Sexual Exploitation, Trauma and Womens Health

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Sexual Exploitation, Trauma and Womens Health

• Wendy Freed MD
• February 27, 2006

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Overview

• Overview of Sexual Exploitation
• Psychological Effects
• Medical Effects
• Case Example Cambodia
• Impact of Trauma on Womens Participation in
  Development

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Vulnerability to Sexual Exploitation

• Poverty / Desperate situation
• Abusive families
• Gender inequality
• Lack of access to education
• Prior sexual abuse 65-90
• Emotional vulnerability

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Methods of Control

• Deceptions and betrayal
• Threats to victim/family
• Verbal abuse
• Physical violence
• Sexual assault
• Psychological manipulation
• Social isolation/confinement

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Stockholm Syndrome

• Gratefulness for survival
• Denial of violence/harm
• Identification with pimp or brothel owners
  perspective on the world
• Misperceive roles of rescuers/captors
• Difficulty separating from captor

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Mental Health Impact

• PTSD
• Complex PTSD
• Depression
• Suicidality
• Self Mutilation

• Anger and rage
• Dissociation
• Substance Abuse
• Traumatic brain injuries

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Sexual Assault and PTSD

• Rape has higher likelihood of causing PTSD than
  other traumatic events
• Prostitution 9 countries
• 68 (Farley 1993)
• US Viet Nam combat veterans 33
• Ongoing violence in prostitution65
• 65-90 of women have hx childhood sexual abuse

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PTSD

• Anxiety
• Nightmares
• Flashbacks
• Sensitivity to trauma triggers
• Numbing

• Irritability
• Hypervigilance
• Startle reactions
• Poor concentration
• Lose sense of future

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Complex PTSD

• Multiple traumas over time
• Entrenched psychological adaptations
• Internalized contempt/degradation
• Profound loss of trust
• Fear/Loss of safety
• Damaged sense of self

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Complex PTSD

• Numbing and dissociation
• Self-mutilation
• Difficulty regulating emotions
• Impaired Self-Soothing
• Impaired interpersonal relatedness

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Self-Mutilation

• Unbearable psychological pain
• Minimal coping for overpowering affect
• Cutting on self releases endorphins which block
  pain
• Numbing/end of psychic pain is result
• Not a suicidal behavior

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Altered View of Self

• Low Self-Esteem
• Shame
• Self-blame
• Damaged Goods
• Powerlessness
• Passivity
• Submissiveness

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Adaptations to Captivity

• Initial shock and disbelief
• Resistance
• Violence and threats lead ultimately to
  submission and resignation
• Develop survival behaviors

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Survival Strategies

• Create split between public private self
• Consciously think of something else
• Shove feelings aside
• Create false identity
• Wigs, makeup, clothes, attitude
• Avoid disclosures of personal info

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Survival Behaviors

• Enlist sympathy from clients
• Be treated less harshly
• Act flirtatious and solicit clients
• Avoid beatings from brothel owners
• Pay off debt more quickly/earn more
• Women create fantasy for client that has nothing
  to do with what she feels

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Survival Behaviors

• Chemical dissociation
• Drug and alcohol use
• Psychological dissociation
• Gradual process becomes more entrenched coping
  mechanism
• Persists long after the trauma is over

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Dissociation

• Gradually B. learned to switch off. She never
• managed to do it completely, there were always
  times
• when she came back and found herself lying under
• some sweating hulk. Then she wanted to cry out
  in
• horror NO! it isnt happening to me! But these
  times
• became less and less frequent. Soon she couldnt
• switch herself on again during the day.
• Everything seemed to be happening on the other
  side
• of a dirt glass, but it was worth it. A skin had
• formed over her mind, and she was free inside
  it.
• Barker, 1984

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Loss of Self

• You starting changing yourself to fit a fantasy
  role of what they think a woman should be. In
  the real world these women dont exist, they
  stare at you with starving hunger it sucks you
  dry you become this empty shell. Theyre not
  really looking at you. Youre not even there.
• Farley, 2003

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Medical Effects

• Sexual violence/Rape
• HIV/AIDS/STDs
• Pelvic Inflammatory Disease (PID)
• Infertility
• Unwanted pregnancy
• Forced abortion

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Medical Effects

• Physical violence
• Physical Assaults
• Broken bones/Teeth
• Knife injuries
• Beatings
• Head injuries
• Increased risk for homicide

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Medical Effects

• Hepatitis/TB
• Anemia
• Skin infections
• Psychosomatic problems
• Culture
• Mind/Body

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Immediate Medical Needs

• General Physical Exam
• Documentation of Injuries, Scars
• STD/HIV Screening
• TB, Hepatitis Screen
• Pap/Mammogram
• Vision/Dental

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Access to Medical Care

• Victims need access to care
• Medical care must be linked to broader social
  services
• Services need to be bilingual, and culturally
  appropriate.

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Cambodian Example

• Population suffered massive trauma during Pol Pot
  genocide 1975-79
• Extensive psychosocial disruption
• 1991 UNTAC/economic development
• Increased demand for commercial sex
• 85 rural peasants, 50 under age 15
• Education low priority for girls

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Cambodia Example

• Recruit young girls from villages
• Promises of jobs for girls
• Families trust female recruiters
• Advance salary given to family
• Demand for virgins
• After virginity sold, resold to brothel

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Price List

• Recruiter to family 50 US
• Brothel owner to recruiter 150 US
• Virgin girl 500 US
• Cost of commercial sex 2 US

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Cultural Attitudes re Sex

• Men Are Gold, Women Are Cloth
• No constraints on mens behavior
• Girls virginity linked to family honor
• Group Activity
• Drink and go to brothel
• Bauk/Gang rape

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Photo from the workign group on Trafficking in
Women and Girls JPIC commission of the Union of
Superiors General Rome,Italy, 2003
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Psychological Effects

• Sexual Trauma/Shame
• Betrayal/Loss of trust
• Fear/Loss of safety
• Damaged sense of self
• Cultural Meaning
• Value of being good daughter
• Virginity/Loss of value

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Sexual Trauma

• Violation of most intimate aspect of self
• Ones body is where violations occur
• Tiny cubicle where they live is also prostitution
  space
• No right to refuse consent rape
• Shame unique to sexual trauma
• Sense of being damaged, dirty

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Trust and Betrayal

• Sold by family/friend betrayal worse
• Loss of trust in family/friends
• No trust with people trying to help
• No trust to reveal full details of story

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Self-Blame

• Exaggerated sense of responsibility for
  interaction that led to being in brothel
• Self-blame
• Sexual abuse at home
• Believing promises
• Too trusting
• Ending up in brothel

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Disruption in Normal Development

• Village life working in rice fields, chores at
  home, caring for siblings
• Separation and losses
• Family - Freedom
• Siblings - Childhood
• Village -Virginity
• Community - Future
• Profound depression and hopelessness

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Value of Being a Good Daughter

• Ones identity is not as an individual, but as a
  subordinate part of the whole
• Values and cultural expectations
• Make sacrifices for the family
• How far does this go?
• When can she say no?
• When can she say it is enough?
• Meaningful if sacrifice valued
• Despair if sacrifice squandered

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Developing Culturally Competent Treatment

• Safety is a pre-condition for treatment
• Women must be out of prostitution
• Recognize that what these women experience is
  sexual trauma
• Address the meaning of the experience within the
  culture and to the individual

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Developing Culturally Competent Treatment

• Avoidance is a symptom of PTSD and a
  characteristic of many cultures
• Address difficulty for caregivers and survivors
  to talk about sexual trauma
• Create a trauma narrative to fit into a larger
  life narrative
• Karma, acceptance, resignation

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Trauma Impact on Recovery

• Examples from Cambodia
• Programs emphasize job training
• Ignore dealing with trauma
• Family visits/pressure
• Individual small businesses often fail
• Poor boundaries/please others
• Prevention
• Anti-poverty programs involve families
• Keeping girls in school

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Prevention

• Anti-poverty programs
• Keeping girls in school
• Families need financial support
• Communities need education rebenefit

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Trauma Impact on Recovery

• Seattle/Domestic Prostitution
• Education drop out
• Drug/Alcohol abuse
• Family dysfunction
• Need a caring community
• Need housing financial stability
• Poor decision making skills

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Challenges

• Need to incorporate mental health treatment to
  address trauma impact as part of recovery after
  sexual exploitation
• Challenge of providing culturally competent
  treatment in the US and elsewhere regarding
  sexual trauma
• Need to address the harm of prostitution

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Perspectives

• Our attitudes towards prostitution influence how
  we do treatment
• Prostitution as violence perpetrated by one
  person against another who has less power,
  exploiting economic, psychological and social
  vulnerabilities of the weaker one
• When defined as work it makes the harm of
  prostitution invisible