Resilience among females with a commercial sexual exploitation history:
A literature review
Master Thesis
M.Sc. Forensic Child Development Studies Graduate School of Child Development and Education
University of Amsterdam
Rike van der Heide Student number: 12244481
Supervision and Examination
Dr. E.S. van Vugt University of Amsterdam, the Netherlands Prof. Dr. N. Lanctôt Université de Sherbrooke, Canada Prof. Dr. G.J.J.M. Stams University of Amsterdam, the Netherlands Amsterdam, May 2020
Abstract
A comprehensive literature review was conducted to provide an overview of resilience among females who exited commercial sexual exploitation (CSE). Searches were performed in the databases of Web of Science, PsycInfo and Google Scholar. In total, 12 studies were included in which 232 adult females, with a history of CSE, participated. Resilience was conceptualized as a dynamic process that includes individual and systemic factors as well as turning points (crucial life events). A narrative approach was adopted to identify the themes related to resilience during the process of exiting CSE: (1) ‘Spirituality/Religion’, ‘Hope’,
‘Awareness’, ‘Self-concept’; (2) ‘Family connections/family support’, ‘Survivors presence’; ‘Supportive professionals’; (3) ‘Arrest/Hospitalization’, ‘Pregnancy’, and ‘Hitting rock bottom’. In general, females reported more internal strengths (individual level) than external
strengths (systemic level) or turning points. However, the themes on the systemic level and the turning points were all related to the individual level. It is discussed how resilience can be addressed by professionals in the clinical practice. To highlight all aspects of resilience, to understand these aspects, and to stimulate resilience in females who exited CSE, more high-quality research is needed.
Resilience among females with a commercial sexual exploitation history:
A literature review
Introduction
Prostitution is known as one of the oldest professions in the world and most of the time it is associated with adult females who get payed for the exchange of sexual services (Benoit et al., 2017). While there are females who voluntarily choose to practice prostitution, the majority of adolescent and adult females are victims of some sort of sexual exploitation. The most recent numbers of sexual exploitation worldwide have been reported by the International Labour Organization (ILO). The ILO reports that in 2016, 4.8 million people were victims of forced sexual exploitation. More than 99% of the victims of forced sexual exploitation were female, of which 21% minors (ILO et al., 2017). Worldwide, these numbers are not equally divided. Most victims were in Asia-Pacific (70%), 14 % in Central Asia and Europe, followed by 8% in Africa, 4% in America and 1% in the Arab States (ILO et al., 2017). Due to the fact that many females do not report their victimization or are not taken seriously by the police and other judicial authorities there is a high dark number (Lyons et al., 2017; ILO et al., 2017). It can be difficult for women to report their victimization because of shame, stigma, emotional attachment to their exploiter, or out of fear of being criminalized and the consequences that reporting might have on their relatives (Benoit et al., 2017; Farley, 2009; Mittal et al., 2017; Prostitution Law Review Committee, 2008; Van San & Bovenkerk, 2013). Based on these data, it can be said that commercial sexual exploitation (CSE) can be, and is recognized as a global human right’s problem (Bruhns et al., 2018; United Nations, 2019).
The terms ‘CSE’ or ‘commercial sexual exploitation of children (CSEC)’ are mostly used in the case of women and men who get involved in sex work before their eighteenth birthday (Gutierrez et al., 2008), and when children’s rights are being violated. The term commercial sexual exploitation (CSE) includes both child and adult victims of sexual
exploitation and is used in this study to make sure it is about females who did not choose to work voluntarily as a sex worker or were not allowed to exit when they wanted (Ham & Gilmoure, 2017).
To date, research has mainly focused on risk factors and negative effects associated to CSE (Gerassi, 2015; Hossain et al., 2010; Muftic & Finn, 2013). For instance, females are often exposed to dangerous, and sometimes even life-threatening, working conditions (Bruhns et al., 2018, Cecchet & Thoburn, 2014; Oselin, 2010). As a result of the working conditions, females tend to experience many physical problems such as headaches, back pain, stomach pain and were often exposed to infectious and sexually transmitted diseases (Farley et al., 2004; Muftic & Finn, 2013; Zimmer et al., 2007). In addition to the physical conditions and risks, the mental risks are just as important to mention. Many females suffer from numbness because of the traumatic experiences they have been exposed to. Mental health issues such as anxiety, memory difficulties, depression and posttraumatic stress disorder (PTSD) are
frequently reported among females with a history in CSE (Cecchet & Thoburn, 2014; Farley et al., 2004; Gerassi, 2015; Hossain et al., 2010; Zimmer et al., 2007). Also, substance abuse is often linked to mental health issues related to CSE (Potterat et al., 1998). More precisely, substance abuse was for some females the reason they ended up in CSE. Others were forced by their pimps to use substances or were forced to exchange money, or perform sexual activities, for drugs (Gerassi, 2015; Holger-Ambrose et al., 2011). Besides substance abuse, the feeling of having nowhere to go and shame and stigma also held females back to seek for help (Wilson & Dalton, 2008). Goffman (1963) described stigma as a form of social judgment which separates individuals from others (Benoit et al., 2017). Females who were victims of CSE had to deal with stigma during the CSE, but also after they exited the industry. The consequences of stigma can be far-reaching. A negative self-concept and negative formation of the identity are examples of this (Corrigan et al., 2013; Hotaling, et al., 2004; Wilson &
Dalton, 2008), which can result in social exclusion. Additionally, females found it hard to get in contact with others outside the industry of CSE (Dewey, 2014; Hickle, 2017).
As previously mentioned, there also have been females who managed to get out of CSE. They received the right help and/or found the strength within themselves to adapt to or maintain a healthy way of living. Those skills or positive characteristics that some individuals showed, while others struggled, are referred to as resilience (Jew et al., 1999; Tugade & Frederickson, 2004). The definition of resilience is still evolving these days. In general, resilience refers to the positive adaptation of individuals after negative experiences or the ability to ‘bounce back’ following a stressful situation (Tugade & Frederickson, 2004). In addition, resilience is considered a dynamic process (Masten, 2018; Windle, 2010), in which the social system of an individual can adapt successfully to adverse situations that threaten (future) development. It is a process of effective negotiating or managing stress and trauma through resources or assets within one self-and/or within the environment of that individual (Masten, 2018; Windle, 2010). This leads to the conclusion that there are internal and external strengths on the micro, meso and macro level (Bronfenbrenner, 1994; Masten, 2018;
Resiliency Initiatives, 2012). The internal strengths include several factors or personality characteristics (micro level), such as self-control, self-concept, empowerment, cultural sensitivity and social sensitivity. Commitment to learning, family support and expectation, peer relationships (meso level), school culture and community cohesiveness are factors which are considered the external strengths (macro level) (Resiliency Initiatives, 2012).
Resiliency mostly occurs after (an) adverse life event(s) (Bonanno, et al., 2010; Southwick et al., 2014). These events can include accidents, exposure to extreme violence, imprisonment, or the loss of loved ones. Both internal and external factors of resilience are crucial to overcome traumatic experiences or adverse life events (Masten, 2018; Ungar et al., 2007). Where some people felt overwhelmed, others were able to continue a healthy
functioning and some were even able to see such events as a reason to change their lives (Bonanno et al., 2010; Pyrooz et al., 2017). Therefore, these adverse life events, and
additional experiences of life events resulting from adverse situations, such as pregnancy and institutionalization (e.g., hospitalization) may be considered turning points that result in resilience. (Masten et al., 2004; Rutter, 2012).
In 2015, Love mentioned that there was a paucity in literature on resilience of females who have been sexually exploited and exited sex work. An explanation for this might be that research on resilience in general is still relatively new, especially where it concerns specific populations. However, resilience has recently received increasing attention, which is also evident from current trends in research and practice that do not only focus on risk factors, but also on factors that may help individuals cope with adverse situations (Hickle, 2017; Seery et al., 2010; Zolkoski & Bullock, 2012). Rutter (2012) implies that resilience buffers risk factors and strengthens protective factors. Therefore, research on risk and protective factors is
important. On the other hand, it also shows the importance of focusing more on the resilience of females who have been through very traumatic experiences such as CSE to improve
individual functioning, physical health and psychological well-being (Frederickson, 1998). By focusing more on resilience, it is possible to work in a more targeted and effective manner both on a preventive level and in supporting victims (Southwick et al., 2014). Research has shown that stimulating resilience of individuals and systems is more effective than reducing risk factors (Bromley et al., 2006; Rawana et al., 2011; Southwick, et al., 2014; Tebes et al., 2007). However, to date, there is little consensus about which programs are suitable to increase resilience or what components/factors are needed for effective interventions
(Chmitorz et al., 2018; Helmreich et al., 2017; Leppin et al., 2014). Additionally, there is no overview of research available regarding resilience factors in both female adolescents and adults who exit CSE. The purpose of this current study is to provide an overview of research
about resilience in females who exited commercial sexual exploitation. This resulted in the following research question: ‘What is known in research on the concept resilience in females who exit commercial sexual exploitation?’
Method Design
To bring findings of multiple qualitative studies together, a comprehensive review was conducted by the following different stages (Thomas & Harden, 2008). At first, electronic databases were selected based on their relevance. Comprehensive searches were performed in Web of Science, PsycInfo and Google Scholar, using specific search terms. The search terms
resilience, recovery and exiting were combined with the following keywords: prostitution, child sexual exploitation, sex work and sex trafficking and derivatives of these terms. For the
concept of commercial sexual exploitation, the following terms were used: sexual exploitation OR sex work* OR prostitut* OR “sex* AND traffic*”. These search terms were combined with recover* OR resilien* OR exit* OR leav*. In order to find relevant studies, the inclusion criteria were established and articles that did not meet the criteria were excluded. All articles were read and summaries were made. A narrative approach was used to explore what was known about the experiences of women exiting commercial sexual exploitation (Chase, 2005).
Data collection
At first, all titles and abstracts were screened. Based on the relevance of the titles and the content of the abstracts, 50 studies were selected for detailed reading as shown in Figure 1. For the purpose of this review with a narrative approach, quantitative- and mixed methods studies were excluded, only qualitative studies were included. In addition, studies were only included in case of the following inclusion criteria: all participants were female (a); all participants experiencedcommercial sexual exploitation (b); all participants were eighteen
years or older when they participated in the study (c); the studies identified resilience and/or recovery among female adolescents/adults who exited the commercial sexual industry (d); were peer reviewed (e); were available in full text (f), and were published in English over the last fifteen years, from the 1st of January 2004 till the 30th of March 2019 (g). All articles that did not meet these criteria were excluded.
Figure 1. Flowchart of search strategyab
aSubnote: P = PsycInfo / W = Web Of Science
bSubnote: No new articles were found in Google Scholar. For this reason, this database is not shown in the figure
For the purpose of this study, the term females was used to identify both adolescent and adult females’ experiences in CSE. Many females in this study got involved in CSE before their eighteenth birthday, also called ‘early onset’. Both early onset and late onset, which means that they became victims of CSE after they turned eighteen years of age, were combined and included in this study.
Found articles (N = P 547 / W 360) Exclusion based on titles/duplicates (N = P 522 / W 330) Included studies (N = 12)
Possible relevant studies after screening
(N = P 21 / W 29)
Exclusion based on analysing full articles
(N = 37) Screened by titles and
abstracts (N = P 25 / W 30)
Exclusion based on abstracts (N = P 4 / W 1)
Data analysis
A narrative approach was adopted to determine the different themes of resilience among females exiting CSE (Chase, 2005). First, two researchers read the articles selected for this review and summaries were made of all factors that were related to or lead to resilience in females exiting CSE. Second, a coding scheme was created to provide an overview on the general information of the articles, information about sample descriptors and the
conceptualization of variables such as: CSE, resilience/recovery and internal/external reasons for exiting CSE. The extracted data from the included articles were compared and recurring themes were identified. Overlapping themes where combined and all themes related to resilience were synthesized based on consensus between the researchers. Resilience was divided into two different levels: individual (internal strengths) and systemic (external strengths) (Southwick et al., 2014; Masten, 2014, 2018). All themes were categorized under the corresponding levels of resilience. In addition, themes were identified that did not fit the levels of resilience. Therefore, a third factor that included turning points, or so-called crucial life events, was added (Bonanno et al., 2010).
Women of different ages were included, but all the women were older than eighteen when they participated in the study. Studies that did not report the age of the participants or participants who were younger than eighteen years of age at the time of the interview were excluded. In ten studies the age of onset at which the commercial sexual exploitation started was reported by means of an age range. Two studies did not specify the onset.
In one study, both women and men were interviewed. For the purpose of this study, only the experiences of the females were included. In one other study gender was not specified. As the results of this study corresponded with the other studies, this study was included as well. All studies reported on the way in which the participants were informed
about the study and consented to participation. Studies were excluded when it was not
explicitly mentioned that participants gave their consent to scientific use of their information. Results
Background characteristics
In total, 232 individuals participated in the twelve studies that were included. Eleven studies were conducted in the United States of America, one other study was conducted in The Netherlands. The participants ranged in age from 18-66 years. In the study by Dewey (2014) the age range was not mentioned. All participants were females, except for the studies by O’Brien (2018) and Viergever et al. (2019). O’Brien (2018) indicated that there was minimal diversity in the data that was collected from both men and females, and therefore no distinction was made in the reporting of the data. The study of Viergever et al. (2019)
reported the results separately for females and males, and thus only the results of the female participants were included in the current study. Except for the studies by Dewey (2014) and Viergever et al. (2019), the age of onset of CSE was reported in the studies ranging from 8 to 39 years of age.
Participants identified themselves in most studies as white or Eastern European (35%), black or African American (34%), bi- or multiracial (7%), Hispanic (5%), Asian (1%),
otherwise or unknown (18%). In two studies ethnicities were not reported (Cecchet & Thoburn, 2014; O’Brien, 2018). All qualitative studies were published between 2007 and April 2019. An overview of the included studies is presented in Table 1. An overview of the identified themes is provided below. First, themes related to resilience on an individual level (internal strengths), and on a systemic level (external strengths) are described. In addition, turning points, also called ‘crucial life events’, that lead to resilience are presented. The indicated numbers in the citations are linked to the study numbers as shown in Table 1.
Table 1
Description of all studies included in this review
Authors Year Average age Range Gender Onsetᵃ Size (N) Publicationb
1 Hickle 2017 45.5 25-59 F 13-31 19 A
2 Viergever et al. 2019 26.0 23-21 F/M Unknown 14 A
3 Bruhns et al. 2018 Unknown 18-30 F 14-17 11 A
4 Valandra 2007 34.0 18-47 F <18-39 8 A
5 Gutherie 2011 20.9 18-26 F 12-19 19 B
6 Dewey 2014 Unknown Unknown F Unknown 50 A
7 Cecchet & Thoburn 2014 18+ 22-55 F <18 6 A
8 Hickle 2014 44.5 25-59 F 13-31 19 B
9 Corbett 2018 25.0 21-26 F 8-17 13 A
10 Dodsworth 2011 Unknown 18-65 F 14-31 24 A
11 Oselin 2012 Unknown 20-55 F <18-18+ 36 A
12 O’Brien 2018 40.8 29-66 Unknown <18 13 A
ᵃSubnote: ‘Onset’ reflects the age on which the participants got involved in CSE bSubnote: Type of publication: A = Journal article / B = Doctoral dissertation
Conceptualization of resilience. Both the terms ‘resilience’ and ‘recovery’ were used in the studies that were included in this review. Seven studies gave a clear conceptualization of resilience. Overall, resiliency was described as a way of overcoming adversity and living a healthy life after being exposed to adverse- or traumatic circumstances (1; 5; 7; 8; 9; 10; 12). One study described recovery similar to resiliency (2). One study did not refer to either ‘recovery’ and ‘resilience’ but instead, to ‘internal and external factors’ which helped exiting CSE (11). However, not all articles used a clear definition of resilience or recovery (3; 4; 6). Resilience on an individual level (internal strengths)
In connection to resilience on the individual level, the data showed different recurring themes. Analyzing a wide variety of factors produced four different themes which can be considered internal strengths: ‘Spirituality/Religion’, ‘Hope’, ‘Awareness’ and ‘Self-concept’.
Spirituality and/or religion were mentioned as very important motivations to leave
CSE, especially because of values and beliefs that were inconsistent with CSE. Some of the participants were raised in religious households and had a strong need to get right with God (11). In the study of Hickle (2016) participants spoke about the essential role of their spirituality and religion in exiting CSE. They felt that God, a higher power, gave them the power to change themselves (1; 2; 4; 8; 11). One of the participants said: “I called on God to
help me make a change, and my road to recovery is God’s will, and I don’t want to let it go”
(4). Another citation of one of the participants was: “I started working, and I started praying,
and exercising, and trying to figure out, and reach out to all my resources, for how I can learn how to be a normal woman, or a healthy mother, ’cause I had no idea… I started going walking and praying every day and just asking God to transform me and help me heal” (3).
Spirituality and religion helped the females to change their point of view on life and
ultimately made them ready to change their lifestyle (4; 7, 8). Religion and spirituality were not only important during the process of exiting CSE. Females felt that one of the key
elements in their recovery was their relationship with a higher power (2;4;12). “God finally
rescued me the last time I went to jail, and it finally clicked after I was arrested that this was God’s way of helping me out. I prayed for God to strengthen my faith in him and to put Him in my life… to feel what I knew was right and what I was raised to believe in. I embraced that and ran with it because that was my lifeline and I knew with no doubt in my mind that if I would have kept going the way I was going I would end up dead. After I was released, I went right into the program because I knew this was my one shot” (11), and, “I thank God every day for like, you know, being able to talk about it” (5).
Religion and spirituality were at the same time related to another resiliency factor: ‘hope’ (1; 8). Hope was mentioned as a very powerful force by one of the females (12). Many of the females were mothers. Most of them did not have custody over their children because of their living circumstances during their involvement in CSE (1; 7; 8). One of the main reasons to leave CSE was the hope of being reconnected and reunited with their children (1; 8). Additionally, participants hoped for a better life. They had a strong future orientation with the ambition to find a job and hoped for professional and personal development. They
described meaningful goals and saw the future positively (2; 3; 12).
Further, the results showed, that ‘awareness’ on various levels led to resiliency. By becoming more aware of their isolation, lack of freedom, and the constant threat of violence or even death, some participants decided to leave CSE (1; 3; 5; 8; 9; 11). The females
regained a healthy fear for their health and lives what made them either search for support to escape CSE or take matters into their own hand and leave the exploited situation themselves (1). One of the participants said: “I just started not being numb anymore and just reality
started creeping in and I started thinking about family and it just started coming at me real hard” (8). Cecchet and Thoburn (2014) described resiliency with themes such as the desire to
live, their motivation for change and positive thinking, not only during the process of exiting CSE, but also afterwards, when they had the strength to survive.
The last theme related to resilience within the domain of internal strengths was
‘self-concept’. Building a positive self-concept was very challenging for many females in CSE
(10). However, the data showed that during the process of exiting, many females had a clear and mostly positive concept of themselves (1; 3; 6; 8; 9; 10). During the exit, developing a new identity was seen as a proactive process (1; 3; 5; 10). Females experienced personal growth, which among other things resulted in more confidence, self-worth and self-esteem (1; 3; 5; 8; 9; 10). Females noted that they were determined to change and had the desire to have a better life (2; 5; 6; 7; 9; 10; 11). Feeling capable in taking care of themselves and their own needs (self-efficacy) and being responsible for their own lives were important factors related to resiliency (1; 5; 6; 8). One of the females noted: “Try not to focus on what everybody wants
of you. Try to focus on what you want of yourself and work on your self-esteem. Work on what you want and what need and what you like in life.” (5). Positive thinking, feelings of
empowerment (5; 6; 7; 8; 10) and wanting something better for themselves was related to the love these females showed for themselves. The females realized that they deserved love and respect from themselves and others (3; 4). Two females said: “The best love is your own love.
You can love yourself so good that that is the love no one can give you. That love for yourself” and “The best love I feel, like is loving yourself. And I started taking pride in my relationships.” (5). During and after exiting, many females searched for support by means of
psychotherapy to heal themselves (2; 3; 5; 7; 8). Besides searching for support, most of the women wanted to help other females who were in CSE as well (1; 2; 3; 7). For instance, they wanted to start an education or a career in social work (1; 3; 7). One of the females described this process: “I feel like I matter. I feel proud. It makes me wanna cry. I hate the fact that I
it was because I help people. Everything I’ve done is not gonna be in vain if I can go help somebody else and ease their pain...I have respect for myself and I’ve learned to love myself. I had to put little stickies on my mirror for years that said, ‘You are a treasure and a temple.’ ‘You are a good person.’ Because I would wake up in the morning and everything would hit me like a ton of bricks...it was like this voice kept telling me, oh, you’re dirty, you did this, you did that...but now that voice is gone.” (8).
Resilience on a systemic level (external strengths)
All studies described external strengths that were related to resilience and exiting CSE. In total, three themes, which can be considered external strengths, were identified: ‘Family
connections/family support’, ‘Survivors presence’ and ‘Supportive professionals’.
‘Family connections/family support’ was reported in nine of the included studies as a factor that led to resiliency during the exit of CSE and to persist afterwards. The
encouragement, support, concern and care of family members, partners, friends and children was very important in exiting CSE (1; 3; 4; 8; 9; 11; 12). The connection to family, children and friends reduced feelings of isolation and provided emotional support and motivation to successfully exit CSE (1; 3; 4). The females wanted to be accepted, valued and trusted by others (1; 12). Maintaining the relationship with family and significant others was an
important reason to exit CSE and made it possible for females to persist (11; 12). On the other hand, participants also mentioned that it was crucial to cut ties with certain friends or family and exploiters who were connected to their lives in CSE (3). Females needed to build new relationships that were consistent with their future plans and goals (3; 5; 6). One of the females said: “… surround myself with good people, because I didn’t know how to be good” (3). Being able to rely on family and reach out to them was one of the reasons that made it easier for females to exit CSE and being able to persist (1; 3; 4; 11; 12). One of the
says, “a threefold chord is not easily broken.” So, if you have the lifeline like the personal relationship or physical lifeline to get out of the life, and then you have a goal or purpose once you get out, something that a person can connect you with that you can value and be valued at, and then you have a relationship with someone that really cares for you— that’s a threefold chord. It can’t be easily broken. That’s how you’re going to rescue people for real— like, really get them out” (12).
‘Survivors presence’ encouraged the development of resiliency (12) and was an
important factor in making the decision to exit CSE (1; 3; 4; 8; 11; 12). Seeing and interacting with other females who successfully exited CSE gave hope and became a motivation to leave CSE (1; 5; 8; 11). One of the females said: “I saw the evidence through my sister and another
lady in my neighborhood that was out on the streets and doing really bad. I saw the changes in them after they went through the program and that’s what helped motivate me to want to leave” (11). Many of the females were searching for others they could relate to and they
found that in females with similar backgrounds and life stories (1; 11): “I don’t think there’s a
chance in hell that any of the women that you’re dealing with are going to open up, are going to change, are going to get any better unless they can find somebody they can relate to” (8).
Getting support from other survivors and being able to rely on them, was empowering and helped them to process their traumatic experiences (1; 3; 4). For many females it was hard to talk about their experiences of CSE but talking to females who had been through the same made it easier for them (5). Two of the participants stated: “Counselors are the most helpful
when “they [have] walked the life they talk about, and this makes it more comfortable for me to share with them.” (4) and: “It’s not like people are just talking from like ‘Oh, the
psychology,’ you know. They have been there. They have experienced what you are talking about. And that makes it more comforting... She knows what she is talking about, and it’s like easier to come and talk to her… When you’re in the life and you try to leave and you do leave,
you don’t think that there is ever a program like this. You don’t think that people will ever understand what you’ve been through or why you even went that way... but there are people who went through this and there are people who can help you.” (5).
Besides the presence of other survivors, ‘supportive professionals’ were just as important for many females in exiting CSE and in developing resiliency: “I see a therapist, I
see these mentors or people who believe in you, who are walking this journey of life with you, who are investing in you, making a significant investment in you and then the service
providers can come alongside all-both of those- and it becomes this beautiful collaboration of the three. That is what I see to make the most significant benefit for human trafficking
survivors to be able to really live life fully and not fall back into the life” (12). Professionals,
from the criminal justice system and mental health services helped females exit CSE and stimulated them in building resiliency. Females stated that building a positive relationship with professionals was a helping factor in exiting CSE (1; 3; 4; 5), as well as the reliability on professionals and a safe and secure environment to rehabilitate (3; 5). Females experienced that they could have empowering and positive relationships with professionals, even from the criminal justice system, and got the support they needed (1; 3; 4; 5; 8; 11; 12). “Believe it or
not, a lot of it [help] came from the police officers. They got tired of seeing me out there. You know, before it was like, ‘Hey Little Bit’ (my street name), you’re looking better, but when are you going to do something?’...that was part of my support system actually” (8). The
unconditional and nonjudgmental support from professionals was especially important in exiting CSE (3; 5; 10): “I had a really solid case manager, that really, just really supported
me, whether I [was] with [my pimp], whether I was at my mom’s, or I was in juvenile hall. ... She would come to court for me, like really understanding what was going on. And didn’t even doubt anything that I said” (3). Knowing about programs which helped females who
professionals such as probation officers, law enforcement and social workers were crucial factors in successfully exiting CSE (1; 8; 11).
Turning points (crucial life events)
Besides the internal and external strengths related to resiliency, so-called ‘turning points’ that activated or motivated females exiting CSE and led to resiliency within females were reported as well (3; 8). The three main turning points or crucial life events mentioned in the studies were: ‘Arrest/Hospitalization’, ‘Pregnancy’, and ‘Hitting rock bottom’.
Some of the participants were forced to exit CSE due to arrest and/or hospitalization (1; 5; 8; 9; 11). Females noted that being arrested, going to jail or being hospitalized saved their lives and helped them to exit CSE (1; 5; 8; 9; 11). “As crazy as it may seem, probation
is one of the huge things that saved my life and got me out of it because that probation officer and surveillance officer believed in me and every time they’d see me go off the path, they would put me back on it...my surveillance officer picked me up [from jail], took me directly to treatment for addiction and everything...they believed in me because they’d seen what I had done. It makes me cry” (8). Several participants were addicted to drugs and/or alcohol while
they were involved in CSE (1; 8; 9; 11). Receiving treatment for an addiction was crucial in staying out of CSE, because addiction was often one of the main reasons to continue or re-enter CSE (1; 8; 9). Some females mentioned that their time in prison or in a hospital was their way out of CSE (1; 5; 8; 9;11). Moments of clarity and getting space for personal reflection, for instance by getting sober during their arrest or hospitalization, was one of the main reasons to decide to exit CSE: “God saw in his infinite wisdom to do it for me. I got
arrested again for the last time and I’m like, okay, there has to be something else. There just has to be. And that’s when I started going to all the groups in jail… and I started listening to people” and “Five year of prison sentence for drug related charges” was my exit out of prostitution because I was separated from everything that I had known… I started doing the
self-help programs… I was able to recognize and have awareness and decided that I wanted to change my life.” (8). Females were able to think of alternative options outside CSE (11).
Another female said: “I never really thought about leaving before I came to the hospital, but I
knew I couldn’t get high no more because I would start hallucinating and all kinds of stuff… I was scared. I used the whole time I worked on the streets. I think once I got sober, I got a moment of clarity and it dawned on me at that time that that was not the way I wanted to die. Before being sober, I had never thought of leaving” (11). The fear of going back to jail,
getting charged with felony, the fear of the consequences of CSE overall, and the risk of using substances again made females want a better life for themselves (1; 3; 5; 8; 11).
The data showed that ‘hitting rock bottom’ was a reason to exit CSE (4; 7; 8; 9; 10; 11). Being tired of the life, feeling exhausted, not being able to do ‘it’ anymore, a mental breakdown and being burned out by the work were examples of the way ‘hitting rock bottom’ was described in the included studies (4; 8; 7; 9; 10; 11). Many females experienced violent attacks and/or witnessed extreme violence during CSE (10; 11). Critical moments, such as violent attacks, could result in females changing their pathways (10; 11). Outcomes appeared to be dependent on females’ own resilience. Some females regained control over their lives after hitting rock bottom, while for others these moments were considered as more destructive and made their lives even harder (10).
In one of the included studies, pregnancy was considered the main catalyst to exit CSE (7). Several participants left CSE when they found out they were pregnant (5; 7; 9; 11): “I
had my daughter—that’s why I stopped prostitution. ... My daughter was my wake-up call.”
(10). As mentioned before, females wanted a better life for their children and more important, they wanted to be a mother to their children and keep them (7; 11). Participants noted that they wanted to be better parents than they had had themselves (10; 11). The only way to survive, themselves and their children, was to exit CSE (7).
Discussion
This review aimed to provide an overview of the research on resilience in females who exited CSE. During this study it became apparent that research on resilience in females who exited CSE is still limited (Love, 2015). The first studies with a clear conceptualization of resiliency in females who have been in CSE can only be found from 2004 onwards and are outnumbered by studies on risk factors and negative consequences associated to CSE
(Gerassi, 2015; Hossain et al., 2010; Muftic & Finn, 2013). This is remarkable, since females in CSE often suffer from traumatic events where resilience is crucial to overcome these events (Tugade & Frederickson, 2004). In the current study, resilience was studied from both an individual and systemic perspective. Additionally, turning points that led to resilience were described.
On an individual level, four themes were identified that contributed to resilience in females who exited CSE respectively: ‘Spirituality/Religion’, ‘Hope’, ‘Awareness’ and
‘Self-concept’. It occurred that spirituality and/or religion were among the most frequently
mentioned reasons to leave CSE. The values and beliefs related to religion and/or spirituality of the females were generally inconsistent with CSE. Furthermore, religion/spirituality provided hope and gave females the strength to exit CSE. According to Lazarus (1999), hope arises when the current life circumstances are damaging, threatening and/or involve
deprivation and are therefore unsatisfactory. During their victimization of CSE, the females hoped for a better life for themselves, for their children, or hoped to be reunited with their children. Hope contributed to well-being and positive adaption (Gallagher & Long, 2019; Snyder, 2002; Magaletta & Oliver, 1999) and provided referential thoughts and self-efficacy (Snyder, 2002) to begin and continue the process of exiting CSE.
The next theme ‘awareness’ particularly occurred when females stopped using substances such as drugs and alcohol. Abstinence increased females’ awareness about their
circumstances in CSE, and they were also more able to take back control over their own lives. These changes fit the breakaway model of Månsson and Hedin (1999) based on the “role exit” theory of Ebaugh which includes the following stages: (1) first doubts, (2) seeking
alternatives, (3) turning point(s), and (4) creating the ex-role (afterwards) (Månsson & Hedin,
1999). These stages are not bound by order or absolutely essential for everybody but can be recognized in the results of this current study. Awareness, and also hope, often resulted in first doubts about the life in CSE and to resiliency. Females became more aware of the constant threat of violence or even death and their isolation and lack of freedom. Awareness increased their healthy fear for their health and lives what made them search for alternatives outside the life of CSE. Females either searched for (professional) support or took matters into their own hands and left the exploited situation themselves.
For many females in CSE, and also afterwards, it is very challenging to build a positive self-concept, due to shame and stigma (Hotaling et al., 2004; Wilson & Dalton, 2008). Both public stigma (e.g., minimization or normalization of the violence in CSE by informal/formal (support) systems (Sallmann, 2010) and self-stigma (e.g., internalizing stereotypes; Corrigan et al., 2013; Sallmann, 2010) seem to affect personal (life) goals and have a negative effect on self-esteem and self-efficacy (Corrigan et al., 2013). In the current study many females discussed their determination to change and personal growth they experienced during their exiting process. Among other things, this growth resulted in more self-worth, self-esteem, self-efficacy and development of a new identity, factors also mentioned in the current study in terms of self-concept and a thought to help women to no longer see themselves as prostitutes (objects) but as human beings who deserved love and respect (Corrigan et al., 2013; Månsson & Hedin, 1999).
In general, females reported more internal strengths (individual level) than external strengths (systemic level) that helped them to exit CSE. An explanation for this may be that
women in CSE have often been in isolation for a long time or either have no or small supportive network. Also, females often had to cut ties with friends and family who were connected to their lives in CSE, to be able to desist (Cimino, 2019; Hedin & Månsson, 2004). Nevertheless, important factors on a systemic level, also associated to the individual level, were mentioned among which: ‘Family connections/family support’, ‘Survivors presence’ and
‘Supportive professionals’. Not only during exiting, but also in the stages after CSE, the
females mentioned that is important to be surrounded by supportive others. Being valuable to others, and connectedness to family and friends reduces feelings of isolation, has a positive effect on building resilience and increased desistance from CSE. These findings are in line with prior research of Hedin and Månsson (2004). They found that supportive others are crucial in leaving prostitution. They mentioned that a heterogenous social network with both informal and formal support is needed to build a new life (Hedin & Månsson, 2004). The vital role of the presence of other survivors in recovery from, for instance, addiction is well known in literature (Solomon, 2004; Hotaling et al., 2004). The findings of this current study showed that the presence of experts by experience was important to support women during their process of exiting. It made it easier and more comforting for females to openly talk about their experiences in CSE, helped them to process their traumatic experiences and provided hope. Experts by experience served as role models for the females (Hotaling et al., 2004). The females saw that it was possible to get out and stay out of CSE and build a new life. Also, probation officers, law enforcement personnel, therapists and social workers were key persons for a successful exit of CSE. It is important for females to maintain positive relationships with professionals and experience unconditional and nonjudgmental support during their (multiple) attempt(s) to exit CSE (Hotaling et al., 2004; Hedin & Månsson, 2004). Positive relationships with professionals contribute in overcoming adversity and help stimulate resilience (Hotaling et al., 2004).
Associated with the themes on an individual and systemic level, three so-called ‘turning points’ that lead to resiliency in exiting CSE were reported, namely:
‘Arrest/Hospitalization’, ‘Pregnancy’, and ‘Hitting rock bottom’. Sanders (2007) categorized turning points in four types of transition out of prostitution: the ‘reactionary transition’ (e.g., violence, significant life events (e.g., imprisonment, child removal or pregnancy, and ill health), ‘gradual planning’ (e.g., drug treatment program, therapeutic engagement, rehousing), ‘natural progression’ (e.g., desire for a better/safer life, concerned about
conditions in CSE), and ‘Yo-Yoing’ (e.g., drift in and out of prostitution). Sanders (2007) and Månsson and Hedin (1999) mentioned that turning points, both positive and negative, can cause doubts about one’s identity, and makes them want to change their current (exploited) situation. For example, Sanders (2007) reported that feelings of becoming a mother, falling in love or not want to lie to loved ones are often inconsistent with prostitution. Also, the fear of extreme violence is often a reason to exit prostitution. In the current study, arrest and/or
hospitalization literally forced females to exit CSE. Treatment for addiction, or not being able
to use drugs/alcohol due to arrest or hospitalization created moments of clarity. The fear of going back to jail, charges, felonies, and the fear of the consequences of CSE overall, made females to decide to leave CSE. Hitting rock bottom was related to this turning point. Many females witnessed and/or experienced extreme violence. These moments sometimes forced the females to regain control over their lives. The last main catalyst to exit CSE was
pregnancy. Many females lost custody over their children while they were in CSE. The desire
to keep, raise, and be a mother to their children often resulted in changing their lives/lifestyle and finally leaf CSE.
Regarding the current study, several limitations should be mentioned. First, the
population in this study only includes females who have been in CSE. In addition, while most reported victims of CSE worldwide (70%) are from Asia-Pacific (ILO et al., 2017), no studies
have been found that have been conducted in, or were related to that region. The results should thus be mainly understood within this context and cannot be generalized to men and/or transgenders who have been in CSE or females who work voluntarily or legally within the sex industry. Second, the heterogeneity of the included population is notable on various levels such as the age at which participants got involved in CSE, ethnicity (e.g., Eastern European, Afro-American, Caucasian), religion, and reasons for entering and exiting CSE. This could limit the generalizability of the results. Thirdly, in identifying the themes related to resilience, only case reports were found. Not all included studies used a clear definition of resilience and factors related to resilience may not have been systematically questioned or discussed within the separate studies. Futher, the definition of resilience is still evolving and discussed these days. To date, there is no agreement on resilience being a process, trait or an outcome (Southwick et al., 2014). Individual, systemic and environmental factors are considered related to resilience, but were all discussed differently in the included studies. Finally, the limitations of all included studies must be taken into account for this study (e.g., different interview methods and coding methods).
Based on the results, it is recommended to make more use of experts by experience or peer supporters to help females exiting CSE. This way it becomes easier to get in touch with females in CSE and it shows females that it is possible to get out and stay out of CSE (Hedin & Månsson, 2004; Hotaling et al., 2004). In addition, it is important that professionals are non-judgmental and provide unconditional care. It appears that females often make multiple attempts to get out of CSE and they need professionals who will not let them down during this process (Solomon, 2014; Hotaling et al., 2004). Thirdly, females need information about programs that help them to get out of CSE and about recovery from (drug) addiction. This information must be provided in the places where females work, but also to the police and in hospitals. Within the care system the focus should be on resiliency factors such as ‘religion
and spirituality’ and females must be helped to get in touch with their friends and family
(again). It is known that some females remain in CSE because of several aspects such as: addiction, economic needs or by pimps who maintain control by using violence, debt or even love (Cimino, 2012; 2019). More information is needed on how to stimulate resilience in those females who cannot exit CSE and/or how to reach out to them and their friends and family.
Finally, it can be said that is not possible to separate the individual level from the systemic level and the turning points. The turning points hospitalization, hitting rock bottom and pregnancy often resulted in resilience on the individual level, such as awareness about one’s safety and hope for a better life. Also, wanting to be a mother to their children and taking control over their own lives again corresponded to the individual level of resilience. In addition, turning points also lead to resilience on the systemic level. Professionals, other survivors and family and friends often come into the picture when females are not doing well (hitting rock bottom/hospitalization). Family connections and support are also linked to resilience on the individual level when females start to let family in to support them and ask for help. The support of others and the will to leave CSE are the best predictors of
successfully exiting CSE (Cimino, 2019; Hedin & Månsson, 2004; Sanders, 2007; Roe-Sepowitz et al., 2012). More research into these factors and to increase knowledge about working on a systemic level will contribute to improving the quality of life of females who exit CSE and improving care.
Many females with a CSE history suffer from trauma related symptoms (Choi et al., 2009; Hedin & Månsson, 2004). However, people who suffer from trauma can also show resilience (Yehuda & Flory, 2007). As Hedin and Månsson (2004) described, it is important to help females work through their traumatic experiences, to decrease trauma symptoms (Choi et al., 2009). Therefore, it is recommended to provide trauma therapy to females who have
been in CSE (Choi et al., 2009). It should be mentioned that every situation is different and the population of females in CSE diverse, therefore no generalized advises can be given. This current study contributes to our understanding of resilience that occurs when females exit CSE. To highlight all aspects of resilience, to understand these aspects, and to stimulate resilience in females who exit CSE, more high-quality research is needed.
Acknowledgements
First of all, I would like to thank dr. E. van Vugt for providing the opportunity to study a topic that suited me. As a result, this study inspired personal and professional development and was completed with great pleasure. I am very grateful that I was able to conduct this study in Montreal at Université de Sherbrooke under the supervision of dr. E. van Vugt and prof. dr. N. Lanctôt. Their knowledge, input and feedback contributed significantly to improve this work. Finally, I would like to thank them for their hospitality during my stay in Montreal. It has been an exceptional experience.
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