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Sexual victimization is strongly associated with mental health problems, traumatic responses, earlier onset of substance use and criminal justice involvement. It is well known that multiple forms of sexual victimization and aggression have been experienced by most incarcerated women. Two hundred women with a substance use disorder and involvement with the criminal justice system within the previous two years (parole, probation, arrest, or incarceration) were recruited from multiple sites in metropolitan Chicago. We examined whether empowerment moderates the relationship between trauma symptoms, trading sex and the experience of being forced or coerced to have sex. There was a significant three-way interaction between sexual coercion, trading, and empowerment scores on trauma symptoms. For individuals who have not traded sex, lower levels of empowerment were associated with a larger difference in trauma symptomatology between individuals who have been coerced and those who have not been coerced. For individuals who had been coerced to engage in sexual activity, lower levels of empowerment were associated with a larger difference in trauma symptomatology between those who have traded and those who have not traded. The promotion of empowerment beliefs and attitudes in women disproportionately impacted by violence and sexual trauma may reduce the harm that results from being victimized. Furthermore, providing specific interventions that educate women regarding gender roles and cultural values may help women avoid situations that result in exploitation and coercion.
Compared to the general population, a large number of justice-involved women1, have significant histories of physical and sexual abuse, often beginning in childhood (Klein & Chao, 1995; Najavits, Weiss, & Shaw, 1999). Women experiencing sexual abuse have been found to have worse health outcomes compared to women experiencing physical abuse (e.g., Bonomi, Anderson, Rivara, & Thompson, 2007; Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997). Experiencing sexual trauma has been associated with substance abuse initiation (e.g., Covington, 1999), Post-Traumatic Stress Disorder (PTSD) (Najavits, Weissman, & Shaw, 1997; Salina, Lesondak, Razzano, & Weilbaecher, 2007), poor health outcomes (Lurigio & Swartz, 2000), domestic violence (Cohen et. al., 2000) HIV risk behaviors (Malow, Devieux, & Lucenko, 2006), a higher likelihood of re-experiencing sexual trauma (Casey & Nurius, 2005 ; Maker, Kemmelmeier, & Peterson, 2001) and trading sex (Edwards, Halpern, & Wechsberg, 2006; Vaddiparti et al., 2006). Having multiple sex partners and trading sex for drugs or money is also related to higher levels of psychological distress (Edwards et al., 2006; El-Bassel, Simoni, Cooper, Glibert, & Schilling, 2001; El-Bassel, et al., 1997).
Sexual aggression towards women continues to be a significant problem that affects many women in this country (Bachman & Saltzman, 1995). Approximately 1 in 5 women reported having been raped and 13% of women mentioned having been sexually coerced in their lifetime (Center for Disease Control and Prevention [CDC], 2012). Compared to the general population of women in this country, justice-involved women have experienced disproportionate rates of physical and sexual abuse, and are more likely to have histories prostitution. (Klein & Chao, 1995; Lynch, Heath, Mathews, & Cepeda, 2012; Najavits et al., 1999). In a NIDA funded study of 283 women receiving substance abuse and mental health treatment in a jail based treatment program, 68% of the women reported sexual victimization (Salina et al., 2007). Furthermore, many justice-involved women have a complicated interaction of risk factors that increases the likelihood of engaging in sexual trading. These factors include the need to obtain drugs or money for drugs (Maher & Curtis, 1992), higher levels of psychological distress (Edwards et al., 2006; El-Bassel et al., 2001; El-Bassel, et al., 1997) or having untreated trauma (Inciardi & Surratt, 2001).
In addition to sexual trauma, the high incidence of trauma exposure and subsequent posttraumatic stress in justice-involved women (Green, Miranda, Daroowalla, & Siddique, 2005; Lynch et al., 2014; Salina et al., 2007) often results in additional incidence of traumatization events, such as physical and sexual violence, and an increase in the risk of other violent acts, including abduction and murder. (Teets, 1997; Wilsnack, Vogeltanz, Klassen & Harris, 1997). Increased risk for further violence in justice-involved women is often related to unmet basic and functional needs which present difficulties in daily living in addition to substance use and mental health disorders (see Najavits & Heins, 2013, for a review; Salina, Razzano, Lesondak, & Parenti, 2011).
The rates of sexual abuse in African-American women are higher than those of White and Hispanic/Latina women (Langton, Krebs, Berzofsky, & Smiley-McDonald 2013) and most African-American women in criminal justice settings are victims of childhood and adult physical and/or sexual trauma (Richie & Johnsen, 1996). Furthermore, African American women are likely to suffer from multiple risk factors such as substance abuse, poverty, involvement in abusive relationships, and mental illness (Freudenberg, Daniels, Crum, Perkins, & Richie, 2005; Raj, Silveman, Wingood, & DiClemente, 1999; Sterk, 2002). Among African American women who had been sexually abused as children, those who were revictimized as adults were more likely to have engaged in prostitution (West, Williams, & Siegel, 2000).
Given the high incidence of sexual trauma in a justice-involved population, it is imperative to understand how multiple traumatic events may be associated with individual well-being. There is an abundance of literature discussing the adverse effects of experiencing multiple traumatic events (e.g., Turner & Lloyd, 1995; Lang et al., 2003). The model of cumulative adversity suggests that compared to individuals exposed to a single traumatic event, those exposed to multiple traumatic events will have a complex constellation of traumatic symptoms (Cloitre et al., 2009). Traumatic events influence and impair functioning in a number of ways, usually stemming from an individual’s attempts to cope adaptively. One factor contributing to experiencing trauma and subsequent symptomatology is the perceived lack of predictability and sense of personal control (Frazier, Mortensen, & Steward, 2005; Frazier, Steward, & Mortensen, 2004). As such, traumatic events usually result in emotional turmoil and dysregulation (Van der Kolk, 2005). In particular, female sexual trauma survivors often demonstrate fewer adaptive life skills compared with women without trauma histories (Herman, 1992) and greater symptom complexity has been found in adults exposed to multiple sexual traumas at a young age (Briere, Kaltman, & Green, 2008; Follette, Polusny, Bechtle, & Naugle, 1996).
However, an increasing body of literature has documented that for some individuals, adverse experiences do not necessarily lead to adverse health or psychological consequences (e.g., Bonanno, 2004; Seery, Holman, & Silver, 2010). For example, in one study of youth exposed to violence, 54% displayed resilience (Martinez-Torteya, Bogat, von Eye, & Levendosky, 2009). These findings suggest positive adaptation is common in the face of adversity. One possible way individuals may be protected from adversity is through a sense of empowerment, or the awareness and strengthening of an individual’s skills and ability to control and improve one’s life circumstances (Rekart, 2005). Others have proposed that empowerment principles consist of multiple factors including access to resources and the development of skills to cope with adversity such as trauma (Johnson, Worell, & Chandler, 2005). Johnson et al. (2005) developed the Personal Progress Scale-Revised (PPS-R) to assess these coping skills and access to resources, and found that the PPS-R reliably measured attitudes, symptoms and beliefs related to empowerment.
Personal empowerment is especially important in a population of women who have been sexually victimized as sexual abuse has been found to be related more strongly to feelings of lack of control than other types of abuse (Franklin, 2011). Women who have been sexually abused and involved with the criminal justice system may perceive heightened hopelessness and less control due to the reinforcement of these feelings when interacting with the system. There is preliminary evidence that empowerment may be especially important for high-risk populations such as previously justice-involved women who are trauma survivors: promoting empowerment has been shown to reduce trauma-related symptoms in women (Fallot & Harris, 2002; Toussaint, VanDeMark, Bornemann, & Graeber, 2007), and promoting a sense of control has been found to be associated with reduced harmful outcomes in women who trade sex (Pyett & Warr, 1999; Rekart, 2005). There is some evidence to suggest that protective factors such as empowerment may play an important role in an individual’s psychological well-being after experiencing trauma (Barner & Carney, 2011; Jewkes, 2002; Wright, Perez, & Johnson, 2010).
Thus, empowerment may be one possible mechanism that protects women experiencing sexual trauma against adverse outcomes, such as psychological issues (e.g., Barner & Carney, 2011; Jewkes, 2002; Wright et al., 2010). However adverse events such as forced sexual experiences and engaging in sex work are not well understood in relation to an individual’s perception of empowerment and experience of psychological symptoms related to trauma. Previous studies examining trauma and empowerment have focused on interventions aimed at providing skills and resources to increase empowerment, such as reframing ways of thinking and assertiveness training (e.g., Fallot & Harris, 2002; Toussaint, VanDeMark, Bornemann, & Graeber, 2007). However empowerment may also be a personal, state-level characteristic regarding one’s perception of the amount of control he or she has in a particular situation, rather than a skill to be acquired (Johnson et al., 2005). The purpose of the present study therefore was to assess whether individuals’ baseline empowerment feelings without intervention moderates traumatic symptoms for women who have been forced or coerced to have sex and women who have traded sex.
Two hundred women who reported having an alcohol and/or other substance use disorders and who had been involved with the criminal justice system within the preceding two years were recruited from multiple sites in metropolitan Chicago and its suburbs from 2008 to 2011. We recruited participants from multiple substance abuse treatment sites throughout Chicago, the surrounding suburbs and Northern Illinois as well as Cook County Jail. Research staff also posted recruitment flyers and these flyers were distributed in places that might provide some form of services to formerly justice-involved women. Participants were also recruited using snowball techniques, which permits other participants to refer women to the study. All women in the study were enrolled using IRB approved informed consent procedures.
At baseline we collected, via face-to-face interviews, general demographics on all participants, including race, education, marital status, housing and employment status in the last year as well as income history and its source. We also collected data on the types of criminal charges for which participants had been arrested, their previous criminal histories, number of arrests and months incarcerated. Participants received stipends of $40 for participating in the initial interview.
We enrolled 200 participants drawn primarily from communities of color. The sample consisted of African American women (74.5%), and most of the sample was currently unemployed (66%; n=132) and had been incarcerated many times (M=16.5 times). Only 22.8% (n=45) reported receiving their primary income from legal employment; the next highest primary sources of financial support was selling drugs (17.3%; n=34) and sex work/prostitution (14.7%; n=29). Of the women who were employed (34%; n= 68), 26.5% (n=18) reported their major source of income over the last year was a result of illegal activities, including selling drugs and prostitution/sex work. More than two thirds of the sample (67.9%; n=129) reported that they had traded sex for drugs or survival. Of those reporting trading sex, the vast majority (71.9%; n=92) reported engaging in this high risk behavior 10 or more times. Only 3.1% (n=4) reported engaging once in sexual trading.
In addition to the majority of the sample engaging in trading sex for drugs, money or survival needs, the majority of the participant reported experiencing forced or coerced sexual abuse a multitude of times. Only 32.3% of the entire sample (n=61) reported that they had never been forced to have sex. Of those participants who reported being forced or coerced sexually, 78.9% (n=101) reported that this had occurred to them more than once, with almost 20% of those who had been forced (n=25) reporting that they had been forced 10 or more times. Only 14.3% (n=27) reported that they were forced only one time.
This measure is designed for use in research with adults to evaluate current symptoms (e.g., “Not feeling rested in the morning”; “Having sex that you don’t enjoy”) associated with childhood or adult traumatic experiences including aspects of posttraumatic stress and other symptom clusters found in some traumatized individuals. Participants indicate how often they experience each symptom on a scale from 0 (“never”) to 4 (“often”). The mean score was 27.11 (SD= 18.99; range 0–77). Cronbach’s alpha for this measure in our study was .93.
This instrument consists of 28 items designed to measure personal empowerment (e.g., “I feel prepared to deal with the discrimination I experience in today’s society”; “I am aware of my own strengths as a woman”). Participants indicate how often they believe each statement to be true of them on a scale ranging from 1 (“almost never”) to 7 (“almost always”). Of the 184 women in the study who completed this measure, the mean score was 5.26 (SD= .578 range 3.36–7.00). Cronbach’s alpha for this sample was .85.
This study also queried whether a woman had been forced/coerced to have sex in her life by asking “Have you ever been forced or coerced to engage in unwanted sexual activity?” Participants responded “yes” or “no”. We phrased this question specifically to most broadly capture both the forced aspect of having to engage in sexual acts, which are often accompanied by physical threats and those incidents that were coerced, which would indicate a woman’s lack of power to refuse to engage in these acts. Only 32.3% of the entire sample (n=61) reported that they had never been forced to have sex. Of those participants who reported being forced or coerced sexually, 78.9% (n=101) reported that this had occurred to them more than once, with almost 20% of those who had been forced (n=25) reporting that they had been forced 10 or more times. Only 14.3% (n=27) reported that they were forced only one time.
To gauge whether participants had ever traded sex for survival needs, we asked “Have you ever traded sex for drugs or money?” Participants responded “yes” or “no”. In this sample, more than two thirds of the women (67.7%; n=128) reported that they had traded sex for drugs or survival. Of those reporting trading sex, the vast majority (71.9%; n=92) reported engaging in this high risk behavior 10 or more times. Only 3.1% (n=4) reported engaging once in sexual trading.
To examine whether empowerment moderates the relationship between trauma and trading sex and being forced or coerced to have sex, we ran a 2 (sexual coercion: yes, no) × 2 (trading sex: yes, no) general linear model with empowerment as a covariate (as measured by the Personal Progress Scale-Revised) predicting trauma score (as measured by the Trauma Symptoms Checklist). Means and standard deviations for each condition are in tables 1 and and2.2. We also ran an empowerment × trading × sexual coercion interaction. Because of small sample size and concerns about normality, a 1000 bootstrap resampling procedure was used. Standard errors from the bootstrap estimates are reported. See table 3 for correlations among study variables.
There was a significant three-way interaction between sexual coercion, trading, and empowerment scores on trauma F (1,166) =6.66, p<.05, ηp2= .04. In order to untangle this categorical-continuous interaction we examined the interaction of our fixed factors at low, medium, and high levels of our continuous variable (Aiken & West, 1991). We therefore examined the sexual coercion × trading interaction at a low level of empowerment (i.e., one standard deviation below the mean of empowerment; x= 4.47), at the average level of empowerment (mean level of empowerment; x= 5.26) and at a high level of empowerment (i.e., one standard deviation above the mean of empowerment; x= 6.04.)
For women who had not traded sex, trauma score was related to whether or not they had been coerced to engage in sexual activity in their lifetime. Women who had been coerced to engage in sexual activity had significantly higher (t (166) =6.59, p<.01, d=1.75) trauma scores (M= 48.29, S.E. =3.68) than women who had not been coerced (M=21.98, S.E. =4.70). However, among women who had traded sex, there was no significant difference in trauma scores, regardless of whether or not they had been sexually coerced in their lifetime (t (166)=.24, ns).
For women who had been coerced to engage in sexual activity, elevated trauma score was related to whether they had traded sex. Women who had traded sex had significantly lower (t (166) =3.36, p<.01, d=.75) trauma scores (M=33.22, S.E. =2.63) than women who had not traded sex (M=48.29, S.E. =3.68) However there was no significant difference in trauma scores (t (166)=1.64, ns) among women who had not been coerced to engage in sexual activity, regardless of whether or not they had traded sex.
For women who had not traded sex, trauma score was dependent on whether or not they had been coerced to engage in sexual activity in their lifetime. Women who had been coerced to engage in sexual activity had significantly higher (t (166) =3.67, p<.01, d=.976) trauma scores (M=33.17, S.E. =3.41) than women who had not been coerced to engage in sexual activity (M=18.68, S.E. =3.02). However there was no significant difference in trauma scores (t (166)=1.08, ns) among women who had traded sex, regardless of whether or not they had been sexually coerced in their lifetime.
There were no significant differences in the level of trauma symptoms among women who had been coerced to engage in sexual activity, regardless of whether or not they had traded sex (t (166)=1.29, ns). There were also no significant differences among women who had not been coerced to engage in sexual activity, regardless of whether or not they had traded sex (t (166)=1.28, ns).
There were no significant differences in trauma scores among the women, regardless of whether or not they had traded sex or whether or not they had been coerced to engage in sexual activity.
This study attempts to untangle the complex relationship between sexual victimization, current trauma symptoms and perceptions of empowerment in a sample of justice-involved women with substance use disorders. We found a significant three-way interaction between sexual coercion, sex trading, had traded sex, and perception of empowerment on an individual’s experience of trauma symptoms. Women experiencing low levels of empowerment and who had been coerced but had not traded sex had significantly higher trauma scores than women who were neither coerced nor had traded sex. This finding was obtained as well with women who had both been coerced and had traded.
For individuals with higher levels of empowerment, however, the differences among these groups in the number of current trauma symptoms as measured by the Trauma Symptom Checklist begin to disappear (see Figures 1 and and2).2). At average levels of empowerment women who had solely been coerced did not have different levels of trauma symptoms than those who had both been coerced and had traded sex for drugs or survival needs. However, women who had solely been coerced still had significantly higher trauma than those who had not been coerced or traded. At high levels of empowerment, there were no differences among any of the groups.
The finding that, at low levels of empowerment, women who had solely been coerced had higher levels of trauma compared to women who had both been coerced and traded is particularly puzzling. Previous research on cumulative adversity suggests that individuals who had experienced two or more types of traumatic events would have the higher levels of trauma compared to those who experienced one type (Cloitre et al., 2009). There are several possibilities for this finding. One may be that we did not include in the analyses other types of non-sexual traumas that may have influenced our findings. Another possibility is that trading sex may somehow serve as a “protective” factor for women who have been coerced. Sex work, while clearly exploitive, may result in some women perceiving themselves as having more control or resources as they are able to generate income for themselves. The first author has found this phenomenon clinically in her work with younger justice-involved women who may generate as much as $3000 weekly in the sex trade and who often resist being diverted to legal but much less lucrative jobs as part of their treatment and rehabilitation while involved in the criminal justice system.
Another possible explanation for why women who have experienced both coercion and trading reported lower trauma scores than women who have only been coerced is that these women may be psychically “numbing” their feelings through both cognitive strategies and substance use. Numbing is a major clinical manifestation of trauma (e.g., Orsillo, Theodore-Oklota, Luterek, & Plumb, 2007). The notion that numbing may be occurring is further supported by the finding that at higher levels of empowerment, women who had been both coerced and had traded did not have lower trauma scores than women who had solely been coerced. Indeed, previous studies have found that empowerment is a protective factor against the development and maintenance of traumatic symptoms and responses to other adverse events. It is possible, then, that a sense of personal empowerment is indeed a protective factor for this population. More generally in our sample, women with higher levels of empowerment had lower trauma scores on the TSC, regardless of whether they had traded sex or been coerced.
The relationship between empowerment and trauma in our sample suggests the importance of using an empowerment framework when providing treatment for women who have experienced traumatic events. It is likely that empowerment may need to be promoted in different ways depending on the type of trauma experienced and the degree to which lack of control and forced dominance of another are present and yield a sense of personal powerlessness as a result. Treatment interventions should consist of both a specific focus on promoting a sense of personal empowerment when designing treatment programs (e.g., Fallot & Harris, 2002) and a larger understanding that women who are disproportionately impacted by poverty, incarceration and sexual exploitation will need to be addressed within an empowering framework, regardless of whether they have been sexually exploited. These developments need to occur now as the stigma is diminishing of disclosing sexual exploitation and the growing understanding of the high rates of human sexual trafficking that occurs in the United States.
Though this study provides insight into the relationship between empowerment, sex trading, and sexual coercion, there are several limitations. First, this study was cross-sectional and retrospective. As such, we cannot be sure that the experience of sexual coercion influenced trauma outcomes. It is possible that women’s current feelings of trauma influence their perspective on whether or not they had been coerced to engage in unwanted sexual activity. Relatedly, we did not formally define coercion for the women in the study as our goal was to understand women’s perceptions of their coercion experiences and for them to identify whether they had felt forced or coerced into sexual activity. However, this may lead to difficulty generalizing and comparing this study to other studies, where coercion was more strictly defined. Further research is needed in multiple areas, such as how to define sexual coercion for all women, and how race, cultural values, and norms influence women’s perceptions of sexual coercion as well as personal empowerment.
This study provides preliminary evidence that perception of personal power is related to the perception of negative feelings surrounding sexual coercion and engagement in sex work. Thus it is important to incorporate empowerment theory in trauma treatments as well as within programs designed to decrease sexual exploitation. This is especially true when working with groups of women who are often institutionally disempowered by social ills such as poverty and incarceration.
It is unrealistic to presume that by providing individual empowerment interventions we will reduce the widespread effects of societal disempowerment. In order to truly empower women in our society, comprehensive efforts are needed to protect women and girls from sexual exploitation. We need to reduce the demand for the sex trade by increasing efforts to arrest and incarcerate those who would try to benefit from sexually exploiting women and girls. Primary prevention programs targeting girls and women at high risk should explicitly focus on promoting a deeper understanding of how gender roles and cultural values may subtly promote involvement in situations that can ultimately result in exploitation and coercion. More work is needed to reduce the stigma women face when disclosing information about their experiences with the sex trade, sexual coercion, or exploitation. Ideally, appropriate gender-specific interventions should be provided early in the trauma experience and potentially interrupt the cycle of victimization, substance use and subsequent incarcerations. As a society, we also need to provide justice-involved women with opportunities to have survival needs met through job training opportunities, stable housing, promoting self-efficacy, and access to needed resources. Finally, we need to find a way to provide all women with equal access to needed empowerment-focused trauma treatment so that the cost to women and their families are lessened.
The authors appreciate the financial support from the National Center on Minority Health and Health Disparities (grant MD002748).
1Women who are currently or formerly incarcerated are generally referred to as “justice-involved women,” rather than the more stigmatizing words such as “offender or “inmate.”
Doreen D. Salina, Northwestern University.
Daphna Ram, DePaul University.
Leonard A. Jason, DePaul University.