% (43) 60% (39) 59% (64) 12% (6) 49% (62) 41% (46)
Legal assistance 51% (366) 33% (31) 43% (41) 37% (20) 50% (61) 58% (37) 57% (62) Unknown 42% (54) 54% (60)
Legalize prostitution 34% (251) 32% (30) 20% (19) 35% (19) 51% (62) 37% (24) 27% (30) 4% (2) 44% (56) 8% (9)
Child care 44% (335) 12% (11) 49% (47) 7% (4) 36% (44) 48% (31) 44% (48) 20% (10) 34% (43) 87% (97)
from pimp 23% (157) 4% (4) 6% (6) 6% (3) 15% (19) 33% (21) 20% (22) Unknown 28% (36) 41% (46)
TABLE 9. Respondents Who Stated That Prostitution Would Not Be Safer if Legalized
(N = 558)
(n = 100)
(n = 96)
(n = 54)
(n = 123)
(n = 68)
(n = 117)
Prostitution would be
no safer if legalized
46% (226) 26% (25) 44% (22) 59% (27) 15% (13) 59% (40) 73% (79)
menstrual problems, ovarian pain, abortion complications, pregnancy, hepati-
tis B, hepatitis C, infertility, syphilis, and HIV.
Without specific query about mental health, 17% described severe emo-
tional problems: depression, suicidality, flashbacks of child abuse, anxiety and
extreme tension, terror regarding relationships with pimps, extremely low
self-esteem, and mood swings. Fifteen percent reported gastrointestinal symp-
toms such as ulcers, chronic stomachache, diarrhea, and colitis. Fifteen percent
reported neurological symptoms such as migraine headaches and non-mi-
graine headaches, memory loss, numbness, seizures, and dizziness. Fourteen
percent of these women and children in prostitution reported respiratory prob-
lems such as asthma, lung disease, bronchitis, and pneumonia. Fourteen per-
cent reported joint pain, including hip pain, bad knees, backache, arthritis,
rheumatism, and nonspecific multiple-site joint pain.
Twelve percent of those who described health problems in prostitution re-
ported injuries that were a direct result of violence. For example, a number of
women had their ribs broken by the police in Istanbul, a woman in San Fran-
cisco broke her hips jumping out of a car when a john was attempting to kidnap
her. Many women had their teeth knocked out by pimps and johns. Miller
(1995) cited bruises, broken bones, cuts, and abrasions that resulted from beat-
ings and sexual assaults.
Of the 50 Turkish women, 18% reported mental distress, 16% reported joint or
other pain, 10% reported gastrointestinal symptoms, 10% reported gynecological
symptoms, 6% had respiratory symptoms, and 6% cardiac symptoms. Almost
half of the Turkish women had never been examined by a physician.
In Mexico, 52 of 123 women responded affirmatively to an open-ended
question regarding health problems. Twenty-one percent of those who re-
sponded to this question reported gastrointestinal symptoms, and 16% re-
ported neurological problems. Other physical health problems included joint
pain (12%) and cardiovascular symptoms (12%).
In Thailand, 60 of 116 women responded to an open-ended question about
health problems. Thirty percent of these women reported poor health in gen-
eral, and 30% described reproductive system problems. Twenty-five percent
described physical injuries from violence in prostitution, 23% reported neuro-
logical symptoms, 17% joint pain, and 15% gastrointestinal symptoms.
Twenty-eight percent of the Thai women described serious emotional prob-
lems; many told us that they had been lied to, kidnapped, or trafficked into
prostitution, which contributed to their distress. Equating prostitution with
death, one woman stated: “Why commit suicide? I’ll work in prostitution in-
stead.” Another woman explained that she felt “spiritually assaulted” in prosti-
Farley et al. 53
54 PROSTITUTION, TRAFFICKING, AND TRAUMATIC STRESS
TABLE 10. Chronic Health Problems of Women in Prostitution and Women No
Longer in Prostitution*
Chronic Health Problems
endorsed more frequently
not yet out of prostitution
(n = 100)
U.S. women out of
at least 1.5 years
(n = 21)
Colds or flu symptoms
Shortness of breath
Jaw or throat pain
Poor health in general
Chronic health problems
endorsed more frequently
after getting out of prostitution
(n = 100)
U.S. women out of
at least 1.5 years
(n = 21)
Injury caused by violence
Pain/numbness in hands/feet
Trouble with balance or walking
Swelling of arms/hands/legs/feet
Rapid or irregular heart beat
Loss of feeling on skin
*Items from Chronic Health Problems Questionnaire (CHPQ).
In Colombia, the most frequent health complaints were reproductive, car-
diovascular and respiratory symptoms, and joint pain.
From these responses, we developed the Chronic Health Problems Ques-
tionnaire (CPHQ) which was subsequently given to 100 currently prostituting
Canadian women and to a separate sample of 21 women in the U.S. who were
no longer in prostitution (see Table 10). Among the Canadian women cur-
rently in prostitution, 76% reported injuries from violence in prostitution, with
53% having suffered traumatic head injuries. Once women were out of prosti-
tution, awareness of the severity of the previous violence seemed to increase.
For example, 95% of the women already out of prostitution reported violent in-
juries resulting from prostitution, including a 95% incidence of head injury.
Women who were still in prostitution reported these same injuries at 76% (any
violence-caused injury) and 53% (head injury). Approximately half of both
samples reported headaches or migraines. Some of the cardiovascular, neuro-
logical and joint complaints may have been symptoms of substance abuse or
Fourteen of the chronic symptoms we inquired about were more prevalent
among the 21 women no longer involved in prostitution than among the cur-
rently prostituting Canadian women. These symptoms were: any injury caused
by violence, report of any medical diagnosis, memory problems, head injury,
pain/numbness in hands or feet, vision problems, trouble with balance or walk-
ing, allergies, swelling of arms, hands, legs or feet, rapid or irregular heartbeat,
loss of feeling on skin, painful menstruation, vaginal pain, and breast pain (see
Table 10.) The Canadian respondents still in prostitution endorsed an average
of 14 of 32 (SD = 8) symptoms. The U.S. women no longer in prostitution en-
dorsed an average of 12 of 32 (SD = 7) symptoms. There was no significant
difference between the two groups in the total number of symptoms endorsed
(ANOVA, F = 3.3, df. = 1,118, p = .07).
In three countries (Canada, Colombia, Mexico) we inquired about verbal
abuse in prostitution. Eighty-eight percent of 315 respondents reported having
been verbally abused ranging from 84% in Mexico to 91% in Colombia.
Our findings from 9 countries on 5 continents indicate that the physical and
emotional violence in prostitution is overwhelming. To summarize the find-
ings of this study and other research and clinical literature on different types of
prostitution (see Farley & Kelly, 2000; Farley, 2003):
Farley et al. 55
1. 95% of those in prostitution experienced sexual harassment which in the
United States would be legally actionable in a different job setting.
2. 65% to 95% of those in prostitution were sexually assaulted as children.
3. 70% to 95% were physically assaulted in prostitution.
4. 60% to 75% were raped in prostitution.4
5. 75% of those in prostitution have been homeless at some point in their
6. 89% of 785 people in prostitution from nine countries wanted to escape
7. 68% of 827 people in several different types of prostitution in 9 coun-
tries met criteria for PTSD. The severity of PTSD symptoms of partici-
pants in this study were in the same range as treatment-seeking combat
veterans, battered women seeking shelter, rape survivors, and refugees
from state-organized torture (Bownes, O’Gormen, & Sayers 1991;
Houskamp & Foy, 1991, Kemp et al., 1991; Ramsay, Gorst-Unsworth,
& Turner, 1993; Weathers et al., 1993). Severity of symptoms of PTSD
was strongly associated with the number of different types of lifetime
sexual and physical violence. A Covenant House study of homeless ado-
lescents, many of whom were prostituting, found a similar association
between PTSD severity and history of violence (DiPaolo, 1999).
8. 88% of those in prostitution experience verbal abuse and social con-
tempt. Verbal abuse in prostitution has rarely been discussed as one of
Similar findings suggest that the severity of trauma-related symptoms
were related to the intensity of involvement in prostitution. Women who
serviced more customers in prostitution reported more severe physical
symptoms (Vanwesenbeeck, 1994). The longer women were in prostitu-
tion, the more STDs were reported (Parriott, 1994). A number of studies
document the greatly increased risk among prostituted women as com-
pared to nonprostituted women, for cervical cancer and chronic hepatitis
(Chattopadhyay, Bandyopadhyay, & Duttagupta, 1994; de Sanjose, Palacio,
Tafur, Vasquez, Espitia, Vasquez, Roman, Munoz, & Bosch, 1993; Nakashima,
Kashiwagi, Hayashi, Urabe, Minami, & Maeda, 1996; Parriott, 1994; Pelzer,
Duncan, Tibaux, & Mebari, 1992).
Vanwesenbeeck (1994) noted that poverty and length of time spent in
prostitution were each associated with greater violence in prostitution. Like
Vanwesenbeeck, we concluded that those women who experienced the most
extreme violence in prostitution were not represented in our research. Because
of this limitation, it is likely that all of the estimates of violence reported here
56 PROSTITUTION, TRAFFICKING, AND TRAUMATIC STRESS
are conservative, and that the actual incidence of violence is greater than we
Traumatized individuals tend to minimize or deny their experiences, espe-
cially when they are in the midst of ongoing trauma, such as war combat or
prostitution. This leads to a decreased rate of reporting violent events. Based
on a review of previous research and clinical reports, we think that our statistic
on the prevalence of child sexual abuse among those prostituting in 9 countries
(63%) is much lower than the actual incidence of childhood sexual abuse in
this population, which we estimate to be closer to 85% (Silbert & Pines, 1981,
1983; Giobbe, 1991; Hunter, 1994).
Describing the complex connections between childhood sexual abuse,
revictimization, prostitution, and health problems, one woman made a deci-
sion to prostitute after realizing that she had been sexually abused as a child:
. . . there was no sense of having a life; the only life I knew of was prosti-
tuting...Ithought I couldn’t be hurt no more and I felt that I could do
what I want and I could have sex with whoever I wanted because some-
body already gone and messed my system up. (Morse, Suchman, &
Frankel, 1997. [Authors’ italics]
In prostitution, the sexual exploitation of children and women is often indis-
tinguishable from incest, intimate partner violence, and rape (Gysels, Pool, &
Nnulasiba, 2002). Like adult prostitutes, incested children are bribed into sex
acts by adults and offered food, money, or protection for their silence. Use of a
child for sex by adults may thus be understood as prostitution of the child,
whether the act occurs in or out of the family, and whether it is with or with-
out payment. When a child is incestuously assaulted, the perpetrator’s
objectification of the child victim and his rationalization and denial are similar
to the john’s in prostitution. The psychological symptoms resulting from in-
cest and prostitution are similar. One woman described a “prostituting mental-
ity” beginning after sexual abuse by neighbors and family members starting at
age nine and continuing to adolescence, when she began prostituting (Carroll &
Although this study assessed only PTSD as a psychological consequence of
prostitution, additional symptoms of emotional distress are common among
prostituted women, including other anxiety disorders, dissociative disorders
(Ross, Farley, & Schwartz, 2003), substance abuse, personality disorders, and
depression. Depression is almost universal among prostituted women. For ex-
ample, Raymond, Hughes and Gomez (2001) found that 86% of domestically
trafficked and 85% of internationally trafficked women experienced depres-
Farley et al. 57
Another psychological consequence of longterm prostitution is complex
PTSD (CPTSD) which results from chronic traumatic stress, captivity, and to-
talitarian control. Symptoms of CPTSD include difficulty regulating emo-
tions, altered self-perception (in prostitution: a subordinated sexual self),
changes in relations with others (a boyfriend may be gradually seen as another
john), and shifts in beliefs about the nature of the world (Herman, 1992; Van
der Kolk, Pelcovitz, Roth, Mandel, McFarlane, & Herman 1996). In CPTSD,
and in some Axis II personality disorders, the objectification and contempt
aimed at those in prostitution can become internalized and solidified, resulting
in self-loathing that is long-lasting and resistant to change (Schwartz, 2000).
Existing in a state of social death, the prostitute is an outsider who is seen as
having no honor or public worth; (Patterson, 1982; Farley, 1997). Those in
prostitution, like slaves and concentration camp prisoners, may lose their iden-
tities as individuals, becoming primarily what masters, Nazis or customers
want them to be. As one woman said about prostitution: “It is internally dam-
aging. You become in your own mind what these people do and say with you”
(M. Farley, unpublished interview, 1999).
Sex inequality sets the stage for sexual coercion, intimate partner vio-
lence and prostitution, thus contributing to women’s likelihood of becom-
ing HIV-infected. Sexual violence has now been recognized as a primary risk
factor for HIV in women (Romero-Daza, Weeks, & Singer, 1998). Kalichman
and colleagues noted the coincidence of domestic violence and the HIV epi-
demic in Russia, Rwanda, and in the USA (Kalichman, Kelly, Shaboltas, &
Granskaya, 2000; Kalichman, Williams, Cheery, Belcher, & Nachimson,
Half of new AIDS cases are under age 25, and girls are likely to become in-
fected at a much younger age than boys, in part because of the tolerance of vio-
lence against girls and women in most cultures (Piot, 1999). In Africa and
Asia, there is still a widespread belief that sex with a girl child cures HIV. In
their attempts to escape lives of hunger and poverty, young girls in Africa cannot
refuse the sexual assaults of older male teachers who control their educational
future (Reilly, 2001). In a review of a number of studies, Sanders-Phillips
(2002) observed that prostitution and intravenous drug use are the most com-
mon routes of HIV exposure among women of color in the United States. She
suggests as does Worth (1989), that women’s lack of sexual safety is caused by
their subordination by men and by specific other factors that increase their vul-
nerability such as race/ethnic discrimination and poverty. Aral and Mann
(1998) emphasized the importance of addressing human rights issues in con-
junction with STDs. They noted that since most women enter prostitution as a
result of poverty, rape, infertility, or divorce–public health programs must ad-
dress the social factors which contribute to STD/HIV. We agree that it is essen-
58 PROSTITUTION, TRAFFICKING, AND TRAUMATIC STRESS
tial to address the root causes of prostitution: sex inequality, racism and
colonialism, poverty, tourism, and economic development that destroys tradi-
tional ways of living.
In addition to STD and HIV, prostitution causes a multitude of other physi-
cal symptoms. Physical health problems result from physical abuse and ne-
glect in childhood (Radomsky, 1995), from sexual assault (Golding, 1994),
battering (Crowell & Burgess, 1996), untreated health problems, overwhelm-
ing stress, and violence (Friedman & Yehuda, 1995; Koss & Heslet, 1992;
Southwick et al., 1995). Prostituted women frequently suffer from all of the
foregoing. Intimate partner violence, especially sexual violence, has been
shown to increase gynecological, central nervous system, and stress-related
problems by 50% to 70% (Campbell, Jones, Dienemann, Kub, Schollenberger,
O’Campo, Gielen & Wynne, 2002; McNutt, Carlson, Persaud, & Posmus,
2002). Among our interviewees in 9 countries, we found many health prob-
lems which were the direct result of violence in prostitution, and probably also
the result of chronic and overwhelming stress.
For example, 75% of the Canadian women we interviewed suffered injuries
from violence that occurred during prostitution. These included stabbings and
beatings, concussions, broken bones (broken jaws, ribs, collar bones, fingers,
spines, skulls). Half of the Canadian women suffered traumatic head injuries
as a result of violent assaults with baseball bats, crowbars or from having their
heads slammed against walls or against car dashboards. Not surprisingly, they
experienced memory problems, trouble concentrating, headaches, vision prob-
lems, dizziness, and trouble with balance or walking. These neurological
symptoms are sometimes attributed solely to drug or alcohol toxicity, to PTSD
or to personality disorders. However, they may also result from traumatic
brain injury (TBI). In one study of prostituted women from three countries,
30% of Filipino women, 33% of Russian women, and 77% of US women re-
ported head injuries (Raymond, D’Cunha, Dzuhaytin, Hynes, Rodriguez, &
Unfortunately, physical and psychological symptoms often did not disap-
pear when women escaped prostitution. Instead 38% of the physical problems
we inquired about were more frequently endorsed by women who no longer
prostituted as compared to those who were still prostituting (for example,
pain/numbness in hands or feet, vision problems, problems with balance, aller-
gies, irregular heartbeat, and reproductive symptoms). Psychological distress
is also persistent. Comparing women who were still prostituting with those
who were not, a Canadian study found that “exited respondents were only
slightly less likely to experience depression, and more likely to experience
anxiety attacks and emotional trauma when compared to their counterparts
who were still [in prostitution]” (Benoit & Millar, 2001, p. 71).
Farley et al. 59
More than three-quarters of these people in prostitution from 9 countries
stated that they needed secure housing and job training. More than half ex-
pressed a need for health care in general and half specifically mentioned a need
for individual counseling. These findings are consistent with a study in which
prostituting respondents emphasized a need for mental health care, specifi-
cally requesting drop-in centers, crisis centers, and a phone hotline (Butters &
A Canadian woman told us: “What rape is to others, is normal to us.” A Thai
woman said, “I hate that I have to have sex with someone I don’t like or love.”
For the vast majority of the world’s prostituted women, prostitution and traf-
ficking are experiences of being hunted down, dominated, sexually harassed,
and assaulted. Women in prostitution are treated like commodities into which
men masturbate, causing immense psychological harm to the person acting as
receptacle (Hoigard & Finstad, 1986).
There is widespread misinformation about prostitution, based on propa-
ganda that neutralizes the harms described above and which is disseminated by
organizations that present prostitution as legitimate, if unpleasant, labor (“sex
work”). We address below myths that: street prostitution is the worst type of
prostitution, that prostitution of men and boys is significantly different than
prostitution of women and girls, that most of those in prostitution freely con-
sent to it, that most people are in prostitution because of a previous drug addic-
tion, that prostitution is qualitatively different from trafficking, and that
legalizing prostitution would decrease its harm.
Prostitution is multitraumatic whether its physical location is in clubs,
brothels, hotels/motels/john’s homes (also called escort prostitution or high
class call girl prostitution), motor vehicles or the streets. Women have told us
that they felt safer in street prostitution compared to (legal) Nevada brothels,
where they were not permitted to reject any customer. Others commented that
on the street they could refuse dangerous-appearing or intoxicated customers
and that often a friend would make a show of writing down the john’s car li-
cense plate number, which they considered a deterrent to violence. Raphael
and Shapiro (2002) found that women in Chicago reported the same frequency
of rape in escort and in street prostitution. In a previous study, although we
found more physical violence in street compared to brothel prostitution in
South Africa–we found no difference in the incidence of PTSD in these two
types of prostitution, suggesting the intrinsically traumatizing nature of prosti-
tution (Farley et al., 1998).
60 PROSTITUTION, TRAFFICKING, AND TRAUMATIC STRESS
Ross, Anderson, Heber, and Norton (1990) found that women prostituting
in stripclubs had significantly higher rates of dissociative and other psychiatric
symptoms than those in street prostitution. In the present study we compared
stripclub/massage, brothel, and street prostitution in Mexico and found no dif-
ferences in the incidence of physical assault and rape in prostitution, childhood
sexual abuse, or symptoms of PTSD. We also found no differences in the per-
centages of women in brothel, street, or stripclub/massage prostitution who
wanted to escape prostitution.
Comparable findings have been reported in the Netherlands, where, al-
though prostitution is legal, it continues to inflict harm on those in it. For ex-
ample: 90% of women prostituting mainly in clubs, brothels and windows
reported extreme nervousness, a symptom which may reflect the physiologic
hyperarousal diagnostic of PTSD. In addition, 75% to 80% of the Dutch
women reported distrust, symptoms of depression, irritability, and chronic
physical discomfort (Vanwesenbeeck, 1994).
Since the 1980s, the line between prostitution and stripping has been increas-
ingly blurred, and the amount of physical contact between exotic dancers and
customers has increased, along with verbal sexual harassment and physical as-
sault of women in strip club prostitution.2In most strip clubs, customers can
now buy a lap dance where the dancer sits on the customer’s lap while she
wears few or no clothes and grinds her genitals against his. Although he is
clothed, he usually expects ejaculation (Lewis, 1998). Touching, grabbing,
pinching, and fingering of dancers removes any boundary which previously
existed between dancing, stripping, and prostitution. As in other kinds of pros-
titution, the verbal, physical, and sexual abuse experienced by women in strip
club prostitution includes being grabbed on the breasts, buttocks, and genitals,
as well as being kicked, bitten, slapped, spit on, and penetrated vaginally and
anally during lap dancing (Holsopple, 1998).
Proponents of prostitution argue that most of the violence and trauma-related
symptoms among prostitutes result from street violence or from a drug-re-
lated lifestyle rather than from prostitution itself. The following comparisons will
hopefully set aside that myth. A study of the health of women street vendors in
Johannesburg permits a comparison of the violence against them to violence
against our South African respondents. The street vendors were similarly situ-
ated women who spent much of their lives on the street in the same dangerous
neighborhoods as the women we studied but who were not prostituting (Pick,
Ross, & Dada, 2002). The average age of the prostituted women we inter-
viewed was several years younger (24 years) than the street vendors (30 years).
Seven percent of the South African street vendors experienced a verbal or
physical threat, compared to 68% of the South African prostituted women who
had been threatened with a weapon. Six percent of the women street vendors
had been physically assaulted, compared to 66% of the prostituted women.
Farley et al. 61
Seven percent of the street vendors reported physical sexual harassment, in
contrast to the 56% of our South African interviewees who had been raped in
prostitution. Prostitutes thus suffered much greater interpersonal violence than
street vendors in the same neighborhood in Johannesburg, South Africa. Since
the poverty, proximity to drug dealers, experience of street life and civil war
were the same for both the street vendors and prostitutes, the large differences
in their experiences of sexual and physical violence can be attributed to the na-
ture of prostitution itself.
A Toronto survey of homeless people can be compared to our Canadian
sample of women in prostitution. Crowe and Hardill (1993) found that 40% of
homeless people had been assaulted in contrast to the 91% of our Canadian re-
spondents in prostitution who had been assaulted. Although homelessness is
associated with violence, prostitution is associated with a greater prevalence of
Several researchers have studied the development of men’s attitudes toward
prostitution. Investigating men’s behavior with prostitutes, Scandinavian re-
searchers suggested that prostitution is an expression of men’s sexuality but
not women’s (Mansson, 2001). Like rape myths, prostitution myths (mis-
perceptions about the nature of prostitution as harmless) are a component of a
cluster of attitudes that consider sexual violence to be normal. We found that
college students’ acceptance of prostitution myths was highly correlated with
acceptance of rape myths (Cotton, Farley, & Baron, 2002). Furthermore, the
college men who were most accepting of prostitution tended to be those who
reported having subjected their partners to coercive sexual behaviors
(Schmidt, Cotton, & Farley, 2000).
Although it has sometimes been assumed that prostitution of males is quali-
tatively different from prostitution of females, we did not find this to be the
case (Kendall & Funk, 2003). In USA, South Africa, and in Thailand, we com-
pared women, men, and transgendered prostitutes and found no differences in
PTSD. A similar study found that 76% of 100 women, men and transgendered
prostitutes in Washington, DC stated that they wanted to leave the sex indus-
try. Ninety-one percent of the male prostitutes wanted to escape prostitution
(Valera, Sawyer, & Schiraldi, 2001). These findings are consistent with those
of the present study. For men, boys, and the transgendered, the experience of
being prostituted is similar to that of women and girls.
Another misconception about prostitution is that a large majority of prosti-
tutes are drug-abusing women who entered prostitution to pay for a drug habit.
A number of studies have shown that women increase recreational drug use to
the point of addiction after entry into prostitution (Dalla, 2002). Lange, Ball,
Pfeiffer, Snyder, and Cone (1989) found that 8% of women receiving treat-
ment for addiction reported that their drug abuse preceded prostitution,
62 PROSTITUTION, TRAFFICKING, AND TRAUMATIC STRESS
whereas 39% reported that prostitution preceded drug abuse. In another study,
60% of a group of Venezuelan women in prostitution began abusing drugs and
alcohol only after entry into prostitution (Raymond et al., 2002). Kramer
(2003), and Gossop, Powis, Griffiths, and Stang (1994) discuss women’s use
of drugs and alcohol to deal with the overwhelming emotions experienced
while turning tricks. Medrano, Hatch, Zule and Desmond (2003) found that
substance abusing African-American women who had a greater severity of
childhood emotional abuse, emotional neglect, or physical neglect were at
higher risk of prostituting than women who were less severely abused or ne-
glected in childhood. Medrano et al. noted that this association between child-
hood abuse and prostitution was unrelated to crack cocaine use.
A common tactic used by pimps and traffickers to control prostitutes is to
coercively addict them to drugs. In a similar way, perpetrators of sexual abuse
against children are known to drug children in order to facilitate sexual attacks
or to disorient and silence them (Carroll & Trull, 1999; Schwartz, 2000).
Although it is sometimes assumed that legalization would decrease the vio-
lence of prostitution, many of our respondents did not feel that they would be
safer from physical and sexual assault if prostitution were legal. We found that
46% of people in prostitution in 6 countries felt that they were no safer from
physical and sexual assault if prostitution were legal. Fifty percent of 100 pros-
tituting respondents in a separate study in Washington, DC expressed the same
views (Valera, Sawyer, & Schiraldi, 2000). In an indictment of legal prostitu-
tion, more than half of our German respondents told us that they would be no
safer in legal as compared to illegal prostitution.
The triple force of race, sex and class inequality disparately impact indige-
nous women. Prostitution of Aboriginal women occurs globally, in epidemic
numbers, with indigenous women at the bottom of racialized sexual hierar-
chies in prostitution itself (Scully, 2001). The toxic legacy of colonialism and
generations of community trauma are critical factors contributing to the prosti-
tution of indigenous women (Farley & Lynne, 2003). The overrepresentation
of First Nations women in prostitution was reflected in the Canadian results re-
ported here. These findings are a consequence of their marginalized and deval-
ued status in Canada, with a concomitant lack of options for economic
Indigenous women are almost always trafficked from rural communities
(sometimes reservations) to urban areas. In the process of trafficking–women,
men, and children are transported to markets for the purpose of prostitution or
they are sold for sweatshop labor, domestic servitude, or servile marriages
(also called mail-order brides).5Trafficking may occur within or across inter-
national borders, thus a person may be either domestically or internationally
Farley et al. 63
trafficked. The harm of prostitution itself is similar whether she crosses an
international legal boundary or whether she is moved from, for example,
Chiapas to Mexico City, or from Saskatoon to Vancouver. The experience of
being uprooted from one’s home or community causes distress. Migration it-
self is frequently a consequence of circumstances of degradation, violence,
and dehumanization (deJong, 2000). Migration may also reduce the social sup-
port women count on to protect them from sexual violence (Lyons, 1999).
Trafficking cannot occur without an acceptance of prostitution in the re-
ceiving country. Governments protect prostitution/trafficking because of the
monstrous profits from the business of sexual exploitation. In 1999, Thailand,
Vietnam, China, Mexico, Russia, Ukraine, and the Czech Republic were pri-
mary source countries for trafficking of women into the United States (Rich-
ard, 2000). Source countries vary according to the economic desperation of
women, culturally-based gender inequality, the promotion of prostitution and
trafficking by corrupt government officials who issue passports and visas, and
criminal connections in both the sending and the receiving country such as
gang-controlled massage parlors, and the lack of laws to protect immigrating
Salgado (2002) described what could be appropriately termed a trafficking
syndrome resulting from repeated harm and humiliation against a person who
is kept isolated and living in prisoner-of-war-like conditions. As in prostitution
and domestic trafficking, international trafficking is extremely likely to result
in PTSD. Like women domestically trafficked into prostitution, internation-
ally trafficked women experience extreme fear, guilt regarding behaviors
which run counter to their religious or cultural beliefs, self-blame, and a sense
of betrayal, not only by family and pimps-but by traffickers and governments.
In addition, women may fear loss of immigration status if they attempt to leave
violent husbands or pimps and they may not know how to access legal or social
services. Additional barriers confronted by trafficked immigrant women are
absence of services in the language of newcomer groups, discrimination and
racism, and models of healthcare that are culturally irrelevant.
In the five years since data from the first five countries of this study were
collected (Farley et al., 1998), prostitution has been increasingly normalized in
many cultures where, whether legal or not, it is promoted or tolerated as a rea-
sonable job for women. Internet technology has expanded the global reach of
sex businesses, which have sometimes been adopted as governments’ devel-
opment strategies. For example, the International Labor Organization (ILO)
promoted prostitution as the “sex sector” of Asian economies despite also cit-
ing their own surveys which indicated that in Indonesia, for example, 96% of
those interviewed wanted to leave prostitution (Lim, 1998). Although they are
64 PROSTITUTION, TRAFFICKING, AND TRAUMATIC STRESS
clear regarding their desire to get out of prostitution, the voices of these women
in the “sex sector” are ignored. The economic motivation for this failure to lis-
ten to those in prostitution is evident: 2.4% of the gross domestic product of In-
donesia (US $3.3 billion per year) and 14% of the gross domestic product of
Thailand (US $27 billion per year) was supplied by legal sex businesses (Lim,
A woman in Thailand told us, “I want the world to understand that prosti-
tution is not a good job–so that there are other jobs for women. I want the
government to look into what’s going on.” Instead of the question, “Did she
voluntarily consent to prostitution?” the more relevant question would be:
“Did she have real alternatives to prostitution for survival?” The incidence of
homelessness (75%) among our respondents in 9 countries, and their desire to
get out of prostitution (89%) reflect their lack of options for escape. It is a clini-
cal, as well as a statistical error, to assume that most women in prostitution
consent to it. In prostitution, the conditions which make genuine consent pos-
sible are absent: physical safety, equal power with customers, and real alterna-
tives (MacKinnon, 1993; Hernandez, 2001). Until it is understood that
prostitution and trafficking can appear voluntary but are not in reality a free
choice made from a range of options, it will be difficult to garner adequate sup-
port to assist the women and children in prostitution who wish to escape but
have no other economic choices.
I feel like I imagine people who were in concentration camps feel when
they get out...It’s a real deep pain, an assault to my mind, my body, my
dignity as a human being. I feel like what was taken away from me in
prostitution is irretrievable. (Giobbe, 1991, cited by Jeffreys, 1997)
We can no longer assume that the harm perpetrated against prostitutes is in
any way accidental. The institution of prostitution is carefully constructed and
promoted. Those of us concerned with global human rights must address the
social invisibility of prostitution, the massive denial regarding its harms, its
normalization as an inevitable social evil that can be moved far from the neigh-
borhoods of nice people, and the failure to educate students of law, psychol-
ogy, public health, and criminal justice. Prostitution and trafficking can only
exist in an atmosphere of public, professional, and academic indifference.
1. We use the term “john” throughout to refer to customers of those in prostitution,
because that US English terminology is most commonly used by those in prostitution
themselves. Women in the US also refer to customers as “tricks” or “dates.” The word
Farley et al. 65
“trick” comes from customers’ practices of tricking women into doing more than they
pay for; the word “date” suggests that prostitution as a normal part of male-female rela-
tionships. There are many different words those in prostitution use to describe custom-
ers. Women in Johannesburg, for example, called customers “steamers,” referring to
the steamed-up windows of cars of Dutch settlers who drove into the city from their
farms to buy African girls in prostitution.
2. A pimp is the man or woman who procures the prostitute, promotes, and sells her,
and profits from prostitution. By this definition, pimps are not only the men on the
street, pimps are also strip club owners, bar owners, disc jockeys, taxi drivers, con-
cierges, motel managers, etc.
3. One group of women (over the age of eighteen) who worked in a brothel in Ne-
vada had stuffed “kitties and puppies” in their cubicles, and their favorite foods were
Captain Crunch cereal, and Nestle’s Quik (Rubenstein, 1998). Similarly, Winick and
Kinsie (1971, p. 146) wrote that adult prostitutes’ leisure activities included roller skat-
ing and playing with dolls. We suggest that these are dissociated child parts of young
women who alternate between reenacting abuse in prostitution and seeking soothing
and safety in children’s food and activities.
4. Many women are confused about the definition of rape. If rape is any unwanted
sex act or coerced, then the statistic would be a much higher percentage. Some women
in prostitution assume there is no difference between prostitution and rape, and they
only call it rape if they were not paid, regardless of the violence of the act. Additionally,
many studies, including our own, interviewed women who were currently prostituting.
Asking them about rape is like asking someone in a combat zone if they are under fire.
The responses to inquiries about rape in prostitution must make the clinical as well as
the statistical assumption that a significant percentage of women currently prostituting
deny rape and other violence because it would be too stressful to acknowledge the ex-
treme danger posed by johns and pimps.
5. Sweatshop labor, domestic servitude, and servile marriage frequently involve
sexual exploitation or prostitution in addition to labor exploitation.
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