Trafficking,Client and Police Violence,Sexual Risk and Mental Health Among Women in the Sex Industry at the Thai-Myanmar Border

Abstract

This study describes sex trafficking and associations with violence and health among female migrants in the sex industry in Mae Sot, Thailand. The mixed-methods study included a qualitative interview phase (n = 10), followed by a cross-sectional survey phase (n = 128). Entry via trafficking (force, fraud, or coercion [FFC], or as minors) was prevalent (76.6%), primarily FFC (73.4%). FFC was associated with inconsistent condom use, inability to refuse clients, poor health, and anxiety. Past-year violence was normative including client sexual violence (66.4%), client coercion for condom nonuse (> 95%), and police extortion (56%). Working conditions enabled violence irrespective of mode of entry. Profound unmet needs exist for safety and access to justice irrespective of trafficking history.

Keywords

violence trafficking migrant sex industry minor sex work mental health sexual risk condom police

Background

Women in the sex industry face a disproportionate burden of HIV (Baral et al., 2012) as well as profound risk for gender-based violence, with a cascade impact on STI/HIV risk behavior and infection and other aspects of physical, sexual, and mental health (Decker et al., 2011, 2012; Lang et al., 2013; Ulibarri et al., 2011). Intervention strategies for this population are typically rooted in one of two primary approaches with divergent foundational principles, specifically, an abolitionist framework which conceptualizes the sex industry as fundamentally exploitative, and a rights-based, empowerment approach which seeks to recognize and bolster rights and agency (Tucker & Tuminez, 2011). Sex trafficking is a human rights violation and threat to health and well-being defined by the UN Palermo Protocol as force, fraud, or coercion (FFC) to the sex industry, or entry under age 18 years (UN General Assembly, 2000). While sex trafficking is considered central to the abolitionist framework, it is acknowledged by both approaches. Since the first epidemiological assessment of trafficking within a broader sample of women in the sex industry (Sarkar et al., 2008), a growing body of epidemiological research confirms the persistence of both early and forced involvement in the sex industry in South and Southeast Asia (Decker et al., 2011; Devine et al., 2010; George & Sabarwal, 2013; Silverman et al., 2014) and other geo-cultural settings (Goldenberg et al., 2013, 2014).

Available data suggest a mode of entry to the sex industry confers lasting health and social implications, as early, coerced, and forced sex industry involvement impart risk for violence and sexual risk (Decker et al., 2011, 2020b; George & Sabarwal, 2013; Goldenberg et al., 2014; Silverman et al., 2014). Simultaneously, threats to human rights, personal power, and agency among those in the sex industry are not limited to trafficking survivors. Rather, abundant evidence from a range of settings reveals violence and mistreatment to those engaged in sex work at the hands of a range of perpetrators (Decker et al., 2010, 2011, 2012, 2014, 2020a, 2020b; Gupta et al., 2009). Clarity on the extent and nature of trafficking in high-risk settings, and its implications for health and safety, remains an essential research priority to guide effective, evidence-informed policy that advances rights and unmet needs.

While empirical data are lacking, the risk for trafficking for sexual exploitation is considered heightened in humanitarian settings and in the longer-term aftermath of economic and social disruption that follows conflict, civil unrest, and natural disaster (Mahn et al., 2008; USAID, 2006). Data on sex trafficking and the sex industry in general within the context of large-scale migration and protracted conflict are limited but critically important (Keygnaert et al., 2012; Tanabe et al., 2013; Truong et al., 2014). Such research is particularly valuable at the Thai-Myanmar border, where factors including widespread poverty, lack of livelihood opportunities, and four decades of humanitarian crisis have spurred massive migration to and through neighboring Thailand. Migrants from Myanmar make up a significant proportion of the estimated 3.9 million migrant workers in Thailand (Harkins, 2019). Women in the sex industry are considered particularly vulnerable to police raids, abuse, and harassment (Harkins, 2019). Past research with female migrants and refugees from Myanmar living in refugee camps in Thailand confirms significant conflict-related violence as well as sexual harassment and victimization (Caouette et al., 2000; Falb et al., 2013); however, data on female migrants in the sex industry in this setting are extremely limited.

Against this backdrop, we examine the prevalence and nature of entry into the sex industry via force, fraud, or coercion, or under age 18 years, and explore associations between mode of entry and violence, sexual risk, and health for female Myanmar migrants in the sex industry in Mae Sot, Thailand.

Methods

Setting and Context

We undertook a mixed-methods study to examine migration, trafficking, and health among migrant workers from Myanmar in and around the city of Mae Sot, Thailand. Located in western Thailand, in Tak Province, Mae Sot represents a major transit point for migrants crossing from Myanmar into Thailand (Environmental Justice Foundation, 2013). Researchers collaborated with a local community-based organization, Social Action for Women (SAW), for all phases of the research. Qualitative data were collected February–April 2012 and quantitative data were collected December–March 2013. Further details on the methodology are available elsewhere (Meyer et al., 2016, 2015, 2019). The full study enrolled migrant workers engaged in agricultural work, factory work, and the sex industry. While male migrants may similarly engage in sex work or experience trafficking for exploitation, the sex industry portion of this study focused specifically on women as an identified, high-need population per practitioner partners. The present study reports on two distinct study phases (in-depth interviews [IDIs] and cross-sectional survey), using only data from female migrants working in the sex industry,

Qualitative Procedures

Qualitative interviews were conducted with women who had migrated from Myanmar, aged 18 years and over, residing in and around Mae Sot, and who were involved in the sex industry (n = 10). Recruitment was conducted via community-based sampling in which the outreach team circulated information about the study through their networks and invited eligible participants. Procedures aligned with guidance for interviewing trafficked women (Zimmerman & Watts, 2003) and were designed to maximize safety, confidentiality, and access to crisis and support services (Douoguih, 2008). One-time, semi-structured IDIs of approximately 1 h were conducted in a private location of the participant's choosing. Interviews were conducted in Burmese language by a pair of research assistants with training and experience in qualitative research methods and counseling. As audio-recording was deemed inappropriate, the two-person interviewer team allowed one to conduct the interview and the other to simultaneously transcribe. Transcripts were reviewed for accuracy, and translated into English for analysis. An initial coding structure was developed through hand-coding an initial set of interviews (Creswell, 2007, 2012). Codes were iteratively built upon, merged, and clarified, using the constant comparative method (Boychuk Duchscher & Morgan, 2004), conducted in Atlas.ti.

Quantitative Procedures

Following the completion of the IDI phase of the study, a respondent-driven sampling (RDS) process was undertaken to recruit participants for a cross-sectional survey. The RDS implemented in the sex industry enrolled women who had migrated from Myanmar and were involved in the sex industry (defined as having traded sex for money or resources in the past year), aged 18 years or older, and residing in the greater Mae Sot area. RDS is a peer-driven chain referral method with demonstrated capacity for reach into hidden sub-populations (Johnston et al., 2006), whereby participants recruit a limited number of peers, and recruitment patterns are tracked and integrated analytically (Heckathorn, 1997). Consistent with standard RDS methods (Magnani et al., 2005), five seeds were recruited by the local partner, SAW, and initiated chain referrals with each seed and subsequent recruit provided with three coupons with which to recruit eligible peers. Contact was initiated via phone to minimize safety concerns. Following verbal informed consent, participants completed an interviewer-administered survey in a mutually agreeable, safe, and private location. A total of 334 coupons were distributed with 123 returned for a final sample size of n = 128. Procedures adhered to ethical guidelines for violence-related (Garcia-Moreno et al., 2005) and trafficking-related (Zimmerman & Watts, 2003) research. Interviewers received extensive training and were selected based on their experience and training in counseling and/or qualitative research on mental health, as well as working with migrants on sensitive issues (Kortum et al., 2010). Participants were carefully monitored for distress. At the conclusion of each interview, participants received a universal distress screener, and were provided with a discreet local resource sheet documenting local services for trafficking and violence support and intervention, and 250 Thai Bhat. All procedures were approved by the Johns Hopkins School of Public Health Institutional Review Board and a local review committee assembled for this purpose; further details are available elsewhere (Meyer et al., 2015, 2016, 2019).

Quantitative Instrument

All measures were self-reported. The instrument was developed in English language, translated into Burmese, back-translated, and further refined based on review with native speakers. Demographic variables included age, marital status, level of education, and ethnicity.

Entry to sex work via trafficking was assessed via two items (Decker et al., 2011; Silverman et al., 2014) that operationalize elements of the Palermo Protocol's definition of trafficking, specifically force, fraud, or coercion, and entry under age 18 years. Specifically, participants were asked, “How would you describe how you entered or first began sex work?”; forced, fraud, or coercion, respectively, were indicated by affirmative response to options “tricked,” “forced,” or “pressured, threatened or otherwise coerced,” respectively. Age at entry was calculated based on current age and years in sex work, and handled as a binary variable representing entry under age 18 years. Entry via trafficking was defined as indicating either force, fraud, or coercion (FFC), or under age 18 years at entry.

Sex industry context was assessed via standard single items including length of time in the sex industry, location of sex trade, days per week worked, number of clients per day, and reliance on workplace as a primary residence.

Sexual risk, violence, coercion, and police interference assessments were informed by our formative phase, as well as qualitative and quantitative research. Single items assessed how participants made arrangements with clients, participant's control over arrangements with clients, ability to refuse clients, condom use with clients in the past 6 months, anal sex with clients in the past year, and coercive condom experiences (Decker et al., 2010; Decker et al., 2020a) in the past year including client condom refusal, removal, and anger or violence regarding condom negotiation. Sexual coercion and violence measures included being presented with more clients than agreed to (Decker et al., 2012) and pressured for sex with clients, and physically forced sex with clients, both adapted for use with sex workers (Decker et al., 2014) based on the Conflict Tactics Scale (Straus, 1979). Respondents were asked about their first month of sex work, specifically experiences of forced sex, anal sex, and being presented as a virgin, based on past evidence (Silverman et al., 2011). Two items assessed past-year police interference.

Health outcomes included self-rated health (Idler & Benyamini, 1997) assessed on a scale of 0-100, forgone health care, and self-reported sexually transmitted infection diagnosis. Mental health was assessed using an adapted version of the Hopkins Symptoms Checklist-25 (HSCL-25); depression and anxiety sub-scales were handled as binary variables at the 1.75 cut-off (Mollica et al., 2014).

Analysis

The prevalence and nature of trafficking were calculated for the sample. Due to the small cell size for women entering as minors only (n = 4), the subsequent analysis focused solely on the FFC aspect of trafficking. Demographic characteristics and elements of sex industry context were generated for the entire sample, and compared based on FFC. Control over working conditions, recent sexual risk and exposure to violence, and physical and mental health outcomes were calculated for the entire sample, and based on FFC; logistic regression analyses were calculated in Stata to evaluate associations of FFC while adjusting for confounders deemed relevant to FFC exposure at p < .05. All analyses used robust cluster adjustment to account for the potential for intracluster correlation of participants recruited within the recruitment chain (Szwarcwald et al., 2011).

Results

Qualitative Results

Entry to the Sex Industry

Many participants described initial work at restaurants or storefronts, only to be forced into sex work shortly thereafter.

At the first day [at the restaurant], I made 50 baht tip and 100–200 baht for pocket money in doing so. I already liked that job as I earned 200 baht within a night. After I worked there for 3 days, a Thai man came by a car and picked me up. [Manager] told me to go with him. I refused, but the other girls also told me to go. I had to go with him. That was the first day I became a prostitute. (37 years, IDI#3)

I couldn't go out of this place and after 5 days, the boss told me to go back to my room. I thought she told me to take rest so I went up to my room. After about 10 minutes, the boss knocked on my door and asked me to open. She left a man of about 40 years old in my room and told me, in Burmese language, to serve him well. She locked the door from the outside. I could not refuse and go out of the room so I had to sleep all the night with this man in the room. At about 4 am, she came and opened the door. (30 years, IDI#8)

Many described not realizing that the work was a cover for sex work until they were already indebted for an initial period. Language barriers added to a sense of confusion.

First I had to work as a waitress. … At night, I had seen that others including my friend went up to the other floor with the men. After about two days, I realized that this restaurant was just the cover business and they run prostitution work. So I told my friend that I do not want to work there anymore and I wanted to go and work at another place. My friend said I couldn't and anyone had to work at least 3 months here after they got in this job. She also said that if I went away, the boss would ask the police to arrest me. Since I couldn't understand much, I had to believe them. (30 years, IDI #8)

Often, participants did not realize they had been sold for sex work until after the initial transporters—to whom they were indebted—were long gone.

The two guys who brought me spoke in Thai, I did not understand what they said. … Later a woman came and told me that I have to work at the shop this evening and I have to serve the guests. … They asked me whether I knew what I have to do. I told them I just knew that I have to work at Noodle shop. They said the guys, who sent me here, brought me because I told them I wanted to work this job and they already took 3,000 Baht from my coming income. They also asked me what I wanted to do. They would inform to the police, and they would send me to the police station (if I leave). So I told them not to send me to police station and that I would do anything they asked. They told me that if they got back 3,000 Baht, it is fine, so just go to the shop and serve the guest. … I had to serve a Thai guest and a foreigner until the next morning. … Since I was the new at this shop, I had to accept many customers. (27 years, IDI#10)

Against the backdrop of criminalization, fear of police arrest was a powerful force in compelling women into compliance.

When we were in the first restaurant in Bangkok, we couldn't go since the debt was not over yet. They told us that wherever we ran, we could not escape. If we were arrested by the police, we would not only be arrested but we would also be charged with prostitution. They said we could be even imprisoned. (32 years, IDI#1)

Efforts to refuse sex work resulted in physical violence. Fear of abuse, including that generated by witnessing violence against others, was powerful in securing women's compliance.

I was afraid. Although I didn't want to sleep with the customers, I just had to accept them. Some were beaten when they had quarrels with the customers. I didn't know anything, say anything and if they called me, I just followed. (18 years, IDI#1)

Conditions in the Workplace and Barriers to Exit

Managers ensured women's compliance and diminished their leverage to resist abusive work environments through a complex system of financial extortion, close surveillance, and threats of abuse.

If the boss was Burmese, it was worse. They paid the wages once in 15 days. If we borrowed money, they made us pay it back with a high interest rate. They kept records of money taking but didn't keep record for the money paid back by the girls. If we moved secretly [to another workplace], we were tortured. They followed to the shop we moved. In some brothel, we had to do whatever the customer asked us to do. If we didn't, we were threatened. They didn't want to lose their customers. (25 years, IDI#5)

The boss does not allow us to change the job. She is worried of losing the number of customers. And since she was watching carefully on us even we go outside, how could we change job? (30 years, IDI#8)

Language barriers created an additional sense of isolation and confusion for women.

I was the only one who didn't speak the language. I was the one to open the door and greet the customers by saying, “Sawadee Kha.” I had to go with the customers and sleep with them if they were interested in me. It's not my choice but by the boss's order. When I refused, the boss demanded the money he paid for me. I didn't understand what the boss said in Thai. (27 years, IDI#9)

Women's leverage and freedom from abusive work practices appeared to increase with time, with newcomers described as more vulnerable to coercion including the threat of police.

Now the boss didn't dare to yell at us much because we were old workers and he was worried if we move to another place. For the newcomers, he coerced them so that they couldn't change to another job. He also coerced them with police. (32 years, IDI#1)

Another respondent described that women could only leave or quit under the auspices of returning home after a period.

Workers do not change to other jobs, they just went home if they wanted to quit. They told the boss that their parents’ health was not well or their parents died and took leave for about 10 or 15 days. And then they didn't come back. We have to quit like this. (30 years, IDI#8)

Limited control over client selection; sexual mistreatment and violence

Women described little ability to refuse customers in the face of management pressure, often deriving from financial considerations.

When we were exhausted and could not work, [the boss] didn't allow us to rest. If the customers came, she forced us to go. If we didn't, she scorned us but she didn't yell at us and beat us. If we didn't go, the boss was worried if the customers didn't come for the next time. So we had to go. We knew that some customers had HIV. As we had the experience with them before, we didn't want to go with them. Although we refused, the boss told us to use condom and forced us to go. (23 years, IDI#6)

Women who refused unwanted clients, often after they were no longer new, suffered financially. Refusal of specific sex acts put women at risk of physical assault.

At work, some guests asked us to do what they want. If I refused to do so, they called the boss and complained. The boss had to refund all the advance money given by the guest. On these days, we had to sleep with the guest without getting pay and we were yelled at by the boss. Some guests asked us to have oral sex. When I said that I could not do it, they slapped on my cheeks. Later I just accompanied the guests who were getting along with me. If not, I didn't accompany. As I was choosing the guests a lot, I got just a little money. (27 years, IDI#10)

This limited control over sexual decision-making extended to coerced sex with managers; many respondents described that their managers abused their power over them to coerce unwanted and unpaid sex with little risk of being held accountable.

There was a male manager. He was very bad. He asked money from me by cheating. He forced me to give money and if I didn't, he slaps on my cheek. Although he had a wife, he slept with me. I was afraid of him. Although I didn't want to go with customers, he forced me to go. (18 years, IDI #1)

He [the manager] also picked one of us to sleep with him without any pay, daily. We dared not to speak out about it. (37 year, IDI#3)

Women were also subject to sexual violence from clients with little recourse. Sexual violence was often severe.

Some people, who were on heavy drugs, forced me to have violent sex. When I refused to do once, a customer stuck my neck with his knife and forced me to perform as he wished to. (37 years, IDI#3)

Women also described scenarios of forced sex with multiple sequential clients in what can be considered gang rape.

Another time, I was taken by a customer and put in a room to have sex with 8 people. I only got paid for one person. I ran away naked after I had sex with two men, as I could not bear any more. (37 years, IDI#3)

I met two bad customers. On that night, all the rooms at the shop were full so they [clients] called me out. I followed as I was afraid. I didn't know where they went and they didn't reach to where they wanted to. I was raped in the car by both of them and then they dropped me on the street. Since I didn't know where to go, I was sitting on the street and crying. (18 years, IDI#1)

In contrasting migration-related expectations with the realities they encountered, women emphasized extensive fear as a result of being subject to and witnessing sexual and physical violence.

The other difference was that I thought when I arrived to Mae Sot, I could be able to work easily but in reality, I was afraid of being hurt. I did not expect the bullying of the customers and the cheating and the rape when I arrived. (26 years, IDI#7)

Quantitative Results

A total of 76.6% (n = 98) entered the sex industry under the age of 18 years or via FFC (Figure 1). Overall, 73.4% (94/128) of the sample entered via FFC, and 18.7% (24/128) of the sample entered the sex industry under the age of 18 years, the majority of whom (n = 20/24) were also characterized as FFC. Fraud specifically was the most common means of FFC; 53.1% (68/128) reported fraud in isolation (Figure 2). Fraud in combination with force was reported by 8.6% (11/128). Other combinations included force or fraud with or without coercion. Any fraud was reported by 68.7% (88/128), followed by force (17.2%; 22/128), and coercion (7.8%; 10/128).

Figure 1.

Mode of entry to sex industry: force, fraud, coercion and entry under age 18 years among Myanmar migrant women (n = 128)**.

Figure 2.

Nature of force, fraud, and coercion among Myanmar migrant women in the sex industry (n = 128)**.

The sample was young (64.8% ages 18–24 years), and primarily Burman ethnicity (48.4%), with over half reporting highest educational attainment at primary levels (54.7%; Table 1). Younger women (ages 18–24 years) more often reported FFC entry, relative to their older counterparts ages 25–32 years (79.5% vs. 62.2%, p < .001; Table 1). Most participants had been in the sex industry for over a year; time involved varied by mode of entry with the majority (90%) of women involved for less than 1 year characterizing their entry as FFC (p = .003). The majority of participants (56%) worked 5–6 days per week; those working 3–4 days weekly were more often FFC entry (p < .004). Average clients per day also varied by FFC entry; those seeing four or more clients per day accounted for a third of the sample (33%) and were more likely non-FFC entry (41%; p = .025).

Table 1.

Demographic and Sex Industry Involvement Characteristics in the Sample and by Forced, Fraudulent or Coercive Entry.

		Force, fraud, or coercion
	Sample (n = 128)	No (n = 34)	Yes (n = 94)	p-value***
	%*(n)	%**(n)	%**(n)	p-value***
Total	–	26.6 (34)	73.4 (94)
Demographic information
Age
18–24 years	64.8 (83)	20.5 (17)	79.5 (66)	<.001
25–32 years	35.2 (45)	37.8 (17)	62.2 (28)	<.001
Ethnicity
Karen	32.0 (41)	24.4 (10)	75.6 (31)	.515
Burman	48.4 (62)	25.8 (16)	74.2 (46)
Mon	13.3 (17)	29.4 (5)	70.6 (12)
Other	6.2 (8)	37.5 (3)	62.5 (5)
Education
None	17.2 (22)	13.6 (3)	86.4 (19)	.171
Primary (1–4 standard)	54.7 (70)	28.6 (20)	71.4 (50)
Middle or high school (5–10 standard)	28.1 (36)	30.6 (11)	69.4 (25)
Relationship status
Married or in a relationship	44.5 (57)	28.1 (16)	71.9 (41)	.688
Single, widowed, or divorced	55.5 (71)	25.3 (18)	74.6 (53)	.688
Sex industry context
Length of time in sex industry
< 1 year	15.6 (20)	10.0 (2)	90.0 (18)	.003
1–2 years	39.8 (51)	29.4 (15)	70.6 (36)
2–3 years	28.1 (36)	27.8 (10)	72.2 (26)
3–4 years	7.0 (9)	44.4 (4)	55.6 (5)
4 years or more	9.4 (12)	25.0 (3)	75.0 (9)
Location of sex work^a
Restaurant	46.1 (59)	28.8 (17)	71.2 (42)	.579
Karaoke Bar	14.8 (19)	10.5 (2)	89.5 (17)	.072
Brothel	65.6 (84)	27.4 (23)	72.6 (61)	.684
Phone	78.9 (101)	25.7 (26)	74.3 (75)	.642
Days per week in sex work
3–4 days per week	23.4 (30)	13.3 (4)	86.7 (26)	.004
5–6 days per week	56.2 (72)	26.4 (19)	73.6 (53)
7 days per week	20.3 (26)	42.3 (11)	57.7 (15)
Average number of clients per day
0	0.0 (0)	0.0 (0)	0.0 (0)	.025
1	3.1 (4)	0.0 (0)	100.0 (4)
2	16.4 (21)	14.3 (3)	85.7 (18)
3	45.9 (60)	21.7 (13)	78.3 (47)
4 or more	33.6 (43)	41.9 (18)	58.1 (25)
Workplace as primary residence
Lives onsite	75.0 (96)	21.9 (21)	78.1 (75)	.275
Lives offsite	25.0 (32)	40.6 (13)	59.4 (19)	.275

Responses are not mutually exclusive.

*Column percent.

** Row percent.

*** p-values in bold denote statistical significance at p < .05.

The vast majority of participants (92.2%) indicated that a broker, manager, or third party made arrangements with clients for them (Table 2). Women who entered via FFC were significantly more likely to report the inability to refuse clients for fear of manager violence (39.4% vs. 2.9%; p = .01; small cell sizes prohibited adjusted analyses). Reporting any form of constrained ability to refuse clients was more common among those entering via FFC (46.2% vs. 24.2%; p < .05); this association attenuated into non-significance in adjusted analysis.

Table 2.

Control Over Working Conditions, Condom Use, Sexual Risk, Violence and Health Indicators, and Associations With Force, Fraud or Coercion.

	Sample (n = 128)%^a (n)	Force, fraud, or coercion			OR (95% CI)	AOR^b (95% CI)
		No (n = 34)	Yes (n = 94)
		% ^a (n)	% ^a (n)	p-value
Control over working arrangements
Broker, manager, or other third party makes arrangements with clients	92.2 (118)	91.2 (31)	92.5 (87)	.870	1.20 (0.13, 10.94)	1.22 (0.13, 11.32)
Constraints on ability to refuse clients (any)	40.5 (51)	24.2 (8)	46.2 (43)	.006	2.69* (1.32, 5.47)	1.98 (0.90, 4.38)
Cannot refuse for need of money	26.6 (34)	20.6 (7)	28.7 (27)	.277	1.55 (0.70, 3.44)	0.87 (0.34, 2.34)
Cannot refuse for fear of client violence	14.1 (18)	5.9 (2)	17.0 (16)	.200	3.28 (0.53, 20.18)	3.58 (0.37, 34.28)
Cannot refuse for fear of manager violence	29.7 (38)	2.9 (1)	39.4 (37)	.010	–^c	–^c
Sexual risk and coercion with clients
Condom use with clients
Inconsistent condom use with clients past 6 months	52.3 (67)	41.2 (14)	56.4 (53)	.012	1.85* (1.14, 2.99)	3.03* (1.41, 6.52)
Client coercion for condom non-use
Client refused condom use in past year	98.4 (126)	100.0 (34)	97.9 (92)	–^c	–^c	–^c
Client removed condom in past year	96.9 (124)	100.0 (34)	95.7 (90)	–^c	–^c	–^c
Client angry, used, or threatened violence when respondent requested condom use in past year	75.8 (97)	82.3 (28)	73.4 (69)	.021	0.59* (0.38, 0.92)	1.28 (0.85, 1.91)
Anal intercourse with clients
Anal sex with clients in past year	82.0 (105)	94.1 (32)	77.7 (73)	.026	0.22* (0.06, 0.83)	0.33 (0.09, 1.16)
Client coercion for anal sex
Agreed to vaginal sex, demanded anal in past year	79.7 (102)	94.1 (32)	74.5 (70)	<.001	0.18** (0.07, 0.47)	0.23* (0.08, 0.65)
Client threatened no pay if no anal in past year	69.5 (89)	79.4 (27)	66.0 (62)	.084	0.50 (0.23, 1.09)	0.63 (0.22, 1.80)
Client sexual coercion and violence
More clients than agreed to in past year	67.2 (86)	85.3 (29)	60.6 (57)	<.001	0.26** (0.20, 0.35)	0.31** (0.22, 0.44)
Pressured sex with client in past year	53.9 (69)	73.5 (25)	46.8 (44)	.003	0.32* (0.15, 0.67)	0.47 (0.15, 1.43)
Forced sex with client in past year	66.4 (85)	73.5 (25)	63.8 (60)	.112	0.63 (0.36, 1.12)	0.74 (0.37, 1.48)
Police abuse and harassment
Police demanded free sex in past year	56.2 (72)	61.8 (21)	54.3 (51)	.146	0.73 (0.48, 1.11)	0.97 (0.67, 1.41)
Other forms of police harassment in past year	30.5 (39)	44.1 (15)	25.5 (24)	.021	0.43* (0.21, 0.88)	0.42 (0.11, 1.55)
Early experiences in sex work
First month forced sex	61.7 (79)	79.4 (27)	55.3 (52)	<.001	0.32** (0.19, 0.57)	0.46* (0.26, 0.79)
First month anal sex	43.7 (56)	70.6 (24)	34.0 (32)	<.001	0.21** (0.11, 0.40)	0.28** (0.16, 0.52)
Presented as a virgin	64.1 (82)	58.8 (20)	66.0 (62)	.152	1.36 (0.89, 2.06)	1.05 (0.56, 2.00)
Health status
Mental health outcomes
Depression	87.5 (112)	91.2 (31)	86.2 (81)	.480	0.60 (0.15, 2.45)	1.07 (0.24, 4.80)
Anxiety	75.8 (97)	64.7 (22)	79.8 (75)	. <.001	2.15** (1.41, 3.30)	2.65** (1.68, 4.13)
Self-reported health status
0–65	33.6 (43)	20.6 (7)	38.3 (36)	.061	2.4** (1.58, 3.63)	3.25** (2.12, 4.98)
66–100	66.4 (85)	79.4 (27)	61.7 (58)	Ref	Ref	Ref
Forgone care when needed it in past year	21.1 (27)	20.6 (7)	21.3 (20)	.945	1.04 (0.32, 3.39)	2.33 (0.71, 7.68)
Self-reported STD diagnosis	62.5 (80)	50.0 (17)	67.0 (63)	.070	2.03 (0.94, 4.37)	3.30 (1.00, 10.88)

Column percent.

Adjusted for age, length of time in sex work, days per week, and number of clients.

Not applicable/unstable due to small cell sizes.

Boldface denotes statistical significance at p < .05.

* p < .05.

** p < <.01.

Sexual risk in the form of inconsistent condom use with clients in the past 6 months was common (52.3%), with FFC entry significantly elevating risk (56.4% vs. 41.2%, adjusted odds ratio [AOR] 3.03 95% CI 1.41, 6.52). Past-year client coercive condom negotiation in the forms of condom refusal and removal were overwhelmingly common (98.4% and 96.9%, respectively), and the majority (75.8%) reported having a client respond with anger, and using or threatening violence, when requesting condom use. Client coercive practices related to anal intercourse were common; 79.7% reported having clients agree to vaginal sex only to later demand anal sex, and those with an FFC history were significantly less likely to report this experience (74.5% vs. 94.1%, AOR 0.23, 95% CI 0.08, 0.65).

Client sexual coercion and violence in the past year were pervasive: 67.2% reported having to have sex with more clients than they had agreed to, 53.9% reported having been pressured to have sex with a client, and 66.4% reported having been forced to have sex with a client. An FFC history appeared to offer relative protection; the prevalence of past-year more clients than they had agreed to was significantly lower among those with an FFC history (60.6% vs. 85.3%; AOR: 0.31, 95%CI: 0.22, 0.44).

Police harassment was prevalent; more than half (56.2%) of respondents reported having had police demand free sex in exchange for not being arrested in the past year. Other forms of police harassment were also common (30.5%) and less prevalent for those with an FFC history at the bivariate level (25.5% vs. 44.1%, p = .021), though differences attenuated in adjusted analysis.

Early experiences in the sex industry differed significantly by mode of entry. Forced sex in the first month was significantly less common among women who reported force, fraud, or coercion relative to those who did not (53.2% vs. 79.4%; AOR: 0.46, 0.26, 0.79), as was having had anal intercourse in the first month in the sex industry (34.0% vs. 70.6%; AOR: 0.28, 0.16, 0.52).

Mental health was poor in the sample overall; 87.5% reported depression, anxiety affected 75.8%, and was differentially reported by those with FFC (79.8% vs. 64.7%; AOR: 2.65, 95% CI: 1.68, 4.13). Low self-rated health was more common among women entering via FFC (38.3% vs. 20.6%; AOR 3.25; 95%CI 2.12, 4.98). Past-year forgone health care was common (21.09%) as was STD diagnosis (62.5%) with no differences by FFC.

Discussion

Results from this mixed-methods study at the high-migration Thai-Myanmar border demonstrate experiences consistent with trafficking, specifically entry into the sex industry under conditions of force, fraud, or coercion, or prior to age 18 years. Qualitative and quantitative data alike emphasize the role of fraud specifically in recruiting women for the sex industry, likely reflecting a combination of difficult social and economic realities for migrants, criminalization of migrant workers that undermines their ability to secure safe work, and a reliance on the informal labor market which lacks regulation. The high levels of client violence, condom coercion, and managerial control, coupled with poor physical and mental health in this sample as a whole clearly depict significant risk to sex workers at the Thai-Myanmar border and demonstrate an imperative for health care and violence-related support and accountability.

Irrespective of mode of entry, power imbalances that favor clients and managers over women were evident across domains of working arrangements, condom practices, and violence. Specifically, the vast majority reported brokers and managers as making client arrangements, with 40% reporting some constraint on the ability to refuse clients. For women entering via force, fraud, or coercion, fear of manager violence differentially constrained their ability to refuse clients. Condom coercion in the forms of client condom refusal or removal was overwhelmingly pervasive, irrespective of trafficking history. Results echo past evidence, both from elsewhere in Thailand (Decker et al., 2010) and other settings (Decker et al., 2020a, 2012, 2014), and speak to profound needs for female-controlled methods of family planning and HIV prevention, as condoms will not be sufficiently protective where clients refuse or remove them. Community mobilization and empowerment strategies (Kerrigan et al., 2015) may also be valuable to shift power dynamics to enable women's greater control over their own sexual decision-making and sexual health. Over half of the sample had experienced client-perpetrated forced sex in the past year; other forms of coercion included pressured sex with clients and being presented with more clients than agreed to. Results extend similar results in Thailand (Decker et al., 2010, 2011) and elsewhere (Decker et al., 2020a, 2012, 2014; Gupta et al., 2009), by articulating clients, and secondarily police, as key perpetrators of violence in this setting. The context of felt criminalization within the sex industry in this setting illustrates limited avenues of recourse, which, in turn, perpetuate client violence and coercion with impunity. These experiences likely explain the high levels of anxiety and depression identified in the population, and the low levels of self-rated health.

The comparison of experiences by mode of entry extends a body of research in this area. Entry to the sex industry via force, fraud, or coercion was significantly associated with the inability to refuse clients for fear of manager violence, inconsistent condom use with clients, anxiety, and low self-rated health, echoing past evidence that this method of entry compromises future negotiation capacity and poor health (Decker et al., 2011; George & Sabarwal, 2013; Sarkar et al., 2008). By contrast, those entering via FFC were relatively protected from coerced anal intercourse, being presented with more clients than agreed to, and first-month forced sex and anal intercourse, which is inconsistent with the evidence of extensive violence and sexual risk during this initial period in other settings (Silverman et al., 2011). These differences may reflect underlying differences in client populations or work environments; it may also be possible that the highest risk periods may differ in their relative length, that is, the “first month” referent period may not capture the riskiest period. It is critical to recognize that these contrasts showcase profound risk to those in the sex industry without a trafficking history. Similarly, the lack of differences detected for several key outcomes based on trafficking status is equally informative. Client condom removal and refusal were normative irrespective of trafficking status, as was reliance on third parties to make arrangements with clients and past-year anal intercourse with clients. Neither client mistreatment in the form of forced and pressured sex, nor police abuse and harassment experiences were significantly different based on trafficking status; rather, results illustrate significant risk to women in the sex industry as a whole. Efforts to support migrants in high-transit settings can be most effective by addressing structural issues that influence risk within the sex industry; current results illustrate that a lens focused solely on sex trafficking survivors would overlook profound risk for violence and human rights violations among those who are not trafficked.

Findings shed light on the impact of criminalization, and suggest interactive and accumulating vulnerabilities to this population due to migrant status as well sex industry involvement, irrespective of trafficking history. Criminalization dynamics effectively diminished negotiation power, particularly for women newly arrived and those newly in the sex industry, as illustrated by both the qualitative and quantitative results. A growing body of research demonstrates the impact of a criminalized sex industry, with police exploiting the illegal nature of sex work by harassing those in the sex industry with impunity, and extorting coerced sex under threat of arrest (Decker et al., 2015). Current data echo these concerns and illustrate that where migrants are subject to criminalization and threats of deportation, as Burmese migrants are in Thailand (Arnold & Hewison, 2005; Veerman & Reid, 2011), those in the sex industry and, in particular, those trafficked, may suffer an added dimension of vulnerability and barriers to exit. The study design does not allow comparison to the experiences of non-migrant sex workers as is needed to differentiate the criminalization and economic vulnerability risks unique to the migrant experience from the risks that may simply reflect the profile of the sex industry in Mae Sot.

Several limitations should be noted. The relatively small sample size limits the precision of estimates as well as statistical power for comparisons by subgroups. Although results are valuable and specific to the current setting, the broader generalizability to other high-migration border settings is unknown. Despite the formative research and extensive precautions to enable trust and comfort for participants, there is a possibility for selection bias related to fears concerning discussing experiences in migration and in the sex industry. The cross-sectional nature of analysis precludes inferences related to temporality of experiences. Survey measures, particularly those related to early experiences in the sex industry and in migration, may be subject to recall error or bias, social desirability bias, imprecision, and error. We note that this study was conducted prior to a large-scale registration and nationality verification exercise, which provided official documentation to more than 2 million migrants from Myanmar (Harkins, 2019). As sex work is not considered a legal profession under the registration exercise, migrant workers in the sex industry are likely to remain unprotected by these and other recent policy developments.

Conclusion

Taken together, current results demonstrate stark unmet needs for safety promotion and human rights among women in the sex industry in this high-transit migration setting. Advances must address sexual violence and the coercive practices of clients as well as law enforcement. There exist clear needs to protect women from coercive, fraudulent, and forced entry into the sex industry; simultaneously, our lens must expand beyond these dynamics to support the safety and health-related needs of women in the sex industry, irrespective of entry mechanism.

Footnotes

Acknowledgments

The study team thanks the field data collection and participants for their contributions to this endeavor.

Author Contributions

The study was designed by WCR, MRD and AAM; NA and AAM led implementation with support from SRM and CB; SRM and CB led analysis. MRD and SRM drafted the manuscript, and WCR, AAM, NA, and CB provided essential scholarly contributions and revisions. All authors reviewed and approved the final manuscript.

Ethics Approval and Consent to Participate

All participants provided verbal informed consent to participate; all procedures inclusive of the verbal consent process were approved by the Johns Hopkins School of Public Health Institutional Review Board and a local review committee assembled for this purpose in Mae Sot, Thailand.

Availability of Data and Materials

Due to the sensitive nature of study data, data are not available publicly but are available from the corresponding author on reasonable request.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

Funding for this research was made possible by S-SGTIP-11_ GR-0024 to Drs. Robinson and Decker from the Office to Monitor and Combat Trafficking in Persons. The views expressed in this publication do not necessarily reflect the official views or policies of the Department of State. The funding body had no role in the design of the study and collection, analysis, and interpretation of data, nor in writing the manuscript.

ORCID iD

Michele R. Decker

Author Biographies

Michele R. Decker is a professor in the Department of Population, Family, and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health. She directs the Women's Health and Rights Program of the Center for Public Health and Human Rights. A social epidemiologist by training, her applied research focuses on gender-based violence prevention and response in diverse global settings, and broader dimensions of gender equity and health.

Sarah R. Meyer is an assistant professor in Clinical Population and Family Health at the Mailman School of Public Health, Columbia University, and a research consultant at the World Health Organization. She has led mixed methods studies on violence and psychosocial well-being, primarily in humanitarian contexts, and systematic reviews of evidence on violence against older women and women with disabilities. She holds a PhD in international health from Johns Hopkins School of Public Health and an MPhil in development studies from the University of Oxford.

Casey Branchini Risko is currently a program advisor for the Program to End Modern Slavery (PEMS) at the U.S. Department of State's Office to Monitor and Combat Trafficking in Persons. She has more than a decade of experience working in the anti-trafficking field. She holds a PhD in international health from the Johns Hopkins Bloomberg School of Public Health, where she supported fieldwork for the current study. Her dissertation focused on the intersection between health and human rights violations among migrant workers in Kuala Lumpur, Malaysia.

Nada Abshir is a specialist project manager with over a decade of experience working amid complex political and development challenges in Africa and Asia. She is an expert in the areas of tackling conflict, strengthening stability, and building effective institutions, with core skills in stakeholder engagement, advocacy, operational planning, communications, and program management. She holds an MA in International Affairs from the New School (New York) and is currently based in Nairobi, Kenya.

Aye Aye Mar is the executive director of Social Action for Women (SAW), a Thailand-based NGO working on behalf of women's rights, particularly refugee and migrant women from Myanmar.

W. Courtland Robinson is an associate professor in the Department of International Health with a joint appointment in the Department of Population, Family, and Reproductive Health, and is also core faculty with the Center for Humanitarian Health at the Johns Hopkins Bloomberg School of Public Health. His research focuses on populations in migration, whether displaced by conflict or natural disaster, or in the context of migrant labor and human trafficking.

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