Sex Trafficking in New York City and Vulnerabilities to Re-Trafficking

Abstract

Human trafficking occurs in a cycle of coercion and exploitation of vulnerable people; yet, little is known about those who are trafficked more than one time (re-trafficked). Our study sought to describe the trafficking experiences and explore vulnerabilities to re-trafficking in an urban, majority immigrant, population. This study is part of a parent cohort study that enrolls patients at the EMPOWER Center in New York City, which provides trauma-informed obstetric and gynecologic services to victims of sexual- and gender-based violence. Retrospective chart review was conducted on patients with a history of sex trafficking who were evaluated at the EMPOWER Center from February 2013 to January 2021. A total of 87 patients were enrolled in this study, 23 (26.4%) of whom had been re-trafficked. All were women. Most (88.5%) were victims of international trafficking, most often from Mexico or the Caribbean/Central America. Nine (10.3%) reported contraceptive use and six (6.9%) experienced forced substance use while trafficked. The most reported barriers that women faced in escaping trafficking were threat of violence (28.7%) and financial dependence (19.5%). Re-trafficked patients were more likely to have a history of being undocumented (odds ratio [OR] = 5.29; 95% confidence intervals [CI] [1.34, 20.94]) and experienced childhood sexual abuse (OR = 2.99; 95% CI [1.10, 8.16]), experienced childhood physical abuse (OR = 3.33; 95% CI [1.18, 9.39]), and lived with a non-parent family member (OR = 6.56; 95% CI [1.71, 25.23]). Although these vulnerabilities were no longer significant when analyzed in a parsimonious multivariate logistic regression model adjusting for the other significant variables, likely due to the limited sample size. Almost half (46.0%) reported ongoing emotional effects from being trafficked, which did not vary by re-trafficking status. Our study highlights potential pre-trafficking vulnerabilities, illustrates the complexity of the trafficking experience, and presents potential risk factors for being re-trafficked.

Keywords

prostitution/sex work violence exposure sexual assault child abuse domestic violence

Human trafficking occurs in an environment of disempowerment when a person is exploited for services, labor, or commercial sex. Globally, an estimated 50 million people are trafficked on any given day (International Labour Organization, 2022), although the true prevalence is difficult to estimate due to its hidden nature. Victims may be reluctant to report their experiences due to fear of retaliation, distrust in the police, or feelings of shame (Hepburn & Simon, 2010; Nemeth & Rizo, 2019; Schroeder et al., 2022). In the United States, the number of calls to the National Human Trafficking Hotline can give insight into the scale of this issue. In 2020, the hotline received reports of more than 10,000 situations involving more than 16,000 victims (Polaris Project, 2020). Human trafficking is also a significant form of sexual- and gender-based violence. In North America, 84% of victims are female and 72% of victims are trafficked for sexual exploitation (United Nations Office on Drugs and Crime, 2020). Sex trafficking occurs when someone is recruited, harbored, transported, patronized, or solicited for a commercial sex act “induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age” (U.S. Department of Justice, n.d.). Furthermore, trafficking can occur domestically or across international borders. In the United States, immigrant women are especially vulnerable due to potential language barriers, lower levels of education, immigration concerns, and unfamiliarity with community resources and legal protections (American Civil Liberties Union, n.d.; United Nations Office on Drugs and Crime, 2020).

Certain risk factors can make a person more vulnerable to exploitation and trafficking including economic hardship, recent migration, unstable housing, substance use, criminal history, lower education, and mental health concerns (Chohaney, 2015; Fedina et al., 2019; Polaris Project, 2020). A systematic review by Franchino-Olsen identified child abuse and maltreatment as key risk factors for being trafficked (Franchino-Olsen, 2021). Witnessing family violence, experiencing neglect, sexual abuse, and living in foster care have also been identified as vulnerabilities (Chohaney, 2015; Landers et al., 2017; Reid et al., 2017). One method in which vulnerabilities have been assessed is through the Adverse Childhood Experiences (ACE) questionnaire, which profiles many of the vulnerabilities listed above (Alexis Kennedy et al., 2021; Reid et al., 2017; Toney-Butler et al., 2022). Furthermore, people who have experienced victimization prior to being trafficked may have an increased risk of victimization during the recruitment and transportation stages of the trafficking process (De Vries & Farrell, 2018).

Generally, victims are targeted by traffickers with whom they have some prior relationship. One study on 71 sex trafficked women in Chicago found that the majority were trafficked by their romantic partners though violence and coercion (Raphael et al., 2010). Sixty three percent of the women in the study stated they were financially indebted to their traffickers, making it more difficult to escape. Victims of trafficking have escaped through individually attempting escape, intentional or unintentional contacts with law enforcement, or seeking services from agencies (Duncan & DeHart, 2019). Some victims experience a cyclical pattern of exploitation in which they continue to face psychosocial or environment barriers after escaping the trafficking situation, which leave them vulnerable to being re-trafficked or re-victimized (Baker et al., 2010).

Re-entry into trafficking is a reality of some victims after escape. Children who were trafficked were more vulnerable to re-trafficking in their adult lives (Jobe, 2010; Kafafian et al., 2021). In addition, without adequately addressing the social, legal, and medical needs of survivors, people may be re-exposed to similar circumstances that made them vulnerable to being trafficked the first time (Adams, 2011; Duncan & DeHart, 2019; Jobe, 2010). A recent study on domestic minor sex trafficking survivors suggested non-punitive measures to address chronic runaway behaviors including safety planning and better foster care placement as potential solutions to address re-trafficking (Nichols et al., 2022). While some vulnerabilities have been identified in the context of re-trafficking, literature on adults who have been internationally re-trafficked is sparse. Our study sought to describe the sex trafficking experiences and explore vulnerabilities to re-trafficking in an urban, majority immigrant, population.

Methods

Study Setting

The EMPOWER Center provides trauma-informed obstetric and gynecologic services to victims of sexual- and gender-based violence. The clinic operates within a federally qualified health center serving a low-income population as part of the New York City Health and Hospitals Corporation. Patients in the EMPOWER Center are referred by a health or social service organization, therapist, attorney, or can present themselves.

Study Design

The EMPOWER Center Study is a retrospective cohort study that enrolls all consenting patients evaluated at the EMPOWER Center to better characterize their medical and psychosocial needs. Patients were evaluated for their intake visit by an obstetrician–gynecologist and/or psychiatrist who specialize in the care of victims of sexual- and gender-based violence. For this sub-analysis, we included all patients who were evaluated from February 2013 to January 2021 and reported a history of sex trafficking. The Trafficking Victims Protection Act of 2000 defined sex trafficking when “a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age” (U.S. Department of Justice, n.d.) (2000). Due to the retrospective nature of this study and inability to appropriately discern the level of exploitation and autonomy surrounding each patient’s circumstances, we adopted a more inclusive definition of sex trafficking to encompass all forms of reported commercial sexual exploitation—“whenever a person obtains sexual access to another person through an exchange of something of perceived value (e.g. money, housing, food, clothing, drugs, protection)” (Mathieson, 2020). This study was reviewed and approved by the Institutional Review Board at New York University Grossman School of Medicine.

Data Collection

The electronic medical records of all patients who met inclusion criteria were reviewed by a research assistant, with a focus on the provider notes from Empower Center intake and follow-up visits. A second research assistant verified the data collected. Conflicts were resolved by the principal investigator who performed the obstetric–gynecologic intake visits. REDCap electronic data capture tools hosted at New York University Grossman School of Medicine were used to collect and manage study data (Harris, Taylor, Minor, et al., 2019; Harris, Taylor, Thielke, et al., 2009).

De-identified, quantitative data on patient characteristics (age, gender, marital status, region of origin, preferred language, education, employment status, immigration status, housing insecurity, and arrest history), details of the trafficking experience (type, age at entry, duration, method of entry, trafficker identity, method of escape, barriers to escape, and re-trafficking), medical and psychiatric history, physical exam findings, and, when available, responses to the adult ACE questionnaire were extracted. The ACE questionnaire is a 10-item survey that assesses for childhood maltreatment experiences that may correlate with a variety of adult health consequences (Felitti et al., 1998; Zarse et al., 2019). Additional childhood adversities reported in the provider notes (living with non-parent family, witnessing family violence, death of parent or sibling, running away from home, abandoned by caregiver, housing insecurity, foster care, and family member trafficked) were also recorded when available. Re-trafficking was defined when a patient reported that they escaped their initial trafficking situation and was trafficked again at a later time in accordance with the International Organization for Migration definition (Jobe, 2010).

Data Analysis

Descriptive statistics were calculated for the entire study population, as well as stratified by re-trafficking experience (trafficked once vs. re-trafficked). To increase the comprehensiveness of reporting, composite variables for childhood sexual, emotional, and physical abuse and neglect were created to capture patients who reported such experience to their provider or indicated the corresponding response on the ACE questionnaire.

Chi-squared tests for categorical variables and t-tests for continuous variables were used to assess for potential differences between the trafficked once and re-trafficked populations.

Informed by our literature search on vulnerabilities, we examined the type of trafficking, method of entry, graduated high school, history of undocumented status, experiences as a minor (sexual abuse, physical abuse, emotional abuse, neglect, witnessed family violence, ran away from home, lived with non-parent family, death or parent or sibling, abandoned by caregiver, lived in foster care, trafficked as a minor, housing insecurity, and incarceration/arrest), and experiences as an adult (housing insecurity, incarceration/arrest) (Chohaney, 2015; Fedina et al., 2019; Franchino-Olsen, 2021; Landers et al., 2017).

Univariate logistic regressions were used to calculate the unadjusted odds ratios (OR) and corresponding 95% confidence intervals (CI) for variables that showed statistical significance in the chi-squared and t-tests when appropriate. Significant variables from the univariate analysis were included in a parsimonious multivariable logistic regression model to calculate the adjusted OR. Data analysis was performed using Stata (v.15) (StataCorp, 2017).

Results

Patient Characteristics

A total of 87 trafficked patients were enrolled in this study. Table 1 displays a comparison of patient characteristics by re-trafficking status. All were women with ages ranging from 17 to 50 years, with a mean of 30.2 (SD = 7.7) years. Most were single (78.2%). Housing insecurity was prevalent, with 25 (28.7%) living in a shelter and four (4.6%) living in unstable housing. In all, 32 (36.8%) had a history of arrest, which was most related to being trafficked (37.5%) or their immigration status (28.1%).

Table 1.

Patient Characteristics by Re-trafficking Status.

Patient Characteristics	All Patients (N = 87)		Trafficked Once (N = 64)		Re-Trafficked (N = 23)		p ^a
Patient Characteristics	Freq	%	Freq	%	Freq	%	p ^a
Age	M = 30.2	SD = 7.8	M = 29.3	SD = 7.5	M = 32.8	SD = 8.2	.060
Marital status
Single	68	78.2	52	81.3	16	69.6	.253
Married	16	18.4	10	15.6	6	26.1
Not specified	3	3.4	2	3.1	1	4.3
Region of origin							.248
Mexico	36	41.4	26	40.6	10	43.5
Caribbean/Central America	15	17.2	11	17.2	4	17.4
Asia	12	13.8	12	18.7	0	0.0
United States	10	11.5	6	9.4	4	17.4
Africa	6	6.9	4	6.3	2	8.7
South America	6	6.9	3	4.7	3	13.0
Europe	2	2.3	2	3.1	0	0.0
Preferred language							.359
Spanish	53	60.9	38	59.4	15	65.2
English	26	29.9	18	28.1	8	34.8
Mandarin	5	5.7	5	7.8	0	0.0
Other	3	3.5	3	4.7	0	0.0
High school graduate^b	16	47.1	10	45.5	6	50.0	.800
Employed or in school^c	23	41.8	19	48.7	4	25.0	.105
Housing insecurity	29	33.3	22	34.4	7	30.4	.731
History of undocumented status	10	11.5	4	6.3	6	26.1	.011 *
History of arrest	32	36.8	20	31.2	12	52.2	.074

p Value for trafficked once and re-trafficked groups.

High school graduate was analyzed among those with available data (N = 34).

Employment status was analyzed among those with available data (N = 55).

Indicates significance at p < .05.

Women who were seen at the EMPOWER Center were referred by social service or legal aid organizations (93.1%), healthcare facilities (4.6%), or friends/self (2.3%). They sought care most often for a routine gynecologic exam (72.4%). In terms of gynecologic history, 28 (32.2%) had a history of sexually transmitted infection and 7 (6.9%) had chronic pelvic pain.

In our study, most of them were victims of international trafficking (88.5%), often from Mexico (41.4%), the Caribbean/Central America (17.2%), or Asia (13.8%). Accordingly, Spanish was the most common language (60.9%). Among the 57 who immigrated and for which immigration year is known, the amount of time that they have been in the United States varied from 0 to 25 years, though re-trafficked patients have spent more time in the United States (6.0 years vs. 12.1 years, p = .004). In all, 16 (18.4%) were applying for immigration or adjustment of status. In total, 10 (11.5%) had a history of being undocumented, which was more likely among re-trafficked patients (p = .011).

Psychiatric and Childhood Abuse History

Self-reported psychiatric comorbidities were prevalent: 31 (35.6%) with depression, 12 (13.8%) with posttraumatic stress disorder, and 12 (13.8%) with anxiety (Table 2). Patients in our study also experienced high rates of childhood sexual (29.9%), physical (25.3%), and emotional (24.1%) abuse, as well as neglect (25.3%). Of the 37 patients who completed the ACE questionnaire, scores were high (M = 4.24; SD = 3.02).

Table 2.

Psychiatric and Childhood Experience History by Re-trafficking Status.

Intake Visit	All Patients (N = 87)		Trafficked Once (N = 64)		Re-Trafficked (N = 23)		p ^a
Intake Visit	Freq	%	Freq	%	Freq	%	p ^a
Past psychiatric history
Depression	31	35.6	19	26.7	12	52.2	.053
PTSD	12	13.8	7	10.9	5	21.7	.198
Anxiety	12	13.8	9	14.1	3	13.0	.903
Panic disorder	1	1.1	1	1.6	0	0.0	.547
Other	14	16.1	8	12.5	6	26.1	.128
Childhood experiences
Sexual abuse	26	29.9	15	23.4	11	47.8	.028 *
Physical abuse	22	25.3	12	18.7	10	43.5	.019 *
Emotional abuse	21	24.1	13	20.3	8	34.8	.164
Neglect	22	25.3	14	21.9	8	34.8	.222
Lived with non-parent family	11	12.6	4	6.3	7	30.4	.003 *
Witnessed family violence	11	12.6	7	10.9	4	17.4	.424
Death of parent or sibling	7	8.0	4	6.3	3	13.0	.304
Ran away from home	6	6.9	4	6.3	2	8.7	.691
Abandoned by caregiver	5	5.7	2	3.1	3	13.0	.080
Foster care	4	4.6	1	1.6	3	13.0	.024 *
Family member trafficked	4	4.6	1	1.6	3	13.0	.024 *
Housing insecurity	4	4.6	3	4.7	1	4.3	.947
Arrested/incarcerated	3	3.5	2	3.1	1	4.3	.783

Note. PTSD = posttraumatic stress disorder

p Value for trafficked once and re-trafficked groups.

Indicates significance at p < .05.

Table 2 displays psychiatric and childhood abuse histories by re-trafficking status. Notably, re-trafficked patients were more likely to have experienced childhood sexual abuse (p = .028), childhood physical abuse (p = .019), lived with non-parent family (p = .003), lived in foster care (p = .024), and had a family member trafficked (p = .024).

Trafficking Details

Details of trafficking experiences by re-trafficking status are outlined in Table 3. Among the 67 patients who reported their age when first trafficked, 23.0% were minors. The mean duration of trafficking was 3.1 years but ranged from a less than a month to 19 years. Women were most commonly trafficked by a romantic partner (32.2%) through coercion (70.1%). Among the 61 patients for whom the sex of their trafficker is known, traffickers were most often male (73.8%) or both sexes (18.0%). Nine (10.3%) reported contraceptive use and six (6.9%) experienced forced substance use while trafficked.

Table 3.

Trafficking Details by Re-trafficking Status.

Trafficking Details	All Patients (N = 87)		Trafficked Once (N = 64)		Re-Trafficked (N = 23)		p ^a
Trafficking Details	Freq	%	Freq	%	Freq	%	p ^a
Duration of trafficking^b	M = 3.0	SD = 4.0	M = 3.1	SD = 3.7	M = 2.9	SD = 4.8	.899
Method of entry							.126
Coercion	61	70.1	44	68.8	17	73.9
Abduction	12	13.8	9	14.1	3	13.1
Sold	4	4.6	1	1.6	3	13.1
Not specified	10	11.5	10	15.6	0	0.0
Identity of trafficker							.322
Romantic partner	28	32.2	21	32.8	7	30.4
Employer	22	25.3	15	23.4	7	30.4
No known relationship	26	29.9	21	32.8	5	21.7
Family member	6	6.9	3	4.7	3	13.0
Friend	3	3.5	3	4.7	0	0.0
Police	1	1.2	0	0.0	1	4.4
Coyote	1	1.2	1	1.6	0	0.0
Barriers to escape^c
Threat of violence	25	28.7	16	25.0	9	39.1	.199
Financial dependence	17	19.5	11	17.2	6	26.1	.356
Immigration status	4	4.6	2	3.1	2	8.7	.274
Threat of arrest	2	2.3	1	1.6	1	4.4	.445
Other^d	3	3.5	2	3.1	1	4.4	.783
Method of escape^c
Unassisted	24	27.6	15	23.4	9	39.1	.149
Assisted by an individual	22	25.3	17	26.6	5	21.7	.648
Arrested	11	12.6	11	17.2	0	0.0	.033 *
Trafficker arrested	8	9.2	8	12.5	0	0.0	.075
Released by trafficker	4	4.6	1	1.6	3	13.4	.024 *
Sought legal intervention	2	2.3	2	3.1	0	0.0	.391
Paid financial debt	1	1.2	0	0.0	1	4.4	.093
Not specified	22	25.3	16	25.0	6	26.1	.918

p Value for trafficked once and re-trafficked groups.

Duration of trafficking was analyzed among those with available data (N = 67).

Participant could select multiple responses so percentages may not add up to 100%.

Other barriers to escape were drug dependence, physical entrapment, and threat of disclosure to the patient’s family.

Indicates significance at p < .05.

The most reported barriers that patients faced in escaping trafficking were threat of violence (28.7%) and financial dependence (19.5%). When those trafficked were able to escape, most escaped on their own (27.6%) or with the help of an individual (25.3%), rather than with assistance from a social service organization or legal intervention. The 11 (12.6%) patients who escaped because they were arrested were not re-trafficked (p = .033). A similar trend approaching significance (p = .075) was seen among patients whose traffickers were arrested. On the other hand, patients who were released by their trafficker were more likely to be re-trafficked (p = .024).

Almost half (46.0%) reported ongoing emotional effects from being trafficked, which did not vary by re-trafficking status. A few had sustained physical insults leading to chronic exam findings including scars from cuts (6.6%) and burns (1.2%), neurologic findings (2.3%), breathing trouble (1.2%), and branded tattoo (1.2%).

Risk Factors for Being Re-trafficked

The prevalence of re-trafficking was high with 20 (23.0%) trafficked twice and three (3.5%) trafficked three times. Women who were re-trafficked were more likely to have a history of being undocumented (OR = 5.29; 95% CI [1.34, 20.94]) and experienced childhood sexual abuse (OR = 2.99; 95% CI [1.10, 8.16]), experienced childhood physical abuse (OR = 3.33; 95% CI [1.18, 9.39]), lived with a non-parent family member (OR = 6.56; 95% CI [1.71, 25.23]) than patients who were trafficked once. The other tested variables were not found to significantly affect the odds of being re-trafficked (Table 4).

Table 4.

Analysis of Vulnerabilities to being Re-Trafficked.

Bivariate Analysis	Re-Trafficked Unadjusted OR	95% CI
History of undocumented status	5.29	1.34, 20.94*
Childhood experiences
Sexual abuse	2.99	1.10, 8.16*
Physical abuse	3.33	1.18, 9.39*
Lived with non-parent family	6.56	1.71, 25.23*
Foster care	9.45	0.93, 96.01
Family member trafficked	9.45	0.93, 96.01
Multivariate analysis	Re-Trafficked Adjusted OR	95% CI
History of undocumented status	3.97	0.89, 17.69
Childhood sexual or physical abuse	1.41	0.41, 4.75
Lived with non-parent family	4.61	0.96, 22.11

CI = confidence intervals; OR = odds ratio.

Indicates significance at p < .05.

When analyzed in a parsimonious multivariate logistic regression model adjusting for the significant variables, childhood sexual or physical abuse, history of being undocumented, and history of living with non-parent family members were no longer significantly associated with being re-trafficked (Table 4). A composite variable was created to capture patients who experienced childhood sexual or physical abuse since there was strong correlation between the two (r = 0.72). In addition, having lived with non-parent family member was moderately correlated with childhood sexual or physical abuse (r = 0.46).

Discussion

This retrospective cohort study sought to investigate vulnerabilities to sex trafficking, with a focus on victims of re-trafficking, in an urban clinic population. Our study found that patients who have been re-trafficked were more likely to have a history of being undocumented and certain childhood adverse experiences: sexual abuse, physical abuse, and living with non-parent family members.

This study portrays the diverse experiences of sex trafficking. Most patients in this study were adult victims of international trafficking, many originating from Latin America. Patients presented with acute and/or chronic health consequences from their experience, including almost half with lasting emotional trauma, which is lower than a prior study examining health outcomes in international trafficking victims (Muftić & Finn, 2013). However, unlike in the Muftic study, none of the patients in our study were still being trafficked when enrolled. Although research has been dedicated to identifying victims of human trafficking in the healthcare setting (Bespalova et al., 2016; Greenbaum et al., 2018; Mumma et al., 2017), most patients in our study escaped by themselves or with the assistance of an individual. Although none escaped with the assistance of a healthcare provider or social service organization, our study showed that trafficked women do interface with the healthcare system, thus creating an opportunity for providers to build longitudinal trusting relationships.

Furthermore, a quarter of women escaped because of interactions with the criminal justice system, through their own arrest, their trafficker’s arrest, or seeking legal intervention. This emphasizes the importance of discerning victims from their perpetrators, especially given that traffickers can be male or female. This is further complicated by the fact that many victims of trafficking are immigrants, some of whom have a history of being undocumented. All patients in our population who were arrested for trafficking were not re-trafficked. This could be due to systems in place in the legal sector and courts connecting these individuals to services and consequently decreasing re-trafficking prevalence. The Human Trafficking and the State Courts Collaborative, for example, was developed to guide state courts on finding resources in their areas to aid trafficking victims when they enter the court to provide support to the victims rather than penalize them (Brunson et al., 2014). In New York City, the Human Trafficking Intervention Court offers social service mandates (counseling sessions) in lieu of criminal convictions, although some have expressed that voluntary involvement in social services is more meaningful (White et al., 2017). While there may be some court-guided resources available, it is imperative to note that incarcerating or imprisoning victims in these cases is not the solution to ending the re-trafficking cycle nor the sole way to provide these resources to victims (Adams, 2011; Clinic, 2021). Care must be taken when assisting victims of human trafficking from a collaborative approach among the legal, social service, and healthcare systems.

The most common barrier to escaping trafficking was the threat of violence and financial dependence of the patient to the trafficker. How an individual enters trafficking can be an indication of the barriers one may face when trying to escape. Many patients were economically coerced into trafficking resulting in financial dependence, which aligns with known literature (Moore et al., 2017; Toney-Butler et al., 2022). This may be exacerbated by being in a new country and unfamiliarity with social resources for patients who were internationally trafficked. In addition, there are misconceptions about what trafficking looks like, including traffickers who kidnap individuals and physically hold victims captive (Office of Trafficking in Persons, 2019). This form of trafficking is possible; however, as seen from this study’s population, many patients were coerced into trafficking by romantic partners or employers. The barriers to escaping are often complicated by socioeconomic and psychological factors (Baker et al., 2010). Therefore, it is important to understand the complex path of entry into trafficking to fully encapsulate the difficulties that might emerge when attempting to escape.

Few studies have examined the re-trafficked population, which may be conceptualized as a distinct subpopulation from those who have only been trafficked once. Being re-trafficked could suggest that individuals may have experienced more severe pre-trafficking vulnerabilities or that those vulnerabilities were not mitigated after escaping trafficking the first time. Since current literature on re-trafficking vulnerabilities is sparse, we looked to literature on pre-trafficking vulnerabilities as potential risk factors for re-trafficking as well. Some studies indicate that childhood abuse and neglect are associated with a higher likelihood of being trafficked (Franchino-Olsen, 2021). Similar associations were found in our study: one in four patients had experienced sexual, physical, or emotional abuse or neglect.

Childhood sexual and physical abuse were positively correlated with being re-trafficked. Having lived with non-parent family members was also a significant vulnerability, which may reflect less home stability or parental supervision. This suggests certain adverse experiences during the early stages of one’s life may be more influential in making people vulnerable to cyclical exploitation. Re-trafficked individuals were also more likely to have a history of being undocumented, although the actual prevalence is likely higher given immigration status was not explicitly asked and only recorded if volunteered by the patient. This history may elicit a fear of seeking legal intervention, difficulty accessing health care, limited employment opportunities, or a general sense of disempowerment in a new country (Ornelas et al., 2020; Ortega et al., 2018). However, these variables were no longer significantly associated with re-trafficking when analyzed in a multivariate model, likely due to the high degree of correlation between sexual and physical abuse and not enough power in our study due to our smaller sample size. Witnessing family violence, running away from home, housing insecurity, and incarceration/arrest as a minor are all vulnerabilities for trafficking that have been described (Chohaney, 2015; Franchino-Olsen, 2021), although we were unable to detect an association of these risk factors with re-trafficking in our study. We also did not find an association between level of education and risk of being re-trafficked. Being trafficked as a minor did not seem to increase the risk of being re-trafficked in our population, nor did the type of trafficking or method of entry. However, the modest sample size of our study and the small number of re-trafficked women limit the statistical significance of our findings.

Our study focuses on characterizing patterns of vulnerabilities through differences in prevalence that we observe in our dataset, so a major limitation is inability to draw conclusions about causative effect. Since data were collected through a retrospective chart review, questions were not asked in a standardized format and some women may not have disclosed details of their trauma history or trafficking experience given the sensitive nature of the topic. Thus, the prevalence of abuse, neglect, home instability, and other adverse experiences is likely underreported. Furthermore, the differentiation between sex trafficking and non-exploitative commercial sex is complex (Albright & D’Adamo, 2017; Peters, 2015; Saunders, 2005). Due to our retrospective study design, we are unable to comment on the interplay of exploitation versus choice surrounding each person’s circumstances.

Our study highlights potential pre-trafficking vulnerabilities, illustrates the complexity of the trafficking experience, and presents potential risk factors for being re-trafficked. It sheds light on the lasting impact that early experiences of abuse and home disruptions can have in putting people at risk for being trafficked multiple times. The cyclical nature of human trafficking is difficult to break, and care for victims will require cross-collaboration between the legal, social service, and healthcare systems (Haney et al., 2020).

Providers to trafficking victims should be aware of this cycle to adequately provide care that could lead to their patients not being re-trafficked. A comprehensive need assessment should always be conducted, with a focus on the patient’s safety while recognizing that needs may change as people progress from initial escape to recovery and independence (Macy & Johns, 2011). In an effort to break this cycle, the EMPOWER Center follows an integrated care model and provides services such as legal support, case management, and economic empowerment. Future research should focus on implementing and assessing effective interventions that empower individuals and address vulnerabilities to re-trafficking at its root. When vulnerabilities of trafficking are not mitigated, individuals are at heightened risk of remaining in the cycle of trafficking.

Footnotes

Acknowledgements

We thank Shirley Eng for her contributions to the early planning stages of this study. We also thank the Empower Center, New York City Health and Hospitals Cooperation, New York University Grossman School of Medicine, and Albert Einstein College of Medicine for their support.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research and/or authorship of this article.

ORCID iD

Victoria H. Chen

Author Biographies

Victoria H. Chen, MD, graduated from New York University Grossman School of Medicine. She has an undergraduate degree in Public Health with a minor in Social Policy from Johns Hopkins University. Her research focuses on studying polyvictimization among victims of sexual- and gender-based violence. She is interested in identifying mechanisms to address social determinants of health and its integration into clinical care.

Esther L. Beauchemin, MPH, graduated from New York University School of Global Public Health with a concentration in Epidemiology. She received her BA in Psychology from Denison University. Her research focuses on investigating health outcomes of those who have experienced sexual- and gender-based violence and individuals living in areas with environmental contamination. She is interested in continuing research efforts to address environmental exposures exacerbated by social determinants of health.

Isabella T. Cuan, MSc, is a medical student at New York University Grossman School of Medicine. She received a BA in Neuroscience from University of Pennsylvania and a Master’s in Medical Humanities from University of Manchester. She is interested in interdisciplinary research and advocacy efforts that reconstruct social, economic, and medical systems fueling health inequity to improve patient-centered care among vulnerable populations.

Annum Sadana, BA, is a medical student at New York University Grossman School of Medicine. She has an undergraduate degree in Social Policy Analysis from Rice University. Her research focuses on international health policy. She is interested in efforts to enact global health equity, and in investigating the reproductive health of marginalized populations, especially those who have been forcibly displaced.

Lolayemi O. Charles is an undergraduate student at the New York University School of Global Public Health where she is pursuing a BA in Global Public Health and Sociology. Her research focuses on the vulnerabilities and health outcomes of racialized minorities, and survivors of sexual and gender-based violence. She is interested in the identification of social inequalities in healthcare and the development of sustainable primary healthcare reform.

Julia E. Leschi, BSc, received her degree in Applied Psychology with a minor in Global Public Health from New York University Steinhardt School of Culture, Education, and Human Development. She currently serves as a program coordinator for the Human Rights Clinic at HealthRight International. Her research focuses on survivors of torture and human trafficking, as well as forensic evaluations for asylum seekers.

Veronica Ades, MD, MPH is the Vice Chair of the Department of Obstetrics and Gynecology at Jacobi Medical Center, an Associate Professor of Obstetrics and Gynecology and Women’s Health at the Albert Einstein College of Medicine, and the Director of the EMPOWER Center. She is the Principal Investigator of the Empower Lab, a public health laboratory that conducts research on the intersection of sexual- and gender-based violence and health.

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