Survivors of Commercial Sexual Exploitation Involved in the Justice System: Mental Health Outcomes, HIV/STI Risks, and Perceived Needs to Exit Exploitation and Facilitate Recovery
Round 1
Reviewer 1 Report
General feedback
- The authors investigate an understudied area with data to help inform service & support provision for survivors of sex trafficking, including survivor-identified needs & priorities
- A major issue is in clarifying the study sample & distinguishing comparison groups; it is not clear how the SST group was defined and who comprises the NSST group. There is a need for a better distinction & clarification of sex trafficking vs. other sexual exploitation vs. consensual sex work/involvement in the sex trade; these terms seem to be used interchangeably at times. It is highly important not to conflate consensual sex work with sex trafficking or exploitation. The sample & comparison groups need much more clarification in order to interpret the study’s results & implications.
Abstract
- Needs more clarification of SST & NSST groups
Intro
- Line 30: please include a basic definition of sex trafficking
- Lines 32-33: this sentence doesn’t need both “although” and “though”
- Line 53: HT abbreviation is used but hasn’t been previously defined – please define
- Lines 56-57: for readers that are less familiar with specific types of sexual exploitation, it may not be clear how sexual exploitation differs from trafficking (related to sampling issue). Please clarify/define commercial sexual exploitation to help the readers distinguish groups.
- Lines 65-66: Are there references to support these associations? Also please clarify if these are risk factors for trafficking more broadly or sex trafficking specifically.
- Section 1.2 (lines 77-91): Since ACEs are not evaluated in this study, they are not relevant to discuss here – suggest removing this section. Instead, the authors might provide any evidence or discussion regarding victims’ feelings or experiences having sex with consumers, since these variables are included in the analysis.
- Line 96: STIs is defined here but the abbreviation is used earlier (line 60); first use of abbreviation should include definition
Methods
- Section 2.1 & line 165: More detail is needed to clarify the sample & comparison groups. For instance, the item used to distinguish SSTs and NSSTs specifies human trafficking but not sex trafficking specifically. Further elaboration is needed to understand how the authors distinguished participants who had experienced sex trafficking vs. other forms of sexual exploitation, or those who experienced sex trafficking specifically vs. other forms of human trafficking. It is also not clear if the NSST group included people who had worked (consensually or non-consensually) in the commercial sex trade but who had not been trafficked (per line 145) and/or those who had experienced physical or sexual abuse but not trafficking (per lines 140-141). It may be helpful to include more description of the organization and the clients they serve.
- Section 2.3: This section should be moved up under the current “participants” section; the combined section should be relabeled as “Sampling & Data Collection”
- Lines 173 & 183: Remove case study analysis; that would imply that this is an in-depth investigation of a single or a small number of units of analysis (e.g., one organization); rather, this is a retrospective case-control design that samples from one organization.
Results
- Lines 241-245: Suggest rephrasing to emphasize group membership associated with outcomes (e.g., compared to NSST participants, SST participants were 3x more likely to have a sex buyer who refused a condom, to have flashbacks/nightmares, etc.)
- Lines 252-254: The most needed service seems to be legal (100% of participants), but it’s stated after others reported by 82-84% of participants
- Table 4: Suggest removing 100% labels indicating total sample for each item, and adding table note indicating missing data on most items, so denominators of percentages vary
Discussion
- Lines 267-269: suggest rephrasing the interpretation of HIV/STI risk behavior
o Since condom use is not the only indicator of HIV/STI risk, this discussion can be revised to specify the outcomes which demonstrated significant differences between groups (refusal of condom use or violence when asking for condom use) as potential HIV/STI risk factors vs. discussing HIV/STI risk more generally
o The condom items didn’t specify that condom use behavior was experienced during trafficked encounters specifically vs. other commercial sex encounters; can be rephrased to specify that SST participants were more likely to experience these behaviors than NSSTs, rather than these behaviors occurring during trafficked encounters
- Lines 273-277: Suggest rephrasing to highlight the outcomes that demonstrated significant group differences, and to specify that higher proportions of SST participants reported other outcomes vs. NSST participants but the differences were not statistically significant (likely due to the small SST sample size)
- There are several limitations that warrant further discussion:
o The current sample includes individuals who have sought help from the organization; please discuss how the results or implications may vary among survivors who have not sought help.
o According to the sample description, the NSST group had also experienced sexual exploitation, which may be associated with many of the outcomes investigated. Please discuss how this might impact results, compared to what might be found with people involved in consensual sex work and/or with no sex work experience.
o Analyses comparing SST and NSST participants were bivariate and did not control for covariates. Please discuss how this may have impacted the results.
Author Response
Thank you for your comments. Please consider our careful revisions of our original manuscript. See attached file.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
This exploratory retrospective survey and case control study examined the demographics, reasons for sex trade, trafficking victimization, sexual risk behaviors, mental health outcomes and self-reported needs to exit sexual exploitation in a sample of survivors of commercial sexual exploitation. A sub-analysis compared self-reported survivors of sexual trafficking to those not identifying as survivors of sexual trafficking on twenty different risks and vulnerabilities. Although the study provided insights on the experiences of an extremely vulnerable group of participants, the current report has many short comings:
1. The presentation of the research questions, results and discussion is unclear and misleading. The majority of paper focused on the questionnaire results of the survivors of the sex trade. Only the analysis presented in Table 3 compared the trafficked sample to the not trafficked sample. The research question suggested that the study was focused on survivors of sexual trafficking and the discussion reported that results as reinforcing and present new information of the needs of survivors of sexual trafficking yet the results were from the responses of the whole sample.
2. The authors needed to provide a rationale for using a sampling frame from Freedom from Exploitation, Inc. that focused on educating and training survivors of sex trafficking. Had they anticipated that the majority of the participants would not self-identify as being exposed to sexual trafficking? Given the method of sampling, response bias or the validity of participants self-identifying as being exposed to sexual trafficking appeared to be a major problem with the current study design.
3. Has the reliability and validity of the 55-item questionnaire been tested and established? Is there any evidence that respondents answering the question related to being a victim of human trafficking were giving valid responses?
4. The authors needed to explain why 57 participants were excluded from the study.
5. The authors needed to explain the abbreviation “GED” on page 4, line 171.
6. Why did the authors restrict their analysis of victims of sexual trafficking versus non-victims to the binomial logistic regression; a multiple logistic regression may have clarified the contributions of the significant variables presented in Table 3.
7. The discussion indicated that the victims of sexual trafficking versus non-victims had higher desires to harm the John/sex buyer, levels of disgust, humiliation and dissociation yet none of these variables were found to be significant according to Table 3. Again, the authors appeared to misrepresent their findings.
8. The authors should have acknowledged that study had limited sample size to compare victims of sexual trafficking versus non-victims as only 27 participants self-identified as victims of sexual trafficking.
Author Response
Thank you for your review. Please consider our careful revision to your comments. See attached file.
Author Response File: Author Response.pdf
Reviewer 3 Report
This is an important study on a significant topic.
The authors do a good job of presenting the findings, but I think their predentation could be improved in a few ways.
Here are my questions/comments:
1 Why were people excluded from the results? Did they not complete the survey? The article just says that 47 people were excluded with no explanation.
2 The chi square and univariate charts need more explanation/discussion as to their relevance to your study and findings. As is, they look plopped in amd take up a lot of space.
3 Importantly, one of your concluding statements had to do with the need for increased educational opportunities for this population. That point came out of nowhere as it did not seem to be a point of emphasis in the body of the article. That conclusion needs to be better linked to data and discussion.
4 There are a lot of varia les being examined but the main hypotheses aren't stated clearly or at all. Stating your hypotheses clearly at the outset will better organize your article.
5 Why did less than half of respondents want to leave trafficking? Did they find some benefit in the arrangement or were they the portion that wasn't trafficked to begin with? That point needs some explanation and elaboration.
Author Response
Thank you for your review. Please consider our careful revisions to your comments and suggestions. See attached file.
Author Response File: Author Response.pdf
Round 2
Reviewer 1 Report
Thank you for the opportunity to re-review this manuscript. The authors have thoughtfully addressed the initial review, and made substantial edits to provide more detail about their sample.
However, there is a need for further clarification regarding terminology used throughout the manuscript and how it informs understanding of the sample. In their response to the review (the first and last author response statements), the authors provide information about the sample and justification for use of the term “commercial sexual exploitation”; including that participants in their program view themselves as having experienced commercial sexual exploitation, even if their involvement in the commercial sex trade was not under the control of a trafficker. This information needs to be added to the manuscript so readers can clearly understand the sample and comparison groups. A paragraph is needed early in the paper (suggest adding it just before section 1.1, to the paragraph describing the SST and NSST groups) that clearly states and justifies why the authors are using “commercial sexual exploitation”, and how it relates to the sample.
Additionally, more discussion of this is needed in the limitations section. The authors should discuss that terminology and sample selection are challenges in this area of work, and how these limitations impact their results. This study is focused on people who view themselves as having been sexually exploited, even if their experience in the commercial sex trade was not under the control of a trafficker. This needs to be further discussed to clarify that the sample is not representative of all people who work in the commercial sex trade, including those that do not define or consider themselves to be exploited. For instance, clinical sex surrogates engage in the commercial sex trade for a therapeutic purpose and wouldn’t fit under the term sexual exploitation. The authors need to provide more discussion on how their sample selection presents bias to their results, and the implications for interpreting and applying their findings.
Additional minor comments:
- Suggest some rephrasing to clarify measures
o Lines 173-174: rephrase as “vulnerabilities for sexual exploitation”
o Line 175: rephrase as “emotional & mental processes during commercial sex acts”
o Line 176-177: rephrase as “assistance and services needed to exit the commercial sex trade”
o Line 209, Table 2, and throughout paper: rephrase “HIV/STI unsafe risk behavior” as “HIV/STI risk behavior”
o Lines 246-247 & Table 2: consider rephrasing re: victim/victimization. The two questions about having sex to meet basic needs indicate commercial sex experience. In Table 2, change label to “status in commercial sex trade”
- Table 1: percentages don’t add to 100% (ever homeless goes over 100%). Need table note indicating why
- Table 3: for most variables in emotional & mental processes list (except lied to sex buyer, felt repulsed, felt depressed, had flashbacks), the 95% confidence intervals cross 1.0, which implies their p-value would be >0.05. Are the reported p-values correct?
- Review for grammar & syntax throughout
Author Response
See attached file. Thanks.
Author Response File: Author Response.pdf
Reviewer 2 Report
The authors have not addressed the methodological problems with this study such as how the survivors of sex trafficking were identified, the validity of participants' responses regarding being survivors of sex trafficking, the use of an assessment tool that has no evidence of its psychometric properties, and an analytic approach that failed to control for possible confounding variables.
Author Response
See attached file. Thanks.
Author Response File: Author Response.pdf
