A treatment-asisted recovery mod for victims of prostitution an trafficking.
Prostitution is a social issue of desperate importance both in the U.S. and internationally. Prostitution fuels a literal slave trade. The U.S. State Department's Bureau of Public Affairs estimates that 600,000 to 800,000 individuals, up to 50 percent of whom are children, are trafficked across international borders annually. According to the Swedish Ministry of Industry, Employment and Communications, "International trafficking in human beings could not flourish but for the existence of local prostitution markets for men who are willing and able to buy and sell women and children for sexual exploitation." (1)
In all areas of the U.S., except four or five counties in Nevada, prostitution is illegal. The U.S. government adopted a position against legalized prostitution in a December 2002 National Security Presidential Directive. The criminal justice system devotes tremendous resources to law enforcement, courts, prisons and jails to help combat prostitution. (2) However, the current enforcement of prostitution laws appears to create a revolving door phenomenon. Typically it is women and children who are arrested, while pimps, customers and traffickers often remain free because of difficulties in meeting the burden of proof in the courts. Women are often incarcerated on misdemeanor prostitution charges, released and rearrested on the same charges.
The high costs of law enforcement have motivated some to suggest decriminalizing prostitution. Proponents of decriminalization also support the myth that prostitution is a "victimless crime." The criminal justice community must therefore make it clear that prostitution is costly to society in other ways as well. For example, prostitution has been demonstrated to be detrimental to public health. (3) But more important, in light of current research, it is preposterous to suggest that prostitutes themselves are not victims. In field research in nine countries, it was found that up to 68 percent of women in prostitution met the criteria for post-traumatic stress disorder; this is the same range as treatment-seeking combat veterans and victims of state-organized torture. (4). Other manifestations include depression, anxiety, bipolar disorders and eating disorders. Women who have been exposed to long periods of prostitution activities reveal other symptoms, including cutting, psychological abreaction and psychotic episodes. Even under circumstances where women have worked in legal brothels, there are mental health consequences consistent with any other form of prostitution. Reasons for this are speculative, but it is hypothesized that repetitive prostitution activity coincides with reliance on dissociative coping mechanisms that serve to compress these experiences and in turn leads to crippling psychological symptoms, as earlier described. (5)
The Women's Recovery Center
Volunteers of America (VOA), founded in 1896, provides social services, housing, nursing homes and correctional services and has a presence in 38 states in the U.S. In 1984, the organization established a privately operated jail for women in St. Paul, Minn. After observing repetitive jail commitments of women for prostitution offenses, VOA conducted an informal study of 12 inmates with long-term involvement in prostitution. Each inmate had cumulatively served four to six years of jail time through repetitive commitments. This translated into a cumulative jail time cost of $80,000 to $120,000, with a likelihood of additional costs in the future. Each individual self-identified a chemical addiction with repeated and failed attempts at conventional chemical dependency treatment. In each case, there was a prior history of sexual abuse and a desire to get out of prostitution. With these facts, Volunteers of America began marketing an idea of developing an alternative residential recovery center to serve as a court diversion or a voluntary post-incarceration option.
The 1999 session of the Minnesota Legislature granted funding for Volunteers of America to develop the Women's Recovery Center, which would offer an integrated, gender-specific treatment program. The center admitted its first clients in February 2000. The mission of the Women's Recovery Center is treatment, not research, and while its results cannot prove the efficacy of its treatment model with rigor, all the gathered data suggest it is a success.
Development of Treatment Model
A small panel of prostitution "survivors" was assembled. They expressed frustration both with the lack of treatment and that the treatment provided by conventional therapists failed to take into account the complete context of prostitution. They described an ideal program that would include chemical dependency treatment, mental health treatment with emphasis on sexual trauma, and a cognitive/teaching program of expanded life choices.
Chemical dependency. At the time, new thinking was beginning to emerge regarding chemical dependency treatment for women that was integrated with the treatment of anxiety, depression and related psychiatric/emotional conditions. Paramount in this thinking was the influence of the Wellesley College Stone Center. (6) Studies in the use of the relational model became the gender-specific model adopted by the program. The model acknowledges the relational nature of women in general that historically has been "pathologized" in comparison with the traditional male self-centered orientation. However, the centrality of women's relationships, as seen in the relational model of treatment for chemical dependency and trauma, is seen as a strength and key to recovery.
Sexual trauma/mental health. In addition to physical health consequences, women who have been victimized by prostitution typically have experienced trauma through physical violence, sexual violence and incest, sometimes beginning at a very young age. Through testing after admission, it was observed that as many as 70 percent to 75 percent of women had been preliminarily diagnosed with post-traumatic stress disorder. This observation was found to be consistent with women who are forced into prostitution. When women have left periods of incarceration, they often relapse into drug usage and further prostitution in part to escape the pain of mental health issues. In selected cases, post-traumatic stress disorder is addressed through the use of eye movement desensitization and reprocessing (EMDR), which is a cognitive/neurological approach toward symptom relief. It targets trauma and specific traumatic experiences that are identified and reprocessed at a neurological level and accessed through bilateral stimulation employing light, auditory tones, tapping or other types of tactile stimulation (7) At the Women's Recovery Center, the EMDR experience is accessed by a clinician through a back and forth hand motion. In between "sets" of this eye stimulation exercises, the clinician communicates verbally with the client in an effort to reprocess a traumatic experience. This technique is used in conjunction with other mental health protocols that address incidents or patterns of sexual and physical trauma.
Expanded life choices. Many women in prostitution have experienced a confined existence, handicapped by limited social networks, community support plans and knowledge of the availability of outside community resources. To address this, Expanded Life Choices, developed by Range Technical College, (8) became the third part of the recovery program. Expanded Life Choices is designed to emphasize broadening perspectives on choices such as housing, reproductive health, vocational choices, communication, problem-solving and goal-setting. Through this program, women are able to achieve healthy supportive transitional housing with support services upon completion. Another dimension is the development of a sense of spirituality, though not directly related to an organized religion. Women engaged in prostitution have had such substantial histories of all forms of abuse that they tend to have a distorted (or no) sense of life purpose. This kind of spiritual dimension transcends the other treatment components, yet plays an intricate part of the recovery process.
All three aspects of treatment are vital and must be integrated: Education and training toward another lifestyle fails absent chemical dependency treatment because drug addiction cannot typically be supported by a straight job. Chemical dependency treatment that does not address sexual trauma fails because drugs may be used as an escape from emotional pain. And mental health treatment fails if the hard realities of drug addiction and economic survival are not also addressed. Successful recovery represents a three-legged stool that will topple if any leg is missing.
The Women's Recovery Center admitted its first clients on Feb. 21, 2000. By Sept. 1, 2003, 152 clients had been discharged. Of these, 26 resided for 10 days or fewer and therefore did not receive significant exposure to the program. In fact, a few in this sample left the program within the first 24 hours, likely because they were not prepared for the rigors of treatment, which for many represent a variety of fears including resistance to personal disclosure. Additionally, Minnesota public assistance guidelines at the time disallowed duplicate treatment exposures within a period of two years; the criterion for qualifying as a treatment exposure was 14 days of residency. Therefore, clients who stayed past 14 days stayed with the knowledge that they would not receive another chance at treatment funding within two years. The aggregate statistics presented herein pertain to the 126 clients in residence for 11 days or more.
Clients reported data about themselves upon admission to the program. From this self-reported data clients provided the following information:
Race. Clients were predominantly black and white, with minor representation of Asian, Native American and Hispanic heritage (see Table 1).
Table 1. Racial Characteristics of Client Population Race Residents New Conviction % New Post-Discharge Prostitution/Drug Conviction Post-Discharge Black 64 8 12.5 6 White 41 13 31.7 6 Indian or Native 11 4 36.4 2 American 7 0 0.0 0 Multiracial 7 0 0.0 0 Asian/Pacific 2 0 0.0 0 Islander Hispanic or 1 0 0.0 0 Latina Race % Black 9.4 White 14.6 Indian or Native 18.2 American 0.0 Multiracial 0.0 Asian/Pacific 0.0 Islander Hispanic or 0.0 Latina
Housing. A total of 95 individuals (76 percent) lacked any permanent housing. For example, 40 (32 percent) came directly from correctional institutions while 22 (18 percent) reported coming directly in from the street. Others variously reported coming from shelters and treatment centers, and two clients reported living in their cars.
Poverty. Forty-five individuals (36 percent) reported rarely or never having money for basic necessities. Additionally, 52 (40 percent) reported having enough food either rarely/never or less than half the time.
Addiction, treatment and mental health. Seventy-four (59 percent) reported that they are or have been addicted to alcohol, and 124 (98 percent) reported that they were or had been addicted to drugs. The median reported age of first drug use was 13, and the median reported age of first intoxication was 14. Clients reported having been in previous treatment a median of 4.0 times and an average of 4.8 times.
A total of 85 (67 percent) reported having received professional help for mental health problems, including 74 receiving one-to-one counseling, 59 receiving treatment in a support group, 45 receiving treatment in a hospital and 24 receiving treatment in an institution.
Prostitution. Among 103 clients stating an age of first involvement in prostitution, the median age was 18, and the average was 20.3. Among 100 clients stating a length of involvement in prostitution, the median was 11 years, and the average was 12.0 years. A total of 87 of 103 (84 percent) reported having been paid with drugs.
Clients reported a range of prostitution activities, most prominently listing "street," and including stripping, escort, brothels and participation in pornography (see Table 2). Of 103 clients, 23 had been transported to other cities, 28 to other states and three to other countries for prostitution.
Table 2. Outcomes One Year Post-Discharge by Age Age Residents New Conviction % New Prostitution/Drug % Conviction 19 to 31 40 10 25.0 5 12.5 32 to 37 42 7 16.7 5 11.9 38 to 54 44 8 18.2 4 9.1
Criminal history. A total of 116 (92 percent) self-reported prior convictions, while 106 (84 percent) self-reported prior incarceration.
In September 2004, after four years of operation, Volunteers of America researched computerized records located in a central database managed by the Minnesota Department of Safety, Bureau of Criminal Apprehension. This database is considered official public record and is the best source of conviction data representing all courts in Minnesota. A search was conducted for new criminal convictions among women treated by the Women's Recovery Center in the year following their release. The conviction statistics were compiled for all 126 women released from the Women's Recovery Center by Sept. 1, 2003, allowing for at least one year in the community post treatment. Twenty percent of the group received a new conviction of any kind, while 11 percent received a new conviction for drugs or prostitution.
There is a slight correlation between age and conviction rates, with those under the age of 32 showing somewhat higher overall conviction rates. However, this age group does not show any higher drug/prostitution conviction rate than the other groups despite the fact that this is considered an age group more at risk for criminal activity consistent with age (see Table 2).
The results are particularly striking in light of information self-reported by the women residing at the Women's Recovery Center. The successes were not merely easy cases. Of the study subjects, 92 percent reported prior convictions; 84 percent reported prior incarcerations; 98 percent reported having been addicted to drugs, particularly crack cocaine; and 81 percent reported having used crack cocaine in the six months prior to treatment. The women had participated in a median of four (presumably unsuccessful) prior treatment programs, with a slight positive correlation between the number of prior treatments and the conviction rate after leaving.
Criminal justice costs devoted to what may be a social problem are substantial and indeed misplaced. Considering further that control of prostitution appears to be an ongoing struggle, the contemporary solutions now applied are misdirected. Innovations such as the Women's Recovery Center may provide better outcomes and circumvent the necessity of using the criminal justice system as a method of management or control. The recovery model used at the Women's Recovery Center emphasizes recovery of self, which serves as a direct contradiction to the imprisonment of self under the umbrella of prostitution and trafficking.
An integrated, gender-specific treatment model is more likely to be effective than conventional or no treatment methods at helping women escape prostitution. While the data from the Women's Recovery Center does not constitute rigorous research, it is strongly suggestive of the direction future research should take. Future studies must fill the current gap in assessing the effectiveness of various treatment programs and it is expected that such research will bear out the worth of the VOA model.
(1) Swedish Ministry of Industry, Employment, and Communications. 2004. Fact sheet: Prostitution and trafficking in women. Article #N4004. Stockholm, Sweden.
(2) Pearl, J. 1987. The highest paying customers: America's cities and the costs of prostitution control. The Hastings Law Journal, 38(4):43-59.
(3) Parriott. R. 1994. Health experiences of women used in prostitution. Unpublished paper. Available at www.angelfire.com/mn/fjc/healthex2.html.
(4) Farley, M., A. Cotton, J. Lynne, S. Zumbeck, F. Spiwak, M.E. Reyes, D. Alvarez and U. Sezgin. 2003. Prostitution and trafficking in nine countries: An update on violence and posttraumatic stress disorder.
Journal of Trauma Practice, 2(3/4):33-74; and Farley, M. (Ed.). 2003. Prostitution, trafficking, and traumatic stress. New York: Haworth Press.
(5) Parriott, R. 1994.
(6) Wellesley Centers for Women. 2001. Wellesley relational model instrument development. Wellesley College. Available at www.wcwonline.org/content/view/896/299/.
(7) EMDR Institute Inc. 2004. A brief description of EMDR. Watsonville, Calif. Available at http://emdr.com/briefdes.htm.
(8) Nemancik, T., M. Primozich and K. McQuillam. 1992. Expanded life choices. Hibbing, Minn.: Range Technical College.
William F. Nelson is director of Correctional Services for Volunteers of America of Minnesota. In partnership with a PBS affiliate, Nelson directed a documentary about the Women's Recovery Center treatment model called Prostitution: Beyond the Myths. He can be contacted at email@example.com.