Findings from this first national investigation of the prevalence of trafficking among Thai FSWs indicates that approximately one in ten Thai FSWs enter via trafficking mechanisms (i.e., under age 18 or via force, coercion or deception). As compared with their non-trafficked counterparts, sex trafficked FSWs faced greater levels of HIV risk spanning sexual risk, violence at initiation, and mistreatment in the workplace. Likely due these risks, trafficked FSWs demonstrated greater negative reproductive health outcomes and elevated risk of ulcerative STI. These findings advance the empirical basis for describing and understanding the health impact of trafficking as an entry mechanism to sex work, and indicate the critical need for attention from the public health community to the population of sex-trafficked FSWs. Given the recent attention to the health of sex trafficking victims represented by the UNGIFT,16
current data provide empirical support for efforts to eliminate sex trafficking as a health and human rights violation, serve as a much-needed empirical basis for the tailoring of HIV prevention interventions to consider the specific vulnerabilities of those trafficked into sex work, and, importantly, highlight the broad range of sexual and reproductive health outcomes that appears to disproportionately affect this population.
Findings advance prior work illustrating elevated HIV infection among trafficking victims10–12
by providing the first quantitative evidence that many mechanisms posited to explain the high HIV prevalence among FSWs appear to be more prevalent among sex trafficked FSWs relative to their non-trafficked counterparts in Thailand. Several forms of sexual risk, specifically recent condom failure and recent condom non-use, were more common among trafficked FSWs, suggesting elevated risk of exposure to STI/HIV. Though attenuated to a trend towards elevated risk in adjusted analyses, anal sex was more prevalent among trafficked FSWs, suggesting a clear mechanism for HIV acquisition. Notably, while not found differential based on trafficking status, well over half of the FSWs sampled reported client condom refusal, with a smaller number reporting unprotected sex in response to condom refusal. These findings illustrate the persistence of HIV risk mechanisms beyond the control of FSWs among both trafficked and non-trafficked FSWs.
Corroborating prior concerns 36, 37
and evidence from investigations focused solely on sex trafficking victims10, 12, 18
both violence victimization and working conditions varied based on trafficking status. Trafficked FSWs were over twice as likely to report sexual violence at initiation to sex work, indicating clear mechanisms for trauma, and suggesting that HIV prevention efforts targeting FSWs face limitations in protecting sex trafficked FSWs as they may become infected prior to accessing such educational efforts. Patterns of elevated violence victimization among trafficked FSWs were not limited to violence at entry; over half of trafficked FSWs reported recent workplace violence or mistreatment, suggesting that sex trafficking poses ongoing vulnerability, and potentially reduced decision-making or negotiation power, throughout the duration of sex work. Notably, over one third of non-trafficked FSWs reported recent workplace mistreatment, highlighting the vulnerability of FSWs to mistreatment regardless of mechanism of entry. Current findings that trafficked FSWs are over three times more likely to work in multiple locations supports hypotheses that these victims may be shuttled between workplaces,38
possibly to avoid police detection, thus posing a potentially critical barrier to their ability to access help and health care.37
Current findings that sex trafficked FSWs demonstrated slightly lower levels of HIV knowledge relative to non-trafficked FSWs support prior concerns that this population may face deficiencies in this critical health information.15, 16
Coupled with findings that sex trafficking was not associated with receipt of STI/HIV information targeted for sex workers, this trend towards differences in HIV knowledge may reflect limited HIV knowledge obtained prior to trafficking, perhaps due to young age at entry. Notably, no differences in STI or HIV testing were detected based on trafficking status in the current study. Only two thirds of the sample reported having ever received an STI test, and less than half were familiar with STI/HIV resources specific to FSWs, suggesting that education and access to these services represent unmet need among the population of Thai FSWs.
In addition to compromising condom use and other protective behaviors, sex trafficking also posed risk for sexual and reproductive health outcomes. Sex trafficked FSWs demonstrated a three-fold increased risk for pregnancy relative to non-trafficked FSWs. While the intendedness of these pregnancies cannot be determined, the three-fold elevated odds of abortion among trafficked FSWs relative to those non-trafficked suggests these pregnancies were unwanted, and suggests unmet contraceptive needs among this group. Recent STI symptoms were common, with over two thirds reporting any such symptom over the past four months. No differences were detected based on trafficking status. The observed trend towards elevated risk for lesions or warts for trafficked FSWs may reflect higher prevalence of ulcerative STI and suggests elevated risk for further transmission. Given current evidence of greater STI/HIV risk factors among trafficked FSWs, further research aided by clinical diagnostic testing is recommended to overcome limitations of syndromic STI assessment.
Taken together, these findings support the need to integrate assessment of trafficking as an FSW entry mechanism (i.e., entry via force, fraud, coercion or below age 18) within STI/HIV surveillance, research and programmatic efforts for FSWs to enhance our ability to describe these patterns, and, importantly, provide services that appropriately acknowledge the apparent persistence of differences in STI/HIV risk among FSWs experiences based on trafficking status. Clinicians serving FSWs for STI/HIV prevention and treatment, as well as general health concerns, should be aware of the possibility of trafficking among such patients; potential indicators of trafficking may include very young age, fear of violence, and constraints on freedom of movement or accessing services. Providers should familiarize themselves with local support resources for trafficking victims and be prepared to make referrals as needed. More broadly, findings highlight the need to support programmatic and policy efforts to eliminate sex trafficking as a health and human rights violation. Currently, Thailand is ranked by the US Department of State Office to Monitor and Combat Trafficking in Persons as a Tier 2 nation; thus while the government does not fully comply with minimum standards for trafficking elimination, it is making significant efforts to do so.39
Finally, critical to STI/HIV prevention efforts targeting the commercial sex context is the inclusion of male FSW clients. Evidence that well over half of the FSWs sampled reported client condom refusal, coupled with findings of elevated risk for condom failure and condom non-use among those trafficked, illustrate mechanisms for risk that may extend beyond the full control of FSWs, indicating the need to broaden prevention efforts to include male clients of FSWs. Male client-oriented approaches to HIV risk reduction likely represent a critical component of preventing the further transmission of HIV via commercial sex, and may also reduce the demand that drives the market for commercial sex from trafficked FSWs thus making trafficking of women and girls less lucrative. Thailand’s recent efforts to prosecute child sex tourists39
represent one critical component of anti-trafficking, demand reduction efforts. Further research is urgently needed to inform development of both HIV intervention efforts targeting male clients as well as primary prevention efforts to reduce this behavior.
Despite the advances represented by the current investigation, findings should be considered in light of several limitations. Most notably, despite consistent evidence of migrants and ethnic minorities among FSWs in Thailand,15, 40–43
the current sample was comprised of a relatively small portion of ethnic minority women. All survey procedures were conducted in Thai, which likely limited linguistic accessibility for non-Thai speakers. Thus, conclusions concerning the portion of non Thai nationals and ethnic minorities among Thailand’s FSW population should be made with caution. Moreover, this approach likely underestimates the prevalence of trafficking among FSWs as non-Thai speakers (e.g., those from Cambodia, Laos, Burma, as well as hill tribe communities within and surrounding Thailand) may be particularly vulnerable to trafficking as an entry mechanism to FSW.15, 41, 42
Given the high levels of violence and coercive sexual risk noted among migrant and undocumented FSWs, particularly those from Burma,15, 40, 41, 43
further investigation will benefit from efforts to include this sub-population. The sampling strategy utilized, i.e., reliance on cooperation from establishment owners, may have also limited the participation of undocumented and/or more recently trafficked FSWs; the longer durations of involvement in sex work and older ages at the time of participation among those trafficked suggest that recently trafficked FSWs may have been undersampled. The cross-sectional nature of the data limits conclusions about causality, however as the exposure of interest (i.e., sex trafficking as an entry mechanism to sex work) occurred prior to many of the outcomes assessed, ordering of this exposure relative to recent outcomes may be assumed. The syndromic approach to STI assessment, though recommended for settings which lack diagnostic facilities,44
is limited in its specificity, thus interpretation of findings is best limited to symptoms rather than diagnosis. Further research aided by clinical diagnostic testing is needed to clarify and confirm the present findings.
Findings from this first investigation of the prevalence of sex trafficking among Thai FSWs, and HIV risk and related health outcomes provide clear indication that sex trafficking as a mechanism of entry to sex work confers both immediate and long-standing risk for health threats and human rights abuses within the context of sex work. These data support concerns that current HIV prevention programming targeted towards FSWs in Thailand and elsewhere (i.e., the 100% Condom Use Campaign) may be stymied by limited negotiation power among trafficked FSWs, evidenced by greater levels of violence and inability to successfully use condoms among this group. Thus, sex trafficking may be a critical factor in the persistence of the Southeast Asian HIV epidemic. Moreover, current data illustrate the need to expand the concern for the health of this population beyond HIV to a fuller spectrum of health concerns spanning sexual and reproductive health as well as violence victimization. The critical need to strengthen efforts to prevent sex trafficking, support interventions to promote the heath of victims, and to intervene to protect the health and human rights of victims of this form of gender-based violence cannot be overstated.