Dean dissertation by ICSW

The Institute for Clinical Social Work

Child Sexual abuse and the Link to Commercial Sexual Exploitation

A Dissertation Submitted to the Faculty of the Institute of Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By Jennifer Dean, LCSW

Chicago, Illinois January 23, 2022

Abstract

This study used Interpretive Phenomenological Analysis methodology to explore the experiences of women who had become involved in commercial sexual exploitation after having survived childhood sexual abuse. Interviews with six female participants who were interviewed a minimum of two times each provided insight into their lived experiences, and the personal pain which drove their future decisions. Subjects candidly discuss graphic abuse at the hands of both their childhood and adult perpetrators, as well as the internal compulsions that arose as a consequence of this abuse. Survival techniques and coping strategies are examined, along with reliance on substances or other methods used to temporarily numb their daily realities. Relationships, trust, and attachment patterns, along with themes of personal identity and need for control are investigated. Psychological and somatic responses to trauma, as well as revictimization rates and the impact on survivors is a primary focus of this study. Resilience, purpose, beliefs and strengths are also analyzed as a path towards healing in this eye-opening look into the world of sex-trafficking and exploitation, commonly known as “The Life.”

For my children, Elias, Emmet, and Lila, and my husband Nick

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Acknowledgements

I was unsure of how to get through the process of writing a dissertation, however I was fortunate enough to have interviewed these six women for this study. Their life stories are full of courage and perseverance, and this kept me focused on my desire to share their experiences. Even when the stories they told were extremely painful to recount, they remained honest and committed to the process. I am honored to have been the recipient of your trust, you have all touched my heart. My committee has mentored me throughout this process, and I am grateful and extremely appreciative to each of them for the time and commitment they have devoted to this study. Lynne Tylke has provided insight that has been invaluable, and the encouragement I have received from these five women has allowed me the ability to champion many more. Thank you all, so very much.

Table of Contents Page Abstract…………………………………………………..……………………...........….ii Acknowledgements…………………………………..……………………..........……...iv List of Tables....................................................................................................................vii Chapter I.

Introduction……………………………………………………..………..........…1 Statement of Purpose Significance of this Study for Clinical Social Work Statement of the Problem and Specific Objectives to Be Achieved Research Questions to Be Explored Theoretical and Operational Definitions of Major Concepts Statement of Assumptions Epistemological Foundation of Project Foregrounding Case Example

II.

Literature Review…………………………………………………....…………21 Trauma, Dissociation and Somatic Disconnection Early Childhood Sexual Abuse Prostitution or Commercial Sexual Exploitation v

Table of Contents—Continued

Chapter III.

Page

Methodology……………………………………………………….........………49 Introduction Research Sample and Plan Information Needed Research Design Data Collection Data Analysis Ethical Considerations Issues of Trustworthiness Limitations and Delimitations The Interviews The Role and Background of the Researcher

IV.

Results…………………………………………………….......…………………68 Phases of Research Introduction to Participants Superordinate Themes, Sub Themes and Respondent’s Experiences

Discussion…………………………………………………......…………….....159

Table of Contents—Continued

Chapter VI.

Page

Conclusion……………………………...…………….......……………………202 Clinical Considerations Recommendations for Future Research Concluding Thoughts

Appendices A.

Flyer…………………………………………........……………………………211

Letter to Potential Participants………………...…….……………………….213

Consent for Participants………………….......…………………….…………215

References……………………………………….........………………………………..219

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List of Tables

Table

Page

1. Questionnaire Responses.....................................................................................70 2. Themes..................................................................................................................73 3. Theme References................................................................................................75 4. Comparison of Findings......................................................................................77

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Chapter I

Introduction

“To assume that there is consent in the case of prostitution, is to disappear its harm” (Farley, 2003, p. 2).

Statement of Purpose The purpose of this phenomenological study is to understand the lived experiences of women who are currently victims of commercial sexual exploitation, and who are also survivors of childhood sexual abuse. The in-depth interviews examine the real life experiences of these women through a theoretical and psychodynamic perspective, which differentiates this study from previous studies with this population.

Significance of this Study for Clinical Social Work This research offers a window into the lives of women who have suffered from child sexual abuse and trauma, and then enter a life of commercial sexual exploitation. Mitchell (1988, p. 26) believes that psychopathology can be defined as “the tendency of people to do the same painful things, feel the same unpleasant feelings, establish the same self-destructive relationships, over and over and over.”

Child sexual abuse (CSA) is a risk factor for women who experience adult victimization (Aakvaag, Thoreson, Wentzel-Larsen, Dyb, 2017, p. 1601), and women exposed to CSA have likely experienced other forms of childhood violence. Melissa Farley, in her 2003 article Prostitution and the Invisibility of Harm, reports that “60 90% of women working in prostitution had been sexually assaulted as children” (p. 6), and goes on to state that “familial sexual abuse functions as a training ground for prostitution” (p. 10). In Roe-Sepowitz’s (2012) study on juvenile entry into prostitution, she found that childhood sexual abuse “was reported by almost 80% of the participants, more than any of the other childhood abuse categories” (p. 573). Although sexual abuse has “consistently been identified as a robust risk factor for involvement in commercial sex” (Cole, Sprang, Lee & Cohen, 2014, p. 124), women who work as prostitutes are still viewed as criminals by much of society. Examining how their development has been impacted by trauma symptoms and dysregulation, societal judgment, criminal records, lack of education, inability to enter the work force and other factors which have created an unstable environment was the goal of this study. The qualitative research in this study explored the options and dilemmas these young women must contemplate when faced with personal survival and was intended to pave the way for a broader perspective of those who are impacted by early childhood sexual trauma and enter the world of commercial sexual exploitation. This study allows clinicians to better understand the lived experiences of these women, to more effectively respond to their emotional needs.

Statement of the Problem and Specific Objectives to Be Achieved Women who are victims of commercial sexual exploitation are forced to perform sex for money multiple times a day. Each act is a re-experiencing of early childhood trauma for many, and often times further trauma is inflicted due to physical and verbal abuse, rape and inhumane treatment. In 1914, Sigmund Freud observed that: We have learnt that the patient repeats instead of remembering, and repeats under the conditions of resistance. We may now ask what it is that he in fact repeats or acts out. The answer is that he repeats everything that has already made its way from the sources of the repressed into his manifest personality— his inhibitions and unserviceable attitudes and his pathological character-traits. He also repeats all his symptoms in the course of the treatment. And now we can see that in drawing attention to the compulsion to repeat we have acquired no new fact but only a more comprehensive view. We have only made it clear to ourselves that the patient's state of being ill cannot cease with the beginning of his analysis, and that we must treat his illness, not as an event of the past, but as a present-day force. Muller (2010) speaks to these same ideas, and points out that individuals are often “unaware of the painful longing for what might have been, distress about having been abandoned by the person trusted most, and the wish to complete the relationship that was somehow derailed too soon” (p. 83). CSA and its relationship with adult sexual violence has been well documented. “Childhood experiences are carried into adulthood, leading to an increased likelihood of re-exposure to violence” (Aakvaag, et al., 2017, p. 1602). Dr. Ingeborg Kraus, in her

2016 lecture on “Trauma as a Pre-Condition and Consequence of Prostitution,” reported that children are the most frequent victims of sexual violence, and 70% of them will again become victims of sexual violence as adults. Dr. Kraus further explains that “when we look at the pre-condition for women entering prostitution, we must realize that the majority of women have experienced severe forms of violence in childhood.” In a 2014 study comparing the trauma of sexually exploited youth and youth who had been exposed to CSA (Cole, et al., p. 135), the researchers found that “involvement in commercial sex, over and above the effects of sexual abuse and assault, is associated with emotional, developmental, psychological and behavioral dysregulation in those involved.” How do some children become exposed to sexual predators, and then later become involved in commercial sexual exploitation? Young children who have been abused or neglected can easily become vulnerable to predators who understand how to engage emotionally hungry kids. “They can become confused about what constitutes kindness, intimacy and safety, which may result in greater vulnerability to subsequent exploitation by adults (e.g., pimps), who initially seem kind, protective and safe” (Cole, et al., 2016, p. 135). Pimps can also begin intimate relationships with vulnerable girls by providing them with the attention, love and promises of safety they are yearning for. “Once girls become emotionally attached, pimps establish emotional dependency as quickly as possible, beginning with changing a girl’s name. This removes her previous identity and history, and additionally, isolates her from her community” (Farley, 2003, p. 7). Coy (2009) points out that “entry into prostitution is embedded in previous experiences of objectification and sexual abuse” (p. 66), and that “sexual abuse signifies to women that bodies can be appropriated by others for their sexual gratification,

reinforcing both a sense of “personal powerlessness and disembodiment, and wider male entitlement of sexual access to women” (Coy, 2009, p. 66). Victims of CSA are left to somehow make sense of the feelings of shame that can severely affect their future decision making abilities. Carl Goldberg, Ph.D., in his book Understanding Shame (1991), writes: Child abuse is a crisis in trust between a child and an adult who has violated a caretaking position with the child. The experience is painfully shameful because it violently conveys to the child that his personal power against environmental intrusion is quite limited. He is forced to recognize that his body, mind, and spirit are controlled by others, not himself. And in doing so, it undermines the victim’s sense of legitimate entitlement to take proper care of himself (p. 36). Youth who are victims of CSA are likely to suffer from deep feelings of shame, and if they have then been trafficked into commercial sex the feelings of shame can increase. If they do have the opportunity to receive counseling services, it may not always be effective. “The developmental injuries imposed by this type of experience in childhood or adolescence can create a barrier to effective therapeutic engagement” (Cole, et al., 2016, p. 141). Roe-Sepowitz’s 2012 study found that girls who had suffered physical and sexual abuse were more likely to enter prostitution as teenagers, and were more likely to suffer dissociative symptoms than women who entered prostitution as adults (p. 570). Women who are victims of commercial sexual exploitation suffer from shame brought on by their experiences. Survivors expect to be shamed by outsiders...and “suffer a strongly stigmatized sense of self, believing that “people can tell” they are prostitutes merely by looking at them” (Baldwin, 2012, p. 273). Women working in

prostitution are at risk for internalizing “toxic public and private contempt directed against them” (Farley, 2004, p. 1092) because they feel invisible as human beings. This internalized shame, coupled with an abuse history, can compel these women to further subject themselves to victimization at the hands of their pimps and the johns (or tricks) who pay for their services. Violence is prevalent in this population, and is considered part of the job. “Traumatic brain injury (TBI) occurs in prostitution as a result of being beaten, hit, or kicked in the head, strangled, or having one’s head slammed into objects such as car dashboards” (Farley, 2004, p. 1098). When a young woman who has been exposed to violence and sexual assault is then coerced into performing sexual acts as a way of survival, she must find a way to live through the experience. In order to survive, we need to have a regulated system. Once dysregulation occurs, it is far easier to become dissociated and “reduced to automated processes and isolated portions of our memory” (Hill & Schore, 2015, p. 28). Dissociation is a way of surviving a situation which would otherwise be impossible to survive. Hill, et al., (2015, p. 32) state that dissociation is an “inborn, adaptive, automatic response to a life-threatening event from which there is no escape and which induces terror – overwhelming, painful affect consisting of fear and horror.” Many women feel as if they cannot engage in commercial sex unless they dissociate, and suffer from numbing and avoidance symptoms. These symptoms “impede a survivor’s ability to recall and describe events and feelings associated with prostitution” (Baldwin, 2012, p. 273). Drug and alcohol use helps the victim experience psychological dissociation, and also provides an analgesic for injuries from violence. “When women in

prostitution do not dissociate, they are at risk for being overwhelmed with pain, shame, and rage” (Farley, 2003, p. 21). There are a myriad of ways in which dissociation affects women who are victims of sexual exploitation. What makes some able to dissociate to a lesser degree, and able to continually perform the work? What makes others re-experience the trauma so severely they feel as if they are watching the events from outside of their bodies each time they perform a sexual act? When researchers Cooper, Kennedy, & Yuille interviewed prostitutes in their 2001 study regarding their level of dissociation in comparison to their early traumatic experiences, they did indeed find some significant differences. They noted that although the associations between abuse and consequent dissociation can be robust, individual differences are apparent (Cooper, et al., 2001). The researchers also found that there was no association with assaults while the participants were working on the streets and their scores on the Dissociative Experiences Scale, and theorized that the women may have learned alternative strategies to cope other than dissociation. One theory included the idea that abuse on the streets was not considered abuse by these women because it was just part of the job, which helped the women find alternative strategies to survive these attacks. When Ross, Farley and Schwartz (2003) looked at dissociation among women in prostitution, they noted “pathological dissociation is only one element of the trauma response, and is accompanied by extensive co-morbidity including anxiety, mood, substance abuse, psychotic, eating and personality disorders,” They have surmised that “since women in prostitution report high rates of childhood trauma in addition to violence while prostituting, one would predict elevated levels of pathological dissociation and of other forms of co-morbidity” (Ross, et al., 2003, p. 200).

Somatic symptoms (SS) may bring on a myriad of severe physical complaints. “Following childhood trauma, SS may cause significant interference in daily functioning” (Kugler, Bloom, Kaercher, Truax & Storch, 2012, p. 662). Researchers Paras, Hassan Murad, Chen, Goranson, Sattler, Colbenson, Elamin, Seime, Prokop, & Zirakzadeh (2009) found there was “a significant association between a history of sexual abuse and a lifetime diagnosis of functional gastrointestinal disorders, nonspecific chronic pain, psychogenic seizures and chronic pelvic pain” (p. 555). SS and dissociation are topics of study that have been widely researched, however the ways in which these coping methods enable victims to tolerate daily trauma has not been studied in length. There has been very little literature on the topic of the complicated relationship between early childhood sexual abuse, commercial sexual exploitation and dissociative responses. My work with women who are victims of commercial sexual exploitation had made me curious about their lived experience. Having survived sexual abuse, rape, emotional abuse and violence, it is common to hear women report that it is now their choice to prostitute. After having been forced to perform sex against their will for much of their lives, women in prostitution often come to the decision that “they may as well charge for it now.” Does this perspective help victims gain a sense of control over their choice to continue such re-traumatizing work? Do they implement strategies for survival that become so normative, to the point where they don’t even identify them as problems? Early attachment styles play a large part in understanding why these children were vulnerable to begin with. Main and Soloman’s 1986 research proposed that parental behavior which seemed frightening could be the cause of disorganized/disoriented infant attachment, and “these behaviors suggest a conflict between simultaneous dispositions to

physically approach and to flee the caregiver” (Duschinsky, 2015). Mitchell (1998) noted, “If only painful experiences are provided, the child does not give up and look for pleasurable experiences elsewhere, but seeks the pain as a vehicle for interaction with the significant other” (p. 26). Mitchell explained these complicated relationships by illustrating that to “abandon these bonds and entanglements is experienced as the equivalent of casting oneself off from intense human contact altogether, an impossible option” (Mitchell, 1998, p. 28). Legalizing prostitution is a controversial subject, with many countries in favor of this as a solution for regulating conditions, health and safety for women. Some of the behaviors which result from childhood sexual abuse can seem prostitution-like. “A common symptom of sexually abused children is sexualized behavior” (Farley, 2003, p. 12). Women who work as prostitutes are not considered victims, but are thought of as criminals who should be arrested for breaking the law and lowering the reputation of a neighborhood. “Women are purchased because they are vulnerable due to a lack of educational options, as a result of previous physical and emotional harm” (Farley, 2003, p. 5). Farley (2006) reports how the “emotional and physical helplessness of the sexually abused child may be reenacted in the prostitution transaction, with vigilant attention to the tiniest shard of control” (p. 13). Research that takes an in-depth look at how these women have been subjected to familial trauma, holes in the educational system, and deficits in our societal structure is currently lacking. These sensitive, in depth interviews have been conducted with the goal of understanding these women’s experience of childhood sexual abuse and their experience of commercial sexual exploitation. The stories delve into the various factors

that may influence these women to repeat a trauma which has already handicapped their young lives. When we have a better understanding of the drives that are underlying their decisions to be in or stay in “The Life,” we as a society may rethink our stance towards protection and punishment of this vulnerable population. By illuminating the multiple factors that may inadvertently steer girls and women towards a life of commercial sexual exploitation, my hope is that lawmakers will be influenced to reconsider the fines and jail time these women receive when they are arrested for prostitution.

Research Questions to Be Explored This qualitative study focuses on the subjective experiences of women who were affected by early childhood sexual trauma, and later became victims of commercial sexual exploitation. Using an Interpretative Phenomenological Analysis design (Smith, Flowers & Larkin, 2009), data was collected by conducting open-ended interviews which were semi-structured with six women who entered the world of commercial sexual exploitation. Some of the questions explored in this study were: 1. How do early attachment issues affect the likelihood of early childhood sexual abuse and later involvement in commercial sexual exploitation? 2. As children, were coping mechanisms utilized to make experiences more tolerable, and did they employ similar coping mechanisms as adults during traumatic experiences? 3. Do participants experience somatic symptoms and mental health symptoms, as a result of their experiences? 4. Do participants notice a compulsion to repeat early trauma?

Theoretical and Operational Definitions of Major Concepts Early childhood sexual abuse was defined by the guidelines formulated by the 1999 WHO Consultation on Child Abuse Prevention (62) which stated that: •

Child sexual abuse is the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society. Child sexual abuse is evidenced by this activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust or power, the activity being intended to gratify or satisfy the needs of the other person. This may include but is not limited to:

•

The inducement or coercion of a child to engage in any unlawful sexual activity

•

The exploitative use of a child in prostitution or other unlawful sexual practices

•

The exploitative use of children in pornographic performance and materials For the purposes of this study, prostitution will be defined as commercial sexual exploitation, and refers to crimes which involve any type of sexual abuse or exploitation of a child or an adult in exchange for monetary and non-monetary benefits.

Dissociation Currently, the Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition (DSM-V) defines dissociation as “a disruption and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (APA, 2013).

Somatic disconnection refers to the loss of experience of being in your body. Thus, “thoughts are disconnected from emotions, there is a lack of awareness of the somatic feelings and some behaviors can become repetitive and automatic” (Luoni, C., Agosti, M., Crugnola, S., Rossi, G., & Termine, C., 2018).

Commercial sexual exploitation of children is a crime that involves the sexual abuse or exploitation of a child and provides financial benefit for another person, or is in exchange for something of value.

Statement of Assumptions The following list of assumptions was drawn from the researcher’s experiences as a clinical social worker who works directly with this population, in addition to academic research: 1. Early childhood trauma impacts the future development of the individual. 2. Child sexual abuse is considered traumatic and victims will have experienced symptoms which are related to their experiences. 3. There is a connection between CSA and commercial sexual exploitation. 4. Commercial sexual exploitation has most likely been traumatic. 5. Victims of child sexual abuse and commercial sexual exploitation utilize psychological defenses to make their experiences more manageable. 6. Victims of commercial sexual exploitation lack emotional and community support, as well as financial support from community services.

7. Commercial sexual exploitation leads to stigmatization in the community and isolation. 8. Participants are at risk for being uncomfortable sharing information. 9. Sharing information could contribute to reliving traumatic experiences, as trauma is not remembered but re-lived.

Epistemological Foundation of Project Data for this study was drawn from the actual experiences of the participants in this study. It is safe to assume the researcher has influenced the participants of this study, however the intention of the research questions was to understand the lived experience of each of the participants.

Foregrounding My background and interest in the problem. I became a social worker in order to work with vulnerable populations. During my training, I volunteered at an organization which provided services to women who had been sex trafficked or had been arrested for prostitution. Once arrested on prostitution charges, participants were offered prostitution diversion classes as an incentive to remove the charges from their permanent record. When I began work for this organization, I wondered immediately why all of these women were being arrested. Weren’t they just trying to make a living, in the only way that was available to them? The women I spoke with believed they were providing a much-needed service in the world and even protecting other, more vulnerable people from potential threats. I suspected this was their

way of normalizing their work, or even a defensive justification. The “johns” or “tricks” that engaged their services were not being arrested, or if they were it was extremely rare. I discovered that when these women were raped, robbed or beat up, they rarely reported the crimes because in their experience, very little was done to assist them. It was immediately apparent to me that early childhood sexual trauma had impacted a large cross section of the population I was now working with. Having experienced such terrifying early childhood experiences, I wondered why these women would expose themselves to what surely seemed like opportunities for further abuse. Entering “The Life,” which is the term used for working in commercial sexual exploitation, seemed like an inevitability for so many young women that had already experienced betrayal at the hands of those they trusted most. I became very interested in understanding how experiencing sexual abuse as a child impacted their sense of self. Becoming re-traumatized seemed like the norm, and the pull that drove them into this line of work was clearly very strong.

Clinical experiences. I was initially frightened to begin my work with this population. I had a preconceived idea of what a woman who was involved in commercial sexual exploitation would be like, and I was not sure how I would hold my own in my work with them. Although I had to surmount these challenges in order to explore this population, I was compelled to dive into this work because I believed these women must have had dire circumstances that led them down this path. I began facilitating prostitution diversion groups, and it was immediately clear that the group was teaching me far more than I was

teaching them. I knew nothing about their histories, their traumas and familial traumas, their socio-economic challenges, and the racial injustices they suffered. Yet I learned, and we began to learn together. Our groups became an experiential world where these women could explore the events they had been exposed to, and begin to think about the impact on their physical and emotional well-being. Doing this research seemed like the natural next step in my work with them. The participants in these groups encompassed every type of personality I could imagine, and I never knew who would walk in the door and join a group on any given day. There were soccer moms who needed to earn some extra money for their family, and college girls who needed to pay their tuition. There were grandmothers and teenagers, heterosexuals, homosexuals and transsexuals. There were people from privileged backgrounds and economically devastated backgrounds, Americans and women from every country imaginable. Some were escorts who were paid huge sums for their services, some walked the streets and were exposed to extreme violence at the hands of their john’s and pimps. Some had addictions, some did not, some were educated, some were not, and some had children and some did not. Most participants in these groups initially defended their right to do sex work, professing it was an easy way to make good money. Yet there were many, many stories that showed the darker side of commercial sexual exploitation. Participants swapped stories of the kidnappings, beatings, rapes and humiliation that often came with the job, and the uncertainty of knowing what each night might bring. I saw that none of these women had chosen this job because they wanted to do it, but all felt compelled to do the

work. They cited the need for money, and of course money was at the core. However, I wondered if there was another pull toward the choices they made. The groups were ethnically mixed, but there was a predominance of young African American women. As the group leader, I was generally mistrusted and oftentimes scorned. The first question I would get from new group members was “You been in The Life?” When I admitted to a group that I had never been involved in commercial sexual exploitation, I was immediately discounted. How could I possibly understand what they have gone through? How could I, a Caucasian social worker in her late 40s, relate to a twenty-year-old African American girl who may have lived in foster care and been picked up by a pimp at age 14? The answer was, I couldn’t. The girls would often try to intimidate me, they would band together and become hostile and interrogating. I learned to weather these attacks, and I would just listen. I wanted to be someone they could come to, someone they could share with, and someone who would empathize with their terrible stories. And although I had not experienced what they had experienced, I had experienced my own traumas. It was now my goal to understand these young women and learn from them, without causing them to feel like I may be judgmental about their lifestyle. As much as I may have wanted to convince them to leave “The Life,” I learned how to accept and understand their choices, which reduced the shame they may have experienced. I shared myself openly, and put words to the pain they could not always express. Once the girls understood that I was not a threat, and I wasn’t here to judge them or even change them, they generally warmed up to me. I have made hundreds of intense and caring bonds with these young women over the years, and I have learned so much about their stories. Their stories are what has compelled me to do this research, as I have

found that the choices they often make and the amount of suffering they experience to be truly devastating. In the following years I graduated with my MSW, gained my licensing hours, passed my exams and entered a Doctoral program. Yet I never stopped my work with the victims and survivors of commercial sexual exploitation, and I am currently in my seventh year with the organization. I have taken on several different positions in the organization. Along with group work, I have provided individual therapy for participants and currently advocate for financial aid and victim’s assistance for those who have lost years of their life due to human sex trafficking. In individual therapy, the trend I noticed in group therapy became more apparent. It seemed the majority of the women I spoke with had been sexually molested or raped as children. This took place at the hands of fathers, step-fathers, brothers, uncles, family friends, grandfathers, cousins and foster parents. I bore witness to story after story of young helpless children falling victim to molestations, and listened as they spoke of never being protected – and oftentimes even getting blamed – for what took place. These experiences may have left them feeling as if they had been damaged by the abuse, and commercial sexual exploitation was all that was left for them. Perhaps they felt invincible because they had already experienced so much pain, so they assumed they could not feel any more. By the time these girls made it to their teenage years, they had often been taken out of the home, and either placed in foster care or with a relative. They had adopted coping techniques for their inner anguish. Survival became necessary for most, and survival often meant love and protection. Pimps prey on girls like this, and before they

knew it they were caught up with a “boyfriend” who suddenly turned them out. “Turning them out” means forcing a girl to sell sexual services for money, which they would end up seeing very little of. There is also a lot of clout a girl can gain when she is turned out and has a boyfriend. Young girls become hardened and street smart very quickly, and learn what to do to keep their boyfriend/pimps happy. Physical abuse is extremely common, and these girls often blame themselves for not bringing in enough money or otherwise not making their pimps happy.

Case Example I have unfortunately heard the above story or similar stories hundreds of times. The stories haunt me, and I am often unable to sleep at night because of the violence and horror these girls have been exposed to. One such story stays with me, the story of Eden. Eden’s background was a bit unusual, as she was from an intact and financially well-off family. They owned a family business, which her uncle and father ran together. Eden, along with her siblings and cousins, often played in the store and felt safe and happy there. When Eden was six, her uncle began to find excuses to get her alone, and began molesting her. He warned her not to tell anyone or else she would get hurt. Eden did not tell anyone for years, and when she finally confided in her mother, very little was done to rectify the situation. The uncle was no longer permitted to come to the house and Eden did not come to the store, however the police were not called and no other consequences were put in place. A few years later, Eden was molested again by a cousin. This time, she didn’t bother to tell anyone because she believed no one would really care.

When Eden was fifteen she met a boy. He was older, and Eden felt excited and validated by his attention. Within three months she was working for him, selling her body on the streets. Eden felt proud of herself, she was independent and making more money than she had ever dreamed of. Finishing high school became unimportant, and Eden distanced herself from her parents, friends and loved ones. She believed that she may as well sell her body for sex, rather than give it away for free. As the years went by, Eden was arrested for prostitution several times. The arrests on her record made it impossible to get employment. She no longer had any relationship with her family, and had few other options except to continue the work she was doing. She had somehow escaped her pimp boyfriend, and she was now finding clients through the different ads she posted online. One night, Eden went out on a call. She was picked up in a car and was told she was being taken to meet the driver’s boss, who was famous. Eden was instead taken to an abandoned warehouse, where she was raped and sodomized for six hours. Eden now suffers from extreme Post-Traumatic Stress Disorder, and cannot even be alone in her apartment without fear of being attacked. Eden did not report the rape, because she believed the police wouldn’t have done anything to help because she was out on a call and willingly entered the car. Eden believed the rape was ultimately her fault, just as she believed she may have contributed to the molestations by her uncle and cousin. Eden, who was once a vibrant young woman, was now a shell of her former self. She can no longer work because of her trauma, yet she has no other means for making an income and has a record of prostitution. She lost her apartment and became homeless, and turned to drugs to numb the pain.

The choice to pursue this research is extremely personal, as I have experienced the effects of childhood trauma and the propensity and desire to repeat it. This unconscious process robs people of the ability to make educated choices in their lives, and leaves them baffled at the state of destruction they may find themselves in. Through the reflections and responses from the participants of this study, this research will offer a window into the internal experiences of women who are victims and survivors of commercial sexual exploitation.

Chapter II

Literature Review “In the commercial sex transaction, ownership transfers from the woman to the buyer who assumes belonging of the body within the parameters of certain (contractual) boundaries” (Coy, 2009, p. 66).

The following review of the literature is organized into three sections, related to the themes of trauma, dissociation and somatic disconnection, early childhood sexual abuse, and prostitution or commercial sexual exploitation. Each section will be written with the funneling method in mind, and will begin with works that provide a theory base for this work, and will then include works that are relevant but not specific to the work, works that may only represent aspects of my work, and lastly works that match this current study as closely as possible. This literature review was conducted by doing an extensive search of the books, articles and lectures which have been written or presented in each of these categories, with the goal of representing the current thinking and assumptions for each of these themes. My hope is that this literature review is easily comprehended, so that it can be directed at a wide audience that may or may not be scholarly in nature.

Trauma, Dissociation and Somatic Disconnection Psychological trauma affects those who feel powerless, because they are helpless to do anything which could potentially change their situation. “Trauma shocks the brain, stuns the mind, and freezes the body. It overwhelms it's unfortunate victims and hurls them adrift in a raging sea of torment, helplessness, and despair” (Levine, 2015, p. xxi). Trauma refers to “an event or an experience that involves the imposition of severe (or traumatic stressors - exposure to actual or threatened death, serious injury or sexual violation)” (Berzoff, 2016, p. 484). Memories, if they are non-traumatic, become assimilated and over time even start to disintegrate in clarity. In his book Trauma and Memory (2015), Peter Levine breaks down how traumatic memories become imprints, and how “these past overwhelming experiences leave deep impressions in the brain, body and psyche of the sufferer.” Traumatic memories will continue to arise as fragmented splinters which cannot be remembered in the narrative sense, but are re-experienced as “indigestible sensations, emotions, images, smells, tastes, thoughts, and so on” (Levine, 2015, p. 7). When these events become unchanged by other experiences, it could lead to symptoms of Post-Traumatic Stress Disorder (PTSD). Van der Kolk & Fisler (1995) report how “the patient may experience loss of recollections for traumatic experiences and vivid intrusions of traumatic images and sensations.” Amnesia for some elements of the trauma with later return of memories is also a common symptom of PTSD. Traumatic experiences, however, differ in their level of severity. The age at which the individual was traumatized, along with length of the trauma, will contribute to a variety of other manifestations which can affect each person differently.

It was not until 1980 that a diagnostic category to reflect the impact of traumatization was introduced to the Diagnostic and Statistical Manual of mental disorders (DSM). The DSM-5 introduced trauma and stress-related disorders as a new diagnostic category (Clark, Classen, Fourt, Shetty, 2015). Post-traumatic stress disorder symptoms fall into three main categories, hyperarousal, intrusion and constriction, which creates the feeling of always being on the lookout for danger. “They also have an extreme startle response to unexpected stimuli, as well as an intense reaction to specific stimuli associated with the traumatic event” (Herman, 1992, p. 36). “Traumatic reactions occur when action is of no avail. When neither resistance nor escape is possible, the human system of self-defense becomes overwhelmed and disorganized” (Herman, 1992). “Chronically traumatized people no longer have any baseline state of physical calm or comfort. Over time, they perceive their bodies as having turned against them” (Herman, 1992, p. 86). Allen Schore’s (2001) work demonstrates how the amygdala which is present at birth, responds to external stimuli and modulates automatic and arousal systems. Early trauma actually changes the development of the infant’s right brain which processes attachment, social and emotional development, and bodily sensations. Since the “right prefrontal cortex of the brain is critical in processing emotions, any intense feelings of stress will cause negative feelings and actually contribute to a developmentally immature defective right brain” (Berzoff, Flanagan, Hertz, 2016). “The slower developing left brain has spurts of growth around the age of language development and again at adolescence, but the development of leftbrain dominance is only achieved very gradually over the course of the first eighteen years of life” (Fisher, 2017, p. 23).

In scans of the brain area taken during recall of traumatic incidents, researcher van der Kolk and his team discovered that the Broca area in the brain, where the speech area is located, went offline whenever a flashback was triggered. Traumatized people may not be able to describe what happened to them, but their bodies can re-experience the terror and helplessness (van der Kolk, 2015). For a sexually traumatized child, part of what is overwhelming is “the ability to cognitively contain and process the enormity of the relational betrayal and physical impingement with which she is faced” (Davies, Frawley, 1994, p. 28). There is an abundance of evidence to show that severe threats can cause biological reactions to the brain and the body. “The ordinary human response to danger is a complex series of reactions that can affect both body and mind” (Herman, 1992). When one has suffered from severe maltreatment or neglect from their caregiver when they were an infant or young child, Disorganized attachment (DA) can develop. When the child is terrified of their caretaker but also relies on them for safety, their attachment strategies are likely to become disorganized. As a consequence, “multiple, segregated, incompatible working models of attachment may develop” (Howell, 2011, p. 96). Yet “when elements of the experience are not integrated into a unitary whole, but are stored in memory as isolated fragments and stored as sensory perceptions, this is referred to as Dissociation” (van der Kolk, Fisler, 1995, p. 6). Dissociating during a traumatic experience allows the brain an opportunity to find a way to escape from dealing with an experience that may just be too overwhelming. It is a protective device, and allows survivors of extreme trauma to go on with life, despite the many unthinkable events they have suffered. Consciousness can even become split into

many different parts, as a way of further protecting the individual. Dell & O’Neil (2009, xxi), explain that “the essential manifestation of pathological dissociation is a partial or complete disruption of the normal integration of a person’s psychological functioning.” van Der Kolk and van Der Hart (1991) illustrate that rather than pushing traumatic experiences away, there is an uncoupling process that occurs. “Many trauma survivors report that they automatically are removed from the scene; they look at it from a distance or disappear altogether, leaving other parts of their personality to suffer and store the overwhelming experience” (van Der Kolk, et al., 1991). Clark, et al., (2015) expounds that with repeated traumas, it is necessary to continually compartmentalize the traumatic experiences to allow the person to function and maintain some of their critical relationships. Dissociation for children often provides them with the opportunity to be safe in an unsafe world. The child they show to the world may appear to be fine, getting good grades and functioning. Splitting or fragmenting can ensure that the rejected “not me” child is kept out of the way, and long after the traumatic events are over, dissociation is often what these individuals must continue to rely on to protect themselves from further trauma (Fisher, 2017). Dissociation also serves to keep the parent or perpetrator as “good,” so the child can continue to be dependent on them. Dissociation is an unconscious defensive maneuver, and traumatized children might use dissociation to keep themselves from feeling overwhelmed by the painful memories during times when they are not being traumatized, so they are able to function successfully in many aspects of their lives (Putnam, 1988). Dissociation has been characterized as “distinguishing when a person’s consciousness, sense of identity, or behavior is sufficiently dissociated to represent an abnormal and/or pathological process”

(Putnam, 1989, p. 6). In his book Shadow of the Tsunami (2011), Bromberg discusses the dissociative mental structure, and explains that not only is it “designed to prevent what may be too much for the mind to bear, but it also has the effect of enabling dissociatively enacted communication of the unsymbolized affective experience” (p. 21). Bromberg goes on to explain that dissociation “does not simply deny the self-access to potentially threatening feelings, thoughts and memories; it effectively obliterates, at least temporarily, the existence of that self to whom the trauma could occur” (Bromberg, 2011, p. 21). Sandor Ferenczi’s writings of 1931 and 1932 illustrate his developing ideas on trauma, especially childhood sexual abuse. Ferenczi identifies splitting in his work “Confusion of Tongues Between Adults and the Child” (Ferenczi, 1932), and explains how in response to extreme trauma the psychic apparatus splits. Even though the experience has been recorded in the memory of the child, there is another part of the brain that wants to believe nothing has happened, and splits off. He writes: If the shocks increase in number during the development of the child, the number and the various kinds of splits in the personality increase too, and soon it becomes increasingly difficult to maintain contact without confusion with all the fragments, each of which behaves as a separate personality yet does not know even of the existence of the others (p. 65) In Palaez’s 2009 article, Trauma Theory in Sandor Ferenczi’s Writings, he interprets Ferenczi’s theory as “the reaction that gives rise to the trauma is the break with reality, which results in the self-destruction of consciousness” (p. 90). He summarizes Ferenczi’s theory to explain that a traumatic situation can create a numbing effect.

“Motility, perception and thought come to a halt. By virtue of this loss of perception, the personality finds itself totally unprotected” (p. 90). In the 2003 article Something Wicked This Way Comes, Bromberg describes how dissociation is a way for the mind to creatively adapt information, and believe that whatever might be happening is not happening to me (p. 561). Dissociation provides a way for consciousness to protect itself by leaving the body, which can then numb the effects of abuse or other traumatic situations. People who experience this phenomena report their experiences of dissociation “are like day dreaming or viewing oneself from outside one’s own body” (Roe-Sepowitz, Pate, & Bedard, 2007, p. 9). Dissociative symptoms provide victims with a way to deal with extreme stress from traumatic events, and can additionally assist them in diminishing their emotional reactions which may result from a triggered traumatic memory. Thus, “thoughts are disconnected from emotions, there is a lack of awareness of somatic feelings and some behaviors can become repetitive and automatic” (Luoni, Agosti, Crugnola, Rossi, & Termine, 2018). Stolorow & Atwood (1991, p. 187), when discussing the extreme states of disconnection of mind and body, explain that this typically involves “profound failures of early affect attunement, damaging physical intrusions, deprivation of contact needs, and felt threats to physical survival.” The “active disidentification with the body protects oneself from dangers and conflicts associated with continuing embodied existence” (p. 190). Stolorow and Atwood go on to explain that “when a child regularly perceives that his affective experiences are intolerable or injurious to a caregiver, then the symbolic articulation of affect may become blocked in order to safeguard the needed bond.” These researchers further explain that often in cases of childhood sexual abuse, there can be

additional disturbances between the mind and body. There may be a feeling that the mind is floating outside of the body, but this does not develop into a complete split. “An attempt is made to protect the integrity of the self through its removal from the field of bodily violation and intrusion” (p. 191). Dissociation does not always demonstrate itself as just an escape mechanism of the mind. Somatic disconnection, or Somatoform dissociation is defined as: A specific form of dissociation with somatic manifestations due to alterations of normal integrative functions of consciousness, memory or identity related to stressful experiences. The symptoms can involve bodily functions such as motor inhibition or loss of motor control, gastrointestinal symptoms, dissociative seizures, painful symptoms, alterations in perception or alterations in sensation of pain, for example inability to register pain or painful affect during a traumatic event. (Bob, Selesova, Raboch, & Kukla, 2013, p. 1). Somatic Symptom Disorder (SSD) became a new entry in the DSM V (American Psychiatric Association, 2013) and is characterized by “the presence of one or more somatic symptoms that are distressing or associated with functional impairment and excessive thoughts, feelings or behaviors related to the symptoms or health concerns” (Byrne, O’Connor, Wilson, O’Raghallaigh, MacHale, 2019, p. 6). “Somatoform dissociation involves negative symptoms, such as anesthesia of various sensory modalities (for example, apparent disappearance of body parts, bodily numbing) analgesia and inhibited movement (e.g. stiffening of the body), as well as positive symptoms, such as site-specific pain (e.g. pain while urinating,

pain in genitals)” (Nijenhuis, van Dyck, Kuile, Mourits, Spinhoven & van der Hart, 2003, p. 88). Somatofom dissociation can also arise from traumatic experiences, which prevents the individual from effectively processing somatic experiences. “Somatoform dissociation is linked to a number of psychiatric disorders that are relatively resistant to treatment” (Waller, Hamilton, Elliott, Lewendon, Stopa, Waters, Kennedy, Lee, Pearson, Kennerley, Hargreaves, Bashford, & Chalkley, 2001, p. 82). “SSD symptoms have been linked to trauma in childhood and are frequently related to physical, sexual or emotional abuse and oftentimes localized pain may depend on the reactivation of a previously dissociated traumatic memory linked to sensorimotor response” (Bob, et al., 2013, p. 4). Sexual trauma survivors may find ways of consciously forgetting their trauma by consigning symptoms to the body, and researchers Farley and Keaney (1997, p. 39) found a strong association between somatization and dissociation. Their study also showed that “as the number of perpetrators of childhood sexual abuse increased, the number of chronic physical symptoms in adulthood also increased. A 2009 review confirmed these findings, and demonstrated how “sexual abuse was associated with a lifetime diagnosis of nonspecific chronic pain, functional gastrointestinal disorders, psychogenic seizures, and chronic pelvic pain” (Paras, Murad, Chen, Goranson, Sattler, Colbenson, Elamin, Seime, Prokop, Zirakzadeh, p. 555). Nijenhuis, et al., (2003, p. 87) also found that women who had chronic pelvic pain (CPP) also had a high prevalence rate of reported sexual abuse. Additionally, it has been shown that “survivors of sexual abuse face a spectrum of often challenging health

concerns, resulting in greater health care use and cost and significant morbidity” (Paras, et al., 2009, p. 559). In the study performed by Waller, et al., (2001, p. 93), the link between somatoform dissociation and childhood trauma which involves physical contact was examined. Their findings offer substantial support for the hypothesis that abuse which involves contact is more often associated with somatoform dissociation than other forms of trauma. The researchers theorize that “the somatic response may serve the defensive function of preparing the individual for inescapable physical injury or the threat of such injury.” Like other forms of dissociation, it is an internalized escape mechanism. Byrne, et al. (2019, p. 15), explains the process of the body’s response to trauma in a meaningful way: When the body container was in pain, thus broken and inaccessible, and could no longer be used in the same way to contain psychic pain, distress that could not be thought about had no expression; or perhaps symptoms were an expression of the body pushed to its limits to manage psychic pain. Traumatized children are more likely to experience somatic symptoms, which can impact their everyday functioning and quality of life. “Such symptoms can be often chronic and intense, to such a degree as to require medical investigations, sometimes invasive, to exclude possible organic causes” (Luoni, Agosti, Crugnola, Rossi, & Termine, 2018). In a 2012 study of traumatized children, researchers found that “95.2% self-reported at least one somatic symptom (SS), and over 80% of caregivers reported that the children experienced at least one SS” (Kugler, Bloom, Kaercher, Truax, &

Storch, 2012, p. 669). Kugler, et al., in their study of youth who had experienced sexual abuse, also noted the youth experienced high rates of SS (2012, p. 669).

Early Childhood Sexual Abuse Child Sexual Abuse (CSA) and its long-term effects on the individual has been widely studied. Perpetrators of CSA are oftentimes caretakers that the child must depend upon, or other relatives or acquaintances that the child has a relationship with and trusts (Aakvaag, et al., 2016, p. 1613). The signatory element that creates the potential for abuse is a “gross imbalance of power between the perpetrator and the victim: the parties are not consenting equals, but a powerful adult coercing or manipulating a weaker, smaller, possibly dependent minor” (Napoli, Gerdes, & DeSouza-Rowland, 2001, p. 74). Child sexual abuse committed by a parent is usually more severe than sexual abuse committed by an unknown person, or another person who may be acquainted with the child (Aakvaag, et al., 2016, p. 1611). This is because “when a victim is dependent on a caregiver, withdrawal may actually threaten ultimate survival goals, particularly if the caregiver responds with reduced caregiving and/or increased aggression” (Deprince, 2005, p. 129). Freyd (1996) discusses the idea of Betrayal trauma theory, where traumas high in betrayal will be associated with a reduced ability to detect violations in the abusive relationship. She goes on to explain “that under certain conditions, betrayals necessitate a “betrayal blindness” in which the betrayed person does not have conscious awareness, or memory, of the betrayal” (p. 9). When this happens, those who were abused by a trusted adult or a parent may not have memory of the abuse for many years, especially because

there is often the absence of physical force or violence. However, Noll et al. (2003) explains that this does not negate the very real power differential that exists between the victim and the perpetrator. A victim “not physically forced into adult-child sexual relations may be more likely to consider herself a willing participant in the abuse and engage in self-blame to a greater degree” (p. 583). Unfortunately, “the imbalance of power, and the perpetrator’s ability to override even the most intimate of the victim’s personal boundaries, creates an overwhelming sense of helplessness in the survivor of sexual abuse” (Napoli, et al., 2001, p. 75). Sexual abuse can have an extremely detrimental impact on development, and in their 23-year longitudinal study, Trickett, Noll and Putnam, (2011, p. 8) illustrated some key points. Abused females met criteria for significantly more DSM diagnoses than comparison females, with dissociation, even more than depression or anxiety, noted to be broadly associated with trauma. Higher dissociation scores emerged around duration of abuse and age of onset, and parental abuse was a significant indicator of higher dissociation scores (Vonderlin, Kleindienst, Alpers, Bohus, Lyssenko, & Schmahl, 2018, p. 2473). Dissociation in sexually abused children and adolescents was also found to be associated with more frequent risk-taking behaviors, and less competent functioning (Kisiel, & Lyons, 2001, p. 1038). Davies and Frawly (1994) explain this could be because the trauma survivor does not have the ability to modulate arousal, and due to norepinephrine and dopamine depletion from inescapable stress, the individual is psychobiologically hypersensitive to arousal. They can then develop a dependence on the feelings that result from searching out stressful stimuli, which can bring about a state of

soothing calm or numbness. However, after the opioid effect recedes, it can be replaced with anxiety or even aggression (p. 30). Revictimization is the experience of both childhood sexual abuse and later sexual or physical abuse as an adult (Messman, et al., 1996, p. 398), and the research on revictimization implies that childhood experiences with violence make an individual vulnerable to new experiences of violence and abuse (Aakvaag, et al., 2016, p. 1602). The term revictimization refers to being victimized multiple times, or abuse that occurred in childhood and then again in adulthood. Revictimization may lead to a greater propensity to dissociate (Zlotnick, Begin, Shea, Pearlstein, & Costello, 1994, p. 465), and when these researchers conducted a study to look at the relationship between revictimization and dissociative experiences, they found a “reported history of sexual revictimization by a greater number of offenders (four or more) is significantly related to a higher level of adult dissociative experiences.” One hypothesis for this is that with repeated trauma, the use of dissociation is reinforced until it becomes a stable and automatic defense. The researchers’ other hypothesis is that individuals who suffer from dissociative pathology are more vulnerable to revictimization. In Wyatt, Gunthire and Notgrass’s 1992 study of the effects of CSA on sexual revictimization, they discovered that among women who reported contact abuse before age 18, “almost half (44%) experienced either contact or noncontact abuse in adulthood, and 30% reported only contact abuse incidents since age 18” (p. 170). Barnes, Noll, Putnam and Trickett, (2009, p. 7), found that for those experiencing sexual victimization, abused females were 3.03 times more likely to have experienced sexual revictimization by a non-peer than were comparison females. These results are unfortunately not

uncommon, as demonstrated by a team of researchers who assessed rates of adult sexual assault (ASA) among women in an inpatient setting to determine whether a history of childhood abuse was associated with their assault. The results indicated that a history of childhood abuse was associated with over a threefold increase in risk for ASA (Cloitre, Tardiff, Marzuk, Leon, & Portera, 1996, p. 479). There are multiple other factors which contribute to revictimization risk, including the age at which initial sexual assaults occur and their severity, along with ongoing victimization by a single perpetrator which caused women to be more likely to be victimized by a family member or current or former partner than singly victimized women (Casey & Nurius, 2005, p. 516). Race also plays a role in revictimization rates, as demonstrated by the Urquiza & Goodlin-Jones study (1994, p. 228). When sampling a multiethnic group of 243 women recruited randomly from volunteers from two community colleges, they found a pattern emerged among the ethnicities. For white women who experienced child sexual abuse 44.2% were also raped, while white women without a child sexual abuse history were raped 14.1% as adults. For African-American women, 61.5% who experienced child sexual abuse were raped, while 18.8% without sexual abuse were raped. For Latina women, 40.0% who experienced child sexual abuse were raped, while 10.3% without child sexual abuse were raped. For Asian-American women this relationship was not significant. PTSD symptoms resulting from CSA can cause a victim to ignore or just not recognize danger cues in the environment, which may make her more vulnerable to an increased risk of ASA victimization (Risser, et al., 2006, p. 689). Hyperarousal seems to play the primary role in explaining the association between CSA severity and ASA severity (p. 694), and the team of Filipas & Ullman (2006, p. 667) explain how “more

PTSD symptoms were also associated with more maladaptive coping strategies, greater CSA frequency, and longer abuse duration.” This research team also found another longterm consequence of child victimization that may be mediated by PTSD and self-blame are maladaptive coping strategies. When individuals blamed themselves for the abuse and experienced PTSD, they often dealt with the feelings through drug or alcohol abuse, sexual acting out behavior or isolation. Lemieux & Byers, (2008), when looking at the experiences of women who were undergraduate psychology students, found that “half of the women who reported CSA experiences involving attempted or completed sexual penetration and a third of the women who reported CSA experiences involving only sexual touching reported sexual victimization experiences in adulthood.” They also found women who had experienced CSA were significantly more likely to have experienced psychological abuse in childhood (p. 138). “Traumatic sexual experiences, such as CSA and rape, are associated with numerous acute and chronic psychological difficulties, including PTSD, depression, suicidality and self-harm behaviors, anxiety, substance abuse, dissociation, interpersonal difficulties, low self-esteem, and feelings of guilt and self-blame” (Messman-Moore & Long, 2003, p. 538). Substance abuse is prevalent with early trauma exposure, and research shows that women victimized by multiple perpetrators had significantly higher drug use than non-sexually victimized respondents. They also struggled with more physical symptoms, depression symptoms, and posttraumatic-stress-related symptoms (Casey et al., 2005, p. 523). PTSD, alcohol abuse and feelings of numbness can increase the likelihood of future sexual victimization (Ullman, Najdowski, & Filipas, 2009, p. 378). “As a result of their initial sexual assault experience, adult victims may develop

distorted perceptions of their physical body and/or sexuality, which may increase their victimization through specific cognitions and behaviors” (Urquiza, et al., 1994, p. 229). Dissociation may also affect revictimization risk, because “the failure to recall traumarelated information may increase revictimization risk to the extent that high dissociators fail to track threatening information” (Deprince, 2005, p. 128). Revictimization often affects future relationship choices, and it is thought that “women who have experienced sexual abuse as children learn and adopt an inappropriate repertoire of sexual behavior, and may learn to associate sexuality with pain, punishment or other negative consequences” (Messman, et al., 1996, p. 399). Additionally, despite feelings of shame and betrayal, “sexually ambivalent individuals may maintain a seemingly contradictory compulsion to recreate the sexual arousal associated with sexual exploitation” (Noll, et al., 2003). In one study that sought to identify the risk of victimization in adulthood for women and men who had experienced some form of childhood maltreatment, researchers found that “women who had been physically abused as children were three times more likely to experience sexual abuse by an intimate partner, and nearly six times more likely if they had been sexually abused as children. If they had experienced both types of childhood abuse, they were nearly eleven times more likely to experience sexual abuse by a current intimate partner” (Desai, Arias, Thompson, & Basile, 2002, p. 649). After numerous traumatic encounters with trusted individuals, women begin to expect that close relationships involve harm. This belief system and relationship-harm expectation may make these women behave differently from their peers. For example, “women who associate relationships with harm may be more likely

to stay in a relationship that becomes violent and/or feel disempowered to leave such a relationship” (DePrince, Combs, & Shanahan, 2009, p. 170). “CSA victims who develop feelings of powerlessness as a result of unpredictable and uncontrollable abuse experiences may attempt to feel more in control of their sexuality by engaging in consensual sexual behavior when using substances” (Walsh, et al., 2013, p. 7), and Messman, et al. (2010, p. 8) point out that “risky sexual behavior is especially relevant to the context of revictimization, given extensive evidence linking women’s sexual behavior to increased vulnerability for sexual assault.” The tendency to experience further abuse can be called a learned expectancy (Messman, et al., 1996, p. 399), and traumatic sexualization refers to “the development of inappropriate and dysfunctional sexual behaviors as a result of sexual abuse” (Walsh, Messman-Moore, Zerubavel, Chandley, DeNardi, & Walker, 2013, p. 2). Children also learn that sexual behavior is the way to achieve attention, affection or even privileges (Messman, et al., 1996, p. 400). In Fergusson, Horwood & Lynskey’s research on child sexual abuse (1997, p. 796), they found that “those reporting CSA involving attempted or completed intercourse had the highest rates of teenage pregnancy, early onset sexual activity, unprotected intercourse, and sexually transmitted diseases.” In addition, these young women also had the highest rates of sexual victimization after the age of 16, including both sexual assault and reports of rape or attempted rape. Adult rape is significantly associated with CSA (Aakvaag, et al., 2016, p. 1611), more than half of CSA survivors reported some form of unwanted sexual contact in adulthood, with 26.4% reporting unwanted sexual intercourse. “High levels of psychological maltreatment were also evident, as well as more unwanted fondling and

unwanted oral-genital contact with an acquaintance due to misuse of authority” (Messman & Long, 1996, p. 496). This may be explained by examining how aspects of PTSD affect revictimization. Messman-Moore & Long, (2003), detail how intrusive thoughts and other re-experiencing symptoms may make it difficult for victims to notice or take action during abuse. “Sustained hypervigilance and exaggerated startle response can create within the abuse survivor a constant state of “being on alert,” however continued arousal symptoms may actually desensitize the survivor to real threat and decrease the likelihood that she will respond to perceived danger” (p. 545). This is demonstrated by the study with researchers Rich, et al. (2005), who looked at the experiences of college women at a Midwestern university, and found sexual assault in adolescence predicted a sexual assault during the 2-month follow-up period. Additionally, “the severity of a sexual victimization experience during adolescence predicted the severity of a subsequent sexual victimization during the 2-month follow-up period” (p. 1388). Predictably, women who reported both CSA and ASA were significantly more likely to be revictimized over the course of one year than were women who reported ASA only (Ullman, et al., 2009, p. 376). Verbal and nonverbal behaviors in sexually abused females have also been examined. The abused females “were significantly higher on the coy factor, which included contradictory approach and avoidance signals such as full smiling while shrugging their shoulders, or showing their tongues while crossing their legs” (Trickett, et al., 2011, p. 9). The researchers note that “childhood sexual abuse can deleteriously affect optimal sexual development, and sexually abused adolescents report engaging in risky sexual behaviors that are consistent with the contraction of HIV and becoming a teen

mother” (p. 11). One way survivors can temporarily avoid their negative feelings associated with childhood sexual abuse is to engage in sexual behaviors, which can allow them the opportunity to ignore memories which were specific to their abuse (MessmanMoore, et al. 2003, p. 552). Self-perception of the CSA survivor plays a large role in the risk factors for revictimization. Women with a history of CSA are more likely to be have multiple partners and to label themselves as promiscuous, when compared to peers who have had similar sexual experiences. “Such self-perceptions may be apparent to potential perpetrators and may influence the decision to target these women for sexual coercion” (Messman-Moore, et al. 2003, p. 552). “Risky sexual behavior has also been conceptualized as a tension-reducing behavior utilized to regulate emotional experiences among child abuse victims” (Messman-Moore, Walsh & DiLillo, 2010, p. 8). When looking at what motivates human behavior, “motivation theorists make a distinction between behaviors that involve the pursuit of positive or pleasurable experiences and behaviors that involve the avoidance of, or escape from, negative or painful ones” (Cooper, Shapiro, & Powers, 1998, p. 1529). According to Cooper, et al., “people who are especially responsive to threat and punishment cues are predisposed to experience negative affect and to respond in an avoidant and fearful manner.” When applied to sexual behavior, they found that “higher levels of using sex to reduce negative affect were significantly positively related to total number of sexual partners as well as number of poorly known sexual partners.” Additionally, when a woman begins a new sexual relationship with an unconscious desire to reduce negative affect, she is likely going to be unable to evaluate the risks or trustworthiness of her partner (Orcutt, Cooper,

& Garcia, 2005, p. 730). These researchers also found a history of CSA was associated with a twofold increase in ASA (p. 737). Orcutt, et al. go on to explain that unfortunately, “using sex to reduce negative affect may increase risk of sexual assault by way of contact with multiple, poorly known partners and impaired decision-making in potentially sexual situation” (Orcutt, et al., 2005, p. 737). Noll, Trickett, & Putnam (2003) noted there is “likely more than one developmental trajectory describing the effects of sexual trauma on later sexuality.” Early sexual behavior, preoccupation with sex and heightened sexuality can all be symptoms of sexual trauma, as well as evidence for sexual aversion and avoidance. “There are also those who experience both a sexual preoccupation and an aversion toward sex simultaneously – those who believe sex is undesirable but who also possess a compulsion to engage in sexual activity” (p. 566). Noll et al. note that “those who experienced severe abuse or who experienced biological father abuse would exhibit more pronounced sexual distortion” (p. 576). Unfortunately, the effects of CSA and the aftereffect of PTSD seem to be ongoing. “The self-destructive behavior, profound dissociation from physical and emotional sensations, and a compulsion to re-create scenarios similar to the victim’s unresolved memories of the original traumatic event often live on with the survivor” (Napoli, Gerdes, & DeSouza-Rowland, 2001, p. 73).

Prostitution or Commercial Sexual Exploitation ‘The saying ‘the world’s oldest profession’ portrays prostitution as just another career choice.” (Kennedy, Klein, Bristow, Cooper & Yuille, 2007, p. 2)

After living through childhood sexual abuse, trauma, and potential dissociation, one might think victims would steer clear of any experiences that may expose them to further abuse. As stated in the previous section, trauma begets trauma, and this cycle is explained by the research of Smith, Davis, & Fricker-Elhai’s 2004 study. Victims and non-victims differ in their perceptions of risky behaviors, and their expectations regarding their likely involvement in risky behaviors. Victims of CSA and ASA not only believed there was less danger associated with risky sex or drug use, but believed there were benefits associated with both of these behaviors (p. 300). This supports the research that CSA victims are unaware or less aware of danger, which could place them at further risk for revictimization. Simons & Whitbeck, (1991), also demonstrate the continuance of trauma by showing how CSA, as well as neglect or physically and emotionally abusive parenting, increases the likelihood that a young woman will become involved in a dangerous life-style, which increases her risk of being victimized. These researchers also found that “sexual abuse contributes indirectly to involvement in prostitution by increasing a young woman’s ties to deviant peers and familiarity with the culture of the streets” (p. 376). Meston, Heiman, & Trapnell (1999, p. 391), when studying the relation between early abuse and adult sexuality, found that “sexual abuse was associated with more liberal sexual attitudes and behavior, as evidenced by a higher frequency of intercourse and masturbation, a greater range of sexual experience and fantasies, and a greater likelihood of engaging in unrestricted sexual behavior.” Researchers theorize that the child may be rewarded for sexual behavior that is developmentally inappropriate and learn to use sexual behavior as a strategy for manipulating others. Yet it isn’t only sexual abuse that

contributes to commercial sexual exploitation. The correlation between childhood emotional abuse and exposure to trauma has been previously documented, but Stolz and colleagues (2007, p. 1219) found that emotional abuse predicted engagement in sex work among street youth. Engaging in prostitution is one of the long-term effects of sexual victimization, and past investigations have found more serious effects – prostitution among them – to be related to specific characteristics of the sexual abuse episode (Nadon, Koverola, & Schuldermann, 1988, p. 207). Additionally, Nadon, et al. (1988, p. 214) found that “over 60% of the prostitutes they studied experienced very serious abuse involving sexual intercourse.” Another study that looked at the abuse history of women who were prostitutes found that “90.0% of the participants who commented about a child abuse history reported having been abused, and 80.3% of those had been sexually abused” (Nixon, Tutty, Downe, Gorkoff & Ursel, 2002, p. 1023). Results of a study by Choi, Klein, Shin & Lee (2009, p. 942) show that women with a history of CSA by a significant other entered prostitution at a significantly younger age, which can then expose these women to even greater trauma at the hands of pimps and johns. There are studies, however, which looked at comparisons between child sexual abuse and prostitution and found that “the link between child sexual abuse and prostitution is not direct, but requires runaway behavior as an intervening variable” (Seng, 1989, p. 673). And yet other researchers, such as James and Meyerding (1977), profess in their study on early sexual experience and prostitution, that “a woman who views herself as sexually debased or whose sexuality is more than normally objectified may see prostitution as natural, or as the only alternative” (p. 1384).

Are early childhood experiences and cycles of abuse solely responsible for later entry into prostitution? According to social learning theory, “childhood sexual exploitation teaches the victim to view herself as sexually degraded, which in turn prepares her for entry into an adolescent and adult role in which deviant definitions of self are functional” (Brunschot, & Brannigan, 2002, p. 220). These researchers compared two groups, one group composed of current prostitutes and the other a comparison group. When the two groups are compared, the target (prostitute) group “is 5.4 times as likely as the comparison group to have experienced a negative home life; 3.5 times as likely to have been raised in a non-traditional home; 4.95 times as likely to have had parents with drug or alcohol problems; 7.3 times as likely to have had a first sexual experience at age 13 or younger; 3.6 times as likely to have been physically abused, 2.3 times as likely to have been sexually abused; 6.8 times as likely to have attempted suicide; 16.9 times as likely to have run away, and 27 times as likely to have been expelled from school” (p. 225). This research suggests that one of the biggest predictors of a girl entering prostitution is early age of first coitus, however this research also noted that the girls who did have sexual intercourse at age 13 or younger were with men who were on average 5 years older than themselves. Other studies unfortunately have similar findings. Silbert and Pines (1982) interviewed two-hundred juvenile and adult women street prostitutes in the San Francisco Bay Area, and found that of the subjects, “60% were victims of incest and sexual abuse at the ages of three to sixteen. Of these cases, 70% involved repeated abuse by the same person. Two-thirds of the subjects were abused by natural, step, or foster fathers; 10% were molested by strangers” (p. 479). Furthermore, over 90% of these girls lost their

virginity through child sexual abuse, yet in 91% of the cases the victims felt as if there was no one they could tell, and nothing they could do about it. Almost all the juveniles felt they had no other options available to them at the time they started. In Dolla’s 2010 study of women who worked as prostitutes, “63% of participants reported being sexually molested during their formative years and several women were molested by more than one person. Two of the participants were impregnated by their sexual perpetrators; one by her brother, the other by her father” (p. 349). Dolla’s research also highlights how street prostitution is inherently dangerous, most participants relayed incidents of severe abuse suffered at the hands of their boyfriends, clients, and/or pimps. Many reported “having been raped, beaten with objects, threatened with weapons, and abandoned in remote regions” (2010, p. 350). Farley & Barkan interviewed 136 women who were working as prostitutes (1998, p. 41), and discovered that “83% had been physically threatened with a weapon, sixtyeight percent of these respondents reported having been raped since entering prostitution, and forty-eight percent had been raped more than five times.” This study also found that “sixty-eight percent of their respondents met criteria for a diagnosis of PTSD, with 76% qualifying for partial PTSD” (Farley & Barkan, 1998, p. 45). In Nixon’s 2002 study which looked at the levels of violence and abuse sustained by women who were involved in commercial sexual exploitation, typical assaults included “being stabbed or cut, raped, gang raped, raped at gunpoint, forced to engage in degrading sexual acts, choked/strangled, beaten kidnapped, stalked, held with a gun to head, tied up, tortured, beaten with objects (e.g. baseball bat, crowbar), and run over” (p. 1027).

Societal views on commercial sexual exploitation further complicate the issue, as women are often not even perceived to be victims. Coy, in her 2009 work, explains that prostitution “should not be reframed as employment like any other since it is ontologically damaging to the embodied self.” Her research demonstrates “how early sexual abuse and objectification has created a template for the way that women act with their bodies and demarcate boundaries of ownership and use” (Coy, 2009, p. 66). Coy expands on these ideas, citing that “sexual abuse signifies to women that bodies can be appropriated by others for their sexual gratification, reinforcing both a sense of personal powerlessness, and (dis)embodiment, and wider male entitlement of sexual access to women.” Dr. Melissa Farley, executive director of the nonprofit organization Prostitution Research and Education, has said that “the expression sex worker implies that prostitution is an acceptable type of work instead of brutal violence” (Farley, 2003, p. 4). She reports that dissociation in prostitution results from both childhood sexual violence and sexual violence in adult prostitution. Farley believes dissociation is a job requirement for surviving prostitution. (Farley, 2004, p. 1106). Prostitution, in addition to a history of CSA by a significant other, is associated with high levels of posttraumatic reexperiencing, somatization, dissociative experiences, identity problems, relational problems, and affect regulation problems (Choi, et al., 2009, p. 942). Furthermore, results of the study by Choi, et al., showed that the significant difference in dissociative experiences between prostituted and non-prostituted women was related to a history of CSA by a significant other (2009, p. 946).

Dissociation in sexual situations can become a “skill” that enables a survivor of sexual abuse to prostitute herself without consciously experiencing any emotional or physical disturbance (Napoli, et al. 2001, p. 79). The need to dissociate and to separate oneself away from the body was discussed at length by the women Coy interviewed, and this was used as a coping mechanism during commercial sex exchanges (Coy, 2009, p. 67). Many women associated their survival of childhood sexual abuse with the way they separated from their bodies, and then learned to repeat these actions when involved in prostitution. “This enabled women to remain calm throughout each commercial sex encounter, and as such, processes of distancing from the body became an automatic response” (Coy, 2009, p. 69). Researchers Lutnick, et al., hypothesize that it may be that “women who trade sex have developed specific coping strategies when they are raped, or that they may not view it as an assault but an occupational hazard” (2015, p. 7). Yet over time, Farley (2003, p. 20) believes that in an attempt to defend the self, women in prostitution may make a conscious decision to disconnect from parts of the body. This “piecing-out of parts of the body in prostitution results in somatoform dissociation, with the body numbed, considered not-me, the body a commodity, itself traumatically compartmentalized in the same way that traumatic affects and memories exist in states of dissociated consciousness.” How exactly do these young women end up working in commercial sexual exploitation? “A number of juvenile prostitutes have never had intercourse with a boyfriend. They went from the home (after having lost their virginity through sexual exploitation) to the streets as runaways, where they were recruited as prostitutes” (Silbert & Pines, 1982, p. 482). Often times girls are coerced into prostitution by an older man

who poses as their boyfriend. “They are therefore physically and emotionally dependent upon him and this may be reinforced by the use of alcohol and drugs” (Walker, 2002, p. 184). In Coy’s research (2009) with women who sold sex on the streets, she found that “only two women cited drug use as a reason to begin to sell sex, but all began to use illegal drugs – predominantly heroin and crack cocaine – after becoming involved in prostitution” (p. 63). Coy reports that for some women prostitution is a means to pay for a drug habit, for others drug use is a coping mechanism to cope with prostitution. However, there are studies which show the positive effects of drug, alcohol and mental health services with women who are involved in commercial sexual exploitation. “Women who received a longer duration of treatment for substance abuse and who received more mental health and psychosocial services were more likely to have ceased prostitution, and cessation of prostitution was predictive of less frequent drug use and alcohol use, as well as fewer mental health symptoms” (Burnette, Schneider, Timk, & Ilgen, 2009, p. 36). Many girls are brought in prostitution by pimps who pretend to love them. The pimps “play on their vulnerabilities and insecurities and distort a young woman’s sense of right and wrong with alarming speed” (Kennedy, Klein, Bristow, Cooper, & Yuille, 2007, p. 7). This form of pimping, in which the girl forms an emotional attachment to her pimp, is the most desirable method pimps use to recruit new girls. Kennedy, et al., in their research on women who are exploited by pimps, report that prostituted women have trouble giving up the fantasy of a perfect life that the pimps promised them, and think that the time on the streets is only a detour before their real future together will begin. Yet “violence perpetrated by pimps tends to emerge as soon as the women do not meet their quota, or are suspected of talking to the police, trying to exit the trade, or for just getting

out of line” (Kennedy, et al., p. 8). The women spoke of the effects of the violence in terms of not only physical injuries but also the tremendous emotional toll. “Selfdestructive, self-injurious behaviors and suicidal ideation are common trauma reactions” (Nixon, 2002, p. 1038). Although most women do try to leave prostitution, most end up coming back because they have no other way to earn an income. Some respondents returned to prostitution “because it was part of their identity – that was simply who they were” (Nixon, 2002, p. 1036). Other women claim that they enjoy working in commercial sexual exploitation, and this may be a defense against feelings of powerlessness where a version of reality is created where they now have perceived control over an adult client (Walker, 2002, p. 184).

Chapter III

Methodology “In most cases, prostitution is a far more psychologically complex act than other crimes.” Napoli, et al. (2001, p. 72)

Introduction The purpose of this research was to explore the experiences of women who have been victims of commercial sexual exploitation, who have also been victims of child sexual abuse. After spending many years working with women who had been trafficked or were currently working in commercial exploitation, I saw patterns of behavior which I wanted to explore. The majority of these women reported early childhood sexual abuse, and I wanted to understand these connections on a deeper level. Additionally, I am a psychotherapist in private practice, and noticed that many of my patients had also been victims of sexual abuse. Some of these patients also reported extreme sexual behavior, even though they generally had far fewer risk factors in their childhoods than the group who were currently working in commercial sex. The current literature illustrates the connection between abuse in childhood and later exposure to increased sexual trauma. This qualitative study focuses on the subjective experiences of women who were previously or are currently victims of commercial sexual exploitation, and looks at the ways in which their history of abuse affects their current experiences. How have women

tolerated the difficult feelings that can resurface on a daily basis, when exposed to repeated intimacy with someone who might be physically and emotionally threatening? They are also often faced with alienation from society and family, loss of future career, potential addictions, and the stress of raising children on their own despite feelings of shame, anxiety, and isolation. The following chapter outlines the methods I used to complete this research, including design, data collection and analysis, presentation of the findings and reliability, validity and limitations. This study used a qualitative design methodology as described by Bloomberg & Volpe (2019), in order to “promote a deep understanding of a social setting or activity as viewed from the perspective of the research participants” (p. 38). As a researcher, I was personally drawn to the idea that an underlying assumption of qualitative research is that “rich data that is nested in a real context can be captured only by way of the interactive process between the researcher and the research participants” (Bloomberg, et al., 2019, p. 42). The goal of this research was to develop an awareness of how the current experiences lived by these subjects have been impacted by these challenges, and how this has altered who they are. A qualitative approach enabled this researcher to explore the internal worlds of the participants, and attempt to make meaning of how their past experiences may or may not impact their day to day worlds. Corbin & Strauss (2008) explain that qualitative researchers want the opportunity to connect with their research participants and to see the world from their viewpoints (p. 5). Seeing the world and experiences from the participants' viewpoints is the driving force behind this research, and a qualitative approach is the only way to capture the nuances of their experiences. Furthermore, this researcher has used herself as a research instrument by creating a safe

environment where participants felt secure in disclosing what might potentially be uncomfortable material. An interpretative phenomenological analysis (IPA) approach to the data was taken, in order to allow this researcher the opportunity to interpret the meaning of the individual lived experience of each of the subjects. The idea behind this type of research, according to Smith, Flowers & Larken (2009) is to explore experience on its own terms. The data for this research was obtained by semi-structured, open-ended interviews from six subjects who met the research requirements. The purpose of this type of interviewing, as described by Bloomberg & Volpe, is to “describe the meaning of a concept or phenomenon that several individuals might share” (2019, p. 101). IPA is committed to “understanding how particular experiential phenomena have been understood from the perspective of particular people, in a particular context” (Smith, et al., 2009, p. 29). The small and purposively-selected sample in this study allowed for each case to be carefully analyzed. This researcher’s personal experience in working with this population combined with the lived experiences of the research participants enables this study to focus on how this “moment in time” has either altered the subjects or perhaps catapulted them in a particular direction. The positive process of engaging with the participants is a key component in an IPA research method, whereby the “researcher is making sense of the participant while the participant is making sense of something about their experience” (Smith, et al., 2009, p. 35). Although an epistemological assumption is that reality is coconstructed between the researcher and the participants, my hope as a researcher is that this combined effort will illuminate aspects of the participants' experiences that otherwise may not have surfaced or have been explored.

Research Sample and Plan The IPA method encourages a small sample size, in order to focus on the quality of the individual interviews. IPA also requires ‘rich’ data, which means that participants should be encouraged to tell their stories and express themselves freely and openly (Smith, et al., 2009, p. 56). A “criterion-based sampling” approach was used to select participants, in which all the individuals studied represent people who have experienced the same phenomenon (Bloomberg, et al., 2019, p. 187). Six women were recruited for this study, and study participants met specific inclusion criteria: 1.

Have identified themselves as having been commercially sexually exploited

in the past, or may be currently in the process of commercial sexual exploitation. 2.

Have had a history of child sexual abuse. The World Health Organization

defines CSA as: The involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violate the laws or social taboos of society. Child sexual abuse is evidenced by this activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust or power, the activity being intended to gratify or satisfy the needs of the other person. This may include but is not limited to: the inducement or coercion of a child to engage in any unlawful sexual activity; the exploitative use of child in prostitution or other unlawful sexual practices; the exploitative use of children in pornographic performances and materials.

Have entered the world of commercial sexual exploitation either through

trafficking, persuasion from a pimp or on their own. 4.

Had access to either a phone or computer and had cellular data and/or wifi.

5. Agreed to be videotaped for the interviews. The purpose of these requirements was to interview women who were victims of a crime, and whose later decision making may have been affected by their earlier trauma. Participants were not limited by current age, race, ethnicity, or whether or not they were currently being sexually exploited. Participants were also not limited by the nature of their commercial sexual exploitation, or by the relationship of the adult who committed the child sexual abuse (be it a family member, family friend or unknown person to the participant). In order to participate, subjects were asked if they would be willing to discuss personal experiences and if they had a desire to share what might be deeply uncomfortable material in the hope of shedding light on the potential effects of the abuse they had suffered. Participants additionally agreed to further process these experiences with an available therapist who was referred by the researcher, if the participant felt it was necessary. Exclusion criteria included males, or people who currently identify as male. If the participant was not subjected to sexual abuse as a child, and was not recruited into commercial sexual exploitation or entered willingly on their own, they were excluded from this study. Furthermore, participants were excluded from the study if there was an inability to understand the research project, or if the subject matter of the interview was deemed to be too overwhelming for a particular subject.

This research elicited descriptions of the subject’s experiences, in an attempt to understand how they processed episodes of child sexual abuse and then later commercial sexual exploitation.

Information Needed A hermeneutic study design supports an exploratory approach to informationgathering and analysis. Revealing the essential meanings in these experiences was the focus of this design. The approach is designed to develop awareness of the unique complexities of each participants’ lived experience. The participants for this study consisted of six females who met the study requirements, and the following demographics were collected: age, age of first sexual abuse, who their abuser was in relation to them, nature of sexual abuse, age at which they entered commercial sexual exploitation, number of years in commercial sexual exploitation, number of children, employment status, relationship status, education level, race, and questions pertaining to history of victimization and abuse.

Research Design Data was collected by interviewing six women who had been pre-screened and pre-qualified. The small sample size was intended to create a deep level of analysis with each participant, whereby the nuances of their internal experiences could be explored and considered. Due to the sensitive nature of the material, one unstructured interview approximately 60-90 minutes in length, along with a member checking (shorter) follow up interview, was performed with each participant. This was intended to allow the

participants to feel as if they had some control over what they chose to share or not share during the course of the interview, as well as provide confirmation that what they intended to say was accurately interpreted. In an unstructured interview, participants are able to determine what subjects to talk about, at what pace, in what order, and to what depth (Corbin, et al., 2008, p. 38). Smith et al. believe that “an unstructured interview capitalizes upon IPA’s ability to explore unanticipated and unexpected findings” (2009, p. 70), which will allow this researcher to refrain from directing the participants towards any particular conclusions or expected associations. Interviews took place in a teletherapy format, which enabled the researcher to observe participants nonverbal behaviors, body language, inflections of voice and significant pauses while revealing material. Rather than interpreting these nonverbal behaviors, it was the intention of the researcher to follow up and find out directly from the participant what the behavior meant to them.

Data Collection The sample for this study was recruited by the researcher asking administrators at the agency Journey Out, who work with this specific population, to refer potential participants who might be appropriate for this study. Subjects who had previously entered therapy, as well as subjects who had no previous therapy experience were welcomed. Additionally, a flier was sent to professional and personal contacts asking for referrals for my study. The letter described the study and listed the benefits and potential risks of participation (See Appendix A). I asked potential participants to contact me by phone, so that I could review the inclusion/exclusion criteria with them. I then followed up with an

email to all potential participants in which I again described the nature of the study and the potential risks and benefits from participating in this study (See Appendix B). Due to the nature of Covid 19, interviews were not conducted in person. Selected participants received an informed consent document in advance of our interview (See Appendix C) via email. The informed consent included my commitment to protect the confidentiality of the participants, including my promise to not use any identifying information or material that was distinctive or can be easily recognized. Participants were asked to sign and return the informed consent via email in advance of the interview date. Participants were also offered the right to withdraw up to the point in which data analysis began. Interviews were conducted through a HIPAA compliant teletherapy website, and were recorded to ensure accuracy of information. All recordings have been kept in a secure location, and will be erased once the research is completed. Participants were asked to fill out an emailed questionnaire prior to the first interview. The purpose of the questionnaire was to collect demographic information on each of the subjects. Questions will include: -How old are you? -What race do you identify with? -What level of school did you complete? -Do you currently work and if so, what is your occupation? -Do you have any long term physical illnesses? -Were your parents married throughout your childhood? If not, at what age did they separate/divorce and were both involved in your life?

-Do you have siblings? If so, how many brothers, sisters, and were they older or younger? -Who lived in your household when you were growing up? -Did your caretakers have any addictions or mental illness? -Were either of your parents arrested for anything? If so, for what? -Was there domestic abuse in your household? -Did you live in foster care or out of the home at any point during childhood? If so, at what age did you move? -Was your household religious when growing up? If so, what was the religion? -Are you currently in a relationship? If so, are you married? -Do you have any children? If so, how many, and what are their genders and ages? -Who lives in your household now? -How old were you when you entered The Life? -How many years have you been in The Life? And what age were you when you left (if you are no longer in The Life). Smith, et al., (2009), advises us on the benefits of constructing a schedule for a semi-structured interview. Starting the interview with a question allows the participant to delve into a descriptive experience, however when phrasing the particular questions it is important the interviewer does not “make too many assumptions about the participants’ experiences or concerns, or lead them towards particular answers” (Smith, et al., 2009, p. 59). The aim of these interviews is to elicit detailed, in-depth, first-person accounts of the participants’ histories and present life experiences.

Each participant was asked to attend one interview and one follow up interview. Participants received a gift card in the amount of $20.00 for each interview. The interviewer used open-ended questions as well as prompting questions, which elicited richer content during the interview. Smith et al. (2009, p. 63) advises telling participants at the beginning of the interview that “you are interested in them and their experiences, and to be clear there are no right or wrong answers. It was the intention of this researcher to let each participant know at the beginning of each interview that I was interested in their current experience, along with their experiences of being sexually abused and exploited, in an attempt to understand the meaning of those events to them. Below is a list of questions, as well as prompts that may have been used in order to better conceptualize the participants’ experience during the interview: 1. Tell me what was it like in your household when you were growing up? Possible prompts: Who did you grow up with? Can you tell me about them? Who did you seek comfort from when you were fearful, anxious, sad, or just upset? What did they do to comfort you? 2. You mentioned that you had experienced sexual abuse, can you tell me about that? Possible prompts: When did it happen, by whom, how old were you, how long did it go on for? Was there more than one experience? What did you do? How did you feel? What did you think? 3. Tell me about how you first became involved in The Life? Possible prompts: How did it happen? Tell me about the first experience. What did you think? How did you feel? Was there anything you figured out that could make the experience easier on you?

4. Tell me your thoughts and feelings about the time you spent in The Life. Does it/did it affect your relationships with family, children, friends, significant others? If so, how so? 5. Tell me about what happened in your house because of the abuse? Possible prompts: Who knew about it? If anyone knew, how did they find out? Did you report the abuse? What happened to that person? Are they still in your life now? What is the relationship like now? What was the impact of the abuse on your life? Do you think it affected your identity at all? 6. If you chose to be in The Life, is there anything about it that you find difficult? If so, what do you do about that? Possible prompts: Do you think you have any addictions? If so, tell me about the process of using your addiction. Did you ever feel something that you couldn't explain or understand? Did you ever have the experience of feeling like you were not in your body? Do you think you have ever disconnected from your emotions? Do you ever have strong emotions that emerge? Do you think you might suffer from anxiety? If so, what are your symptoms? If strong emotions came up and you didn’t use your techniques, what do you think would happen? 7. Have you ever had any physical (symptoms) or sensations in your body that you didn't understand or couldn’t explain? Do they show up while you are working, or before, or after? 8. Tell me about your relationships. Possible prompts: What are the relationships like? What makes you feel comfortable in a relationship? Do

they give you comfort or do you give them comfort? Do you wish you had other relationships in your life? 2. Describe any other feelings that might surface when you are currently, or were seeing johns or tricks? Possible prompts: Did anything feel good?

Data Analysis Field notes were taken before and after each interview, in order to capture any observations or feelings the researcher had that were unable to be documented in the transcripts. These field notes added an additional source of data to the research process. In order to ensure the participants voices’ were adequately reflected, a system of checking was in place during the beginning of the second interview. This entailed summarizing the main points of the first interview with each participant, and confirming the details had been correctly understood by the researcher. Besides ensuring the research is correctly interpreted, this process was intended to help participants understand the commitment the researcher had in representing their stories. The hope was that when participants had a sense that their voices were truly heard, they would feel more comfortable and relaxed and perhaps place even more trust in the researcher. The qualitative data was transcribed from audio tape into text. As nonverbal messages and somatic reactions were integral to this study, a coding system was introduced which recorded these reactions. The text was read through in its entirety multiple times, in order to derive a sense of the verbal and non-verbal language from each participant. Additionally, the recordings were also viewed multiple times, in order to watch for, listen for, and identify any themes as they emerged from the data. The themes

were then examined and interpreted, and the researcher used the method of abstraction to look for connections between emergent themes. “Abstraction is a basic form of identifying patterns between emergent themes and developing a sense of what can be called a ‘super-ordinate’ theme” (Smith, et al., 2009, p. 96). The goal of this method was to then organize the themes into concepts which allowed for further interpretation, as well as potentially illuminating the questions yet unanswered.

Ethical Considerations Prior to conducting these interviews, this study was approved by the Institutional Review Board of the Institute for Clinical Social Work, and the Clinical Director of the non-profit organization Journey Out. The mission of Journey Out is to help victims of commercial sexual exploitation and sex trafficking leave a life of abuse and violence, and empower them to reach their full potential and achieve their goals. This researcher has been bringing trauma-informed care to individual clients at Journey Out for seven years, along with facilitating prostitution diversion groups which allow clients to feel less isolated and better able to explore their future opportunities. This research complied with the standards for human subject research established by The Institute for Clinical Social Work, and the researcher had the intention of conducting all interviews with the utmost respect and courtesy towards the participants who were willing to share themselves in this process. The risks to individuals participating in this study included re-experiencing trauma, due to the emotional intensity of the content of the interview questions. The researcher minimized these risks by carefully monitoring individuals during the

interview, and stopped when needed to allow a participant the necessary amount of time to regroup and continue. In the event of psychological distress to the respondents, participants were provided a list of referral sources to seek assistance in the event a crisis results from the interview. The list contained free mental health providers at the organization Journey Out, as well as other referral sources which could be accessed by the respondents. The researcher had previously obtained consent to use a digital recorder to obtain the information reported by the subjects during their interviews. To help protect anonymity, the names of the participants were stored separately from the data and kept in a locked file. No one had access to the participant’s information except the researcher.

Issues of Trustworthiness During the process of each interview, the researcher inquired extensively about her understanding of the participants’ self-narratives, to ensure the researcher did not mis-interpret the meanings the subject attributed to each experience. It was my intent to create quality qualitative research, research that Corbin & Strauss (2008, p. 347) describe as “research that has substance, gives insight, shows sensitivity.” Conducting the study in this manner leads to credibility in the study, which refers to “whether the participants’ perceptions match up with the researcher’s portrayal of them” (Bloomberg, et al., 2029, p. 202). Some additional recommended strategies from Bloomberg et al. that this researcher implemented to ensure credibility included: 1.

Self-reflection, to ensure an open and honest attitude in the research

regarding the researcher's own subjective perspective and biases. I kept a

journal of my reactions to each interview, where I recorded my feelings about which parts of the interviews brought up powerful emotions in me. 2.

Conveying detail, by discussing how I facilitated an in-depth

understanding of the phenomenon under study. 3.

Presenting any discrepant findings that may arise.

Dependability refers to the “stability and consistency of data over time” (Bloomberg, et al., 2019, p. 204). Research needs to be documented, logical and traceable, and Bloomberg et al. (2019) recommend a process that this researcher adhered to, including: 1.

The discussion should include triangulation and sequencing of methods

and present a well-articulated and transparent rationale for these choices. 2.

Included detailed and thorough explanations of how the data was

collected and analyzed, as well as maintaining a clear record of field notes and transcripts. In terms of transferability, Smith et al. (2009, p. 51) speak to the process of allowing the reader to make links between the analysis in an IPA study, the literature, and the rich accounts the participants provided. When readers are also able to take into account their own experiences both personally and professionally, it should enable them when reading this study to “evaluate the transferability to persons in contexts which are more, or less, similar.”

Limitations and Delimitations Findings from qualitative research and designs are not generalizable to a larger sample, however the intent for this study was to provide insight into the struggles this population is faced with. Although a limitation to this research is that recollections of the participants were the main source of data for this study, ultimately, Smith et al. (2009, p. 19) help us to understand that the experience of our participants “belongs to their own embodied position in the world.” They warn that “small sample size, sample selection, reliance on certain techniques for gathering data and issues of researcher bias and participant reactivity” all may contribute to the limitations of a study, and serve to remind the researcher of the potential shortcomings of their work. Due to the fact that this researcher is Caucasian, upper middle-class, privileged in terms of advanced education, a novice researcher and in her mid-50s, she is aware that her potential biases may have influenced the interpretations made in the research material. Additionally, this researcher has not experienced early childhood sexual abuse or sexual exploitation, however she does have a desire to champion women affected by severe trauma and communities impacted by socio economic limitations. To control the delimitations, the researcher was explicit about what exactly the study would and would not cover. The interview material is rich with fascinating content; however it would be unrealistic for this interviewer to be able to approach this research from every angle. An issue to be aware of is what Smith et al. (2009, p. 67) refer to as the challenge for the interviewer of having “feelings of being overly intrusive, and feelings of being overly excited about the issue and accidentally leading the participant.” I found this

advice to be sound, and focusing on these potential limitations in myself before the interview process allowed me the opportunity to reflect upon my stance as a therapist and researcher, so that I could bring my attention back to highly engaged listening and sensitive questioning.

The Interviews To achieve the study aim and objectives, interviews were conducted with the study participants between May and July of 2021. The interviews were conducted in the United States, in the English language, and were conducted through a Zoom format and video-recorded for accuracy. At least two interviews were conducted with each of the participants, and three interviews with one participant were collected, to achieve clarity of their experiences. Each of the interviews lasted between 60 and 90 minutes and the interviews were subsequently transcribed using transcribing software. Due to the sensitive nature of this study and ethical reasons, the study participants' identities are anonymized. Once the transcripts were corrected and completed, they were read and re-read, in order to enter into a phase of “active engagement with the data” (Smith, et al., 2009, p. 82). I entered a process of noting my personal reflections, feelings, observations and responses to the interviews. According to Smith, Flowers and Larkin (2009), interpretive noting helps the researcher stay close to the participant’s explicit meaning, which involves “looking at the language that they use, thinking about the context of their concerns (their lived world), and identifying more abstract concepts” (p. 83). The data was then imported into Nvivo qualitative software, to organize and code the data.

Throughout the coding process, patterns with the data began to emerge and similar codes were combined into super-ordinate themes and subthemes. Once a saturation level was reached and no new codes emerged from the data, five main themes stood out from the data. Multiple sub themes then emerged under the main themes. Direct quotes from the subjects were used to gain a deeper understanding of the participants’ lived experiences. The analysis considers the similarities and dissimilarities of the participant findings, in order to gain a broader perspective of the complexities of the material at hand.

The Role and Background of the Researcher As this researcher is also a psychotherapist who works in a psychoanalytic fashion, and who has extensive knowledge and expertise in working with the population whom she is researching, interviews were conducted in such a way that promoted both sensitivity to the topic and empathy for the inherent challenges some might face while answering the research questions. This researcher has conducted a literature review and has extensive knowledge regarding attachment, development, and the implications of childhood abuse on later life experiences. Although this information informs the researcher and could create preconceived ideas as to the outcomes of the individuals abuse experiences, the researcher was dedicated to uncovering each participant's individual story, and understanding the connections that may or may not exist between earlier abuse experiences and later victimization. This researcher herself was the instrument used to collect data, and was not emotionally separated from the data or from the experiences of the participants. However, having a background in trauma therapy and a good understanding of the emotional

implications for bearing witness to this type of material, the researcher felt prepared to create an interview environment that was both supportive and therapeutic for all who participated. Oftentimes women who have been commercially sexually exploited choose to remain in their current situation, and this research is intended to illuminate the meaning behind those choices. The benefits of this research are applicable to social workers, case workers, therapists, law enforcement and those who create and enforce policy, so they might have a broader perspective of the psychological implications that drive or perhaps limit the abilities of this marginalized population. This population is often stereotyped, criminalized, oppressed and jailed, and the desire to de-stigmatize women who have limited choices and opportunities in life was the driving force behind this study. My hope is that this research allows the reader to feel like they have walked in the participants’ shoes, and it will stimulate powerful discussions and further research on this topic. If we can better understand the internal worlds and coping strategies of the participants who have shared their life stories, there is the possibility we might develop more effective treatment models and change policy at the macro level to better serve this overlooked population.

Chapter IV

Results “It is that thin line between the unanticipated but containable shock and the unanticipated but uncontainable shock that separates what is perceived as potentially traumatic from what is perceived as safe but on the edge.” (Bromberg, 2003).

The purpose of this phenomenological study was to understand the lived experiences of six women who were victims of childhood sexual abuse, and who had also experienced commercial sexual exploitation. Participants’ identifying information was kept confidential, and so for the purposes of this writing each was given a pseudonym; Kadeesha, Raquel, Maria, Luciana, Lynn and Madison. Based on the responses of the six participants, I was able to identify five main superordinate themes which emerged from the material. The first theme, The Way It Was, represents the participant’s everyday lived experiences and how they interpreted them. Theme 2, My Relationships, examines how participants see themselves relating interpersonally with those they are closest with. Theme 3, How I Feel, sheds light on both the physical and emotional manifestations of abuse, and Theme 4, Doing What I Had To, delves into specific strategies participants relied upon to cope with their abuse. Finally, theme 5,

Who Am I?, focuses on how the participants were able to develop an identity in the face of these experiences. In addition to these five main themes, each of the super ordinate themes are further broken down into sub themes, which illustrate specific details of the overall theme. For example, the sub themes for the theme How I Feel are “Somatic Symptoms,” which describe what the subject is actually feeling in her body, and “Mental Health Symptoms,” which deals with the emotional consequences of her trauma. In order to understand how these themes emerged, first I will describe the different phases of the research, and then I will provide a brief description of the recipients in order to provide pertinent background information. I will then revisit the themes and their meanings, and finally I will end with a discussion of the participants’ experiences by theme, and give quotes from their actual interviews with the intent of illustrating how each theme was represented.

Phases of Research In the first phase of this research, a questionnaire was distributed to participants and results were collected via email. The questionnaires collected basic demographic information, with results presented below in Table 1.

Table 1: Questionnaire Responses Lynn

Madison

Maria

Kadeesha

Luciana

Raquel

Age

Race

Caucasian

Hispanic

Black

Hispanic

Caucasian

Completed school

Undergrad

Some college

9th grade

Occupation

Call center

Case manager

Nanny

Cleaning houses

Host

Long term illnesses

Asthma, sleep apnea, spinal stenosis, sciatica, depression, anxiety

Anxiety

Depression, anxiety, PTSD

Anxiety, depression

Hashimotos

Parents married?

Divorced at Age 5

Divorce at Age 5

Yes

Siblings

1, 1 half sibling

2 brothers

3 sisters, 1 brother

1 sister, 1 brother

2 sisters, 1 brother

1 sister

Members of household during childhood

Brother, dad, stepmother, her children

Mom, brothers, grandma, uncle

Siblings, mom, stepdad

Uncles, aunts, cousins, sister, brother

Parents, grandparents, Siblings, Various family

Mother, father, sister

Caretakers with addiction or mental illness

Father was hoarder, possible alcoholic, anger and anxiety. Step-mother undiagnosed

Mother, alcoholic

Mother drug, alcohol, depression Anxiety

Mother drug addiction, anxiety

Mother had depression

Parents arrested?

Unknown

Yes

Domestic abuse in childhood household

Yes

Lived in foster care?

No, but rehab facility

Yes

No, placed grandparents’ home

Religion in childhood home?

Lutheran

Jehovah’s Witnesses

Catholic

Christian

Currently in relationship?

Yes

Have children?

Yes

Who currently lives in household

Lives alone

With children

Lives alone

Mother and sister’s

Lives alone

Husband

How old when entered life, years in life

31, 11 years

14, 7 years

15, 4 years

17, 6 years

20s, 13 years

28, 4 years

The second phase of this research invited the women to share their experiences in an intimate interview environment. All participants were fluent in English, and were able to meet a minimum of two times over a video conferencing format. One participant (Luciana), chose to be interviewed three times. Thirteen interviews were completed, with

each lasting between 60 and 90 minutes. Interviews attempted to explore several issues, including: 1.

How do some children become exposed to sexual predators, and then

later become involved in commercial sexual exploitation? 2.

As children, did they utilize coping mechanisms to make experiences

more tolerable, and did they employ similar coping mechanisms as adults during traumatic experiences? 3.

Do participants experience somatic symptoms and mental health

symptoms, as a result of their experiences? 4.

How do early attachment issues affect the likelihood of early childhood

sexual abuse and later involvement in commercial sexual exploitation? 5.

Do participants notice a compulsion to repeat early trauma?

Table 2 below and Figure A visually represent the themes and sub themes which emerged from the interviews.

Table 2: Themes Super-Ordinate Themes

Sub themes

The Way It Was

•Generational Abuse •Abuse and Neglect •Sexual Abuse •I Just Wanted Someone’s Attention •Frightening Adult Experiences

My Relationships

•Childhood Relationships with Caregivers •Abandonment •Adult Relationships or Lack of •Trust/Attachment

How I Feel

•Somatic Symptoms •Mental Health Symptoms

Doing What I Had To

•Addiction •Dissociation •Showing Them or Getting back at Them •Other ways to make myself feel better •No Other Options

Who Am I?

•Perceptions of Identity •Vulnerability to Manipulation •Don’t Know Why I Do It •Feeling Powerful, Feeling in Control •My Purpose, Strengths and Beliefs

Figure A: Figure A below represents these relationships in a different format, illustrating how the super ordinate themes gave rise to sub themes, which in some instances gave rise to sub sub themes. For example, The Way It Was has a sub theme entitled Abuse and Neglect. Sexual Abuse is a sub sub theme of Abuse and Neglect, and I Just Wanted Someone’s Attention is now a sub theme of Sexual Abuse.

In order to substantiate my choices of themes and sub themes, Table 3 illustrates the frequency with which each subject was affected by the corresponding theme and sub theme, and the total number of references made to each theme.

Table 3: Theme References # of Participants

# of References

Abuse and Neglect

Sexual Abuse

Wanted Someone’s Attention

Frightening Adult Experiences

Generational Abuse

Childhood Relationships

Abandonment

Adult Relationships or lack of

Trust/Attachment

Theme 1: The Way It Was

Theme 2: My Relationships

Theme 3: How I Feel Mental Health Symptoms

Somatic Health Symptoms

Addiction

Dissociation

Other ways to make myself feel better

Showing them or getting back

No other options

Perceptions of Identity

Don’t know why I do it

Feeling Powerful/control

Vulnerability to manipulation

My Purpose, Strengths, and Beliefs

Theme 4: Doing What I Had To

Theme 5: Who Am I?

Finally, Table 4 represents the comparison results of findings, broken down by Themes and Participants. Table 4: Comparison of Findings

Results

Kadeesha

Luciana Lynn Madison Maria Raquel

Abuse and Neglect

√

Sexual Abuse

√

Wanted Someone’s Attention

√

Frightening Adult Experiences

√

Generational Abuse

√

Theme 1: The Way It Was

Subthemes

√

Theme 2: My Relationships

Subthemes

Childhood Relationships with Caregivers

√

Abandonment

√

Adult Relationships or Lack of

√

Trust/Attachment

√

Theme 3: How I Feel

Subthemes

Mental Health Symptoms

Somatic Health Symptoms

Theme 4: Doing What I Had To

Subthemes

Addiction

√

Dissociation

√

No Other Options

√

Other Ways to Make Myself Feel Better

√

Showing Them or Getting Back at Them Theme 5: Who Am I

√

Subthemes Don’t Know Why I Do it

√

Feeling Powerful, Feeling in Control

√

My Purpose, Strengths and Beliefs

√

Perceptions of Identity

√

Vulnerability to Manipulation

√

Introduction to Participants KADEESHA is a 32-year-old black woman who currently works as a nanny. Kadeesha never knew her father, and her mother was in The Life and in jail during much of Kadeesha’s early years. Kadeesha and her sister lived with their grandmother for a short time, and with their mother when she was out of jail. Kadeesha’s mother soon died of AIDS, and Kadeesha and her sister were placed in foster care. They were then moved around to various uncles and aunts’ homes. Kadeesha witnessed severe domestic abuse at the home of her uncle, and her sister was impregnated by her uncle’s son. Kadeesha was then sexually molested by the husband of one of her aunts. They were moved again, and Kadeesha had a short period of stability at the home of another aunt who introduced her

to the religion, Jehovah’s Witnesses. As Kadeesha struggled to finish high school, her aunt kicked her out of the home after an argument. Having to suddenly support herself, Kadeesha was quickly preyed upon by a pimp and was thrown into The Life. She suffered years of traumatic abuse at the hands of various pimps before she was able to escape. Since her escape, she has taken some college classes and currently works in a steady job. She finds it very difficult to have long-term relationships, and still suffers from depression and anxiety symptoms from her years in The Life. When I interviewed Kadeesha, I was struck by her innocence. It was as if I was speaking with a young girl, who still relied upon adult approval to determine her next move. Kadeesha also had a tendency to wistfully drift off, and I felt as if I had to bring her back to the present several times. She would seem unfocused, very quiet, and could come across as quite shy at times. I noticed that I wanted to take care of Kadeesha, to protect her from any more terrible things that might happen in her life. I was very cognizant of treading carefully with my questions, to ensure that Kadeesha would be able to tolerate the interview. RAQUEL is a 52-year-old Caucasian woman who was raised in what appeared to be a stable Christian home. Raquel’s mother suffered from depression from her own traumatic childhood experiences, and was seemingly unaware of the sexual abuse that was taking place in the home at the hands of Raquel’s father. When Raquel’s father would come into her room at night and “tickle” her as she lay in bed, Raquel was confused by the various emotions that she felt. She enjoyed the attention and felt special, yet also knew that the touching was “taboo.” She equated reporting the abuse with losing

her father’s love, and carries intense guilt for not stopping the abuse earlier. Raquel became extremely sexualized as a teenager, and finally began working in “whack shacks,” where she would dance privately for men while they pleasured themselves. After years of drug abuse, relationships where she recreated her childhood abuse, and health issues, Raquel is now married and working in a business. She still feels the lasting effects of her sexual abuse, which has affected her marriage and her desire to become a parent. During the interview, Raquel presented herself as extremely intelligent, determined, successful and powerful. Her demeanor was a bit hardened, even slightly jaded. She was incredibly frank with her stories, and had amazing insight into her past trauma and coping mechanisms. I noticed that I felt intimidated by Raquel, and hung back, waiting for her to take the lead. I was impressed by her ability to take control of her life, yet struck by her vulnerability when describing the confusing abuse she was subjected to at the hands of her father. MARIA is a 22-year-old Hispanic woman whose mother was also in The Life. Maria’s mother was trafficked by her parents as a child, and later on by Maria’s father. Her mother had few options to support her children and was forced to bring Maria along and leave her in the car while she went out on the streets looking for work. There was a period of time when Maria did have a young female babysitter, however she was molested by the sitter and was confused and humiliated by the experience. Maria’s mother remarried, and Maria’s new step-father also molested her. When Maria confronted her mother and asked her to kick her husband out, Maria’s mother chose her husband and abandoned the home, leaving Maria to care for her three younger

siblings. Although her mother finally came back, Maria had a difficult time moving on and found herself living a double life as a 15-year-old girl. She went to high school, but created a new persona for herself and began secretly working in The Life. Maria has now left The Life and works as a case worker and advocate for women in The Life. She is not in a relationship. Maria was very talkative in the interview, and I had the sense that it was extremely important to her to make people understand what she had experienced in her young life. Being a caseworker, it was clear that Maria had some familiarity with processing the abuse which made up most of her childhood. Even so, I found myself wondering how she was functioning in life, after withstanding so many years of early childhood abuse. I felt myself wanting to slow her down, to assure her that I was hearing her. It was clear to me that Maria had been diligent in her attempt to create a better life for herself, and her flurry of words may have been her way of getting the bad memories out and away from her as quickly as possible. LUCIANA is a 48-year-old Hispanic woman who grew up in a small town in Mexico. Her family was very poor and her parents were forced to travel to other towns to work, leaving Luciana and her siblings in the care of her grandparents for weeks on end. Luciana’s grandparents were overwhelmed with the responsibility of caring for twelve young grandchildren, and the kids had little supervision. Both Luciana and her sister were molested by various uncles, and Luciana found that she was very confused by the conflicting emotions that came with the attention her uncle paid to her. Luciana moved to the United States as a teenager, and was soon raped by another relative. She later had a child with an extremely abusive man, and after leaving him experienced many years of

trafficking, physical abuse and blackmail as she struggled to support and care for her son. Luciana suffers from extreme anxiety and depression, and currently works part-time cleaning houses. She is not in a relationship. When I spoke with Luciana, I found that I was riveted by her. She is a striking woman and has a presence, even though she is tiny in stature and extremely thin. Her accent and choice of words made her all the more endearing. Luciana was not shy or embarrassed to speak of her experiences, and even asked for a third interview to ensure I would hear all of her story. Although Luciana has spent much of her adult life trying to process her trauma, she found that she still feels awkward around other people and doesn’t think she fits in. There was an innocence about her, which is hard to believe after all she has been through. Luciana brought a kind, gentle energy to our interviews, even while she struggled to make sense of all the abuse she had suffered. LYNN is a 44-year-old Caucasian woman. Lynn’s mother was an alcoholic, and after divorcing Lynn’s father found herself unable to care for her children. Lynn and her brother lived with their father and new step-mother, who was physically abusive to Lynn. Lynn’s father suffered from hoarding disorder and seemed incapable of protecting his children. Lynn was molested when she slept over at a friend’s house one night, and later became extremely sexually active in high school. Although Lynn graduated from college, she found herself working in prostitution as a way to support her alcohol and gambling habits. As Lynn’s addictions grew, her life spiraled out of her control. Lynn was eventually arrested and lost her home, car and everything she owned. She is currently working at a call center in Las Vegas, and although she is no longer drinking alcohol, she does still gamble. Lynn is not in a relationship.

Lynn presented as an extremely sincere, funny and open woman during the interview. She spoke frankly about her addictive nature and has worked diligently to pull herself out of a dark period in her life. I felt very comfortable around Lynn, which was due to her easy-going manner and willingness to communicate. Lynn was also selfdeprecating at times, and I wondered about her outwardly sunny disposition, and if there was a darker side that she was not as willing to show. MADISON is a 34-year-old Caucasian woman. Madison was repeatedly sexually molested at the hands of her paraplegic grandfather when she was only five years old, and then blamed and punished for the abuse by her grandmother. Madison’s mother was a severe alcoholic, and Madison often had to locate her blacked out mother somewhere in the neighborhood and find a way to get her home. Madison’s mother was so ill-equipped to care for her children that she didn’t notice the string of older men who lived in the apartment building and were having sexual relations with her young daughter. At 13 years old, Madison was groomed by a pimp, and began a life of abusive relationships and prostitution. She had two children, and eventually was able to leave The Life. She currently works as a mental health advocate and case manager for men who sexually abuse children, in an attempt to search for answers. She lives with her two children and is no longer in a relationship. I experienced Madison as deeply insightful and very grounded, which was the opposite of the way she described herself in her interviews. I felt as if I held back a bit during her interviews, because Madison seemed confident enough to tell her own story and make connections without needing much from me. I admired Madison for her commitment to her children, and for the strength she displayed in breaking the cycle of

abuse she had faced since her early childhood. I also witnessed the softer side of Madison, the part that wrestled with understanding why she continued to make some questionable choices in her life.

Superordinate Themes, Sub Themes, and Respondents’ Experiences Theme I: The way it was. This section highlights the participants’ traumatic life experiences, and is explored through their own personal narratives. Each of these traumatic experiences has set the foundation for their future exploitation and created life-long somatic and mental health symptoms, as well as affecting their personal views of self. The Way It Was describes how these women adapted to the challenges they were faced with, and explores the ways in which their childhood traumas propelled them towards terrifying adult experiences. The first sub theme in this category is Generational Abuse, which looks at how trauma experienced by caretakers adversely affected and influenced the behavior of the participants in this study.

Generational abuse. Maria, who was 22 at the time of this interview, describes growing up with a mother who worked in commercial sexual exploitation (also defined as “The Life”). Growing up, I saw my mom being in The Life, I was oftentimes left alone and unsupervised, forced to go along with her as well when she was going out to work, so I feel like I was exposed to it at a very young age, I would say, before

kindergarten, maybe like four or five, three even. And certain things happened before I was even enrolled in school, sexual abuse as well, and I think a lot of that came from having parents who were not even able to take care of themselves at the time. Maria expresses insight into the fact that her mother was unable to take care of herself and thus unable to take care of her young daughter, however she also acknowledges how she was left unprotected and vulnerable to sexual predators. Knowing from a very young age that her primary attachment figure could not keep her safe may have left her with the feeling that she was not worth protecting. Maria lived with her mother and her abusive step-father, who found ways of using her mother’s generational abuse to shame and taunt Maria. At first it started just physical, like it wasn't sexual, it was just physical like talking down to me, you know telling me that I'm dumb, blaming me for the things my mom had to go through, because my dad was my mom's original trafficker. She was originally trafficked by her parents when she was younger, when she became an adult my dad was the one who trafficked her. So, it was always this blame like “Oh you're a bad person, like you come from a bad person, so it's built in you to be bad.” It was a lot of degrading me, making me question my authenticity, telling me I come from evil, I’m created from this horrible event. He made it seem that she suffered with me because she had to stay with my dad for longer than she would have if I wasn’t here. It was my fault that she suffered, it was my fault that everything happened. And he was always hitting me, talking down to me. And I would tell my mom because it carried on till I was in

high school, and I'd say “How come when he hits me you don't say anything?” And I remember telling her “When I was little and my dad hit you, I would always stand up for you, I would tell him not to. I would get in the way and I would defend you. And now when I’m being hit you’re nowhere to be seen..” The severe abuse suffered by Maria’s mother set up a cycle of self-preservation for her, which remained in place even when it came to protecting her own children. As Maria is subjected to ongoing physical and verbal abuse at the hands of her step-father, she begins to formulate a sense of who she is and what she believes about herself. In this interview, I had the sense that Maria would excuse her mother’s abandonment of her, as a way of keeping her attachment figure available to her. Yet despite Maria’s ability to clearly see her mother’s struggles, she nonetheless has a longing for her mother to protect her and to reject her step-father. Her attempts to try to get her mother to engage left me with the sense that Maria had a desperation to be noticed, and would do anything to get her mother to finally acknowledge her. Madison, 32, stoically and unemotionally describes her own mother’s generational abuse. My mom experienced her own trauma that was never healed and then passed down to her children, so, pretty classic situation of someone having children before they ever healed anything. And even to this day, my mom hasn't healed much. She's pretty much the same person. Additionally, Madison has insight into how the experiences of each generation have affected the next, and how Generational Abuse was the beginning of her own trauma story.

My grandma, she was always in my life, she also experienced a lot of trauma. So, I came from women that were molested, in domestic violence marriages and physically abused. I was like born from the blood of that, you know. As Madison notes, she was “born from the blood” of violent and abusive experiences, and seems to feel as if this is the path she will inevitably follow. When speaking with Madison, it was clear that the rage she felt toward her mother for her lack of protection and nurturance was turned inward, in an attempt to pay her mother back for abandoning her. Kadeesha, who was 31 at the time of this interview, had a similar experience with her own mother. She describes the experience of growing up with a mother who had sustained her own childhood trauma and was also in The Life, and how it created an unstable and unpredictable environment for Kadeesha. One time I remember, I remember, there was always like something under her bed, you know at the doctor they tie that thing around your arm, to draw the blood, so there was that. I didn’t ever see any needles, but I remember that thing. And then I remember her and her boyfriend for days on end would just stay in the room, like they will literally just stay, yeah, I just don't know what she was addicted to. Kadeesha’s memory of her mother’s substance abuse left her to wonder why her mother got something from her addiction and her boyfriend that she herself could not provide. When Kadeehsa speaks of this time, she seems distant and unreachable, as if she is a hollow vessel that no one had ever bothered to fill. Kadeesha longed for an attachment to her mother, yet unfortunately the addiction and her mother’s later illness

left her unavailable and unattainable, and Kadeesha was left to make sense of these experiences on her own. Raquel, who was 52 at the time of this interview, ponders her mother’s own generational abuse, as a way of understanding why her mother was unaware of the sexual abuse that was taking place in their own household. You know my mom grew up the oldest of seven children and she was the only one who graduated from high school, you know they grew up very poor. She had fathers, four different fathers in and out of her life, and then one who committed suicide. Another father was a drunk, they didn’t always have food but they always had beer in the fridge. Even at 52 years old, Raquel still seems to be angry and in search of answers. She has come to the conclusion that her mother had to take what she could get in order to survive a challenging childhood. If her mother was repeatedly abandoned by her own father figures, she would place extreme importance on keeping her husband from abandoning her as well. This realization might shed some light on her mother’s reluctance to notice what was happening in the home, however it does little to mitigate Raquel’s experience of being left on her own to defend herself against her father. As Maria, Madison, Kadeesha and Raquel describe, the effects of Generational Abuse left their mother’s without viable strategies, decision making abilities and coping mechanisms which could enable them to change the trajectory of their own daughters’ lives. Their mothers were effectively disabled by trauma, and although these subjects are able to understand this on a cognitive level, their immense sorrow at being left exposed and vulnerable to emotional, physical and sexual abuse is clear. Generational Abuse is an

example of The Way It Was, because these young girls were compelled to learn ways of adapting and surviving with parents who were ill equipped to protect them, or to create stable environments for their daughters to grow and thrive in.

Abuse and neglect. The subtheme of Abuse and Neglect encompasses childhood neglect, emotional and physical abuse at the hands of caretakers. “Neglect is the ongoing failure to meet a child’s basic needs and is the most common form of child abuse” (Radford, 2011). Neglect can include not providing nurture, food, clothing, shelter, proper health care and education, as well as not properly supervising a child or keeping them safe. Emotional abuse can be described as a situation where “the perpetrator aims to gain power and control over the victim” (Tracy, 2012). Tactics used include humiliation, shaming, blaming, being hyper-critical or judgmental, embarrassing, ridiculing, threatening, name calling, insulting or employing the use of guilt. Emotional abuse includes verbal abuse, which can mean yelling, swearing or insulting another person. Creating a situation in which one doubts their own feelings and thoughts, known as Gaslighting, also falls under the definition of emotional abuse. Emotional abusers tend to deny the abuse and blame the victim. Physical abuse includes any form of intentionally harming a child, including hitting, kicking, throwing, shaking, or burning. Kadeesha discusses the neglect she experienced as a child, as she tried to fend for herself amidst a chaotic upbringing. My dad had passed away, I don't think I have any memory of my dad. My mom was in jail and we lived with our grandma, but I don't know why or how long we

lived there. I remember just waking up and having to clean up, we always had to clean. My brother was, like around, he will be in and out. I remember, he would cook sometimes. And then neighbors, like I would just go to a neighbor's house and eat at the neighbor's house. I just remember my mom being in jail and not really seeing her a lot when I was younger. And then when I got a little bit older I would hear around that she was a prostitute, like I would hear that even as a child, I heard someone say that before. The instability and multiple caregivers in Kadeesha’s early years have likely impacted her ability to attach, yet Kadeesha still seeks out food and caretaking wherever she can find it. The neglect increases however, when she first enters the system and is then placed with violent family members. Witnessing violence is also considered to be abuse, yet Kadeesha wistfully speaks about her mother with a mixture of empathy and longing. You know I just think it was a tough life for her, I don't really know why she couldn't… like she was like, trying to get her life, like stable and get us and stuff and then she finally did get us, and I remember we were in a good spot and then she told us she had HIV, and then it just seems like everything went downhill from there. Because like before then, I have memories of like, her good days, her hair will be done, make-up on her face. I remember that, but I remember after that day like I never seen her like get dressed up ever again. And then that will be the time where she will be in the room, like with the boyfriend and she, got like really sick and weak and I remember she was just going to dialysis and stuff and then me and my sister had to go to these groups like twice a week, like dealing

with parents with HIV. They would come pick us up in a van and we liked to go, because they will give us snacks. My mom passed away when I was 11 or 12 and then from there, we went to a foster home and then from there, we went to family’s house. Then we lived with my uncle and it was kind of crazy because I remember, he would violently beat his wife, and they have a baby and I remember like trying to stop him from like beating her, and there was like nothing we could do about it, and it was like very, very sad. Eventually, she left him so then when she left it got even crazier because he turned into a pimp. Life then was less stable, like a lot of just like fend for yourself type thing. But I always liked his girlfriends because I always felt like I wanted to find a mom in them. He had one and she was always like, “I'll be your mom and I’ll take care of you,” and she was really nice to me and stuff, but he was like beating her so eventually she left. Kadeesha’s body was slumped down as she recalled these memories, and I was aware of how difficult it was for her to share this part of her childhood. As Kadeesha struggled to find a maternal figure to attach to, it became apparent that each relationship was increasingly unstable and unsafe. Her exposure to violent abuse, along with abuse by way of neglect, placed her in a position where she needed to fend for herself. The neglect Luciana experienced was due to the fact that her parents were forced to leave the small town where they lived in Mexico to go find work. Although Luciana stayed back with her grandmother, there were so many children to watch that there was no protection from family members who preyed on the kids. After my little sister was abused I never think about myself, all I would think about is how to protect my siblings, I don’t want them to be touched in the way

this man touched me, I don’t want anyone to abuse them, I don’t want them to be controlled the way this man controlled me. I started working, making money here and there at 11 years old. I feel like I didn’t have a childhood because I was always out there, watching my siblings, trying to protect them from others. Things weren’t much better when Luciana’s mother was home. My mother used to beat us up like animals for little things that we would do. And for a Hispanic family that's normal, when the kids do something the parents beat them up. I remember my mother beating me with the radio cord. She would just leave marks on my legs and my back and same thing for my siblings. What horrible memories I have. Luciana’s experiences with neglect and abuse left her vulnerable to the advances of predatory family members, and the role she adopted as protector of her young siblings left her with a pervasive sense of fear and unease. Lynn has memories of living with her abusive stepmother, which still deeply affect her today. So okay, sorry I might get a little emotional. So, me and my brother moved in with my dad and my new step-mother and her son. We were living in like a little, like an apartment. It was the first time my step-mother hit me. I guess we're sitting like by the bedroom and I must have done something, I was just a kid so maybe I was like six at this time. I just remember her just whacking me, and I just remember like really being shocked (begins to cry). It’s just so funny how this affects me now, just a memory, but um I remember just being shocked, because this woman just hit me and I remember feeling like I was like suffering in silence.

Like when the abuse would happen, when she hit me or punched me or kicked me or whatever it was…I mean, she knocked me down in front of one of my friends one time, when we were walking down the street (cries harder). Sorry, I was so humiliated. The shock and humiliation Lynn experienced at the hands of her step-mother, along with the realization that her father would not defend her, created a world where Lynn felt increasingly isolated. Additionally, she lived in an unsanitary environment and witnessed other family members being abused. I remember it was always very cluttered and my dad throughout the years was like a hoarder, and I remember there being mice. It was just dirty. I heard my dad and my step-mother arguing one time in the kitchen. I don't know why I happened to like look around the corner and at that very moment, I saw my dad throw my stepmother down on the floor, he took the phone and he was like beating her with it. So, I witnessed that, I witnessed when my half-sister was about three years old, you know kids sometimes they break things or whatever, and my little sister broke something I guess that belonged to my stepmother’s grandma or something. And my stepmother came in and got so mad and threw my little sister on the floor and just started kicking her head. That was very traumatic to see, and there was definitely verbal abuse and stuff like that. Witnessing the violent physical abuse perpetrated upon her little sister, along with the realization that her father was also unstable, unreliable and abusive, left Lynn with no place to seek safety.

Maria also experienced neglect that left her terrified and vulnerable, when she was forced as a young child to wait alone at night in a car, while her mother went out looking for work as a prostitute. Waiting in the car for me was the worst because you're just waiting, like there's people coming and going and you just feel like you're stuck in time, like you're just waiting… waiting, when is she going to come back? And there were times when you just had to go to the bathroom and you just peed yourself because you couldn’t leave the car. Maria’s memories of time passing in the car bring to mind the fragile state she found herself in on a daily basis. Maria seems distant as she speaks of these times, as if she has found a way to separate herself from these memories. She was aware that her basic needs and safety were not taken into consideration, and observed how the rest of the world outside the car was passing her by while she was being left behind. Later on, when Maria’s mother decided to leave the family home with her new husband who Maria had accused of sexual abuse, Maria was forced to re-experience this state of neglect. She ended up leaving with him and I stayed alone, I have little sisters to take care of. And I thought, she has three kids to take care of, is she going to come back?. And I thought, what if I can’t handle this, I don’t want my sisters to go into foster care, I know what that’s like. To be so lost, I really had to grow up quickly. And so, when she came back I felt relief for them, but, for me, I just felt like the one person that I always needed and the one person I always wanted still wasn't there.

Maria’s heart-wrenching accounts of caring for herself and her siblings in the face of ongoing abuse and neglect forced her to take on the parenting role herself. However, her inability to gain access to her mother set Maria on a path of attempting to get recognition and attention in any way she could. The sub theme of Abuse and Neglect explains how experiencing terror, loneliness, violence, shock, horror, shame and guilt as a young child served to overwhelm their capacity to feel grounded, safe, integrated and loved. As these women have testified, these situations contributed to feelings of worthlessness and instability, which compelled them to discover new ways of achieving the validity they were longing for.

Sexual abuse. The National Child Traumatic Stress Network defines sexual abuse as “Any interaction between a child and adult (or another child) in which the child is used for the sexual stimulation of the perpetrator or an observer. It can include both touching and nontouching behavior including voyeurism, exhibitionism, or exposing the child to pornography.” Sexual Abuse is a subtheme under Abuse & Neglect, due to the specific ways in which the subjects reported sexual abuse impacting their adolescent, teenage and adult behavior. Madison explains the role that child sexual abuse played in her life. I feel like I was a very overly sexualized child because I experienced being molested when I was five years old, and so that really propelled a lot of like these issues around sex and sexuality. My father's father, who was paraplegic, was paralyzed and he was in a wheelchair. He molested me when I was five years old.

And the reason why I bring up the fact that he was in a wheelchair is, I feel like there's a societal belief like if someone's disabled in that way, like how could they molest you? And so that was confusing to me to

see this person who has this

disability, but yeah, this is still happening and in some ways that was invalidating to what was happening to me, if that makes any sense. I remember being given alcohol, but the more damaging part of the molestation was that his wife, who was my grandmother, was aware of this abuse happening, and she would punish me for the abuse. I always carried around an inappropriate guilt for people that were abusing me, and I could never figure that out until I was like, oh, this was the first person that ever made me feel guilty about something. Madison must contend with the conflicting roles of needing to help her handicapped grandfather, along with the confusing messages of submitting to his sexual advances. This split, coupled with the guilt and punishment Madison then endured at the hands of her grandmother, resulted in Madison seeking out new ways to recreate the cycle of abuse. Madison looks back on her early teenage years, and realizes she had no individual agency in her ability to protect herself against future abuse. She recounts the following story in an emotionless, detached voice. My first sexual act, like actual intercourse was in my own house with a guy that was much older than me. And it was a rape, I didn’t want to have sex with him. I always envisioned rape to be like “No, I don’t want to do this,” and I didn’t say that to him. It was more just compliance.

Kadeesha remembers how she also took on the role of acquiescing to the early childhood sexual abuse in her life. When I lived with my grandma there was this Aunt that I used to go to her house and she had a husband and I remember he was like really nice to me. And then I remember like him just like inappropriately touching me. I don't think I questioned him, “Like what are you doing?” I was just like “Oh okay, like he touches me like this.” There was another time when my mom had this friend and her son came over and he was just touching me too, and I was just like “Okay.” Like I just thought some guys touched you and some guys didn't. I was scared, like “What else are you going to do with me?” You know. Living in a state of fear, and never knowing which adults were safe and which were not created an unstable pattern in Kadeesha’s life. She could not trust anyone, and there was no one who was safe to attach to. When Luciana was sexually abused at a very young age, it also impacted her relationships with men, as well as the ways she experienced herself. You know, I was probably four or five years old, when my uncle started touching me in a very bad way, touching my body. He will never hurt me, he would just touch me, my chest, my God, at 5, 6 years old? I don't understand why he will touch my little chest, my crotch. He would touch my chest and my crotch, and he would touch himself, he would make me touch his parts. And I remember since the first time it happened, I became somebody else, I was very shy. I was afraid to talk. Because he will tell me “I don't want you to tell anybody. I don't want you to tell your mom, I don't want you to tell our grandma and grandpa. Because this

is our secret. I love you and the other cousins are not my favorite, you are my favorite so if you tell them you're not going to get more candies, I’m going to give these candies to another cousin.” Then by 10 years old, I witnessed my little sister being sexually abused and I could not save her. Every day I try not to think about it, but that's the most horrible memory that happens in my brain. Luciana is severely impacted when she speaks of her sister, and the pain she is still in is apparent in her pained expression. She could no longer be the happy, out-going child she had been and withdrew into herself in order to manage the overwhelming experiences that were happening to her. She loved and trusted her uncle, yet also understood at this very young age that something was wrong about the time they spent together. Coming to terms with the betrayal of a trusted loved one is often too much for a child to manage, so children find other ways of expressing the extreme distress they are faced with. We can see that Raquel’s account is another example of this betrayal, as she recalls the confusion she felt at the hands of her father, whom she deeply loved. My dad used to come into my room to tickle my back and I loved to be tickled, and I don't know when it started but he just started doing more than just tickling me, he would say “turn over let me tickle your front.” When I was 14 we moved and he came up to my bedroom and he said “Do you want me to tickle your back?” I said “No, I don't” and he never asked me again, and that's when it stopped. So I felt like I was responsible for this, and if I had just said “no” at any time previously then it would have stopped. And I mourned it a little bit, it was a strange thing, it was this kind of special relationship I had with my dad.

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Both Luciana and Raquel found ways of taking blame and responsibility for the sexual abuse, as a way of allowing their loved ones to remain “good.” The mourning that Raquel feels about the ending of this part of her relationship with her father is the basis for the sub-theme “I Just Wanted Someone’s Attention.”

I just wanted someone’s attention. I Just Wanted Someone’s Attention is a subtheme of Sexual Abuse, which attempts to capture the mindset of the sexual abuse victim who desperately wants to please her perpetrator. It is not in any way meant to imply that the victims gave their perpetrators permission to commit abuse. However, some of the women interviewed pondered the reasons why they went along with the abuse, and the often-confusing role that sexual abuse played in their lives. Raquel attempts to examine the mixed feelings she had about keeping her father’s love, alongside the upsetting feelings she wrestled with about the ongoing sexual abuse. It was something that I enjoyed, it was something that I looked forward to, which was also very hard on me. That’s been a lot to get through, that part of it. I was afraid to lose my dad if I were to have said something, you know because he was like the nice parent. Raquel’s feelings about “enjoying” the advances from her father resulted in intense feelings of guilt and shame. She was unable as a young girl to separate the much needed attention she received from the sexual abuse, and lived with the fear that if she did not acquiesce she would lose her father’s love. This dilemma left Raquel with no choice but to allow the abuse to continue. Although Raquel felt she could not risk telling

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her mother, she also believed that her mother was aware something inappropriate was happening in the house. I ran down the stairs and I had like my underwear in the dryer and I ran down the stairs naked to go grab stuff and my mom said “What are you doing? Put some clothes on, your dad could see you.” And I said, “Well he's my dad.” And she said “Well he's my husband.” So, things like that made me think that she knew, to some degree. Confusing scenarios such as these resulted in Raquel feeling as if she was the “other woman” in the house, competing with her mother for her father’s love. Kadeesha found that her early sexual abuse also drove her to search out sexual attention as a teenager. I remember after that just being kind of hyper-sexual, after that I knew I had a vagina and it felt good down there and when I had friends come over I would want to hump them. That impacted my life by just being too fast, just growing up too fast in that area. As a teenager I just thought that sex was love, so if they wanted to have sex with you they loved you. As a teenager I just wanted love, like, I just wanted to find a boyfriend that would tell me he loves me. I always needed. you know, I need you to fill that. When Kadeesha was older, she continued her pattern of being overly sexual in an attempt to be loved by her boyfriend/pimp. I just got really depressed from living in hotels and I was like miserable. At one point, after a year or two, he just started being like really, really mean to me, like I remember he hit me and told me to kill myself, nobody loves me. I was definitely disconnected from my emotions. I didn't think my emotions mattered, honestly. I

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didn't think that was important. I was like, I don't need to be happy. I thought, like as long as he was happy, like everything was good. As we can see, what began as Kadeesha’s longing for attention descended into a loss of self as her desperation to be loved and cared for increased. As Luciana remembers the abuse at the hands of her uncle, she also recalls how she initially craved attention from any adult who noticed her. I think that it was the love that I wanted, I wanted to have affection. But not abuse, not sexual abuse. Which is a completely different thing, so in my little mind, I was confused. I'm confused, but then, after a while I like it, I like that attention. I like to hear how much he loved me; I like to hear that I’m the favorite niece. I did not like it at first, but after a while I got used to it and I think I enjoyed, and I’m embarrassed to say this. I did like it, after a while. And when I think about it now I just want to vomit. I guess, I was a needy child because my parents were away and nobody was taking care of me. My grandmother had too many grandchildren to take care of. We were very poor; we didn’t have anything to eat. Yet my uncle would buy me candies and cookies, and hold me like he was protecting me. I feel loved. But I think that’s the wrong way to show someone love. I didn’t know what love was. He would say he loved me and kiss me on my mouth. It’s sickening to think about those moments. But as a child I didn’t tell my parents because I thought it was my fault for letting this person touch me.

Like Raquel, Luciana finds that blaming herself for the sexual abuse prevents her from acknowledging the fact that the uncle whom she loved and trusted might actually be

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harming her. “Liking the abuse” may also be a vehicle for justifying the abuse, because if these young girls are able to reconcile the idea that these were enjoyable experiences, they can then free their loved ones from being responsible for their illicit acts. After the molestations at the hands of her paraplegic grandfather, Madison talks about the additional sexual abuse she was exposed to, and how she believed she was responsible due to her own search for attention. I experienced probably ongoing sexual abuse between that first experience at five and then probably again around 11 to 14. A lot of men that lived in the same like apartment complex that I lived in, my friends’ father's, people like that. But I also felt in a way that I was a willing participant, because I was very sexualized and that was a way I saw feeling validated through people. I was really out of control once I was 14, and the way I met the very first trafficker that I ever became involved with was at a bus stop. I was kind of already on a self-destructive mission of like I don't care; I'm going to do what I want to do. I was set out to cause as much chaos and pain as I could for feeling resentful and angry about what I had endured. He picked me up and we were hanging out, there was another guy with him. And I went to their house and you know, there was sexual things that took place there, and I think that traffickers or these perpetrators, they're really good at spotting this over sexualization. I remember this guy showing me attention, and you know well at that point, I didn't know what a trafficker was, I didn't know what any of that stuff was, so I viewed it like a boyfriend, you know someone who's paying attention to me. So, I would spend time with him and he is the person who introduced me to the concept of prostitution.

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Madison’s view of herself as a “willing participant” captures the mindset of the sexual abuse survivor, and illustrates the often traveled path of young women searching for attention in the only way they know how to get it. Sexual Abuse and I Just Wanted Someone’s Attention are sub themes that attempt to make sense of the highly confusing messages that surface from early childhood sexual abuse, and shows how this abuse becomes a predisposing factor to future sexual acting out behavior, emotional damage, depression, anxiety and trauma.

Frightening adult experiences. Frightening Adult Experiences is the last sub theme under the Superordinate theme of The Way it Was. This theme describes degrading, abusive and scary experiences these women have been exposed to while working in The Life, along with other traumatizing events that befell these women after their previous exposure to generational abuse, neglect, emotional, physical, and sexual abuse. Kadeesha recounts one of the terrifying experiences she had whenever one of the other girls she worked with would experience panic and asthma attacks at the hands of their pimp. Like it was pretty bad cause he like beat her and stuff, and we had to drop her off at the hospital because she would have like an asthma attack, like near death asthma attack. I remember her getting like a treatment, like a breathing treatment, and then they would try to get information from her like “Who did this to you?” So she would escape the hospital and run out and hop in the car and we would hurry up and drive off. Memories of life with another pimp left her in a constant state of fear.

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He would hit me. He was like, “Oh you're black, you're not good for nothing because you're not nothing.” He was a black man, but every day, “You’re black, you’re nothing. I don’t even know why I have you, you’re nothing.” Just always scared, like all the time I was scared for my life honestly. They could have killed me so honestly every time I took a call I was afraid for my life. He would say things like “Scared money don't make no money,” so I would repeat stuff like that in my head like, “If I’m scared I'll never make no money.” These overwhelming, life or death experiences resulted in Kadeesha finding herself in more and more violent and abusive situations. This scenario is similar for Luciana, who believed she was finally embarking on a new life when she came to America. I wanted to keep going to school, but my parents couldn't afford it. One of my cousins was going to a Catholic school and a couple of my uncles were here in the United States and they told my parents that they could help me if I was a good girl, if I was not any trouble. I’m told to stay with a cousin, she was probably 10 years older than me. She had a husband about her age. He drove me one day and he raped me, I was screaming and nobody could hear me, it was a cold night. Nobody can help me. I do remember I scratched his face with my fingers, with my nails. I remember going back and I went straight to my cousin and I told her what happened and that I scratched his face, and she said this is your fault, you have been flirting with my husband the whole time, the way you dress, the way you talk. You tried to seduce him away from me. She was 26 years old; I was 15.

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After once again experiencing betrayal by a family member following the rape, Luciana may have come to the belief that she deserved the sexual abuse. Later on, after Luciana succumbed to years of brutal trafficking, she recalls the frightening adult experiences which she had become accustomed to. Oh, my God, my ovaries, my crotch, it was absolutely painful and those people who control me, they will give me medication. My vagina would hurt so much, I cannot take it any longer, I remember being very, very sick and one particular occasion that I thought I was gonna die because I thought I had pneumonia and I couldn't breathe. I was coughing so much and yet they will not let me go, I was there to please this man. And I thought I was not going to make it. So, I remember getting medication for the pain, and they will say you had to take it. I was sore, bruised. I was in pain for so many days. By now, Luciana’s ongoing abuse had become normalized, and likely outweighed the alternative of being unable to support herself and her son. After starting in The Life at age 14, Madison recalls some of the frightening adult experiences she survived. You know I dealt with a lot of life or death situations, things like that. I’m surprised that I didn't die. That was, I mean that was God, because that was not me. I didn't care. When you’re on the street, you have to be aggressive sometimes. It’s the only way you're going to get out of a situation. You know there's a lot of competition between traffickers. Lots of rules you have to follow. I had a gun pointed at my face, I remember just listening to my instinct and I turned around and walked away and he didn't shoot me, so that's good.

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Later in her life, Madison questioned her decision making when she decided to have a child with one of the abusive men she was with. He was rambling about something, and he takes my baby and he goes outside and gets in the car and I go to open the door to get her out and he just drives off with her in the car. He was using PCP which I was not aware of, and he was completely psychotic, he was having a psychotic episode. He was telling me that he could taste chemicals in the air, and that I can see through with eyes, and all this crazy nonsense stuff and my baby was in the car and he's on the phone with me going to Walmart to try to purchase a gun. It lasted about four hours, the incident with my baby, and the police tried to get my baby out of his hand and he refused to give the baby. They had three people that had to rip my baby out of his arms while he was being tasered, it was really horrific, her clothes were ripped off of her body. That propelled me into the DCFS system because of domestic violence, I had a case for over two years because of this incident and other domestic violence incidents with him and I had severe post-traumatic stress after that incident. When Madison stopped caring about her own survival, it was a strategy that allowed her to continue to work in The Life. Yet it’s clear that when it came to the survival of her child, Madison was deeply impacted and traumatized by this terrifying experience. Maria had her own tools that helped her survive incidents that seemed unsurvivable once she entered The Life.

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There was a time where somebody was armed, and I remember just thinking, am I really going to give up all that I worked for, for this? And I just tried to like escape mentally, you know, just tried to completely disappear. If my body wasn’t safe, at least my mind was. I remember being able to look down and see the whole situation, and just thinking, like this is how it's all going to end. Maria’s technique that separated her mind from her body helped her survive this frightening adult experience, yet there were other fears that plagued Maria and caused her to come to certain conclusions about herself. I was always scared that something would happen, you know, like STD’s or something like that, like HIV, like those are my biggest fears. And I was always wanting to like detach myself from even seeing, like I never even wanted to look down and see what it looks like or what it was like, I always felt there was this dirty part. At the time I believed it was something that I wanted, it took me you know to almost lose my life to be like, this isn't what I want to do. And now both my fake reality and my real reality are not mixing in with each other and people are starting to know, and that hit me hard you know, like it took me back to that time in elementary school with the rumors about my mom. Like my younger self, I felt her at that moment, like in me. I felt that I had let her down, and she was crying and now I had to be the protector of her. Now she is hurting and I just allowed her to get hurt, and I couldn't even justify why I was hurting that inner child inside of me. I couldn’t say it’s going to get better because it's not, it’s only going to get worse and eventually I’m going to end up being trafficked, sold or killed.

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Maria’s touching account of her younger self paints the picture of a young girl's desperate attempt at becoming like her mother, perhaps with the hope of engaging her mother and regaining her as an attachment figure. Once Raquel began to work in what she calls “whack shacks,” she recalls one of the frightening adult experiences she was subjected to. I remember a time when a guy came at me and I was ready to cold cock him, and he had a look that told me if I did anything he would kill me. And I just grabbed my clothes and ran out of the room, but that was distressing because that was the first time that I didn't feel powerful in there, that I felt unsafe and I felt, I felt really dirty. When Raquel felt unable to take care of herself, she also felt dirty. This brings to mind the fragility of the power stance which she believed kept her safe, and she instantly collapsed into a state of worthlessness when it was gone. The subtheme of Frightening Adult Experiences is the last theme under The Way It Was, and highlights the lack of control these subjects were faced with on a daily basis. Although these frightening adult experiences went with the territory of being in The Life, the severe trauma these subjects endured compounded their already fragile self-states. The theme The Way It Was delves into how generational abuse, neglect, physical and sexual abuse, and frightening adult experiences have all impacted the emotional wellbeing of these six subjects. The assumptions they made about themselves due to the abuse they suffered drove them towards further abuse and revictimization, which only served to exacerbate their trauma symptoms. Through no fault of their own, these young

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victims were set up for a life of poor decisions, which were merely attempts at mitigating the overwhelming feelings of despair they were faced with.

Theme 2: My relationships. Exploring primary relationships, and how those relationships have molded the lives of these subjects is the focus of this theme. Comparing the subjects’ childhood relationships with caregivers to their adult relationships, or lack of adult relationships, gives further indication of the impact these childhood relationships had on the future lives of these women.

Childhood relationships with caregivers. Every child views their relationship with caregivers through their own perspective, a child’s perspective. Children tend to assign meaning to events and behaviors that may or may not be true, and then act out of this perceived meaning. This sub theme will examine how these subjects made meaning of some of the events and relationships from their childhoods, and how those meanings instilled belief systems and patterns in their adult lives. Raquel's relationships with both her father and her mother were severely impacted due to the abuse at the hands of her father. Yet Raquel found a way to justify her father’s abuse of her, and by placing the blame on her mother she was able to preserve her relationship with her father. You know I started masturbating at a young age and stuff like that, like he would leave, and I would masturbate. Looking at it now I'm like, oh my gosh, but I mean

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I'm a child, I’m completely dependent on these people, you know I have to make it fit somehow. When it did come out and my mom said “Why didn't you tell me, you knew that was wrong.” And I did know it was wrong, I knew it was taboo, something he shouldn't be doing, but to my mind it was something that was a compulsion and he couldn't keep himself from doing, because of my, you know feminine wiles, or whatever as an eight-year-old. I was very angry, I was very angry with my mother, for not protecting me.

Abandonment. Abandonment is the most prevalent sub-theme in the subjects’ childhood relationship with caregivers, and abandonment takes on many forms. Here we see how Kadeesha’s memories of her early life with her dying mother affected the ways in which she was able to attach in relationships as an adult. Like I think like I was emotionally trying to cut off the relationship with her, because I knew she was like dying, you know. So, I just remember like no one really talked about it. I was very sad when she died because I felt like an orphan because I already didn't have a dad. Like my sister had a dad even though she never like seen him or anything, but I just felt like she was lucky if she still had a dad. Well, and then my sister got pregnant by my cousin, my sister was twelve. I’m pretty sure he was probably like 18 or something, because I don't remember him going to school or anything so he had to be out of school. And I just remember us having to move away from my uncle's house after that, like we moved in with my brother. And then probably soon after we moved there my

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sister gave birth to the baby. We only lived with him for like a few months, and then we were like taken from him and then put in foster care. After Kadeesha is effectively abandoned by her mother, she soon discovers the brother who tried to care for them had been brutally murdered, and the sense of abandonment she experiences is more than she can process. I was really like sad, heartbroken, because he was like really protective of me and my sister. Like I knew that he was like the last protector. I don't feel like I had any adults who talked to me as a kid, like no adults who said “Are you okay?” No adult that I felt safe to go to. If I had someone to confide in I guess I probably would have told them that, I just didn't because I just didn't have that. Luciana’s childhood relationships and experiences with abandonment were predicated on the cultural expectations of her town. You know deep in your mind that it’s not right, but you don't know what it is and you don't know how to tell your parents, because your parents have no time for you, because you already know that your parents will not hear you, they will not protect you. At a very young age, if you're a woman you already know what your job is, which is to serve a man. I don't know how to tell anybody because first of all they would criticize me, second of all they will call me names and they would say, “Well it’s your fault.” And I would be embarrassed and the whole family will be embarrassed as well, and probably the family will just kick me out of the family, kick me out of the town, when I did not do anything wrong, I’m a child.

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Luciana’s belief that she would be “kicked out” if she did not conform to the expectations of keeping silent is another form of abandonment, and her only way of achieving acceptance was to allow herself to be abused. As Madison remembers what life was like with her mother, we can see how substance abuse and mental health challenges can also create a scenario where a child feels abandoned by her caretaker. My mom is a pretty big part of my story. I feel like she is the central, or the beginning pain place in my life, like everything started with her, extends from her, relates to her. I was raised by my mom and I didn't have my dad in the household for the first five years of my life. My mom was very sick before I was ever born, so the only way I even know my mother is through her illnesses, she has a lot of mental health challenges and a lot of challenges with addiction. So that is pretty much what my childhood consisted of. I had chronic anxiety as a child, and when I say chronic I mean to the point where I would be physically sick, because my mom would often like disappear for periods of time or we wouldn't know where she was at. My mom was an alcoholic, she was a very mean, mean alcoholic and as a kid I used to wonder like why would somebody get so intoxicated just to be angry, I didn't really understand that about her. The thing that I feel like my mother really neglected the most was like failure to protect. There was so much stuff that happened to me in childhood when she was in the home with me, so she just was not capable, isn't capable. I hated her at a point in my childhood, I really hated her. She would disappear and I remember being I don't know 12, and like

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walking around the neighborhood looking for her and like finding her randomly on someone's porch and walking her back to our house. Madison’s attempts to get her mother to notice her, and see the abuse which was occurring right in their home left her with a disruption in her attachment. She was then unable to soothe herself, and lived with chronic anxiety. Maria’s experiences with abandonment by her primary caregiver left her questioning her worth, as she was left to observe her mother’s actions from the confines of the car. Eventually, you start to realize that something is off and you start wondering why, and sometimes I would wait in the car and you see like these other people and I would always fear like if she's going to come back. Or sometimes you might even see her getting beat up or her coming back injured and just wondering like, who is she? I couldn't talk to like my kindergarten friends about how my mom was going out to the streets or how my dad was hitting her. How my dad would bring guys over so that they could you know, get with my mom. Teachers were teaching you the ABC’s, teaching you how to count, and I couldn’t even concentrate in class. I was always the kid that cried a lot in elementary school. My mom would leave me at school and I was like I don't know if she's going to come back, like what if someone hits her and I can't defend her, and I'm stuck in school. I cried so much and the kids would say, like you do this every single day, your mom’s gonna come back. But they didn't understand, I knew that there was a possibility that she couldn’t. And especially when I saw a gun pointed to her head, like I knew that each day she dropped me off it wasn’t guaranteed that she would pick me up. I

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started when I was 15, like, I was always just curious as to what The Life was about, like seeing how my mom did it, this curiosity…how is this life something that my mom preferred over me? To see if I could handle it better than she did or try to just understand why this lifestyle meant so much or impacted so much of her life, to the point where it made me question whether I was loved or not. Perhaps Maria’s attempt to be in The Life, just like her mother, was her way of stopping the ongoing abandonment, in the hope that her mother would finally see her and take care of her.

Adult relationships or lack of. This sub theme examines the relationship choices these subjects have made as adults, and if these relationships are satisfactory and fulfilling in their lives. It is also important to note if the women have chosen to limit their adult relationships, and if they have, why? Do they have a propensity to find relationships that mimic their childhood experiences? Do relationships feel unsafe? Or perhaps they don’t even trust themselves to make relationship decisions. This sub theme delves into the painful truth of adult relationship patterns, and how these relationships, or lack of, affect their present-day realities. Lynn, in an attempt to become closer with her brother, opened up about what she did for a living. With family and stuff, I remember my brother. I told him that I was in The Life, and then him using that against me to shame me. And him saying “Oh, you sick fuck.”

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Raquel noticed that she replicated the sexual abuse at the hands of her father in her adult relationship. I was involved with a man; we were together for nine years and I was so like addicted to him. And we had a very, very active sex life, but he would engage in the same way, I never initiated sex, you know it was always at his initiation. I would hold still and wait for his advances on me, oh my gosh I was just like 100% recreating that situation. Although Raquel is now married to a different man, her relationship choices are still based on her previous trauma. She has now found a relationship where she feels finally seen, however this meant removing sex from the equation. Well, you know it's interesting, my husband is wonderful, he is an alcoholic and sober and he is Asexual, and it's been really interesting because I've always been in these sexually dynamic relationships and I feel like a part of why he's in my life is so I could have a relationship with a man who loves me because he loves me, not because he wants to have sex with me, which I didn't have with my father.

Trust/attachment. Trust/Attachment is a sub theme of Adult Relationships or Lack of, and examines the conflicting emotions of wanting to be loved, yet being unable to trust or attach to a present day partner, due to the fear of being abandoned once again. Kadeesha’s account of her attempts at relationships reflect her intense fear of future abandonment.

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When I get into a relationship it's real like, I’m really clingy. I suffocate someone when I’m with them, I need to know that they love me. I can even get jealous if they have too much family. They don’t understand me and how much I need from them. After years of childhood abuse, Luciana’s adult relationships seem to follow a similar pattern. Now I’m 48 years old, and when I think about my relationships with men, all I have ever wanted is protection. But then I end up being abused by the person that I'm in love with. I don’t know if that makes sense, but the mind of the abused person is very complicated. I wish to go back in time and you know scream and yell and ask for help, but you know, there was nobody to protect me. Luciana's account of searching out abusive relationships, and then tolerating the abuse in order to recreate the feeling of being cared about is a familiar story. Madison also found herself choosing dangerous adult relationships. I noticed for me that once I got out of The Life I transitioned into relationships that were domestic violence relationships. Trafficking also gave me this sense of security that if you need me you're not going to leave me, and I built a lot of my relationships after trafficking on that, so I picked people that would be financially dependent upon me. When I got into the next relationship, I really didn't want to tell anybody, like I felt it was so embarrassing. I mean it was about sex for me in the beginning, and I was feeling like very lonely and you know, not cared about and so yeah, a lot of red flags, and I just kind of overlooked and thought that it wasn't going to affect me. So about two months after us being involved I got

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pregnant, and he would call me like 50 times a day and, like in the beginning you know you think like control is “oh this person cares about you and are interested in you.” He was a very, very, very, very, very bad alcoholic, verbally nasty to me, he also has a lot of mental health issues, he's like delusional. Feeling cared about is an intoxicating feeling, and succumbing to a controlling partner felt like a small price to pay for Madison, in the hopes of finally having a person she could attach to. Maria finds that her inability to trust or attach prevents her from being in relationships altogether. You know it's hard for me to fully believe that someone is good or that somebody wants to have quality time with me. I don't want to believe it, so I don't allow myself to find the right people. You know, for a while I was in domestic violence relationships, just because I thought that's what I deserve, that's what I was used to. The Superordinate theme of My Relationships, and sub themes of Childhood Relationships with caregivers, and Adult Relationships or Lack of, attempted to explore the effects of primary relationships on these young women's lives. The compulsion to reenact these relationships in their adult lives was examined, along with the fear of engaging in adult relationships altogether.

Theme 3: How I feel. This theme explores both the physical and mental health symptoms which these women must contend with, as well as their feelings surrounding their symptoms. What do

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they ascribe their symptoms to, and what have they done to relieve their symptoms? These questions are explored in the theme How I feel.

Somatic symptoms. Somatic Symptoms include anything that one feels in their body. This can include pain, neurological symptoms such as headaches, shortness of breath, weakness and dizziness, or digestive symptoms such as bowel problems, constipation or incontinence. Sexual symptoms might include pain during sexual activity, or painful menstruation cycles. Insomnia, restlessness, fatigue and blurry vision are also examples of somatic symptoms. Kadeesha’s experienced somatic symptoms which were central to her chest area. “When I was in The Life I felt a lot of chest pain, a lot of that ‘I can't breathe” feeling. I still get those random chest pains.” Lynn’s somatic symptoms actually put her in the hospital. I will say that I do have issues in my spine that didn't start until I started in The Life, like right soon after I started, I started having severe sciatic issues. I never had any spinal issues until then, and I was suffering from pretty bad sciatica I mean, to the point where one time, because I started in The Life in 2008 and soon after like early 2009 I remember being hospitalized because it was so bad, like the pain was so bad. Even as a child, Madison seemed to understand that her somatic symptoms were somehow connected to her anxiety.

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I used to call them side aches when I was a kid and they would always happen on my right side. For my whole childhood literally, every doctor told me there was nothing physically wrong with me. They were really connected to my childhood, I remember having them pretty often and I also remember my mom not believing me, like “Oh you're just, you know you're fine,” you know that kind of thing. But like I wasn't fine. Maria’s somatic symptomatology signals her to look at how the anxiety or worry might be affecting her. I get these chest pains, like just the feeling of when you're like really sad and it just stays in your chest, like everything could be going so well, and then these pains in my chest come and I just have to calm myself down for it to go away. But there's times where it can go on for weeks until I really sit down and figure out what caused it. Raquel’s somatic symptoms seemed unusual, and as an adult she learned what her symptoms really meant. My whole life I've had chronic problems with yeast infections and bacterial infections and all of these things and I went and saw a colonist because I had problems, I always was constipated. I started doing these colonics and I did a series of 10 and like nothing was coming out, so one day she asked me if there had been childhood sexual abuse, and I said yes, and she said, “Do you know when it started?” I said “I'm really not sure I just remember it always being that way,” and she said, “Is there a possibility that it could have happened with you as an infant?” I said “Yes.” She said as an infant, the only way an infant can express

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themselves or say “No” is by holding their bowels, and I'd like you to consider the possibility that this is what was going on, and I'd like you to thank your bowels for giving you a voice at that time. And let them know that you have other ways to communicate now and just release them of their duty of holding the “No” for you. And so I did, and almost immediately everything was released, and so it was a pretty profound moment for me from the standpoint that I had always felt like a victim, and in some ways it made me feel like a warrior to think that I found a way, as such a young girl, to try to communicate. Somatic symptoms can be a way for the body to communicate when something is wrong, when there is no other communication technique available. Pain in the chest, which both Maria and Kadeesha experienced, might be a way for the body to express a feeling of suffocation, or even the feeling that breathing itself likely felt unsafe for these women. Perhaps they even felt an unconscious need to hold their breath, which is common for people with trauma symptoms. Pain in the spine and the side, which Lynn and Madison both experienced, may be attributed to closing up the body, an act of doubling over and protecting itself against possible further abuse. And Raquel’s body, even as an infant, was withholding feces as a way to express her personal power over what was happening to her against her will.

Mental health symptoms. This sub theme looks at the mental health symptoms these women are experiencing, and how these symptoms affect their current level of functioning.

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Depression, anxiety, Post-Traumatic Stress Disorder, Obsessive-Compulsive Disorder, Panic Disorders, Phobias, Social Anxiety, Eating Disorders, Impulse Control Disorders and other mental health symptoms are considered and examined, and participants recount the ways in which they have learned to adapt to their symptomatology, or how their symptoms prohibit them from fully participating in their current lives. Kadeesha’s anxiety symptoms often keep her from being present in her life and relationships. I definitely have anxiety, I had anxiety as a kid too. Just not feeling real safe around like men, like just being scared like okay, like what's going to happen, is something going to happen? I was always like that, even moving with my aunt and her husband, like is this going to be a time where I'm about to be molested? I just didn’t know. Sometimes I have real bad anxiety, if I have something I need to do, like I really suffer. It made me not like sex with males, like it's hard for me to even kiss a guy or like be really affectionate because then I start like getting flashbacks from when I had to be affectionate, you know so like it made me real distant with males, it just made me view males as just tricks, clients, like every male was that. Luciana describes how her mental health symptoms impact her life. People think that I have a mental illness, because I don't know how to be a normal person, how can I be a normal person? You know when things happened to me I tend to be angry and have anxiety, I started having anxiety so young. I remember being afraid to go out with other kids. My whole life changed; I was never social with other kids. I started having a low self-esteem about myself, I did not love

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myself anymore. I can talk to men; I can tell them what they want to hear. But when it comes to having a conversation with a woman or with a group of people I’m an awkward person. I don't know what to talk about, I’m shy, I’m embarrassed, I'm shaking, having panic attacks. I want to run away from people. Lynn finds that she still struggles with depression. They say depression is like anger turned inward, I think that's where all my like anger or my depression came from. It's like that anger that I would just turn inwards because I didn't have the courage to speak out. Madison’s mental health symptoms caused her to struggle in many aspects of her life. If somebody would leave and like not come back I would think they were dead, what is the word? Oh, catastrophic thinking, I would struggle with that. I remember being careful about what I was thinking because I thought if I think something, it’s going to happen. So that caused a lot of chronic anxiety for me to the point where I would go to doctors and they would tell me like there was nothing wrong with me. But I had like physical symptoms like where my side would hurt and I would feel sick, so looking at that as an adult I understand that that was like emotional and mental stuff that was like translating its way into my body. In terms of anxiety now, yes, I do still have anxiety and I actually have some post-traumatic stress. I have been able to find some treatment for anxiety and it has gotten a little bit better but it's something that I'll probably struggle with the majority of my life. I've never been the drinker, but the person supporting the drinker or dealing with the drinker so that's more of my sicknesses. Like the codependency part of it. And when you learn to protect the abusers and feel sorry

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for them, that becomes a pattern in your life. Almost enabling other people not to take care of themselves. Maria’s mental health symptoms impact her quality of life, and leave her feeling isolated. As a kid I was very depressed, you know even suicidal at times. I did attempt suicide I think twice, but they were both failed attempts. On depression, anxiety… it's hard, even with medication it’s the mental block, you know what we do to protect ourselves, like there's just certain things that our bodies went through, that we went through that we just can't remember. And we can't talk about it, we can't remember, we just… our bodies just know that they went through it. I still battle with depression. There's times, where on the weekend I can’t get out of bed. If I ever have plans, it's very hard for me to keep those plans because it's just… I don't really want to go out, especially if it's late at night. It's triggering you know, it just kind of takes me back. Like anxiety too, like if I hear people talking sometimes I feel like they’re talking about me, even though they're not. You know if people are looking at their phones and they're laughing and I happen to be in the same room, I always wonder do they know? Are they laughing at me or are they looking at something that has to do with me? I definitely have anxiety; I definitely have hyper vigilance. It's like a little animal in the forest, you know I mean you're just super hyper aware of everything going on around you and synthesizing that all the time to just like make sure you're safe. It's important for me to feel safe, if I don't feel safe I'm just like a ticking time bomb. The mental health symptoms these subjects are describing, including anxiety, social anxiety, depression, suicidality, codependency and hypervigilance,

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can easily be attributed to trauma. All of these women are attempting to find ways of metabolizing the traumatic events of their early years, as well as the ongoing traumatic events in their adult lives. The goal of the Superordinate theme of How I feel, and the sub themes of Somatic Symptoms and Mental Health Symptoms have attempted to highlight how these subjects struggle on a daily basis with debilitating symptomatology that affects both their bodies and their well-being. Learning how to adapt to the physical symptoms they experience, while struggling to manage anxiety and depression proves to be an ongoing battle for all of the subjects interviewed.

Theme 4: Doing what I had to. This theme is all about survival, and the different routes these subjects have taken to ensure their survival. Some of these survival methods are conscious and some are not, but all provide ways of experiencing a sense of relief when no other tools were accessible to them.

Addiction. Doing What I Had To can encompass doing whatever it takes to feel better. When feelings and emotions become overwhelming, addiction can seemingly offer a welcome way to temporarily escape the pain. Addiction can be substance related, where subjects have found relief in drugs or alcohol, or it can be behavioral, such as gambling or sex disorders. These subjects explore how their addictions have provided them with a way to check out, which may have been the only survival tactic they knew of at the time.

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Kadeesha explains how her addictions quickly became out of control. I was addicted to weed, actually, it’s so crazy because I wasn't even a drinker and I became addicted to alcohol, and I didn't know why I was drinking all the time. I had all that like hurt, you know. I would always just be like drinking, but to the point of like blacking out like I'll always just like drink to blackout, and I felt like I was doing that to like keep the emotions down. Like I didn't want to tell anybody, so I would just drink, to the point of blackout, often. Kadeesha’s insight into how overwhelming it was for her to be present with her memories and feelings was the motivation for her to drink until she blacked out. Lynn’s addictions to alcohol and gambling, which was her way of forgetting her trauma, almost destroyed her life. At the time I was like overdoing it with the poker and the gambling, I didn't realize I had an alcohol problem at the time, I mean now looking back that was like so obvious. Gambling for sure, just getting out of hand with it and being more focused on that. There was something in my mind that felt like I had a void to fill. You know I did what I did for a living and then I'd go play poker all night or go gambling. I remember working and thinking I just needed to make enough for a couple of buy-ins. Maybe you know I wasn't okay with what I was doing, and then doing these distractions, it was like I was using these things to fill that void and like this is gonna make it okay. So yeah, it kind of like fed into each other, I guess. So I had at one point, casino markers that I wasn't paying off, and then I

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was facing felony charges. Then I got arrested and I was in jail for 21 days. I had a DUI. I lost my place and my car, and I literally had nothing. Madison realized that what she did for a living actually created an addiction, in the desperate hope that she could finally feel better about herself. I was addicted in a way to The Life. I don't know how other women feel about it, but I feel like it's similar to like a drug addiction in a way, like there's a certain high you get from it. You know you can get any amount of money you want, those things they draw you in, you know. Sex, sex has always been an issue because it was always the way to fill my void and feel cared about. And it was always like a drug addiction, you know, like I gotta feel better about myself, you know. Raquel remembers the feelings and behaviors that drove her addictions, and the things she would do to try to make herself feel better. I think I felt I was just trying to justify it all, I was doing a lot of drugs, you know, I was drinking, I was, I was with a total drug addict alcoholic who would steal my money you know it was crazy, it was crazy, it was crazy. Addiction seemed like a way for these women to put aside their pain and get the relief they were seeking in the moment, which felt necessary for their daily survival. However, this sub theme of Doing What I Had To also incorporates other methods of checking out which were much less conscious.

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Dissociation. Having an involuntary disconnection between certain experiences and the thoughts, feelings and memories that might accompany those experiences is at the root of dissociation. Finding a way to disconnect from reality is a way to protect the mind from living through something that may further traumatize it. Symptoms of dissociation can be memory loss of specific events, feeling detached from your emotional state, and feeling a sense of detachment from certain people or events. Dissociation is a sub theme of Doing What I had To, because it is a way for the mind to survive an event that it perceives as being not survivable. Kadeesha had ways of protecting her mind when she went through some terrible experiences. I just floated around in my mind. I can't remember any particular place that I went to. I feel like this is not me. The feeling of “not me” allowed Kadeesha to survive, because she knew the part of her that was suffering was not really her. Luciana also remembers finding ways to disconnect from the horrors of her life. I feel like that was not me. I feel like that's the story of another person that you just go online, and you check the stories and then you just read it, and you say you feel bad for that person. And I don't feel like that's me, that happened to me, I don't feel like that person. Inside my head, I’m strong. Madison remembers her abuse at the hands of her grandfather, and how she learned to cope with it.

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I think I felt pretty disconnected during that first incident, kind of like seeing yourself from the outside, or quieting your mind, you know as a way to kind of just cope. Not really feeling anything about it, having an awareness like you know what's going on but there's nothing really connected to it. And I still feel that way, to this day. I feel very disconnected from it like I almost feel as if it was somebody else you know. I think the quiet, like trying to quiet my mind was a coping strategy because it's so chaotic outside of you, you know that you kind of create an internal space to kind of retreat to that feels safer. Creating that where I could quiet my mind pretty intensely during those situations was a way to kind of get through it. When I think about how I felt then, it was very similar to how I felt when I was five. So I already kind of had practice for it, which is interesting, because I think sometimes I don't even recognize these things until I say them out loud to somebody else. It was actually almost exactly the same feeling as being five, retreating to a place of quietness, you know. It's like I remember, like a movie, like I can

remember the scenes, but I don't have any feelings attached to

it. It’s weird like how you can feel you didn't have any emotion about something, but it impacted your whole life. Madison’s technique of quieting her mind and seeing her life like a movie was a way of distancing herself from experiences which were far too much for her mind to process. This technique became a learned response for Madison, who found that she repeated the dissociation as an adult during stressful or traumatic situations. Maria had her own way of dissociating, which was the perfect way for a child to escape something that was far too overwhelming to cope with.

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For me, like it may sound weird, but I would always talk to Santa Claus. I don't know why; I wasn’t raised religious but I knew who Santa Claus was so I would always ask for Santa Claus to come and take me. And I would just picture Santa Claus, I would picture myself in the North Pole. And there's like snow and there's like elves and I’m running to Santa Claus and telling him. I physically felt like I was there, I didn't feel like I was here. And I could still do that, like I just take myself there so whatever's happening I don't associate with it, I’m not connected with it, like I’m at the North Pole and with Santa Claus and we're making toys and he's going to take me out of this situation. It was just a very safe place for me, like it was somewhere in my mind that no one could go in, it was protected. Once I was there, there was no bad memory, there was no bad feelings, it was a happy place and it was the only happy place that I had. I knew I could go there and nobody would be able to enter without my permission. In stressful situations especially when I feel like I can't control something, I try to like see if I could escape, if I could just get out mentally and see my surroundings so I don't feel as trapped, you know as small. Obviously now I know like Santa isn’t real and he's not going to come down and take me with him to the North Pole, but I can still take myself there and be that little kid and believe that for a while at least, I can feel safe. Raquel also recalls putting her mind in a separate place, where it could be safe even when her body was not. When Raquel’s mind was safely away, it kept her from needing to acknowledge what her father was actually doing.

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I was holding very, very still like I just remember I would always hold very still and I would just kind of go somewhere else, but I was like on peak alert you know. Like I go into this strange like fantasy place where nothing else really exists, like nothing else really matters and I guess that's kind of the place I was when my dad was doing stuff, I was just in this other place. It is easy to see from these testimonies why Dissociation is a subtheme of Doing What I Had To, and how this coping mechanism was absolutely necessary in order for these young girls to continue functioning in the face of overwhelming and terrifying abuse.

Other ways to make myself feel better. Sometimes there are other ways to find relief, be it through religion, spirituality, or other forms of self-soothing techniques. Here are some of the alternative tools these women relied on to make themselves feel better. Kadeesha turned towards religion as a way of making sense of her life. I went to live with my aunt, and they had three kids and were Jehovah Witnesses. You know, it took some getting used to the Church, but I felt like I welcomed it because I had so much hurt from all that stuff so like getting into religion gave me hope. But then they got divorced because he cheated, and we had to leave the house and we didn’t go to church anymore. Lynn also turned to religion to soothe herself. When I was 19 to 23 I was what I considered a born-again Christian. I was like, now I get this Jesus thing, and I was really into like the Bible and going to church.

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Religion, for Kadeesha and Lynn, gave them a sense of being a part of something. They were no longer alone and they could rely on something outside of themselves for comfort. Luciana turned to music and a cleaning compulsion in an attempt to manage the unwanted thoughts. If Luciana’s immediate environment was sparkling clean, perhaps she was able to feel like she herself had been cleansed. Music has always been my therapy. It brings memories back from when I was a child. I remember my mother having a little radio. When I was home, I would just clean and

clean and put the music loud and block all those images from my

head. And I’m still doing that now. Every day, I put the music loud and I just keep cleaning. Cleaning constantly. Maria’s way of making herself feel better was not always successful, however protecting her mother was tied directly into her self-worth. I think something with me, I thought I needed to take care of her and in a way that made me feel like I was taking care of myself. Like I kind of took on that parental figure role, even though I was a lot younger and didn't even know really like what was right or wrong, but I just knew that she was somebody that needed somebody to protect her. Like making sure that if someone hit or somebody yelled at her, trying to get in between, or you know, stand up for her, and for me at the time, like that was something that made me feel better knowing that at least I'm doing something, and I'm not just letting somebody hit her or yell at her, but oftentimes I got hit and yelled at too.

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Maria’s anxiety and depression symptoms persisted, and she worried about her mother showing up at school and fueling the rumors Maria already had to contend with. She then turned to attempted suicide in an attempt to feel better. And it was just so hard, I didn't know how to speak up for myself, I wanted to get out of it so bad. And I didn't want anyone to know, I didn't want her to go to school, so I saw this bottle of pills, and I took them all and I was just feeling really dizzy and I fell asleep, but then I woke up like throwing up really bad. Raquel had some coping techniques that although unusual, helped her to feel better in the moment. I used to steal things all the time, I was a kleptomaniac like all the time. I mean I would just go out to steal stuff I didn't even need, anything or whatever, I would just steal. I was kind of, I was treating it a bit flippantly I think, because that was a way, that was a coping mechanism, was to kind of just be like no big deal about my body or whatever. When Raquel focused on stealing and other negative behaviors, she was temporarily able to divert her focus from what it was like for her to perform sexual acts for money. Other Ways to Make Myself Feel Better is a subtheme of Doing What I Had To, because as these subjects have illustrated, the ways in which they chose to make themselves feel better were desperate attempts of ridding themselves of the pain they were experiencing. There are other routes these subjects took to help make themselves feel better, and Showing Them or Getting back at Them is one that surfaced often.

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Showing them or getting back at them. Feelings of anger and resentment can oftentimes build up, and directing that anger towards the perceived originator of those feelings can sometimes feel like the only solution. Some of these subjects intentionally directed their behavior with the goal of hurting the people who had hurt them, while others may have found ways to get back at them which were not as consciously planned out. In both scenarios, subjects felt that Showing Them or Getting back at Them oftentimes drove their behavior and their actions. Lynn found ways of expressing her anger through her behavior. And then I was just really rebellious and like smoking weed and drinking and cutting school and shoplifting and I was kind of promiscuous. I think by the time I left high school I had already slept with maybe like four to six people which at the time was like a lot, you know. I think I showed up home one day, and I was like blackout drunk, and so my parents sent me to live in like an all-girls facility which I lived in for the first half of my senior year in high school. Although Lynn’s behavior resulted in her being sent away, it perhaps had the desired result of finally getting the attention of her parents. Madison made it a point to “show” her mother how angry she really was with her, perhaps in the hope that her mother might finally change her behavior and give Madison the love she so desperately needed. You know I used to feel like really angry at her and a lot of my self-destruction was to kind of get back at her. Like I had this goal, I want to make her feel as miserable as she makes me feel. There were times, where my mom was like so intoxicated that she was like laying in our living room floor for like hours and I

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just go in there and make sure she's breathing, so managing all that as a kid…so I really wanted to disrupt her as much as she disrupted me that was like my goal, and once I got to the age where I started to notice that my behaviors could kind of get back at her, I took advantage of that. Raquel also used sex as a way of getting back at her father, as well as her mother who looked the other way during her abuse. When Raquel showed her father she was now allowing other people access to her body, it was a way for her to finally let her father know she was no longer going to be the victim. I was incredibly promiscuous and I started having sex when I was 14. I had sex with lots of guys, I always dated older guys. I was very popular I mean you know, I was fucking all the boys, so that helps you know. Lynn, Madison and Raquel demonstrate how Showing Them or Getting Back at Them felt like a necessary step for them. As these women have described, the compulsion to engage in these behaviors served to finally make them feel as if they were not so helpless after all.

No other options. When their physical lives are at stake, these women have at times needed to do whatever was necessary in order to ensure their personal survival, or the survival of their children. Putting food on the table, paying rent and bills, or trying to save enough money to find another way out for their families are examples of having No Other Options. No Other Options is a place of desperation and pain, and our subjects share their

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heartbreaking memories of the things they were compelled to do when faced with what they believed to be the only viable choice for them. Kadeesha remembers that when she began working in The Life, she believed she had no other choices. I thought this is what I have to do to survive, like, I was like in survival mode. I was just looking for something to hold onto. Raquel felt like she needed to turn to desperate measures to make sure she was not abandoned. I think I didn't feel as if I could rely on anyone or anything, I didn't feel like I had my family really available to me, and I didn't want to turn to them. That just felt awful to think of doing that. I felt like I just had to do it on my own, and I had these other people that I was caring for and I felt responsible for them. And I also felt like I didn't want to be alone, so if I wasn't responsible for them, then they would leave me and I would be alone, so it was very survival minded. Very, very survival minded. And when Luciana fell prey to a boyfriend/pimp, she also found that she became desperate to just survive. This man took everything, I didn't even have a car, or identification, and I was working, but my work was not enough to provide for my kid and I to live. I met a very nice lady and she said she could help me get a job as a waitress. I went with my long dress that I wore and no make-up, the way I was raised back home, I was not allowed to wear pants, short pants, mini-skirts or anything like that, so I will always wear long, long dresses. She said they will hire you for sure, but you need

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to wear a mini skirt, because waitresses need to seem like a happy person, sexy and beautiful, so I bought a little mini skirt. Then they told me that it was not a waitress job, it was a job to dance with men and if I wanted to try it he assured me that I was going to make good money, so I was in shock to hear that. I feel out of place, that was not a place for me. The first dance I had this man immediately wanted to touch me everywhere and I know this is absolutely wrong. But seeing the women making money, I thought, well, maybe I can try and because I’m a single mom I need money. I stayed for one night and I thought I will not come back here anymore, however, two, three days after I went back. I remember well, if I can make $100 a night, you know I can be working day and night, I think I will be able to save some money and buy a car for my little kid and myself. Finding ways to guarantee their personal survival, which includes ensuring they will not be abandoned once again, is the drive behind No Other Options. These often desperate measures demonstrate the impossible decisions these women were up against when faced with the need to take care of themselves and their loved ones. Theme 4, Doing What I Had To, demonstrates how the need for personal survival can take many different forms. Finding ways to distance oneself from the trauma, like using addiction and dissociation, is one way. Behaving in a destructive manner as a way of making your abuser pay, as we saw in Showing Them or Getting back at Them is another. Finding alternative strategies to distract and distance themselves from the overwhelming negative affect they felt, as seen in the sub theme of Other Ways to make

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Myself Feel Better, worked for some. And when all else failed, No Other Options was a last ditch effort to do whatever needed to be done, to ensure personal survival.

Theme 5: Who am I? This theme reflects the participants' sense of who they are and how they perceive themselves. The sub themes focus on the myriad of ways in which these subjects attempt to make sense of their thoughts, behaviors and actions, and how their own sometimes confusing behavior drives them to make choices they are not always comfortable with. Who Am I? is an exploration of the subjects’ inner worlds, and encompasses both the compulsion to repeat past trauma and the strengths which can support them in changing their lives and achieving their dreams.

Perceptions of identity. This sub theme examines the thoughts the participants have about themselves, and the ways in which they believe they are viewed by others. Internal perceptions drive external behaviors, and this window into the personal viewpoints of these women helps us to understand their decision-making abilities as well as their life choices. Madison explains how her work in The Life defined her thoughts about who she was. It's weird to exist in a world where like these people are all around you go into their jobs and have their families and you don't feel connected to them, you feel like you're a separate entity, you know and you're told that you are, you know The Life is it. The Life looks at people outside. The Life a certain way, you know, like

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there's a divide between us and the rest of the world. And so it's easy to be encompassed in that, and then also you're told that you no longer belong over there. You know you're not going to make it over there; people aren’t going to accept you over there; you might as well be good at this. For Madison, feeling like she was on the outside looking in was a very familiar feeling, so finally being a part of something was a welcome alternative. Kadeesha describes the ways in which she felt like she lost her identity at the hands of her pimp. I was always just like disappointed in myself. I felt like not a part of society, honestly, I felt like it was like this secret dark world that I was part of, like this dark world. I felt like the whole time I felt like I wasn't in my body. I stopped looking in the mirror, I stopped looking at myself. Because when I looked at myself I would be like, whoa, like this is really what you're doing, so to avoid that I stopped looking at myself. I think I was just like a body, but I just felt real empty like I didn't know what I liked to do, I didn't know anything about myself honestly, all I knew is basically what he told me. Kadeesha explains how she learned to adapt her personality in order to survive. You know, we watched everything, you know, just watched over our shoulder a lot, there wasn't a lot of relaxation. I remember feeling even uncomfortable when I go out to eat. I will be uncomfortable just because I felt like I was not a normal person, like everyone knows, and they can see it. A lot of times I won't even like be myself or show my personality, because I just never felt like people cared to see that, like I always just felt like I just had to be this robot for the clients and

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just shut up and do whatever. So a lot of time going into like a lot of situations, I’ll just be quiet and smile and then everyone will be happy. Kadeesha’s belief that she was just a shell who had nothing worthwhile left inside of her drove her to obliterate all parts of her personality. Luciana describes her own selfperceptions, and the responsibility she placed on herself for being in this position in life. I would just cry and feel guilty, I would just play music to forget that I'm guilty, that I am the one provoking this, that this is happening to me because I'm causing this. And I know that nobody knows about this, but in my mind I feel dirty. I feel lost. I am in pain. I’m broken from head to toe. I’m trying to heal, it's not easy. My body is all broken, but what is more broken than my body is my mind. Lynn examines her own perceptions of identity, and how these perceptions have come to shape her life and the choices she made for herself. Throughout those years I was very, very secretive of it. Even after I got out. I felt like “Oh my gosh like if anybody ever knew I would feel so exposed. Like all these people could say “Oh, what a dirty whore or something, like how nasty.” I remember talking to somebody in Underearners Anonymous. I was looking for a sponsor and she's like “Why would anybody have a fear of success?” And I'm like are you kidding me, it's just as prevalent as having a fear of failure. You feel like shit inside, you don't feel worthy enough and you see these people succeeding, and you want that, but know I can never do that. So I guess I’m constantly beating myself down, putting myself down, putting myself at a safe level. Lynn’s belief that people knew what she was doing and looked down on her because of it kept her from revealing who she really was to anyone. As long as she was hiding, she

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remained frozen and incapable of success. Maria felt that who she was had already been defined by the experiences of her mother. You know, people knew my mom was in the life and a lot of people in school knew. The dads would say “Oh that girl, I know her mom, her mom is this, her mom is that.” And since elementary school, I was hearing these rumors. Although Maria was able to keep herself in school, her perceptions of identity drove her to live a double life as a student and as a prostitute. Perhaps by being in The Life, she could finally be a part of the thing that felt so important to her mother. I felt like I was living a double life like at school, when it came to school, I never messed with that, like, I always cared a lot about my education and my grades and being a respectable student, but then going home and like knowing that at a certain time I was going to go out and do this. I didn't want people at school to talk about it, it was just a secret that I kept to myself. Raquel's ideas about who she was were also defined by her early life experiences. I grew up feeling like the other woman in my own home. You know I think the thing that's the most profound about it for me is that my sexual awakening happened at the hand of my father and that's created like, as far as my sexuality and things like that and men that I've been involved with and the things that turned me on, it's kind of this re-creation of that taboo kind of situation. When Raquel felt like she had to compete with her mother for her father’s love, she lost her role of being the daughter who desperately needed to be protected. Although Raquel understands that what happened to her was wrong, there was a part of her that found the

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abuse gratifying and was driven to repeat it. Raquel also realizes how she defined herself by her anger, and would change her identity in the hope of changing who she was. I got very connected with my anger; you know I don't think I was as connected with my hurt; it was very much a cover up of emotions. I was doing this stuff tough girl style, like I would change my name, when I was a redhead I was Ginger. And then when I started doing kickboxing I was Roxy, so I was like this tougher girl, you know. It was interesting how that idea of being able to just change my name and then become that character in this environment. It is clear how the participants’ Perceptions of Identity catapulted these women into life choices they were not always comfortable with or proud of. Unfortunately, these perceptions of identity lead us into the next sub theme of Who Am I?, Vulnerability to Manipulation.

Vulnerability to manipulation. Why are some people able to view a situation as dangerous, while others may not regard a situation as even threatening? This sub theme delves into the reasons why these subjects may not be attuned to danger, and how their past traumas might have primed them for future abuse. Madison explains why she believed she was vulnerable to being trafficked at such a young age. I do remember the feeling of being desired and like that was special to me because I didn't get that from my mom. And I don't mean like necessarily in a sexual way, but if that was the only form that it came in, I was grabbing for that

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you know. And then he told me that I would give him the money, and I said why would I give you the money? And his answer was like, well you care about me right, like you love me you care about me and when you love and care about somebody that's what you do for them, you know that's how you show them you are interested in reciprocation, you know. And so it wasn't really hard for me to buy into that idea. My motive was never money, I didn't care about money, my motive was I'm important, I’m special. Madison’s desperation to be loved and to feel important continued to drive her behavior, and she found herself submitting to even more abuse from her pimp and the various tricks she saw. I've been physically assaulted before, emotional abuse, lots of stuff happens. I mean it's very interesting how the control issue develops when you're being trafficked, like basic things like eating when you want, you can't do that, you know you eat whenever it's available. It's weird because you have this freedom to just like walk away but you don't, like you're very conditioned. You feel like a prisoner in a free world, it's very odd you feel very disconnected from society too. That's why they call it The Life right, like you're not a part of the world, your part of the life, it's a very separate thing. Madison struggled with walking away, perhaps because she believed she deserved to be punished as she had been by her grandmother. It is also possible that at first Madison didn’t perceive the situation with her pimp as dangerous, because her past trauma kept her from noticing danger cues. This scenario is all too familiar for survivors of sexual abuse, and Kadeesha, who was only a teenager when she was first trafficked, at first did

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not recognize her original traffickers as dangerous because they seemed like a nice couple. There was an insurance company and he needed someone to swing like this insurance sign on the corner and he was paying me cash every day, so I started working there I started doing that. And I was just like going to work every day and then this guy and this girl, in a nice car approached me and they're like why are you doing this, like you're too pretty, like we can help you. So then, they were like we’re going to buy you a phone so we can call you, so they bought me this phone and then said we're going to show you what you have to do for us, and they took me to a hotel and took pictures of me and put me online. After escaping her original traffickers, Kadeesha was once again manipulated to get back in The Life. And then I got back in The Life because I met this guy and he was gonna be my boyfriend and take me out to eat and stuff like that, but then eventually he was like you gotta do some stuff for me if you love me. So I was like, well this guy like loves me, he says you know you'll get a car, you'll get an apartment, I'll take care of you, just like do this for me. I blocked out all my feelings, and I just was like so in love with him that I literally committed like my whole life to being in The Life, I didn’t care. Like he would tell me I'm the only person here for you, you only have me, and I believed that. Luciana explains how her cultural background played a part in her ability to be manipulated.

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I met a guy and he was very nice, and the way he talks, the Spanish, the accent is like a country guy from my little town so I feel comfortable talking to him, I feel comfortable going out with him. We became boyfriend and girlfriend. I introduced my son to him. I wanted to stop going to the nightclub and just keep my regular job, but he will talk to me very nice and say if we work hard, we can save some money and we can buy a house and then you don't have to work here anymore, maybe you don't have to work at all. In Hispanic culture they criticize you and say you did this to yourself as a single mother. Then he would manipulate me and say you're going to be a single mom for the rest of your life so basically, I'm picking you up and giving you a name, and people will see you with good eyes, your parents, your family will see you with good eyes. After Luciana’s boyfriend began abusing her and trafficking her, he kept her working with the threats of harming her family. He will cover my eyes, so I will not see where I was going exactly. I will stay there for a few days, and he would pick me up and he will collect the money because he's the one who is saving the money to buy our home. He's the one who has a social security, he's the one who is a citizen here now, with my background I don't have anything, I mean who would take me? Soon after he started showing me pictures of my family saying that he knows my family and if I want to protect my family I should keep doing this. The only way out is to is to kill yourself. The only way you can protect your family, but I'm a coward I'm thinking well if I kill myself who's gonna take care of my son? I know that my son is out there, and I

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talked to him on the phone. I don't see him a lot, but I know that he needs to know that he has a mother. Vulnerability to Manipulation shows the destructive paths that led these participants towards a place where the choices they made were subjected to the decisions of their traffickers. Due to the overwhelming effects of the manipulation, we can see that who these women thought they were was clearly defined by who their traffickers told them to be.

Don’t know why I do it. Being unable to grasp what drives you to repeat traumatic situations, or what propels you toward behavior that you don’t consciously choose is the basis for this sub theme. Subjects examine the choices and patterns they have seen in their lives, and question their ability to make good decisions for themselves. Kadeesha reflects back to some dark places, and the things she did at the time which she didn’t quite understand. You know you wake up, you post, and then you like wait for a phone call, but like you know when they're going to get there, you know what you have to do so you just like mentally prepare yourself. Like I have to do this and then it will be over. It's pretty much like torture, I compare it to torture. I was just like infatuated with wanting to be loved so bad, I was like I'll do anything, you know. He would take…I’d give him the money.

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Subjecting herself to what she considered torture, and then handing over the money she made from it was the only way Kadeesha knew how to be loved. Lynn recalls how she would become a series of different personas, in her search for validation. I had such low self-esteem; I know I had. Very low feelings of self-worth. Always chasing my validation from men. And with The Life, I got that besides the money. I did feel wanted, there was something about being able to provide that sexual…but there was always that void I had to fill. It’s all I did for 10 years. I mean I graduated college and then got into The Life. I had to lie constantly; you know I had different names. I had you know my real name and I had my escort name and then I had my massage name and like whenever I answer the phone, all the time switching between the personas. Madison also recalls doing things as a teenager she didn’t quite understand, perhaps in an attempt to gain mastery over the helpless feelings of being sexually assaulted. I became a very sexualized child, like very, very sexualized, and I mean, even when I think back about it now I think everything sexually in my life was related to trauma. So, when I say fail to protect, when I was growing up I had a lot of adult men that were interested in having sex with me like very young, and I mean I remember going to school with these two girls and their father, and he invited me to their house and I remember him having sex with me. And as an adult, Madison still found herself making choices that compromised her future. Her attempts at mastery were likely her way of achieving some cognitive understanding of her early sexual abuse.

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It's crazy as much as you think you know, as educated as you are, you still make those choices because they're ingrained in you. I was in jail multiple times; I have to live with this criminal record for the rest of my life. Raquel recounts the things she did in an attempt to figure out who she was, and can relate her behavior back to her early life experiences. When I was working in the whack shacks I would get very angry. I could feel myself getting more and more angry, because they kept trying to have sex with me and I kept trying to make them think that they were going to have sex with me so they would give me more money. And the more they did, the angrier I would get. I was trying to get the value of my innocence back with the fight and the financial exchange, and once I realized my innocence is invaluable and there's no amount of money that can be in exchange for this, that's when I finally got what was really taken from me. It was just sad

but I felt like a warrior or something,

like I was doing what I had to do. My life felt apocalyptic and it was like just what I had to do to survive the Apocalypse. And I think in some ways it's similar to what I grew up with in that it was a circumstance that I couldn't get out of. I had no control, so I just had to create the story around it for me to be able to navigate it. Raquel’s anger and hurt was apparent even now. I wondered if she felt that by getting the men to pay her more money, she would somehow be making her father pay for what he did to her, as well as possibly being compensated for the pain and shame she had endured.

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Maria found that she too did not understand much of her own behavior, but was desperately trying to figure out who she actually was. I remember, I had told my mom I was going to go to the movies, but I wasn't. I really wanted to go out on my own and see what exactly this lifestyle is and why it's impacted my life so much. I remember having two different outfits. Once I had my working outfit I knew I had been officially changed into the other persona, I was no longer me. You know the way I acted, the way I felt inside wasn’t the same. This girl, she's not depressed, she doesn't have childhood issues. She was just born that day, she's just trying to live life and figure out what is going on, trying to figure out who she is. She doesn't have the same baggage that I do so, it was just like this whole different thing, and I was just kind of excited to see where it went and I think also being as depressed as I was, and having my self-esteem be so low from having my step-father talk down to me and tell me that I'm a spawn of evil, that I was ugly, you know so many things he told me and my self-esteem was so low that when I became this different person, and I saw people actually find me attractive, you know people actually see me as beautiful, you know they're interested in

me, and that raised my self-esteem.

Because this girl didn't have the same issues that I had, she just started living life, and I feel like it was the only way I was able to cope. Even with all of her attempts, Maria realizes the futility in trying to re-attach to her mother by mimicking her mother’s life. For me it just felt like I lost a part of myself and I just remember feeling defeated, it didn't make me feel good, it didn't make me feel like I was proving anyone

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wrong. I couldn’t even look at myself in the mirror just knowing I did something that I didn’t even want to do. The subtheme of Don’t Know Why I Do It encompasses not only the confusion, but the myriad of emotions these subjects felt when they engaged in behaviors which they could not fully understand at the time. The tendency to re-enact unprocessed childhood trauma which was far beyond their developmental capacity placed these women in dangerous situations where they were exposed to further trauma in their adult lives.

Feeling powerful, feeling in control. Exploring the concept of power, and how one regains a sense of control over a life that feels very out of control is the basis for this subtheme. It explores conflicting feelings which often resurface when the subjects find themselves behaving in ways which might be at odds with their deepest desires, yet they somehow fulfill the sense of finally being the one who calls the shots. Kadeesha explains how she used the concept of feeling powerful to justify being in The Life. Well, when I think back to the young me not having control over that, but you know he (Kadeesha’s pimp) had told me that guys only want one thing out of a woman, and I was

like “Oh yeah I remember that, that’s true.” He would

always say, “This is what men want from women so like you're ahead of the game, because you charge for it.” So I felt empowered in that way, like “Oh, this is my body and I’m in control.”

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Luciana also found a way to feel in control, even during circumstances which initially felt out of her control. I think there was a moment where I just wanted to die, where I just wanted to leave, that I just don't know what to do. In your mind when you, I'm lying on that cold bed and there's someone on top of me, someone who smells, someone who… I don't know this person. This person is touching me. This person is raping me. But, yet I don't…there's nothing I can do about it, and I just want to punch his face, and I will just get angry. But also, there were men who would talk nice to me, who will bring me flowers, they will bring me candies. And, I like it, I think I like the attention, and they would give me more money than others, and they will ask for me and I was happy to see them. It’s interesting to see how some of Luciana’s descriptions replicate her description of the abuse at the hands of her uncle when she was a young child. This time, however, Luciana could believe she was the one in control of the sexual exchange. For Lynn, calling the shots in her work life gave her a sense of power she was never able to feel as a child when she was subjected to the humiliating abuse at the hands of her step-mother. I think I felt kind of jaded and I felt there was like some sort of internal monologue that felt like I had failed over and over and over and over again, to find true love. I remember feeling used, and I remember when I decided to get into The Life thinking, “Okay if I’m going to give you what you want, at least I’m going to finally get something out of this.” I liked the freedom. I guess, there was maybe like a little bit of feeling of like having some sort of power. Because I

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dictated to them. This is what you do: You park your car, you do not stand out in front of my building, you carry a briefcase or something so it looks like you're here for something official you know, so I liked that called the shots. The money and the freedom and the sense of power. It felt exciting, I don't wanna say empowering, but yeah there's definitely like a sense of power that you feel. Like I’m in control, I can run these ads and have guys come over and make the money and work when I want and not work when I don't want. Madison realized that she enjoyed feeling in control while working in The Life, because it gave her a way of using the abuse while still submitting to the abuse. I guess in a weird way you feel empowered sometimes you know. Where you're kind of in control of the abuse that's happening to you, when you're in The Life. Sometimes you feel like you're a little bit more in control of it, than when it’s happening to you. Exciting. Like you belong to something. Important, value, freedom. Madison then ponders what those feelings of power actually meant to her. Feeling empowered through sex work or feeling loved in a loving relationship are two different things. I just wish I would have picked better people. When Maria reflects on why The Life felt powerful to her, she realizes that the feelings of being in control were short lived. I felt like I could choose who and where and when, when before I couldn’t, you know. It's just those things happened and I had no control over them, but then, when I was able to make the decisions, I actually felt like I did have control over that. It helped me feel like I wasn’t a victim, you know made me feel like I wasn’t

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being abused, because I controlled it. I remember having those same feelings again, like at the time. I didn't feel gross or disgusted because I felt like I had agreed to it, it was with my consent. But it was when I would wake up the next day, or like on my way home, now I was me again, and I actually did that, you know. I was like 14 or 15 years old. I felt like, for the first time in my life, I had control. Lots of people would try to buy me, right, but I wouldn't say yes to all of them. It was only certain people and I had arranged my price, which I was comfortable with. Raquel found a way of justifying and controlling the terrifying experiences with her father, as a way for her to tolerate the unthinkable. The way that I dealt with it was, “I'm just so like irresistible as a female that even my own father can't keep his hands off of me,” so it was kind of this thing that I was getting my power from, I felt like it was a place where I had some control. I think, in some ways it was empowering to feel like I have this much control and I would feel a little bit fluffed up with it. Through these hauntingly honest testimonies we are able to see how each of these young women discovered ways in which to define themselves, by creating situations in which they could finally feel like they were powerful and in control.

My purpose, strengths and beliefs. Lastly, this sub theme of Who Am I? delves into what actually enables these subjects to survive the traumas they have suffered. It explores the sense of purpose the women feel in their lives, along with their strengths, their belief systems, and their

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dreams. Some may rely on religion, while others might have an inner knowing of the path they are meant to take. Dreams, accomplishments and positive choices are explored and shared, along with the feelings that often accompany the road to change. Raquel speaks to how her past experiences have molded her new outlook on life. Now, looking at it, I feel sad about it, and I feel at a loss about it, and I feel grateful for the experience, I feel grateful for the understanding, I feel grateful for the humility it gave me. It gave me a great deal of humility, but it also gave me a great deal of strength, like, I feel like I can do whatever needs to be done to survive. I don't know if that's necessarily a good thing. But I, I feel I don't necessarily want to have to be that strong anymore, you know? I don't want to be available to do whatever you have to do to get through things. Luciana explains her attempts to guide herself towards a more positive outlook. Now, so the last few years I have tried really hard to you know, to love myself. Because all these years, I feel like I have been taking care of everyone and I'm having panic attacks, because I can’t protect everyone around me. We only have two choices, try to get the best of this or just keep believing in the past, you know and you have to try to do better. Lynn’s path of turning to God to help guide her towards a better future enables her to have a new life with much less trauma. I don't feel shame because I mean I love myself and I forgive myself. I don't even like to say, forgive myself, because I feel like to say I forgive myself is to say, I did something wrong, I did something really bad and I forgive myself. I love myself and I realized that's a part of my life and it's a part of my story. Mentally it

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was a lot, it was a huge burden, huge burden and even though I don't make much money now, it’s ok because I feel like my prayers have been answered. I'm able to take care of myself, I feed myself. That lifestyle, it just cost me so much internally. Just the burden. I think you know anytime you make a change, and you start to trust God, there is that, like a sigh of relief, because you realize like taking on so much and to try to manipulate and control so much is just too much. It's just too much, and to realize it's better to just go in that freedom and peace, like peace of mind. You know that's something that's just priceless. When Madison got out of The Life and began a new career, it gave her insight into what she once believed about herself and others. I went into the helping field because I was always really passionate about it, and back to my mom, to like never having any closure or being able to help her I wanted to, just somehow make a difference. I have a caseload of like 22 people, and I say like two or three of them are women, most of them are males and almost all of them are offenders of some sort. Child molestation, rape, some trafficking, a lot of domestic violence. I wanted to know why, and the most empowering thing that I found about working with offenders for me was that they are so incredibly broken. Even more than me, you know. Because I always viewed them to be like these powerful knowledgeable people that knew more than me, and I just saw them in this light that was not accurate and so when I actually sat in a room with them, and I could see like Oh my God he's not powerful, like that's all a façade. That was super powerful, for me, that was a breakthrough for me. I also have to check myself often, and tell myself that this person is not my abuser, this

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person is not connected to me. Knowledge brings me comfort, I think the more that I have learned

about what has happened to me and what is happening with

other people, it brings me a lot of comfort to know that I do have the power to stop it, I have a power to see it, and I have a power to prevent it from coming back to my life. Madison’s new life has given her an inner strength which she could not have initially imagined. The silence that I would create in my mind was like a way to cope, but the silence outside of me when I experienced it was like, I wanted to jump out of my skin it was so deafening and so uncomfortable to sit in. This is the first time in my life I've ever been by myself, for the last three years. Not being abused, not being trafficked, you know, having a lot of stability in my life. So, I’ve come a long way. Maria realizes that even though as a child her sole purpose was to keep her mother safe, she has now expanded her sense of purpose to the population she was once a part of. I felt like I had a purpose, to make sure that she was safe. Even though I was only four or five. And even now I have this need to be a protector, a provider, making sure that the people around me are safe. As a case manager, advocate to this population I can relate to the children, I could relate to the adults, and the one thing that made me feel so alone for a long time is now the thing that makes me feel part of a huge community of people who can relate. I think that's where I found my self-esteem and I think that's where it grew, because I saw you know

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I'm not alone, there's all these people who have similar backgrounds who have gone through this. Maria also realizes how taking these actions in her life has steered her towards a completely different sense of self. I just remember having dreams about this little girl that was sad and that she needs somebody to help her, but like nobody's coming to get her. I remember having those dreams for so long and then eventually one day it was just like, I am that little girl and she's asking for me, you know she needs me to stop acting the way that I'm acting and help her and then, once I started changing it's weird how I saw this little girl grow up. I’m actually pretty surprised, you know, to be where I'm at now, to have the position that I have now. Like I think younger me wouldn’t have seen me here doing this, so I feel like I made my younger self proud. My Purpose, Strengths and Beliefs demonstrated the many paths these participants took on the road towards self-discovery. The courage these women showed by challenging themselves and taking risks allowed them to re-evaluate their experience of self, and thus re-examine who they really were. The theme of Who Am I? examined the different avenues these subjects took in an attempt at understanding the self. Perceptions of Identity delved into the internal thoughts that drove their actions, while Vulnerability to Manipulation, Don’t Know Why I Do It, and even Feeling Powerful, Feeling in Control were tactics which often led these participants towards destructive outcomes. My Purpose, Strengths and Beliefs illustrated

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how resilience and an internal drive had the ability to catapult some of these participants towards a more centered and integrated sense of self.

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Chapter V

Discussion “What we cannot hold, we cannot process. What we cannot process, we cannot transform. What we cannot transform haunts us.” (Bobrow, 2007).

The purpose of this chapter is to review and discuss the findings in Chapter IV, while focusing on and addressing the four research questions of this study, which are as follows: 1.

How do early attachment issues affect the likelihood of early childhood

sexual abuse and later involvement in commercial sexual exploitation? 2.

As children, did they utilize coping mechanisms to make

experiences more tolerable, and did they employ similar coping mechanisms as adults during traumatic experiences? 3.

Do participants experience somatic symptoms and mental health

symptoms, as a result of their experiences? 4.

Do participants notice a compulsion to repeat early trauma?

Smith, et al., 2009, explain that analyzing the data in an interpretive phenomenological analysis is a joint process of the participant and the analyst. By discovering the lived experience of the participant and the meaning the participant makes of that lived experience, “the end result is always an account of how the analyst thinks

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the participant is thinking” (p. 80). To that end, the themes and subthemes that emerged from the data are: Theme 1: The way it was. This theme relates to the way the participants perceived their own experiences. The sub themes in this theme are: •

Generational Abuse

•

Abuse and Neglect

•

Sexual Abuse o I Just Wanted Someone’s Attention

•

Frightening Adult Experiences

Theme 2: My relationships. This theme delves into the ways in which participants made sense of their relationships, and the effects their primary relationships had on their lives. The sub themes are as follows: •

Childhood relationships with caregivers o Abandonment

•

Adult relationships or Lack of o Trust/attachment

Theme 3: How I feel.

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This theme describes the physical sensations and emotional symptoms the participants live with on a daily basis. The sub themes are broken down into: •

Somatic Symptoms

•

Mental Health Symptoms

Theme 4: Doing what I had to. Finding ways to survive is a necessary strategy for trauma survivors, and this theme breaks down the ways in which these women learned how to take care of themselves. •

Addiction

•

Dissociation

•

Showing them or getting back at them

•

Other ways to make myself feel better

•

No other options

Theme 5: Who am I? Experiences of the self is the basis for this theme, where participants were able to explore aspects of their own behavior. The sub themes which emerged from this theme were: •

Perceptions of identity

•

Vulnerability to manipulation

•

Don’t know why I do it

•

Feeling powerful, feeling in control

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•

My purpose, strengths and beliefs

Theme 1: The way it was. My hope and goal for this section is to break down the nuances of the participants’ experiences, and attempt to make meaning of their journeys through the patterns I noticed in the findings. The first superordinate theme, The way it was, reviews the histories of the subjects’ caretakers, so we can begin to put the pieces of the puzzle in place as we explore the complex trauma that soon became normative in their young lives. Additionally, this theme takes an honest look at the neglect, physical, emotional and sexual abuse the subject’s suffered, and how sexual abuse became a way for some of these participants to engage with their abusers. Finally, frightening adult experiences highlights re-victimization, and the reasons these young women have been preyed upon once again. This theme answers the first research question: How do early attachment issues affect the likelihood of early childhood sexual abuse, and later involvement in commercial sexual exploitation? All six of the participants’ report being affected by the sub themes in this category, and their histories highlight the path they inevitably took towards revictimization, with later involvement in commercial sexual exploitation. Lynn explains her state of mind after physical and sexual abuse as “The thing is, the question mark is always there, you kind of keep needing that reassurance.” Raquel tries to make sense of why her mother didn’t notice the sexual abuse that had been taking place with her father for as long as she can remember; “You know the thing was that, because my mom grew up so poor, my dad is like her knight in shining armor. So the idea that…” After Madison was sexually molested by her grandfather, she remembers how she was then raped and molested by

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numerous adult males in her community, and calls herself “a willing participant in a way, which sounds so distorted when I say that out loud.” Kadeesha recalls the time when she was working for her pimp, “I pretty much thought like this is what I have to do to survive. I was like in survival mode. I was just looking for something to hold onto.” Luciana describes her journey into revictimization as “I needed the attention. I needed someone to protect me. This guy looks like a top man. Like he could protect me from the bad people, from the abusers. But then I end up being abused by the person that I'm in love with.” Finally, Maria’s testimony highlights her direct path into revictimization, as she recalls her entry into The Life. “For me it just felt like I lost a part of myself and I just remember feeling defeated. It didn't make me feel good, it didn't make me feel like I was proving anyone wrong.” When pondering this research question and listening intently to the testimonies in these interviews, I found myself drawn to the ideas of Attachment Theory. The experiences the subjects shared in the theme The Way It Was highlight not only the extreme trauma their caretakers may have been exposed to, but also the many traumas that became normative in their own lives. Luciana’s sense of self stemmed from her lack of attachment as a child growing up in Mexico primarily without her parents, and then witnessing her siblings sexual abuse as well as her own ongoing sexual abuse at the hands of her uncle. “It’s like I am nobody. I love my parents. However, I'm a woman and women don't have a word.” The expectation from these participants that they were deserving of sexual, physical, and emotional abuse, neglect, and a future filled with ongoing trauma became an unconscious process in their lives.

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Madison, whose mother was unavailable due to her ongoing alcohol abuse and blackouts, was punished when she was a small child at the hands of her grandmother after her paraplegic grandfather would give her alcohol and then sexually abuse her. “She would walk in when it was happening and get so upset. She would walk me out of the room, put me in another room, and turn all the lights off. It would be dark and it would be like a period of punishment.” Robert Karen, in his book Becoming Attached (1998), speaks to the importance of mother-love. Whether this love comes from a biological mother or a different primary caretaker, the child should feel that in the sunshine of her love, he can “grow and develop, take an interest in things and people, learn, acquire skills, become a proud member of the family” (p. 14). This description is so completely foreign to the lived experiences of these six women, who felt not only the absence of mother-love even while their mothers were in close proximity to them, but also experienced a distinct lack of trust in the mother to protect them and prioritize their needs. Unfortunately, their expectations of comfort have been reduced and limited by those they are dependent on. “Infants have signaling behaviors, such as crying, that operate to activate caregiving behavior, attracting the caregiver to come near” (Ainsworth, 1989, p. 710). British psychoanalyst John Bowlby is considered to be the founder of attachment theory, which is how an infant achieves closeness with their caregiver. In Attachment and Loss (1982), Bowlby describes attachment behavior as “any form of behavior that results in a person attaining or maintaining proximity to some other clearly identified individual who is conceived as better able to cope with the world” (p. 668). Although it is impossible to know how any of these six women were cared for as infants, we can surmise by the non-

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responsiveness of their caregivers during traumatic experiences that they did not have optimal attachment experiences. Bowlby (1958) coined the term “instinctual responses” to describe an observable pattern of behavior that makes up attachment. These five responses are sucking, clinging, following, crying, and smiling (p. 362). The purpose of these responses are to gain food and be in close proximity to the mother. Crying and smiling behavior in infants serves the purpose of looking for maternal response. When the mother responds to her child’s cry or smile, she is releasing an instinctual response which contributes to the infant-mother tie. Babies cry for a variety of reasons, and they are often soothed by touch, rocking and voice. The infant’s smile is also a social releaser of maternal behavior. Human infants want to be within sight of their mothers, and try to obtain comfort when they are tired, hungry, in pain or anxious. “Particularly when afraid, the infant will cling to his mother with great tenacity. Clinging is also especially apparent at bedtime or after a separation experience” (p. 368). Bowlby explains that when an infant is looking for safety, the mother provides the needed object. However, when the needed object has herself suffered abuse, as many of the participants’ caretakers had, they may be unavailable to respond to their child’s needs because their own needs were never responded to. These particular caregivers may have the propensity to dissociate or disengage emotionally when an attachment cry was uttered, because it reminded them of their own unanswered cries of attachment. Additionally, when caretakers suffer addiction, as was the case with Madison, Lynn and Kadeesha’s mothers, they often become unresponsive to their child’s cues for attachment. It is likely that either the need to obtain the substance of choice derailed these caregivers from paying attention to their children’s needs, or if the

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substance was obtained, the caregiver was then unavailable to their child due to the sedating effects of the drugs or alcohol. One of the unfortunate byproducts of the failures of the first attachment systems is the inability for the child to believe they are being seen. The caregiver teaches the child who they are, and the child develops their sense of self based on how others see them. If they have become defined by the experience of not having their mother see them, this is reflected back to them as a sense of complete non-existence. This feeling of being virtually invisible is intolerable, which can result in wanting to please someone who finally does see them. If they have been seen as undeserving, they are left in an anxious state and not knowing how to seek comfort from someone who is harsh or critical of them. Cooperating with sexual abuse, or succumbing to physical abuse are ways to finally become noticed. Some attachment may feel better than no attachment, and this hunger for validity might make vulnerable children compliant toward manipulating abusers, and then leave them with conflicted experiences. Mary Ainsworth, a colleague of Bowlby’s, created a study with fellow Wittig (1969) called the Baltimore Strange Situation Procedure (SSP) in which 26 infants and their caregivers were observed. The study looked at how infants responded when their caregivers were available and then unavailable, and looked at how separation caused anxiety in the past as well as in the present situation. Ainsworth and Wittig found that most infants used the caregiver as a secure base, which allowed infants to explore and then come back to their attachment figure when needed. This type of infant was labeled as secure, because their relationships with their caregivers were predictable. This responsiveness from caregivers “enables an infant to form expectations, primitive at first,

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both internal and environmental” (Ainsworth, 1979, p. 933). However, there were some infants in the study who did not show distress when they were separated or later reunited with their caregiver, and Ainsworth theorized that these infants had felt distressed in the past yet had learned that they should not communicate their feelings to their caregiver. These infants were labeled as Avoidant because the infants had learned how to avoid revealing distressing feelings, likely because they had learned they may be rejected by their caregiver if they did express their needs. A third pattern was observed with the infants, which was labeled Ambivalent/Resistant. These infants were unable to separate securely from their caregiver, and would become distressed even before a separation occurred. This pattern, which showed distrust of the caregiver, could be a way for the infant to keep the attention of a caregiver who was not always reliable when the infant was signaling his need for attachment. During the early 1980s, researchers Main and Soloman continued to study infant attachment patterns, and a fourth attachment category was developed, and coined the name disorganized-disoriented infant attachment (Main, 1996, p. 239). Main and Soloman noticed that these infants exhibited conflicted behaviors in the parent’s presence. Disorganized-disoriented behaviors show a conflict of approaching and fleeing the caregiver, with displays of fear of the caregiver; contradictory behaviors or affects…or freezing and apparent dissociation (Duschinsky, 2015). Understanding attachment patterns can help to shed light on the first research question, How do early attachment issues affect the likelihood of early childhood sexual abuse and later involvement in commercial sexual exploitation?

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Although an IPA study does not rely on qualitative numbers, it is interesting to note that “The theme The Way It Was” illuminates how four out of six participants reported their mothers suffered from Generational Abuse, five out of six participants were exposed to Abuse and Neglect, all six were Sexually Abused, four expressed the need to “Get someone’s attention,” and five had Frightening Adult Experiences. If their mothers were not securely attached, or perhaps had disorganized attachment patterns due to their own abuse, it would be inherently far more difficult for their daughters to attach. Infants survival depends on staying attached, and if their mothers were inconsistently emotionally available, as was reported by the majority of participants, their children likely learned that they were not going to be soothed by their caregiver and that their attachment strategy has been rejected. Finding a new way to feel attached is necessary, so children often become vulnerable and desperate for the attention of anyone who might acknowledge them, including sexual predators. Succumbing to sexual advances in order to gain some comfort from their abusers, and then repeatedly seeking this form of connection becomes a new pattern which they believe will keep them safe from repeated abandonment. Parents who were victims themselves may also unconsciously place their child in a position to be victimized, in an attempt to enable the parent to work through what happened to them as a child (Everstine & Everstine, 1989, p. 160). This could account for mothers who did not notice the abuse taking place in their own homes, or abuse which was perpetrated on their daughters at the hands of their boyfriends, husbands or relatives. Everstine and Everstine report that although the parent likely does not realize they are placing their children in this position, this pathological action is nonetheless an attempt to

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heal their own childhood wounds. The effects of generational abuse left these mothers helpless and even blind to what was happening to their own children, without strategies to make things different. Their mothers were effectively disabled and unable to protect themselves or their children, which left these subjects feeling helpless and unable to trust in their parent to protect them and keep them safe. Schore and Schore, in their article Regulation Theory and Affect Regulation Psychotherapy (2014), discuss right-brain development and how intimate human experiences are needed for optimal growth. When we think of generational abuse, we can also view it through the lens of what Schore and Schore call epigenetic transmission, whereby “the mother’s history of her own secure or insecure emotional experiences, including when she was an infant with her own mother, are stored in her right brain” (p. 184). This creates the epigenetic transmission of attachment patterns across generations. Attachment styles can be predicted from one generation to the next, and mothers who had insecure attachments due to abuse and neglect which resulted in disorganized attachment can then hand down to their children the attachment style of being both dependent on and fearful of their abuser. This creates the environment where a pimp or abusive boyfriend is exactly what these women have become accustomed to, and they actually seek out these relationships. One of the most fascinating yet disturbing findings in this research, and one which seems to be previously unexplored in the current literature, is the finding entitled “I just wanted someone’s attention,” which falls under the subtheme of sexual abuse. This subtheme examines the conflicting emotions participants experienced as children toward their abusers, and how they currently still struggle to comprehend these feelings. Both

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Luciana and Raquel wrestle with the belief that they enjoyed the sexual abuse, and the feelings of shame that surround this realization are debilitating to these women. Luciana, whose abuse happened at the hands of her uncle, remembers how his advances made her feel. For a young girl who was starved for attention and even food, having an uncle who favorited her made her feel special. She was given cookies and candies, held tenderly, stroked, kissed, and told repeatedly by her uncle that he loved her and she was the favorite. Although Luciana was also told to touch her uncle’s genitals, she did not understand this was wrong, because the man who took such good care of her was asking her to do this. One of her conflicting memories is described below. I remember one particular time we were up by the river. My mother was a few feet away from my uncle and I am wearing only underwear - probably six years old. And he would put his foot…between my legs and massage my crotch. Now, he's been sexually abusing me for a little while now. So, I remember that particular time. And I liked it. I don't know what it was but I liked the feeling. I like the touching. Him getting me out of the water, putting the towel around me. Taking care of me. I felt loved. But I think that’s wrong way to show someone love. I didn’t know what love was. He would say he loved me and kiss me on my mouth. It’s sickening to think about those moments now but as a child, I didn’t tell my parents because I thought it was my fault for letting this person touch me. Luciana’s belief that she was responsible compelled her to keep this secret, and provided her with no way of understanding what was happening to her or any given strategy to be kept safe. She can only accept an approximation of feeling soothed, even if

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that is accompanied by conflict. Raquel, who cannot recall when the tickling games with her father first began, does remember the confusing feelings she had during the abuse. I think I just went to a place of all sensation and not, um…I wasn't like thinking, ‘Oh my gosh, this is my dad and he's doing this.’ It was like, ‘Oh, this feels really good, this feels nice,’ you know? And there was this kind of really slow leading up to things. It's this kind of dance. I wonder if he's gonna’… he's getting really close to my genitals. I wonder if he's gonna brush by. Oh, we just brushed by. It was very titillating for me as a child. Do you know what I mean? It was just like this kind of hyper-awareness This creates desire so they feel even more responsible or at fault. Being exposed to sex at an early age which feels good creates a dynamic that makes it difficult for the child to understand how harmful this attention is. The pleasurable feelings are something they are longing to seek, yet they are tinged with shame because there is an unconscious knowing that something is wrong. The mis-attunement these women felt as they enjoyed bodily sensations they couldn’t quite understand, while simultaneously receiving positive affirmations from the adult men they trusted and adored, can create a feeling of being betrayed by one’s own body. Shame has likely been something these women have internalized since their earliest memories. Shame inducing interactions with the primary caregiver, although often unintentional, can be the result of parents who couldn’t process their own trauma. Daniel Hill, in his book Affect Regulation Theory, believes that “to attune to an infant and bring her out of a shame state, the caretaker herself must be able to tolerate shame (2015, p. 126). If these very young girls had already integrated a sense of shame from their infanthood, due to traumatized or unavailable caregivers who were

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struggling with their own abuse, they were then especially vulnerable to being victimized by perpetrators who used loving emotions to manipulate a child’s trust. Shame stems from making an important “other” unhappy with their actions, and the critique suffered in this shame state is inescapable. Their very survival requires either tolerating the shame or feeling as if they must hide their needs to avoid being shamed by someone important, like their caregiver. Once the abuse had transpired, and these subjects fell victim to these confusing interactions which provided them with the much-needed attention they were searching for, the feelings of anger and disgust for allowing their bodies to respond positively persisted. This anger, turned inwards, becomes an all-consuming rage and shame which is then perpetrated on the self, as well as enacted in future relationships and sexual behavior. When speaking of their adult frightening experiences, the participants’ reactions were noticeably anxious. The women did not seem to register exactly how they may have placed themselves on the path which enabled these frightening events to take place, and seemed as if they had been genuinely helpless in their abilities to have prevented these traumas from occurring. This poses the question of why the subjects did not have the ability to assess danger, and why their decision-making abilities had been so severely compromised. We can perhaps explain this mindset by examining the propensity towards excessive risk taking and the recreation of sexual trauma. The subject is likely trying to master their earlier trauma, which may have taken place because of the disruption in attachment bonds. van der Kolk (1989) reminds us that anger is often turned towards the self in violated people, and this is itself a repetitive re-enactment of real events from the past. This produces an environment where vulnerable and previously abused young girls

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are prone to be assaulted, or preyed upon by pimps who easily manipulate their emotions in an attempt to get them to attach. Along with their history of abuse, women with disorganized attachment have learned from their parents that their source of safety is also their source of fear. This confusing message sets the stage for revictimization and entry into a world of commercial sexual exploitation.

Theme 2: My relationships. After listening to the subjects recount their relationships with their primary caregivers, I had a glimpse of the complexities involved in these intimate relationships. Ainsworth (1979) reminds us that “mother-infant interaction provides the baby with opportunity to build up expectations of the mother, and, eventually, a working model of her as more or less accessible and responsive (p. 934). When children are born to mothers who have their own disrupted attachment style, accessing their mother figure is not always possible. In “Mourning and Melancholia” (1917) Sigmund Freud wrote that melancholy, a form of depression, is a pathological response to the loss of an ambivalently loved object. Although the bonds of love may be broken in reality, the bond persists as a split in the mind, in which one part of the ego rails against another part that represents the lost love. The mind is at war with itself. “The patient represents his ego to us as worthless, incapable of any achievement and morally despicable; he reproaches himself, vilifies himself and expects to be cast out and punished” (Freud, 1917, p. 246).

Abandonment, in one sense or another, was the predominant experience of all six participants. Kadeesha’s experience of abandonment by her mother happened repeatedly,

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and took on many forms. Although we cannot know what sort of parenting Kadeesha received as an infant, we do know from her mother’s involvement in prostitution and drug abuse that it is likely her mother abused drugs early on. If this were the case, Kadeesha would not have received the nurturing, eye contact, soothing and regulating that is so integral to an infant’s existence. Allan Schore, in his book Affect Dysregulation (2003), teaches us about the developing brains of infants, and how they grow in relationship with another brain. This other brain is the primary caretaker, who acts as an “external psychobiological regulator of the experience-dependent growth of the infant’s nervous system” (p. 5). Structural connections in the brain are shaped by the interactive experience between caregiver and infant, which in turn creates maturation in the brain and the ability for self-regulation. Unfortunately, the opposite experience is also true, whereas “mis-attuned relational environments that generate high levels of negative affect act as growth-inhibiting environments.” If Kadeesha’s mother was unaware of her infant’s needs, due to the fact that she was on the streets, working to feed her children or perhaps to pay for her addiction, she would not have been available to regulate Kadeesha’s growing brain. If the primary caregiver is unable to regulate her infant’s psychobiological states, everything from the infant’s nervous systems to their fluid balance regulation can be impacted. Mutual gaze, which lovingly transpires between healthy infants and their mothers, is integral to the growing baby in order to maintain the child’s positive affect state. Schore paints a picture of these interactions, which are an intense form of communication between mother and child. His research reveals how the mother must be psychobiologically attuned “not so much to the child’s overt behavior as to the reflections of his internal state” (p. 7). In this

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way, the mother can control the intensity and duration of her affective stimulation, and help her child maintain a positive affective state. This psychobiological attunement between mother and child continues to increase over the course of the first year of life, and begins the attachment bond experience. When Maria remembers her childhood, she painfully recalls how she would always try to protect her mother when either her father or step-father would abuse her. However, when Maria herself was abused, her mother was not there. “Sometimes she would see but she wouldn’t stop it, so that’s when my trust in her fell. I always had her back and she seemed to not have mine.” When a mother is absent or unavailable, these regulatory processes cannot be completed. The regulation of the infant’s production of hormones is also impacted, which is essential to their socioemotional development. The child has not received the stimulation which is necessary for heightened sympathetic activity and positive affect. When we consider that these are just a few of the ways that an infant is impacted by the proximity and attentiveness of a loving mother, we can begin to understand the gravity of the loss of that attention on a vulnerable infant. Although a baby may survive while being fed and cared for by others, the loss of a caring and present mother figure cannot be underestimated. “Frightening or frightened parental behavior, and helplessness and dissociative behavior in the parent have also been found to predict an infant’s disorganized/disoriented attachment style” (Duschinsky, 2015). It is not a surprise to discover that “these behaviors are observed significantly more frequently in high-risk children who have had traumatic experiences” (Brisch, 2002, p. 78). Other forms of abandonment contribute to such traumatic experiences, and when Kadeesha’s mother

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contracted HIV and then passed away, we can feel the disconnect that Kadeesha experienced by her recollection of “She was just in this room, dying. And that’s all I remember.” Loss of the mother is a traumatic situation for any child, however Berzoff, Flanagan and Hertz (2016) report that caregiving behaviors that are traumatic have been a focus of attachment behavior. They explain that the parent’s internal working models drive her/his caretaking behaviors and “these behaviors affect the internal working models of the infant/child, which, in turn, are reflected in overt behavior” (p. 207). Abandonment also took place for Maria, who spent many nights waiting in the car, terrified and not knowing when her mother would come back from her work on the streets. She remembers these experiences as: The car was off, I didn't have access to the radio, to air conditioning or nothing. I wasn't too far away from the tracks but I never went to look for my mom because you know you see the helicopters, you hear the commotion and you don't want to bring too much attention to yourself, you just want to disappear and sink in with the car, because you don't want a random person to come and get you out of the car and then you're kidnapped or you're killed so I just remember feeling like I had to disappear. I’ve peed myself three times already, I’m wet and cold, and I can’t fall asleep because somebody could come get me.

Other abandonments for Maria came in the form of her mother moving out of the home with Maria’s abuser while Maria was left to care for her younger sisters. It is still difficult for Maria to process this memory, she painfully remembers this time as “When

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she left I was extremely disappointed you know, I was extremely sad to see like, wow like we went through all this and then you left me alone.” This theme adds further credibility to research question #1: How do early attachment issues affect the likelihood of early childhood sexual abuse and later involvement in commercial sexual exploitation? Bessel van der Kolk (1989), speaks about attachment in the face of danger, and explains that children are unable to anticipate the future and experience separation anxiety as soon as they lose sight of their mothers. Even adults, when they feel terror, often have responses such an anger, grief, intrusion and numbing that make them turn towards the nearest available source for comfort to return to a state of both psychological and physiologic calm. Disruption of the attachment bond causes long lasting psychological changes which reduce the capacity to cope with future trauma. Charcot, Janet and Freud have all theorized on the role of traumatic memories, and how past memories affect present day behaviors in the lives of trauma survivors. van der Kolk (1989) has speculated about the compulsion to repeat previous trauma, and believes that repetition rarely allows the trauma survivor to actually gain mastery over their trauma, instead it causes further trauma to the victim. When victims re-enact their trauma, they are exposed to violence, criminal behavior, and even more abuse. Children who were inadequately attached to their caregiver or had a caregiver who was rejecting and abusive are more likely to be hyper aroused (p. 392). This happens because the person who was supposed to be their source of safety is either a source of danger or is unavailable to keep them safe, so children try to re-establish safety by blaming themselves. When abused girls grow up and then find an abusive man to re-attach to, it

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may seem as if this re-enactment is a way of working through their earlier trauma. However, the unfortunate reality is that abused women and their children are then subjected to further abuse by the men they choose. We can see this pattern in the adult relationships or lack of adult relationships, experienced by these participants. Karen (1998, p. 396) explains how many people “find romantic excitement in a lover who displays the qualities of a rejecting parent, which suggests the degree to which they remain not just committed to, but enthralled by early attachment figures.” Maria explains her dynamic with intimate partners as “Being with somebody who treated me nice, it wasn’t something that I was used to and I just thought it was fake you know, like sooner or later they're going to turn out to be mean and sooner or later they’re going to hit me and sooner or later they're going to hurt me, you know, so I just kept to myself.” When Madison ponders her past adult relationships she seems to resonate with this dynamic, and describes her experiences as “I think that's why I learned to protect abusers or feel sorry for them or somehow feel responsible for them, because that is what was molded very young.” She also perfectly illustrates her choice of partners as “I had an alcoholic mother and what do I do? I go and choose alcoholic partners. This subconscious brain of mine…..”Kadeesha describes her propensity to choose pimps and violent men like this “This is my last chance to be protected. After my brother died, I ran into this guy and felt like I have to do whatever this guy says because I'm never going to be protected by a guy again.” Ambivalent attachment patterns can create core feelings of shame, and individuals feel unworthy of love. People with avoidant attachment patterns cut themselves off from anxieties, however they are still motivated by them (Karen, 1998). Luciana describes one

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of her past relationships with her trafficker as “I felt the need to, you know, I felt like he was protecting me. I felt empty, but I was in love with him.” This example of choosing to be in either a relationship with a partner, a pimp or a trafficker who replicates their early childhood sexual abuse is seen in all six of the participants. Another reason adult relationships might be more challenging for survivors is the experience of trauma contagion. The survivor relates physical intimacy to the memory of being controlled, and feelings of trust have usually resulted in being violated and hurt. This confusion makes it extremely challenging for partners of victims of CSA, and Maltas and Shay (1995) postulate that trauma can be transmitted to intimate partners because they are exposed to so much of the survivor’s memories and traumatic stress symptoms. Partners experience high levels of stress from the survivor’s hyperarousal and reactivity, and can also have reactions to their own unconscious role in the repetition and reenactment of the trauma. Eventually, “the trauma is also ‘inside’ him and not just ‘out there’ in the survivor (p. 531).” It is interesting to note that five out of six participants in this study are currently not in relationships, and now choose to stay out of personal relationships. Raquel, the one participant in the study who is currently married, struggles with the dynamics which took place between her mother and her father around her abuse. When her father would come to her room to “tickle her,” it was a way for him to avoid fights with her mother. Raquel, who likely wanted to keep the attachment that she felt for her father intact, found ways of excusing and justifying his abuse. “Like I used to keep my eyes closed when things were happening in there. But a few times that I opened my eyes, my dad’s eyes would be closed. So it was like maybe he doesn’t even know what he’s doing?” After years of

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choosing partners who replicated this exact sexual dynamic, as well as involvement in commercial sexual exploitation which afforded her the opportunity to expel her unacknowledged rage towards her father onto her clients, Raquel finally ended up choosing an asexual adult relationship. “I feel like I needed this kind of time of being with a man who loves me. And it doesn't really have anything to do with the fact that he wants to have sex with me, and that's been really healing.”

Theme 3: How I feel. Why might very young children already feel anxious, or sad, or have somatic expressions of feelings in their bodies? “Babies whose mothers have disregarded their signals, or have responded to them belatedly or in a grossly inappropriate fashion, have no basis for believing the mother to be accessible and responsive; consequently they are anxious, not knowing what to expect of her” (Ainsworth, 1979, p. 933). The theme of How I feel, which describes both somatic and psychological processing of feelings, helps us to make sense of research question #3: Do participants experience somatic symptoms and mental health symptoms, as a result of their experiences? Anger was one of the predominant emotions subjects expressed during participant interviews, and although anger is an understandable and completely justified emotion, I was also aware of how anger would oftentimes be expressed in the form of anxious thoughts or as symptoms of depression. Anxiety and depression, although not typically viewed as coping mechanisms, serve to divert responsibility and blame towards the self.

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In Being Attached, Robert Karen explains that the child with a history of avoidant attachment has learned that she cannot be angry because this will make her mother even more rejecting. These children have learned to shut themselves down and experience themselves as having no need for love (1998, p. 224). The anger that an avoidant child feels is often turned toward self, and can become depression. The “I don’t need you” stance “is a form of self-starvation and is probably intensified by an identification with the depriving parent, such that the avoidant child now becomes the agent of his own deprivation” (p. 226). Bowlby describes how threats of abandonment creates intense anxiety, and may “arouse anger, often also of intense degrees…this anger, the function of which is to dissuade the attachment figure from carrying out the threat, can easily become dysfunctional” (1982, p. 671). In this study, all six of the participants spoke of mental health symptoms they were currently suffering from, and four of the six experience somatic health issues which affect their day to day life. Lynn recalls a childhood visit to the home of one of her stepmother’s friends, and while there witnessed her stepmother’s friend hit her own daughter. Lynn remembers her stepmother’s words at the time, “you don’t see that little girl complaining about it.” As Lynn looks back on her childhood, she comments on “how immensely I struggled with self-doubt, and always second-guessing myself.” Growing up with the intense burden of both physical and sexual abuse, as well as neglect and feelings of abandonment from her alcoholic mother, Lynn believes the depression she now suffers from is “anger turned inwards, because I didn’t have the courage to speak out.” Although Lynn blames herself rather than her abusers for the injustices she suffered, the depression she feels likely stems from her father’s inability to stand up and defend her. Lynn

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internalized the belief that she was not worth protecting, and thus deserving of the abuse which was directed at her. When Maria speaks of her mental health symptoms, she remembers her suicide attempts as a child. Maria “never told anyone what I did or why,” and just stayed home from school until she felt better. Was this because she had learned that nobody would be there for her, no matter how much pain she was suffering? Maria felt ashamed that she was unsuccessful, even in her own suicide attempt. She now says that even with therapy and medication, “depression, anxiety, those things just stay.” When Madison talks about her current mental health symptoms, she replies that she “definitely always has anxiety, which manifests itself into headaches.” Kadeesha describes her anxiety as “really bad,” and must live with the fact that “if I have something I need to do, like I really suffer.” Luciana’s mental health symptoms tend to emerge situationally. “You know, when things happen to me, I tend to be angry and have anxiety. I started having anxiety so young. I became very anti-social.” Like almost all of the subjects, Luciana turns her anger towards herself, commenting that “I never stood up for myself. I wouldn’t,” and further disparages herself when reflecting upon her behavior, “I want to kill myself, but I don't have the courage to do that. Instead, I get drunk, I get sad, I get depressed, and I cry a lot.” Raquel thinks about her mental health symptoms, and describes them as such; “I definitely have anxiety. I definitely have hyper vigilance. It's like a little animal in the forest. I mean you're just super hyper aware of everything going on around you and synthesizing that all the time to just like make sure you're safe. It's important for me to feel safe. If I don't feel safe, I'm just like a ticking time bomb.”

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We can begin to understand some of the mental health symptoms experienced by these subjects when we look at how early attachment sets one up for internal regulation. Attachment theory is about establishing relationships with a caregiver who is physically and psychologically accessible. Affect Regulation Theory posits that regulation is grounded in an understanding of the psychobiological systems that process and regulate affect (Hill, 2015). The state of the body is fundamental for adaptive functioning and subjective experience, and when affect is regulated we can respond flexibly to the internal and external environments and we can function well in the world. However, “when affect is dysregulated, we become dissociated and reduced to automated processes and isolated portions of our memory” (p. 28). Allan Schore teaches us in his book Affect Regulation and the Repair of the Self (2003), that mothers must be psychobiologically attuned to their child’s inner state, and must also monitor their own internal signals. “Reciprocal gaze, in addition to transmitting attunement, can also act to transmit mis-attunement, as in shame experiences” (p. 11). Infants are unable to stay in a negative state for long periods of time, and if they remain in intense negative affect it can be a factor for the predisposition of psychopathology. Schore explains how important it is for the caregiver to regulate her own negative affect in order to facilitate the child’s development of self-regulation. In a growth-inhibiting early environment, a caregiver who is emotionally inaccessible and reacts inconsistently to her child’s stressful states induces extreme levels of stressful stimulation and arousal states, and this maternal dismissive attachment impacts the brain. (Schore & Schore, 2014, p. 184). Additionally, being unable to regulate the intensity of feelings is one of the most adverse effects of early trauma and neglect.

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Being unable to regulate intensity of feelings from early trauma and neglect also impacts these women somatically. Madison’s childhood “side aches” Raquel’s gastrointestinal dysfunction, Lynn’s spinal pain, and Maria’s chest pains are all examples of somatic manifestations of internal feelings. When we look at insecure attachment, we can see that children become dysregulated when they experience lower levels of stress. If one had already suffered from the inability to regulate their system and then encountered trauma from ongoing abuse, they may become so overwhelmed that releasing this stress through bodily reactions could provide them with a small sense of relief. Insecurely attached people become hypervigilant when trying to read signals from others, in order to ascertain what is being asked of them. Attachment functions as protection, and when protection was non-existent for these girls, they may rely on bodily responses to attend to the state of helplessness they felt. Although they had few choices in their early lives, they did have the ability to assert control over how their bodies were responding. For Raquel, withholding her bowels was virtually the only way she could say “no” to the inappropriate touching of her body. Madison could not get her mother to stop drinking or to notice the sexual abuse that was being perpetrated upon her daughter, however she did take her to multiple physician visits when Madison’s ‘side-aches’ did not resolve. Lynn’s spinal pains, which coincidentally began as she started working in The Life, were a way for her body to revolt against the sexual abuse which occurred during an innocent childhood sleep-over. Maria’s chest pains, an indication of her overwhelming suffering, may have been the only way her internalized pain could finally be expressed.

Theme 4: Doing what I had to.

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•

Addiction

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Dissociation

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Showing them or getting back at them

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Other ways to make myself feel better

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No other options

This theme and sub-theme address research question #2: As children, were coping mechanisms utilized to make experiences more tolerable, and did they employ similar coping mechanisms as adults during traumatic experiences? And, research question 4: Do participants notice a compulsion to repeat early trauma? Schore and Schore (2014) reveal that “the emotional environment provided by the primary caregiver shapes, for better or for worse, the experience-dependent maturation of the brain systems involved in attachment affect communicating and affect regulating functions that are accessed throughout the lifespan” (p. 180). When their attachment systems failed to provide safety, these young women unfortunately experienced a lack of personal agency, and had little to rely on when it became necessary to comfort themselves in times of need. This resulted in a passive and submissive acceptance of their abuse, and made them vulnerable to future attacks on their bodies. In order to survive the seemingly un-survivable, it was necessary for these subjects to “Do what they had to,” and this theme and subsequent subthemes detail why these coping techniques were so important to these women. We know that Lynn’s alcoholic mother could not care for her and left her in the care of her father and abusive step-mother, and that Madison’s alcoholic mother was

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often passed out at home or somewhere in the neighborhood, Luciana’s mother worked in another town in Mexico to earn money, Maria and Kadeesha’s mothers were on the streets working as prostitutes and likely using drugs as escape mechanisms, and Raquel’s mother was affected by her own generational abuse and was checked out and unobservant of what was happening in her own home. Insecure attachments with primary caregivers not only change developmental pathways but neurological pathways as well. During the critical periods of early development, having frequent periods of dysregulated and unrepaired events creates disorganized-disoriented attachment histories in the right brain, but it also changes the ability of the brain to defend against traumatic experiences (Schore, et al., 2014, p. 185). The right hemisphere is also responsible for nonverbally processing threats and states of fear and vulnerability. When affect is regulated, we feel integrated and have experiences which seem as if they are real. When affect is dysregulated, it can lead to dissociation where an altered state of consciousness and detachment are experienced. Dissociative behavior can be hyper aroused, which may look like a flashback. In these situations there is full immersion in the experience, however hypo arousal can look like a freeze state, where one is detached from the experience. Dissociated self-states are automatic because they are activated involuntarily. If the brains of these young women were previously psychobiologically altered due to the effects of generational abuse and then left vulnerable and exposed to childhood sexual abuse, they would have far less ability to detect threat. The advances of pimps and traffickers, who are known for their skills of manipulating vulnerable young women, would seem like a welcome relief to women who are desperately searching for someone

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to attach to. Unfortunately, working in commercial sexual exploitation, rather than leading to relief of trauma through mastery, only serves to add more complex trauma to these women’s already overwhelmed systems. Five out of the six participants were found to dissociate during periods of extreme stress. Five out of six participants used addiction to help regulate their overwhelm and additionally, five out of six women found “other ways to make themselves feel better.” Three participants used the technique “showing them or getting back at them” as a way of dealing with their overwhelming emotions, and four felt like they had “no other options.” Whether they used one or several of these tools, participants found they were “Doing what I had to” to ensure their ultimate survival. Regulation theory is the psychobiological system that processes and regulates affect. When affect is regulated we experience self-mastery and are optimally functional. When affect is dysregulated, we become dissociated and reduced to automated processes and isolated portions of our memory (Hill, 2015, p. 28). Automaticity is the ability to do something while thinking about something else, and is what generally takes over in lifethreatening situations. It is adaptive because of its speed, when making a deliberate decision would take too long and it is a post-traumatic defense against overwhelming affect. “Dissociated self-states are automatic in the sense both that they are activated involuntarily and that we are reduced to a scripted set of behavioral and psychological responses” (p. 35). The tool of automaticity describes Madison’s behavior, which she used as a child to help herself feel better. This tool brings to light some explanations for research question #2, As children, were coping mechanisms utilized to make experiences more tolerable,

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and did they employ similar coping mechanisms as adults during traumatic experiences? When Madison thinks about how she survived the abuse at the hands of her grandfather, she replies with “I think the quiet. Like, trying to quiet my mind was a coping strategy because it's so chaotic outside that you kind of create an internal space to kind of retreat and that feels safer. Creating that place where I could quiet my mind pretty intensely during those situations was a way to kind of get through it.” She recalls beginning her work in The Life, when she was just fourteen years old. “I remember Sunset Boulevard was the first place I ever worked. I was so naive and didn't know that this was illegal. I didn't know this was a crime. I didn't know that I could be arrested.” Madison found that she could use her same childhood coping strategy during stressful and highly traumatic situations, “It just came instinctively, like when I was five. I didn't have to practice; I didn't have to think about it. It just came…that same quietness of the mind. All of that just came back. It was actually almost exactly the same feeling as being five.” Madison also describes what it feels like to dissociate. “It's like I remember, like a movie, like I can remember the scenes but I don't have any feelings attached to it. It’s weird like how you can feel you didn't have any emotion about something but it impacted your whole life.” For Kadeesha, dissociation was experienced as: “I just floated around in my mind. I can't remember any particular place that I went to.” Luciana also remembers events as if they were movies, or dreams. “I was very young, four maybe. The other uncle was touching me in a very inappropriate way. I didn't know why he was doing this and I never talked about it. I didn't say anything to anybody. It's like a dream. I see it, sometimes.”

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Raquel describes her propensity towards dissociation as “I mean it’s hard to describe. It's like very present in my body but out here in my mind. It was something outside of me, you know?” When Raquel thinks back as to how she emotionally tolerated her ongoing abuse, she states that “Nothing else really exists. Like nothing else really matters. And I guess that's kind of the place I was when my dad was doing stuff.” When Maria explains her dissociation, and the ways spending time with Santa Claus made her feel, she remembers “It was a happy place, and it was the only happy place that I had. I knew I could go there and nobody would be able to enter without my permission.” Today, Maria uses a similar dissociation tactic. “In stressful situations especially when I feel like I can't control something, I try to like see if I could escape. If I could just get out mentally and see my surroundings I don't feel as trapped, you know as small.” The autonomic nervous system (ANS) also shares some of the responsibility for dissociation and other bodily responses that emerge during times of stress. The ANS is regulated by the limbic system and regulates affect. Along with the hypothalamicpituitary-adrenal (HPA), which is an endocrine system made up of hormonal glands, they generate arousal and tone of affect. The sympathetic aspect is like a car accelerator, it activates the system and increases heart rate and respiratory rate. The parasympathetic aspect is like a car brake, it inhibits sympathetic arousal and can lead to depression. These systems should be in balance with one other, however if the sympathetic nervous system activates the fight flight response and it doesn’t work, the dorsal vagal system from the parasympathetic nervous system is activated. This causes override and we experience a freeze response. Freezing is another survival response, and even serves to prevent cell death. Although dissociation is an important survival response for children

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while experiencing overwhelming affect, it unfortunately does not help them as adults. After learning to dissociate as a child, adults become vulnerable to dissociate when triggered by any stimuli that evokes memories of the trauma. Another explanation for dissociation is broken down by van der Kolk, who describes how people who have been exposed to highly stressful stimuli develop longterm potentiation of memory tracts that are reactivated at times of subsequent arousal (van der Kolk, 1989, p. 404). Long-term potentiation tracts of memory can explain the triggering process, and how even exposure to a situation that may not be necessarily traumatic can cause one to dissociate. During periods of early childhood development, when abandonment, neglect, abuse and witnessing other frightening experiences takes place, long-term potentiation tracks are established. Maria often witnessed her mother being beaten, and she was gone for long periods of time while Maria tended to herself in a dark car. Luciana witnessed her siblings and cousins being sexually abused along with her own abuse, and suffered from abandonment with both of her parents working far away. Kadeesha’s mother was unavailable for a variety of reasons, and Kadeesha witnessed severe physical abuse on a regular basis. Madison’s mother was also unavailable due to her alcoholism, and Madison was brutally punished by her grandmother because her grandfather sexually abused her. Raquel’s mother was unable to process her own traumatic childhood, and abandoned Raquel by not paying attention to abuse in the household, and Lynn’s father was so consumed by his own anxiety and hoarding disorders that he did not intervene when Lynn was being brutally abused by her step-mother. Later in life, when these same women were subsequently raped, abused, shamed, or abandoned by relationships or pimps, the overwhelm was too much to bear.

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The unconscious decision to take themselves somewhere else, or to a familiar dissociated place that served them as children is an automatic response. Subjects may have also experienced a sense of detachment, and the feeling of being out of their body. This partially dissociated state may make objects seem distant and sounds may seem far away. This state can also serve as a protective function, and allows us to appear normal even when affect is dissociated. Childhood abuse and neglect increases hyperarousal as well as decreasing the ability to modulate strong emotions, which means that children who were abused might need high external stimulation in order to feel soothed. Addictive behavior is a way of calming down this hyperarousal, along with exposing themselves to further victimization (van der Kolk, 1989, p. 405). Kadeesha used her addiction as a way to literally not be present for the feelings she couldn’t express. “I would always just be like drinking to the point of like blacking out. I was doing that to like keep the emotions down. I didn't want to tell anybody so I would just drink.” Luciana describes why women in The Life need to check out. “For many of these women, the alcohol and drugs are the only medication. To keep doing this, you should have no feelings and not think about anything.” When she reflects upon her own drinking, she states “I started taking alcohol, taking other stuff…to deal with the pain… not just the physical pain but the images in your head.” Lynn, who used alcohol and gambling addictions as a way to manage her pain, also relied on food to keep herself from being too involved in The Life. Like with the food, I've always kind of had a weight issue so that made me like less desirable, so I wasn't making as much money in The Life.” Madison used sex as an addiction. “Sex has always been an issue

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because it was always a way to fill my void and feel cared about. And it was always like a drug addiction, you know? Like I gotta feel better about myself, you know?” It should now be clear that we organize and disorganize depending on whether or not we are regulated. Feeling helpless and vulnerable can perpetuate social isolation, which in turn promotes regression to earlier states of anxious attachment and to addictive involvement (van der Kolk, 1989, p. 403). Psychological escape can also be explained by state-dependent learning, which is when something is learned under a particular influence but the memory is dissociated until a similar state reoccurs. During states of massive autonomic arousal, memories are laid down that powerfully influence later actions and interpretations of events (van der Kolk, 1989, p. 397). Insecurely attached children have difficulty transitioning from dysregulated to regulated self-states and become dysregulated at lower levels of stress. State-dependent learning could be one of the reasons some participants felt a compulsion to dull their emotional experiences, even if they are perplexed by their reaction to particular situations. Showing Them or Getting Back at Them and No Other Options are sub themes which address research question #4: Do participants notice a compulsion to repeat early trauma? Anger is one of the predominant emotions participants seem to be able to connect with in their interviews. Anger likely arises because as children, someone they loved repeatedly disappointed them. This feeling is so overwhelming that when confronted with separation from the loved one, it’s as if that person is lost forever. When participants notice a compulsion to show or get back at someone, they oftentimes inadvertently repeat earlier trauma. This can be seen with Shannon, when her anger rises up while working in the whack-shacks. She remembers feeling like “I’m going to take

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this guy for all he’s worth, who does he think he is to think he can he can have sex with me? I’m going to make him pay for this.” Maria idealized her mother and her mother’s preoccupation with The Life, and thus decided to be in The Life as well. “I was curious about it; it was something I wanted to experiment with. When she found out she was just disappointed.” Maria’s behavior also fell under the sub theme of No Other Options, when she made choices to split into two people, which allowed her to continue being a student while also working the streets at night. “It was two different people, like that’s her life, and this is my life and we just share the same body, but our minds and everything else is separate. I just felt gross but, at the time when I was this different person, I just didn't associate with it.” Splitting is another form of compartmentalization, because one cannot integrate other self-states. It may seem overwhelming to have contradictory parts of the same person, so splitting serves the purpose of removing one part of the self and keeping it safe, so it is not affected by new or old traumatic situations. For Maria, splitting allowed her to present her innocent self at school, where she would be cared for and receive praise for her accomplishments. This could also be explained as Maria’s secondary attachment strategy (Wallin, 2007, p. 101), a way for her to finally get the attachment she was unable to receive from her mother. Maria’s other self, the one who snuck around and felt a compulsion to enter The Life at fifteen years old, was the split off version who needed to be like her mother in order to try to understand why her mother chose The Life over her. Madison, Kadeesha, Raquel, Maria and Lynn all describe their teenage years as “promiscuous.” This disparaging description of their young selves brings to mind a punishing and judgmental picture of how they viewed these unconscious actions, with no

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ability to have compassion for their overly sexualized behavior due to early childhood sexual abuse. Madison describes this time as “Well, I think I was pretty promiscuous as a child. That's how I felt as a child, so for it to be viewed as abuse is an interesting way to think about it. When it was happening, it felt like I was being promiscuous, like I was seeking it. Because I felt like it worked. It was the first thing in my life that got people to pay attention to me, that made people value me or care about me.” Luciana was the one subject who did not describe herself as promiscuous, however she was raped at the age of 15. This rape could be explained by her inability to detect threat, as she, as well as the other participants, all unconsciously put themselves in situations to repeat early trauma. These compulsions may be attributed to partially dissociated self-states, which can show up as abrupt changes in behavior, and the inability to understand the changes of consciousness. There could perhaps be some self-awareness that something was different about them, however subjects generally note they are unable to react in any other manner.

Theme 5: Who am I? •

Perceptions of identity

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Vulnerability to manipulation

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Don’t know why I do it

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Feeling powerful, feeling in control

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My purpose, strengths and beliefs

This theme and subsequent sub themes examined how subjects viewed themselves, and the conscious and unconscious behaviors they engaged in due to these perceptions.

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This theme sheds further light on research question #4: Do participants notice a compulsion to repeat early trauma? Adverse childhood experiences unfortunately make individuals even more vulnerable to later adverse experiences. Bowlby (1982, p. 675), reminds us that the “earlier adverse experiences are likely to be wholly independent of the agency of the individual concerned, the later ones are likely to be the consequences of his or her own actions, actions that spring from those disturbances of personality to which the earlier experiences have given rise.” This pattern is altogether too common in survivors of complex trauma, and explains why women who struggle with negative and unworthy perceptions of self are then vulnerable to being manipulated into new experiences that are just as traumatic. One way this cycle can be explained through attachment behavior is the way ambivalent children try to get the attention of their preoccupied mothers. According to Karen, ambivalent children are hooked by her unpredictable style and the fact that she doesn’t come through on occasion. They pick up that she will respond sometimes if they make a big enough fuss, and are constantly trying to hold onto her or punish her for being unavailable. They are wildly addicted to her and to their efforts to make her change, and they become enmeshed with her in various unhealthy ways. Later in life they become similarly addicted to other potential attachment figures…yet they do not believe they have what it takes to get what they need from another person (p. 220). This dynamic makes sexual predators, as well as pimps and men who perpetrate abuse, incredibly alluring to women who feel compelled to re-enact the dance for their mother’s attention. Another by-product of the failure of the attachment system is to create a narrative which would explain the lack these participants felt for not being enough to engage their

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parent. Subjects inherently understood as children that their caregivers were more interested in prostitution, drugs, alcohol, or maintaining abusive relationships than they were caring for their vulnerable daughters. It is likely that these young girls felt they were not exciting enough for their mothers, and this instability had the effect of eroding their sense of self. Without self-worth, they are susceptible to inherit their mother’s unhealthy attachment pattern. These attachment styles become generational, which is why following their mother’s examples and joining them in The Life also became generational for them. Having a sense of self and self-worth is necessary in order to fight for more in life, and these women have made choices that have both hurt and helped them in their search for understanding. Bowlby, in his book Attachment and Loss (1969), explains that behavior does not disappear with childhood but persists throughout life. Either old or new figures are selected and proximity and /or communication maintained with them. Whereas outcome of behavior continues much as before, means for achieving it become increasingly diverse (p. 350). When we consider the sub theme Don’t Know Why I Do It, in which 5 out of 6 participants admitted to engaging in behavior they didn’t quite comprehend, and Feeling powerful, Feeling in control, where all six participants acted out scenarios which made them feel powerful, we can begin to understand some of the internal drives that compel these behaviors. Walsh, et al., (2013) summarizes some of the ideas behind why women who have experienced childhood sexual abuse engage in risky sexual behavior. Although it may be “an attempt to establish control over sexual encounters, these victims also may vacillate between preoccupation with sex and fear of sex such that they seek particular

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circumstances or contextual factors to make them more comfortable with engaging in sexual behavior.” Lynn, who was in The Life for over ten years, talks about her habit of watching pornography. “I'll usually watch like pornography and in the pornography there usually is like an age difference between the man and a woman. Even though I like get off on that, I guess I always feel inside like some form of like shame for that, like oh my gosh if people knew they’d think I was some sort of like sexual deviant or something, so definitely shame regarding that.” Lynn is re-enacting her trauma by viewing pornography featuring a much older man, just like the situation she encountered when she was molested while sleeping over at her friend’s house. Even though the trauma excites her, it is an attempt to master what has been overwhelming. However, she can never quite accomplish this. van der Kolk postulates that compulsive repetition of the trauma usually is an unconscious process that, although it may provide a temporary sense of mastery or even pleasure, ultimately it perpetuates chronic feelings of helplessness and a subjective sense of being bad and out of control (1989, p. 401). After viewing the porn Lynn, feels ashamed about what she is doing and wonders what others would think of her if they knew her secret. This causes her to spiral into a state of even lower self-worth, that of someone who may deserve punishment for her deviant acts. Assuming responsibility for abuse allows feelings of vulnerability to be replaced with an illusion of control (van der Kolk, 1989, p. 393). Preventing helplessness is the key, and these types of enactments allow the victim to feel like they actively chose the situation they are now in. Additionally, Lynn found a way to avoid dealing with her trauma by trying to normalize her behavior. When she views pornography or participates in commercial sex, she does not need to address how the trauma has impacted her

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development. She can avoid feeling the anger about the abuse she endured, which left her feeling helpless and vulnerable. Being the powerful one, which might look like a woman who views porn or a woman who tells her tricks when and where to show up, can temporarily eradicate the feelings of helplessness. This state of helplessness can feel so intolerable to a trauma survivor that they will conceivably do whatever is necessary to regain a sense of control over their lives. Lynn also comments that she hates when people say to her that she sold her body. “I never sold my body, it’s still my body.” Once again, this justification keeps Lynn in control, and keeps her protected from acknowledging the traumatic reality of the dangerous situations she puts herself in. Maria explains that for her, being in control helped her address the belief that she was a victim. I felt like I could choose who and where and when, when before I couldn’t, you know. It's just those things happened and I had no control over them, but then, when I was able to make the decisions like I actually felt like I did have control over that. It helped me feel like I wasn’t a victim, you know made me feel like I wasn’t being abused, because I controlled it. While interviewing participants, I noticed that I felt a combination of emotions. Naturally, I was horrified and deeply troubled by the stories I bore witness to. Having worked with women who have been sex trafficked or who were working in CSE for over eight years, I have heard many, many disturbing stories of the childhoods and subsequent adulthoods these women have been subjected to. That has not, however, made listening to these stories any easier. My heart broke during each and every interview, as I listened to the anger, shame, humiliation and feelings of rejection these women suffered from. The

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coping mechanisms they used made sense to me, and I understood why they had each gone down the paths they had. I also felt a deep sense of awe during these interviews. My admiration and respect for each of these six women was enormous, and knowing they had survived such intolerable abuse and then found ways to positively alter their lives was astonishing to me. My purpose, strengths and beliefs is a sub theme that not only speaks to the phenomenal tenacity and courage these women possess, but it proves they are no longer repeating their early trauma. Each of these women have made marked changes in their lives, so that they no longer repeat the cycle of abuse for themselves or for their children. Unfortunately, this is likely not representative of the majority of women who have suffered such life circumstances. These six women had all come to Journey Out, a Los Angeles based non-profit clinic, as a way of escaping their pimps or traffickers. Journey Out provides assistance to victims of commercial sexual exploitation and sex trafficking who want to leave a life of abuse and violence, and provides no-cost therapy, housing and job assistance. I would like to end this chapter by briefly summarizing some of the purposes, strengths and beliefs these six women have focused on, as a reminder that it is possible to change one’s life, even after the effects of complex trauma. Maria says that she always knew “who I wanted to be, and where I wanted to go and what I wanted in life.” Maria’s sense of purpose kept her from falling deeper into The Life, or getting hooked on drugs. Maria is currently enrolled in college and has been involved in many therapeutic programs throughout the years. Her work helping victims of domestic trafficking has assisted her in regulating her attachment system, and she also continues to provide support for her younger sisters. Madison revealed the event which

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finally catapulted her out of The Life, “I had to go to jail pregnant and that was the last time I ever went to jail. I just didn't want to do it anymore; I just didn't want to do anymore. I was done.” Madison has benefitted from extensive therapy, and now works with domestic violence offenders, traffickers and child abuse offenders. This work has given her purpose, and helps her to make sense of her own trauma. Learning that the men she works with are generally scared and hurt people has given her perspective and helped her on the journey towards healing. Madison cares for her two children, and reports “I’ve learned how to be alone and enjoy it, which was a huge thing. I don't think I’ll give it up at this point. I don't think I can even imagine myself living with someone else.” Kadeesha, who has also pursued therapy, has completed some college and has been employed in a prestigious nanny position for several years. Although she continues to struggle with anxiety, she looks forward to having a family of her own one day. Kadeesha believes that having people who have trusted her and believed in her has helped her to leave the abusive relationships behind and to start over. Luciana, who has had some therapy, is working to re-establish a relationship with her now adult son. Luciana also struggles with daily anxiety, but has pursued several forums to help other victimized women. “I’m a little embarrassed to talk to everyone, but I think that the only way to release myself from trauma and all those ugly memories is to share my story so other women will not go through this.” Having this sense of purpose has kept Luciana from re-engaging with men like her former abusers. Raquel, who no longer has a relationship with the father she once idealized, still struggles with the family dynamics around her abuse. After finally coming forward with the abuse as an adult, she discovered that her mother did not choose to leave her father.

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Raquel says that “the fact that she didn't leave him, that's been hard for me. But what's interesting is like she was always upset with her mom for always choosing men over her children.” Although Raquel recognizes the impact of her mother’s own abuse history in her behavior, her attachment pattern still remains impacted due to her mother’s inability to stand up for her daughter. Raquel has spent many years in therapy working on healing from her abuse, and now lives with her husband and has a career she enjoys. She has been unable to become pregnant, and believes that perhaps this is for the best. Lynn, who has pursued therapy and is currently sober, still participates in gambling. She has a steady job and is single, and has worked on “no longer chasing my validation from men.” My purpose, strengths and beliefs demonstrates how therapy has been a reparative experience for all of these women. Although nothing can erase the abusive childhoods all six of these women lived through, the therapeutic dyad can help repair attachment disorders. Karl Heinz Brisch, in his book Treating Attachment Disorders (2012, p. 108), explains that patients “expect that their need for attachment will not be satisfied in therapy either, and that sooner or later they will experience the disappointment of their desire for attachment.” Brisch recommends allowing the patient the ability to regulate the emotional closeness with the therapist, and in this way the patient can finally begin to have a new relationship with someone who is in the caregiving role.

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Chapter VI

Conclusion

From time immemorial mothers and poets have been alive to the distress caused to a child by loss of his mother; but it is only in the last fifty years that, by fits and starts, science has awoken to it (Bowlby, 1969, p. 24).

Clinical Considerations The findings on this study will contribute to the existing literature on commercial sexual exploitation by expanding the understanding of the subjective experiences of women who engage in what is commonly known as prostitution, and their emotional and relational histories that contribute to their reliance on commercial sex. This study focuses solely on women who were victims of early childhood sexual abuse, and then were either trafficked, manipulated, or voluntarily joined what is known as The Life. Due to the small sample size, findings are not generalizable. However the indepth interviews which focused on the thoughts, feelings, compulsions, and survival techniques of these six women bring to light a variety of considerations which seem to have gone mostly unexplored. Avoidant, ambivalent and disorganized attachment patterns have been shown to have considerable detrimental effects on the organizing systems of these participants, leaving them vulnerable to further abuse and traumatic encounters. Addictions, revictimization, and a propensity towards psychological and

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somatic dysfunctions are likely to occur. The most concerning finding, that of “I just needed someone’s attention,” speaks to the contradictory impulses young girls feel when they experience sexual arousal at the hands of their abusers. The desperation to be seen, attended to and cared for was so enormous that for several of these young women, allowing their bodies to respond to their abusers was a natural step. The unacceptable sensory experience creates a split somatic experience, which fosters a dissociative relationship where the body is kept separate from the self. Once these women reached adulthood they became confused and sickened by their bodily responses, which only served to reinforce the negative self-image and self-loathing which they must contend with on a daily basis. This exploratory research serves the purpose of informing policy on the macro level, so that funding can be established to recognize the signs of early childhood sexual abuse in schools. Those on the macro level likely have little to no direct contact with victims of CSA and CSE, and the opportunity to understand the chain of events which leads young girls to a position where they eventually enter The Life will undoubtedly be illuminating. Sex trafficking victims in Los Angeles, where this researcher resides, are on the brink of losing more protection and access to help. There is currently a bill on the table (SB 357) that will harm the most vulnerable communities by giving buyers, traffickers and pimps more freedom. When buyers solicit prostitution and purchase sex trafficking victims, police will have a harder time holding them accountable if this bill passes. In the first nine months of 2021 alone, the Oakland Police Department rescued nine children who have been commercially sexually exploited using the loitering law,

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which SB 357 will eliminate. This research seeks to inform those on the macro level, so that traffickers are prosecuted, funds can be directed towards services and victims can be recovered. Therapeutic interventions are also desperately needed in schools in an effort to help victimized children learn alternative ways of processing their pain, in the hope of preventing the internalization of the shame that encompasses them. Teachers and school social workers need additional training in recognizing the signs of neglect and early childhood abuse, and abused kids must receive in depth therapy with a substitute attachment figure who would ideally be assigned to stay with them throughout their school years. The importance of a consistent, reliably attuned relationship throughout their developmental years is integral for changing the attachment styles abused children have learned in their family of origin. This research can be used to inform and educate on many levels, with the goal of rescuing teens before they head out to the streets. Programs which educate young at-risk girls, boys and non-binary teens are needed, to inform them of the dangers they are generally unaware of. As a psychotherapist for this population, I have participated in one such program. It was directed towards girls who were in the foster-care system, and illustrated the potential ways they may inadvertently become caught up in The Life. The teenagers reacted extraordinarily well to this program, and by the end of the sessions they were well versed in how to protect themselves from these dangers. They felt empowered with the knowledge, and I witnessed actual transformations in these girls over the eightweek program duration. Unfortunately, funding for programs such as these is minimal.

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Although I happily volunteered my time to facilitate these classes, I have been unable to lead more than a handful of groups over the course of many years due to the lack of approvals and funding in schools. With this study and an understanding of Attachment Theory, my belief is that one of the most important interventions we can make as social workers and educators is to assist young women as soon as they become pregnant. Prenatal interventions, to ensure pregnant mothers are sober and receiving adequate nutrition to assist their babies’ developing brains is dire. Providing “mommy and me” classes which not only teach young mother’s how to ensure their child receives appropriate nutrition, but also demonstrate the ways mothers can create attachment bonds is critical. I participated in one such program, aimed at pregnant homeless teenage youth. Along with enticing the teens to attend with free diapers, wipes, bus passes, breakfast and snacks, we modeled appropriate discipline for the babies, toddlers and early school aged children in the program. Social workers rocked, played with and sang to children, and created an environment where love rather than fear was the predominant tool used to manage behavior. There is almost no funding for programs such as these, however young mothers who likely have their own disrupted attachment styles need to learn the importance of eye contact with their babies, listening and responsiveness, and somatic and psychological well-being tools. Additionally, if these new moms were informed of the impact of neglect on their child’s developing brains, perhaps we could give these new little lives a chance at creating secure attachment bonds in the hope of providing protection from a potential abuser.

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My hope is that this research will also promote sensitivity training for members of the police force and judges, when interacting with women who may be arrested for crimes for which they truly had little choice in committing. Landlords, potential employers and credit establishments should also be trained in the challenges women face once an arrest for prostitution is on their permanent record. A re-evaluation of the ways in which our system makes it virtually impossible for women to get out of The Life is desperately needed, due to the stigma, arrest records and lack of training and support available for those who are trying to escape pimps and traffickers and begin anew. I have been invited to sit on boards of organizations who work with homeless youth, and my plan for this research is to inform and train those who work with this population on a micro level as well. I will be delivering presentations to police departments, shelters, clinics and universities in an effort to educate those who come in contact with youth, teens and young adults who have been affected by CSA and CSE. This research is additionally suited to assist clinicians who work directly with this patient population, to provide a better understanding of the nuances which reside in the emotional experiences their patients might be processing. Clinicians who work with atrisk teens and those who have been in The Life will be better able to serve their clients, once they become aware of the failures in their client’s attachment systems and how that has affected their everyday choices.

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Recommendations for Future Research This small qualitative study illuminated many facets of the internal dialogue which drives women who have been sexually abused as children toward a life in commercial sexual exploitation. This study focused solely on girls who had been abused by family members and individuals outside of the family. This study did not factor in length of time of abuse, or the relationship of the abuser to the victim. Future studies could focus their attention on abuse of boys and children who are non-binary, in order to discern if similar coping mechanisms are utilized. Although it is far less common for men to join The Life, boys and men who identify as gay or trans also wind up in commercial sexual abuse. Future research in this area would benefit this community, as well as enabling teachers, social workers and others who work with children and teens to be better able to decipher behavioral problems which may be related to CSA. Additionally, more studies which focus solely on familial abuse are needed, as the dynamics of parent/child abuse are especially traumatizing. Not only are children damaged by betrayal trauma, they are also devastated by the knowledge that they weren’t protected by mothers or other adults who may have been aware of the abuse in the home. Studies which focus on effective interventions for CSA victims, which could serve to teach young children about abuse in the home and how to report it would be most valuable. I would propose that additional studies which focus on CSEC (Commercial Sexual Exploitation of Children) victims that seek to discover alternative ways to lead manipulated teens away from their traffickers and pimps are especially needed. Teens

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often believe they are in love with their pimps, and call them “boyfriends.” I have personally worked with many, many young women who have said to me “You don’t understand the relationship between a pimp and his ho.” As a social worker and psychotherapist who diligently works with this community, my heart sinks when I hear these words. What these words tell me is that the woman in question has formed attachment bonds with her pimp, and currently believes whatever he tells her. She will work around the clock and hand over all her earnings to him, because he is saving the money “for them.” Inevitably, she is beaten by him, the money is gone, and the attachment is broken once again. Examining this dynamic, and the available options to help these women before it is too late would be extremely beneficial. Lastly, I would recommend a study involving commercial sex buyers. Understanding the depth of comprehension buyers have when they are purchasing women for sex would be integral to a plan of getting vulnerable women and children off the streets. Do men understand they are likely paying for sex with underage girls who have a long history of abuse? How much information do they have about why women are on the streets? If they did have more information, would it make a difference in their desire to purchase women for sex? What would influence men to make another choice? There are many dynamics to consider in the effort to save young kids from a future in commercial sexual exploitation. My hope is that we as educators, therapists, and human beings continue to diligently care about implementing change for these unseen members of our communities.

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Concluding Thoughts Sharing intimate, traumatic experiences which have defined personal development and hijacked normal decision making capability is no small thing. Not only does it require a high level of emotional risk to tell the stories and the meaning made from those stories, but it necessitates a willingness to dive back into the well of grief that may still reside from the painful and horrifying memories. The courageous decisions made by these participants to delve deeply into the darkest moments of their pasts, in an attempt to pull themselves outwards and upwards is remarkable. What can they hope to accomplish? How will it keep the walls from closing back in, papered with the familiar shame, guilt, and questioning of the self. Why did this happen to me, was it my fault? The fault can feel endless, the feelings of despair ever deepening. Yet I believe something happens when the stance is taken to share the story. To be heard, to voice a protest. To perhaps tentatively at first, ponder the messages that were given, and later, with a little more garnered strength, push the assumptions even further. The sharing changes the story, brings a sense of validity to their experiences and perhaps even enables them a glimpse into the entitlement they were never able to own as abused children. How dare they, girls who had no power, do something powerful? This, in and of itself, is healing. Not just to each of these six women who shared, mourned, and attempted to understand the minds of their abusers. Sharing has the effect of changing the whole. A group has now been formed, which serves to validate each individual story. Someone

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cared and someone was interested, which is a step toward re-parenting the broken parts and repairing attachment patterns. I, too, as a researcher was made stronger and more whole through this process. The capacity I had to be a trusted object and holding vessel for decades of pain afforded me the opportunity to contemplate my position in this world, including my ability to function on a daily basis and make choices of my own free will. The decisions I have made to champion this community have only been reinforced through this research. The shift that transpires when the power of a group gains momentum is palpable, and my hope is that more and more victims are allowed to feel this shift and gain momentum towards a life better lived.

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Appendix A Flyer

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Hello! I am interested in YOUR life story, as part of a research project for the Institute for Clinical Social work. If you decide to participate, your valuable input could help create policies and laws for women who are in The Life, and also create change for children who were victims of child sexual abuse. The study is CONFIDENTIAL! Your identity will never be given to anyone, and there will be no identifying information about you. Would the study be a good fit for me? The study might be a good fit for you if: •You were a victim of child sexual abuse •You were trafficked or otherwise began work in The Life •You would be open to talking about your experiences What would happen if I took part in the study? If you decide to take part in this research study, you would: •Have a phone call with the researcher to determine if you are eligible •Fill out a survey about your background •Take part in an interview over zoom, which will take 1 – 1 ½ hours, where you will describe your experiences with early childhood sexual abuse and being in The Life. There will be a follow up interview where you can expand on what you said in your first interview. What will I get for my participation? If you participate, you will: •You will get to tell your story •Receive a total of $40 worth of gift cards •Your story will provide valuable insight and aid for social workers, educators, law enforcement and policy makers Research is always voluntary! To take part in this research study or for more information, please contact Jennifer Dean at: Jendean100@icloud.com, or text 818.920.8106 Thank you very much for considering!

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Appendix B Letter to Potential Participants

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Dear (potential participant), I wanted to express my appreciation to you for speaking with me on the phone, and being willing to learn more about this research project. As we discussed, being involved in this research study would mean that I would speak with you for about an hour to an hour and a half on a format like zoom, and then we would have a shorter follow up interview. We could schedule these interviews whenever they are convenient for you. Being involved in this research study would allow you to tell your story, and talk about everything you have gone through. There are no right or wrong answers, I am just interested in you and what life has been like for you. Talking about these experiences may cause you to have some uncomfortable feelings, and you might even have some symptoms that arise from you remembering and talking about these things. If you do, and you want to stop the interview, you can at any time. You can also take advantage of free therapy services at Journey Out, to assist you in processing your feelings. My goal is to make this a positive experience for you. I want you to know that your input is very valuable, and you will be an important part of a study that could make some positive changes for girls and women. If there is anything you do not understand or if you have any further questions, please feel free to call, text or email me at any time. Warmly, Jennifer Dean, LCSW 818.920.8106 Jendean100@icloud.com

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Appendix C Consent for Participants

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Institute for Clinical Social Work Research Information and Consent for Participation is Social Behavioral Research

I,_____________________________________, acting for myself, agree to take part in the research entitled Experiences of commercially sexually exploited women with a history of child sexual abuse. This work will be carried out by Jennifer Dean under the supervision of Lynne Tylke. This work is being conducted under the auspices of the Institute for Clinical Social Work; At St. Augustine College, 1345 W. Argyle St., Chicago, IL 60640; (773)935-6500. Purpose This is a research study that involves speaking with women who have experienced childhood sexual abuse, and were later brought into commercial sexual exploitation. The purpose of this study is to find out about the history of each participant, learn about their lived experiences, and understand what their lives are like today. With this research, my hope is that early interventions would be offered for vulnerable young people who have already suffered enormous personal tragedies. Additionally, my hope is that policies that affect young women in this system could be amended, and women could be helped rather than punished for making the only choices that may have been available to them. Procedures used in the study and duration If you agree to participate in this study, you will be asked to participate in one interview that will last between 60-90 minutes, and then a shorter follow up interview. The interviews will be on an online platform, like zoom, and will be recorded so that the researcher can study the answers of the participants and look for similarities in their experiences. Prior to the interview you will be asked to fill out a short questionnaire and to return it via email, in order to collect some basic information about your life before we begin. Participants will be paid $35 for each interview, in the form of a gift card. Benefits The direct benefit to you is the ability to share your story and all of your experiences with a psychotherapist who is dedicated to working with women in the life. You will also receive the gift cards for agreeing to share information about yourself, as a token of appreciation for your time. Sharing your experiences may help educators be more aware of the signs of abuse in young children, as well as creating programs that can keep young girls safe. Your input may also help clarify to policy makers the barriers women are up against, which prevent them from leaving the life. It is my hope that women who are

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stereotyped, criminalized, oppressed and jailed can be de-stigmatized, and receive the assistance they need. Costs There is no cost for participation in this study. Possible Risks and/or Side Effects The risks for you participating in this study include the possibility of you feeling uncomfortable talking about what might be deeply personal and difficult life experiences. If you do feel uneasy during the course of the interview, you have the right to skip any questions you do not want to answer. You can also choose to take a break during the interview if you feel uncomfortable, and you can choose to end the interview anytime you choose. If you decide that the interview has brought things up that are difficult for you to deal with, you may receive no-cost therapy at Journey Out, or the interviewer can direct you to other no cost therapy options so you can continue to talk about your feelings. Privacy and Confidentiality The researcher will make every effort to protect your privacy and confidentiality. There will not be any identifying information about you written in this study. The videotapes of the interviews will be solely in the possession of the interviewer, along with the transcriptions of the interviews. Each transcription will be given a number, rather than a name, to identify them. The interviews and transcriptions will be kept on the researcher’s personal computer which is password protected, and no one else will have access to the information. Subject Assurances By signing this consent form, you agree to take part in this study. You have not given up any of your rights or released this institution from responsibility for carelessness. You may cancel your consent and refuse to continue in this study at any time without penalty or loss of benefits. Your relationship with the staff of ICSW will not be affected in any way, now or in the future, if you refuse to take part, or if you begin the study and then withdraw. If you have any questions about the research methods, you can contact Jennifer Dean at 818-920-8106 or jendean100@icloud.com or Lynne Tylke at lynnetylke@gmail.com. If you have any questions about your rights as a research subject, you may contact Dr. John Ridings, Chair of Institutional Review Board; the Institute for Clinical Social Work;

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At St. Augustine College, 1345 W. Argyle St., Chicago, IL 60640; (773)935-6500.; irbchair@icsw.edu. Signatures For the Participant I have read this consent form and I agree to take part in this study as it is explained in this consent form: Participant Name (please print): ___________________________________ Participant Signature:__________________________________________ Date: _____________ 1.

Would you like a summary of the results of this study? Yes: ____ No: ____

For the Primary Researcher I certify that I have explained the research to _________________________ and believe that they understand and that they have agreed to participate freely. I agree to answer any additional questions when they arise during the research or afterward. Researcher Name (please print): Jennifer Dean Researcher Signature:__________________________________________ Date: _____________

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