Introduction
Growing up there was a lot of domestic violence in my household, a lot of things that were directly impacting me at a young age. When I was 13, I was placed in foster care, but the foster home wasn’t that great. When I was there, I was raped and abused further. I didn’t see any way out of it, and I attempted suicide. Then I was transferred to a psychiatric hospital. At the age of 15, they put me in in a group home, where I met a pimp who paid me a lot of attention and I thought he liked me. I didn’t realize it at the time, but he had other ideas. Eventually forced me into prostitution. He was vicious and kept me under his control by abusing me physically and mentally. He battered, raped, and branded with irons. But, even with all that, I had a hard time leaving. As awful as the situation was, there were needs that I had that were being met. I was homeless, I felt like I didn’t have anywhere to go, anywhere to get clothes or food or shelter. He was the only thing that was consistent in my life. In addition to selling me to others, he slept with me too. During the time I was trafficked, I had 3 abortions and 4 children, several by my trafficker.
—Sherry, Survivor2
Sherry’s story is one of many we heard during a set of focus groups in four cities in the United States. She and others were part of a pilot study for a national human trafficking survivor survey that is currently being conducted as of the publication of this paper. The survey considers the survivors’ experiences along the pregnancy continuum during and after being trafficked. For the purposes of this study, the “pregnancy continuum” refers to a broad range women’s health issues, from preconception to post-childbirth. The pregnancy continuum encompasses women’s gynecological and procreative health, pregnancy, prevention of pregnancy, miscarriage, abortion, forced abortion, childbearing, and pre- and post-natal care. In this paper specifically, we consider pregnancy continuum issues in the context of sex trafficking in the United States.
This survey is a follow-on survey to a published 2014 study and article on the general health implications of sex trafficking.3 In the course of administering that survey, and subsequent work, we heard stories from over 450 survivors in over thirty cities in the U.S. in which survivors told us of methods of birth control, birth control failure, reproductive violence on the part of the trafficker, hundreds of miscarriages, hundreds of abortions, both voluntary and forced, and, perhaps most surprising to us at the time, hundreds of children born into trafficking situations. This survey is a pilot to test a national study that delves more deeply into these issues and includes questions on gynecological health and the disposition of children born before, during and after trafficking. This survey, unlike the previous study, attempts to capture differences in childbearing, and reproductive and general health before, during and after trafficking. This will allow us to examine the self-reported effects of trafficking on survivors’ childbearing, and reproductive and gynecological health.
Previous Literature & Context
This survey fills a gap in the growing body of literature on health and violence in the context of domestic sex trafficking. More specifically, this survey considers in depth an issue that became apparent in a previous survey conducted by the author and replicated in many subsequent studies.4 While the previous surveys considered the health consequences of human trafficking overall, this survey specifically addresses the consequences relating to the pregnancy continuum. This survey is based on a preliminary survey that was conducted as part of a pilot project. The purpose of this pilot project was to perfect a survey instrument to be used in a nationwide, year-long survey.
Other studies related to the gynecological, reproductive, and procreative issues in human trafficking have been conducted. However, these studies were narrower in scope, or surveyed international participants. For example, a smaller 2015 study surveyed twenty-one women incarcerated on Rikers Island on issues related to contraception, infectious diseases, pregnancy and pre-natal care.5 A 2017 study considered maternity care for trafficked women in the United Kingdom.6 And another study considered coerced abortion outside the context of human trafficking.7 These studies set the stage for our larger and more expansive study which surveys a larger sample size of human trafficking survivors and the entire pregnancy continuum, rather than just one part of the continuum. This pilot study will be followed by a national survey of twenty cities, with a sample size of 300 survivors.
Methodology
This survey collected data from female sex trafficking survivors.8 The survey used a mixed-methods approach, combining qualitative data collection from focus groups and structured interviews with quantitative analysis. It consisted of four focus groups conducted between June and December of 2021 in four different cities.9 On average, these focus groups consisted of eight participants. Participants were identified by using a snowball sampling method. Snowball sampling or chain referral sampling is a non-probability sampling technique where the subjects share difficult-to-find traits. The sample is gathered by asking an individual with the sought-after traits to refer the researcher to other individuals with the same traits. Each new individual is asked to make an additional referral until the target sample size is reached.10 In total, thirty-one survivors were surveyed for this survey. All the participants were domestic survivors of sex trafficking, ranging between the ages of eighteen and sixty. During these focus groups, participants commented on and discussed a range of topics, emphasizing gynecological, reproductive, and procreative health issues. Following the focus group sessions, survivors completed an extensive health survey.11
In the survey, the survivors answered basic demographical questions relating to such factors, as age, socio-economic status, education, and the duration and location(s) of the trafficking experience. Another section of the survey included questions covering general physical and mental health. While the results of this section are not included in this article, they may be considered in future publications by the author.
The majority of the survey, however, focused on the pregnancy continuum. Questions related to all aspects of gynecological, reproductive, and procreative health. The survey asked questions relating to STD/STI exposure and gynecological infections or illnesses contracted during the trafficking experience. Focus group participants responding to the pilot survey were asked to address questions on issues related to reproduction and procreation, such as use of birth control, pregnancy, pre and postnatal care, and the outcomes of those pregnancies. Where pregnancy resulted in the birth of a child, the survey considered issues relating to childrearing. Additionally, questions went beyond medical symptoms and procedures. The survey also considered the survivor’s subjective experiences. For example, the survey considered the survivor’s perceived experience with healthcare providers and the characterizations of medical procedures.
Answers to yes or no questions from the survey were coded and entered in a spreadsheet using a binary coding system (1 if circled, 0 if not). Non-responsive answers were coded as “did not answer”. For the open-ended second component, common answers were assigned a number. If survivors gave an unwieldy variety of answers, the least common answers were grouped into a single “other” category.
This coding system allowed the spreadsheet program to count how many survivors gave each response by counting how many cells in a column were filled with a given number. The totals were then calculated as percentages, both of all survivors and of those who answered the particular question. In the very few instances where clear discrepancies resulted from participant error or misunderstanding of a question, the survivor’s responses were tabulated in the way that was most logical and consistent with other responses. For example, if a survivor indicated having two abortions, but reported zero pregnancies, we deduced that the survivor had two pregnancies and coded pregnancies as such. the coding system allowed for the use of only descriptive statistics—no inferential statistics or significance tests were used. The following results section analyzes the frequency with which individual symptoms and experiences were reported by the survivors in this survey as well as the percentages of survivors who reported at least one symptom or experience in a given category.
Demographics
To assess health issues unique to the pregnancy continuum, all thirty-one survivor participants identified as female. Beyond this unifying feature, there was significant diversity among the women in addition to a few notable trends.
A. Race & Ethnicity
Of the thirty-one survivor participants, a majority identified as white (55%), 32 percent identified as Black or African American, 6% identified as Other; 3% identified as Asian American, 3% preferred Not to Answer. Other choices were Latino, Native American, Alaskan Indigenous, and Other Indigenous, but none of the participants identified as these. In this sample, only 1 respondent identified as Preferred Not to Answer.
B. Education
A majority of the survivor participants indicated that they had graduated from high school or trade school (55%). A smaller number reported that they did not finish high school (16%). Approximately a quarter reported graduating from college (13%) or a graduate school program (13%). Among the survivors, the rate of college graduation is considerably lower than the percent of college graduates in the general population (13% vs. 37.9%).12
C. Sexual Orientation
A majority of the survivor participants identified as heterosexual (65%). However, nearly a third of survivor participants (32%) identified as LGBTQ.
Table 1. Race and Ethnicity
| Race or Ethnicity | % of Survivors | Frequency (N=31) |
| African American or Black | 32% | 10 |
| Asian American | 3% | 1 |
| Caucasian or White | 55% | 17 |
| Other | 6% | 2 |
| Preferred Not to Answer | 3% | 1 |
| Total | 100% | 31 |
Table 2. Demographics: Education
| Highest Level of Education Achieved | % of Survivors | Frequency (N=31) |
| Did Not Graduate High School | 16% | 5 |
| High School or Trade School Degree | 55% | 17 |
| College Degree (Undergraduate) | 13% | 4 |
| College Degree (Graduate) | 13% | 4 |
| Preferred Not to Answer | 3% | 1 |
| Total | 100% | 31 |
Table 3. Demographics: Sexual Orientation
| Sexual Orientation | % of Survivors | Frequency (N=31) |
| Heterosexual or Straight | 65% | 20 |
| LGBTQ+ | 32% | 10 |
| Preferred Not to Answer | 3% | 1 |
| Total | 100% | 31 |
D. Age When Trafficked
Most (77%) of the survivor participants were under twenty-four years of age when they were trafficked. Forty-two percent indicated that they were trafficked when they were under eighteen years of age. As the ages increased, representation dropped significantly. Only 10 percent reported that they were trafficked between the ages of twenty-five and thirty-four, and only 6 percent reported that they were trafficked between the ages of forty-five and sixty.
Table 4. Demographics: Age When Trafficked
| Age when Trafficked (in years) | % of Survivors | Frequency (N=31) |
| Under 18 | 42% | 13 |
| 18–24 | 35% | 11 |
| 25–34 | 10% | 3 |
| 45–60 | 6% | 2 |
| Preferred Not to Answer | 6% | 2 |
| Total | 100% | 31 |
Results
A. Gynecological Issues
I had so many problems that I believe are connected to when I was trafficked. I had vaginal infections, UTIs, PID, (pelvic inflammatory disease), cysts and scar tissue from abortions. When I got out and married, I couldn’t get pregnant, and my gynecologist said I would have to have an operation to make it possible for me to have children. Now I have uterine cancer.
—Benia, Survivor
Among the survivors surveyed, gynecological health issues were widespread and severe. The survey considered twenty-five gynecological illnesses, infections, and symptoms.13 Twenty-nine out of thirty-one survivor participants reported experiencing at least one gynecological infection, illness, or symptom while they were being trafficked. Twenty-six percent of participants reported ten or more problems. Among the whole sample, the average number of gynecological issues reported per survivor was seven. The highest number of gynecological issues reported by one survivor was sixteen. Table 1 highlights some of the most commonly reported gynecological issues.
Table 5. Common Gynecological Health Problems Experienced by Human Trafficking Survivors
| Gynecological Issue | % of Survivors Reporting | |
| Issue while Being Trafficked | Frequency (N=31) | 25 |
| Vaginal Infection (Bacterial) | 65% | 20 |
| Vaginal Discharge | 58% | 18 |
| Pain during Sex | 58% | 18 |
| Menstruation Disorders | 55% | 17 |
| Vaginal Pain | 52% | 16 |
| Urinary Tract Infections | 52% | 16 |
| Dysmenorrhea | 42% | 13 |
| Vaginal Bleeding | 39% | 12 |
| Pelvic Pain | 32% | 10 |
| Bladder Infection | 29% | 9 |
| Ovarian Cyst | 26% | 8 |
| Pelvic Inflammatory Diseases | 23% | 7 |
| Cervical Infection | 19% | 6 |
| Cancer (Cervical) | 13% | 4 |
| % Survivors Reporting at least One Gynecological Issue | 90% | 28 |
| % Survivors Reporting Two or More Gynecological Issues | 84% | 26 |
The prevalence of sexually transmitted infections (STIs) further reflects the physical toll of domestic sex trafficking on a woman’s gynecological health. Seventy-four percent of survivors surveyed reported that they had contracted at least one STI while being trafficked.14 Of those reporting an STI, the average number of STIs reported was 1.6.
Table 6. Prevalence of Sexually Transmitted Infections (STI) among Human Trafficking Survivors
| Reported STI | % of Survivors Reporting | Frequency (N=31) |
| Chlamydia | 45% | 14 |
| Gonorrhea | 35% | 11 |
| Genital Herpes | 23% | 7 |
| Trichomoniasis | 23% | 7 |
| Genital Warts (HPV) | 19% | 6 |
| Syphilis | 13% | 4 |
Table 7. Reported and Calculated Pregnancies among Human Trafficking Survivors
| Type of Pregnancy or Pregnancy Outcome | Number of Pregnancies and Pregnancy Outcomes Reported by Survivors |
| Reported Pregnancies | 59 |
| Calculated Pregnancies | 119 |
| Reported Pregnancies Carried to Term | 44 |
| Reported Abortions | 42 |
| Reported Miscarriages | 32 |
| Reported Still Births | 1 |
B. Birth Control & Pregnancy
“I was pregnant three times during the time I was trafficked and all of them were by different buyers.”
—Maria, Survivor
“I got pregnant twelve times—all of them by my trafficker/pimp. I had three abortions, three children, and many miscarriages”
—Joanna, Survivor
Table 7 above reveals a large discrepancy between the reported number of pregnancies and the calculated number of pregnancies (sum of reported pregnancies carried to term, reported abortions, reported miscarriages, and reported still births). This discrepancy results from the fact that the survey asked participants to indicate the total number of pregnancies they have experienced, but later asked the survivor to indicate the number of pregnancies experienced that corresponded with a certain circumstance such as miscarriage or abortion. Some survivor participants were non-responsive to the question on total number of pregnancies but indicated multiple pregnancies when asked
Table 8. Birth Control Methods Used While Being Trafficked
| Birth Control Method | % of Survivors Reporting Using Method | Frequency (N=31) |
| Condoms | 77% | 24 |
| Pill | 45% | 14 |
| Depo Provera or Other Birth Control Injection | 13% | 4 |
| Morning after Pill (Plan B) | 13% | 4 |
| Diaphragm | 10% | 3 |
| Tubal Ligation or Other Operation | 10% | 3 |
| IUD | 3% | 1 |
about specific circumstances. In such cases, the author considered the sum of the pregnancies indicated, rather than the non-responsive answer to the total number of pregnancies.15 For the purposes of this article, statistics are based on the number of calculated pregnancies, rather than the reported number of total pregnancies.
Among the twenty-seven survivors indicating a pregnancy, there were at least 119 pregnancies. The most pregnancies indicated by one survivor was fifteen, and five other survivors reported experiencing between five and ten pregnancies. Ten survivors reported being impregnated at least once by their trafficker or pimp, and ten indicated that they were impregnated by their boyfriend/husband. Two survivors noted that for them, “boyfriend” and “trafficker” were synonymous. Four survivors reported being impregnated at least once by a customer, and three said they got pregnant by “other.” Those who indicated “other” answered further that the “other” was a drug dealer or family member. Even though 87% of survivors reported using some kind birth control, 87% of survivors reported at least one pregnancy; and 65% reported two or more pregnancies.
C. Pregnancy Outcome: Live Birth
I got pregnant while I was being trafficked, and I knew that I was going to keep the baby no matter what.
—Mary, Survivor
Table 9. Pregnancy and Childbirth-Related Problems Experienced by Victims of Human Trafficking
| Category | % of Survivors Reporting Experiencing at least One Problem | Frequency (N=31) |
| Pregnancy Problems Experienced during Trafficking | 77% | 24 |
| Pregnancy Problems Experienced after Trafficking | 35% | 11 |
| Problems Experienced during Childbirth | 68% | 21 |
| Problems Experienced after Childbirth | 42% | 13 |
Table 10. Children Born to Survivors of Human Trafficking
| Category | Number of Children Born |
| Children Born before Survivor was Trafficked | 9 |
| Children Born during Trafficking | 44 |
| Children Born after Trafficking | 23 |
Although many instances of pregnancy were reported, the chances of the pregnancy resulting in live birth was much smaller. In total, the survivors reported forty-four pregnancies being carried to full term. Compared with the 119 total pregnancies reported, fewer than half of all reported pregnancies resulted in live birth (37%).16 One survivor mentioned her pregnancy as an impetus for her to disclose to a health provider that she was being trafficked. Another said that being pregnant gave her hope for her child even though she felt hopeless in her own situation.
Thirty-seven percent (11/31) of survivor participants reported receiving full prenatal care. Over 13 percent (13.4 percent (4/31)) reported receiving partial prenatal care while pregnant and being trafficked. Only 23 percent (7/31) reported a problem-free pregnancy while being trafficked. After being trafficked, survivors continued to report pregnancy complications with 35 percent reporting problems during pregnancies.17
Eighteen-survivor participants reported the birth of forty-four children while they were being trafficked. Seven survivors reported having had nine children before being trafficked, while twelve survivors had twenty-three children after they were trafficked.
Table 11. Childbirth Outcomes—Where did the Children of Human Trafficking Survivors Go?
| Category | Number of Survivors Reporting |
| Survivor Kept Child (or Children) | 19 |
| Survivor’s Child (or Children) was Cared for by Relative | 4 |
| Survivor’s Child (or Children) was Adopted | 1 |
| Survivor brought Child (or Children) to a Safe Haven Facility | 0 |
| Survivor’s Child (or Children) was Taken by Authorities | 4 |
| Survivor’s Child (or Children) was Taken by Trafficker | 1 |
Most of the survivors reported that they kept and raised their child or children. On the other hand, four survivors reported that their child was raised by relatives, one reported that she placed her child for adoption, four reported that their child was taken by authorities such as Child Protective Services, and one even reported that her child was taken by her trafficker.
D. Pregnancy Outcome: Abortion & Miscarriage
I felt that, given the circumstances (we were living in one seedy hotel after another and I didn’t see any end to it) I couldn’t bring a baby into the world, so I had an abortion.
—Amy, Survivor
The next most common pregnancy outcomes reported were abortion and miscarriage. Eleven survivors reported experiencing at least one miscarriage.18 Nineteen survivors reported at least one abortion. The total number of abortions reported by the survivor participants was forty-two. Using the same total number of pregnancies previously reported, 35 percent of all pregnancies ended in abortion.
The responses given by the survivors show a clear lack of choice with regard to abortion. Seven women reported being forced to obtain at least one abortion by their trafficker, whereas six women reported feeling forced into at least one abortion by their circumstances. Four women reported feeling pressured by friends, family, or authority figures to abort their pregnancy. Among the survivors who reported at least one voluntary abortion, 82 percent reported feeling regret for their voluntary abortion.
Table 12.1. Analyzing Human Trafficking Survivor’s Abortions
| Category | % of Survivors Reporting (N=31) |
| Obtained at least one Abortion | 65% (N=20) |
Table 12.2. Analyzing Human Trafficking Survivor’s Abortions
| Category | % of Survivors who Obtained at Least One Abortion (N=20) |
| Obtained at Least One Abortion Forced by Trafficker | 35% (N=7) |
| Obtained at Least One Abortion Forced by Circumstances | 30% (N=6) |
| Obtained at Least One Abortion Urged, Counseled, or Pressured by Friend, Colleague, Health Provider, etc. | 20% (N=4) |
| Obtained at Least One Voluntary Abortion | 55% (N=11) |
Table 12.3. Analyzing Human Trafficking Survivor’s Abortions
| Category | % of Survivors who Obtained at Least One Voluntary Abortion (N=11) |
| Regrets at Least One Voluntary Abortion | 82% (N=9) |
| Does not Regret Voluntary Abortion | 19% (N=2) |
E. Abortion Alternatives
I didn’t want an abortion but I didn’t know there were places I could get help if I didn’t want an abortion.
—Sandy, Survivor
The lack of choice represented in these survivors’ responses is elucidated by their responses to the questions on their knowledge of abortion alternatives. From a list of various abortion alternatives, only one survivor reported being aware of safe havens, where women can safely and anonymously leave newborns at hospitals and fire stations. Only six survivors reported that they were aware of adoption as an abortion alternative. And only seven survivors reported being aware of Pregnancy Helping Organizations (PHOs) or Pregnancy Resource Centers (PRCs). Considering this lack of awareness of abortion alternatives, it is unsurprising that only three survivors reported utilizing an abortion alternative.
Table 13. Human Trafficking Victims’ Awareness of Abortion Alternatives
| Category of Abortion Alternative | % of Survivors Reporting Awareness of Alternative | Frequency (N=31) |
| Knew about Adoption | 19.4% | 6 |
| Knew about Safe Havens | 3.2% | 1 |
| Knew about Pregnancy Resource Centers | 22.6% | 7 |
| Utilized an Abortion Alternative | 9.7% | 3 |
Table 14. Where do Victims of Human Trafficking Seek Healthcare?
| Type of Healthcare Provider | % of Survivors who Sought Healthcare at this Type of Provider | Frequency (N=31) |
| Hospital/ER | 81% | 25 |
| Urgent Care Clinic | 29% | 9 |
| Neighborhood Clinic | 29% | 9 |
| Private Physician | 35% | 11 |
| Planned Parenthood | 29% | 9 |
| Women’s Health Clinic | 19% | 6 |
| Pregnancy Resource Center/Pregnancy Helping Organization | 6% | 2 |
F. Interactions with Healthcare Providers
I must have gone to dozens of emergency rooms, clinics, and even private physicians and not one of them asked me or understood what was happening to me.
—Jeneice, Survivor
Nearly every topic covered in the survey touched on some medical healthcare issue. Interaction with healthcare providers was inevitable. And yet, the survivors’ experiences with healthcare providers are markedly disappointing. 90.32% of survivors reported that they sought healthcare at a hospital or emergency room, urgent care clinic, neighborhood clinic, Planned Parenthood, Pregnancy Resource Center or Pregnancy Helping Organization, women’s health clinic, or private physician. Most women (80.64%) sought health care at a hospital or emergency room. 35.48% of survivors reported that they sought healthcare from a private physician. Various clinics, including urgent care clinics, neighborhood clinics, and Planned Parenthoods each had the same number of responses with 29.03% of survivors reporting seeking healthcare at one of these providers.
Table 15. Human Trafficking Survivors’ Perception of Quality of Care Received from Healthcare Providers
| Statement on Quality of Care | % of Survivors Agreeing with Statement | Frequency (N=31) |
| Medical professionals delivered care with excellence. | 12.9% | 4 |
| Medical professionals were trauma informed. | 9.7% | 3 |
| Medical professionals made referrals that were helpful. | 6.5% | 2 |
| Medical professionals followed up and provided aftercare. | 9.7% | 3 |
Even though most of the survivors reported interacting with medical professionals, when asked to characterize their general interactions with healthcare providers, only 9.7% of survivors reported agreeing with the statement that medical professionals “understood what happened to [them].” Only 12.9% believed the care they received was “excellent.” Only 9.7% reported that the medical professionals were “trauma informed.” Only 6.5% reported receiving helpful referrals. And only 9.7% reported that the medical professional followed up with them or provided aftercare.
Recommendations
Because this is a preliminary survey with a small sample size, we will not attempt to make formal recommendations until we complete the larger survey. However, we have identified a few possible areas for further exploration:
- Provide training for healthcare providers that includes information on gy-necological, reproductive, and procreative problems of trafficking victims and survivors.
- Build capability in anti-trafficking service providers for understanding of pregnancy in trafficking and equip shelters and service providers to assist pregnant trafficking victims and survivors.
- Work to change systems, including hospital staff, health providers, and Child Protective Services, so that victims and survivors who are pregnant and/ or have children can obtain assistance in having and keeping their children if they so choose.
- Broadly increase awareness of choices for trafficking victims and survivors, including alternatives to abortion and other services to help victims and survivors.
Limitations of Survey
This survey had several limitations. Because it is based on convenience sample rather than probability sample findings in this survey cannot be generalized beyond the sample. These are preliminary findings from a pilot survey, so the sample size is small. The survey is a retrospective self-reporting survey. Self-reporting is a time-honored survey method, but it may have several limitations, the main one being bias in reporting. The participants may not always answer honestly; they may choose the more socially acceptable answer rather than the truthful answer. In addition, participants may not always have the required introspective ability: they may not be able to assess themselves accurately. Participants also may not remember the past accurately—particularly if they involve traumatic events.
We strove to decrease these limitations by letting participants know that there were no “right” or “wrong” answers and that because this information about pregnancy and trafficking was being gathered for the first time, we needed their complete honesty in the answers.
One other limitation of the survey includes the fact that although participants may have experienced multiple pregnancies there was no place in the survey to address each pregnancy individually. Survey tabulations are therefore overall totals and summations rather than individual analyses of each pregnancy.
Conclusion
We know so little about pregnancy in the context of human trafficking. A national study with a larger sample size will tell us more. In the meantime, we can say that in human trafficking, especially sex trafficking, victims get pregnant, often multiple times and experience miscarriage, abortion, and forced abortion. They also decide to carry their children to term and bear children, many times without proper pre- and post-natal care. Finally, they raise children while being trafficked, and the indications from our small focus groups is that children suffer in these circumstances.
