Vida y Muerte en Un Camino

This study utilized a phenomenological qualitative framework with the goal of amplifying the voices of survivors of human sex trafficking. It focused on 15 adult female victims of domestic human sex trafficking, after one year of being separated from the trafficker and leaving the commercial sex industry. Personal Interviews and Photovoice pictures and captions highlighted their experiences after leaving the trafficking situation to determine factors that impact their reintegration into community. A summary of these factors will be provided, including an outline of recommendations for service providers.

Research Approach

Qualitative Semi-structured Interviews

A qualitative study is useful for studying complex topics and social processes, along with those that are sensitive or require emotional depth (Padgett, 2017). Qualitative methods can provide an in-depth understanding of the experiences of human sex trafficking survivors so that the experiences of survivors may further inform our knowledge and our creation and

implementation of aftercare resources. A phenomenological approach to qualitative study aims at gaining a deeper understanding of the nature of everyday experiences. Vagle (2014) states the primary purpose of phenomenology as a research methodology is to understand human

experience and how things are being and becoming. It is not just studying how things work, but how a particular phenomenon manifests and appears in the “lifeworld” (p.23). This study included face-to-face and video call interviews and photography from Photovoice methodology.

Interview Process

interview conducted a semi-structured, self-designed interview (see Appendix C). Main topics included description of self and experiences before, during and after being trafficked. This included forms of coping and key areas of impact, such as identity, emotions, sexuality and relationships. Interviewees were also asked about their experiences with services. The final section asked about their goals and dreams, as well as recommendations they have for service providers, loved ones and other survivors.

Photovoice

In addition to qualitative semi-structured interviews, Photovoice methodology was used. Photovoice is defined as “a process by which people can identify, represent, and enhance their community through a specific photographic technique” (Wang, Burris, 1997, p.369).

Photovoice entrusts cameras to the participants to enable them to act as recorders, artists and potential catalysts for change within their communities. It uses the visual images to provide evidence, and additional expression and promote an effective, participatory means of sharing expertise and knowledge. Wang et al. (1997) created Photovoice with these original purposes: to enable a participant to record and reflect their community’s strengths and concerns, to promote critical dialogue and to increase knowledge about important community issues through display and discussion of the photographs to reach policymakers (Wang et al., 1997). Photovoice first seeks to empower, bringing change at the individual level by providing an opportunity for emotional engagement, reflection, and expression. Then it focuses on improving quality of life at the community level through providing an opportunity for dialogue of points of view in a supportive environment. Finally, it seeks to enforce change in policy on an institutional level as the group has an opportunity to use their photographs to raise awareness, or promote policy change or social action within a community for a specific issue. Often used with vulnerable populations to provide a way for them to share their stories, Photovoice gives power into the

hands of the participant, allowing them to become decision makers in the themes of what is represented in the photos.

This is the first known study using Photovoice methodology for adult domestic sex trafficking survivors. The purpose of utilizing Photovoice in this study was to provide an additional form of expression for survivors to share their expertise and insight into their experience. For a population who has lost power and voice, it is a format that restores these aspects of humanity, and provided an alternative form of expression to words.

Photovoice Process

The common process includes: Introduction to Photovoice methodology, photo training, provision of specific theme, timeframe of taking pictures, and discussion of pictures and social action. This final piece may include a public exhibition where individuals, including key

stakeholders and policymakers, are invited to view the photographs. This final part of the project is decided by those who are involved.

The purpose of this study was to utilize Photovoice methodology as an additional form of expression of key themes of survivorship. Participants were informed that while this study does not include a plan for social action, they were encouraged that the data was collected towards this aim. Participants gave feedback and recommendations on how the photography could be utilized for awareness and advocacy purposes.

Participants of this study were introduced to Photovoice when they first learned about this study. A participant was given the freedom to participate in the interview and Photovoice or only the interview. Participants were given a brief training that included taking pictures, how to

Photovoice; 2. A consent form for specific photos to be used in publication.

Seven individuals participated in the Photovoice portion of this study. Six submitted eligible photos and one additionally participated in the video call. Participants were given the option to use the camera on their cell phone or were given a digital camera. Each participant was oriented to Photovoice and instructed to take as many pictures as they wanted over a period of 30 days. The main limitation of photography was no identifying information, such as faces.

The prompt given was to take pictures that express their experiences of survivorship. Additional explanation of this prompt was given in the video orientation including these questions:

 What is it like to live after being in the life?  What in my life or community has helped me?  What has been challenging?

 What do I want other people to understand about women who leave the sex trade or who have been sexually trafficked?

 How is my life different now from how it was before?  What are my hopes for the future?

Because participants were located in various regions, in-person meetings with all participants were not feasible. Each person submitted their pictures to the researcher, accompanied by a caption. Photos were stored on a secure online portal called Pennbox, only accessible by the Primary Researcher and research team. The researcher contacted the participant weekly during their thirty day period, to remind them about photo submission and check in to see if they had any questions. Participants expressed how these reminders were helpful.

An important aspect of Photovoice methodology is the group process to discuss

photographs and themes amongst individuals from a similar population or group. Therefore, an optional video or audio conference meeting was provided for all Photovoice participants.

Participants used the SHOWED technique to facilitate discussion of photography. Formulated by Wang and Burris (1999) this acronym includes the following questions:

1. What do you SEE here?

2. What is really HAPPENING here? 3. How does this relate to OUR lives?

4. WHY does this situation, concern or strength exist? 5. What can we DO about it?

This was simplified to the following questions: 1. What do you see in these photos?

2. How do you relate to these photos?

3. How do these photos tell the collective story of survivors?

4. What is the message from these stories that is important for others to hear?

During this meeting, the participants had the opportunity to further discuss their observations and reflections of their photographs. They shared the impact and experience of being a part of this Photovoice project and they provided ideas for how the photographs could be utilized for awareness and advocacy.

Due to scheduling challenges, it was not possible to have all six participants on the same call. Rather, four conference calls occurred. During each call, the participants viewed a

powerpoint presentation of all photos and captions. After viewing all photos, some concluding questions facilitated discussion on the collective themes and message of all photos, their personal experience participating in Photovoice and their ideas for how the photos can be used to raise awareness about the experiences of Sex Trafficking Survivors. These questions included:

 What consistent themes did you see and hear in the photos, photo subjects?  What do the pictures have in common?

 What spoke to you about the body of shared work as a whole?

 Who do you want to hear these messages? What do you wish to be conveyed in the research outcomes?

 Any additional thoughts or feedback on your experience in this Photovoice project?  Is there anything you wish to do individually or as a group to share your photos with the

Sampling and Selection

This study utilized the sampling method of purposive convenience selection, with snowball sampling. The sampling size was 15 participants who met the following:

Inclusionary Criteria:

 A survivor of human sex trafficking in the United States  Female

 Over the age of 18

 Separated from the trafficker for one year to ten years.  Speaks English

Exclusionary Criteria:

 A survivor who was born and trafficked outside of the United States.  Male survivors of Domestic Sex Trafficking

 A survivor who is under the age of 18.

 A survivor who was separated from the trafficker less than one year.  Does not speak English

Recruitment Procedure

Recruitment included distributing information and posting flyers through regional and national networks of community organizations and coalitions that provide services for domestic human sex trafficking survivors as well as national survivor networks. Interested participants were directed to contact the Primary Researcher. Finally, snowball sampling was incorporated as participants referred others to join the study. An introductory letter sent by email introduced the study to key contacts.

Pre-interview arrangements with participants included choosing a preferred, private, comfortable setting, providing the purpose of the study and consent information, and answering any questions prior to starting the interview.

Consent Process

Informed consent was obtained by the Researcher before the interview began and after the participant received ample explanation and agreed to participate. The consent form used

language to remind potential participants of their choice to accept or decline participation. It was read and reviewed thoroughly with each participant, encouraging them to ask questions or take additional time with the consent form to review or seek counsel from a support person.

For participants who agreed to join the Photovoice project, they were opportunity to review the consent form with the understanding that they may withdraw this consent at any time during the 30 day period for taking photographs. The Researcher continued with minimum weekly contact with participants during this 30 day period to assess for any changes in consent.

Consent was also obtained for how survivors wanted to be identified throughout the research publication. Participants were given the freedom to use the name of their choice or a general Participant number. In lieu of requiring written signature, only verbal consent was requested from participants. For subjects who enrolled remotely, they were offered to have the consent form mailed to them.

Study Instrumentation

Participants completed a Participant Screening and Demographic form, which included information about age, ethnicity and types/numbers of services utilized after exit from being trafficked. Participants were involved in semi-structured interviews and were provided with an explanation of the process prior to the interview. Sample Study Interview Guide is included as Appendix G. Interviews were audio recorded. Photovoice participants shared their photos on a secure web-based account accessed only by research team and research participants.

Data Management

identification numbers were assigned to protect participant identifying information when it is entered into the database. The list of identifying numbers was stored securely and separately from the research database. This ID number was used on all information collected from

participants, including audio files. Only the researcher had access to these files, which were kept in a locked file cabinet at the office of the primary researcher. Demographic forms were kept in a separate file. The primary researcher was responsible for creating and maintaining the research database. Data used to illustrate findings will only use the respective ID number.

Additional data was stored on a secure online website which included photos and participants’ captions. Photos were stored securely by insuring that the participant’s camera location tag was off.

Strengths and Limitations

Strengths: Utilizing service providing organizations for recruitment of research

participants provided access to a population who otherwise is difficult to identify and track, and who can directly speak to experiences after exiting the commercial sex industry. This sampling also provided data and valuable information from a range of experiences of how services were accessed and experienced.

A sampling that included adult women within ten years of leaving the commercial sex industry provided a broad range of years to acquire enough participants for the sample, but limited the timeframe so that the length of time is not so vast that it could impact the perceptions of their experiences. This sampling also fills a gap in literature to inform research on human trafficking, trauma and post-traumatic growth.

Limitations: Utilizing service providing organizations to recruit participants limits

from being generalized to all domestic sex trafficking survivors. Another factor that must be considered is the process by which survivors obtained services. If their participation in a legal case obligated them to receive services, this may provide a different perspective than those who chose services. Furthermore, some willingly leave their trafficker and are ready for services and the reintegration process. Others are separated from their trafficker by law enforcement and may have a trauma bond or loyalty to their trafficker. These create diverse perspectives in the

sampling, which may be perceived as a strength or limitation. An additional limitation is that this study did not focus on minors, males or international trafficking survivors, whose

experiences are also worthy of being heard and understood. Finally, the presence of the researcher may impact participant’s responses and the personal bias of the researcher may also influence the research data.

Risks & Benefits

Potential harms to participants were minimal and there were no known physical, financial or legal risks to participating in this study. However, one possible risk for participation in this study was potential psychological distress related to content described and expressed during the study. Participants had the freedom to stop the interview at any time. The researcher was also ready to provide information about supportive services and insured that each individual had a safety plan for how to manage emotions and contact a current support system if there was distress after completion of the interview. Throughout the interview, no participants chose to stop. One participant asked to take a short break. Some commented on it being difficult to talk about, but their motivation was to share their experiences to help others. Many commented on how it was helpful to have the opportunity to share and have their experience be known.

An additional possible risk was the potential for loss of confidentiality. Participants disclosed sensitive information during interviews. All identifying information has been kept private and confidential. Any content of the interviews has not been shared with any of the referral agencies and all data was coded with ID numbers and has been stored on computerized datasets. The master list of ID numbers was kept on a password protected computer and accessible only to the main researcher. Participants were informed of their option to not participate or to withdraw from participation at any time. In addition, information about the research will not be left on a voicemail or text.

Photovoice photos were uploaded and stored on the University’s secure web-based Pennbox, which is password protected, only utilized and accessed by the Research team. Participants were instructed that no identifying information should be photographed, including faces. In addition, participants were instructed to turn off location features on digital camera or cellular phone so that the photographs do not have attached identifying information. The primary researcher approved photographs to insure photographs meet the ethics, safety and privacy guidelines. If a photograph revealed faces or identifying information, the participant was reminded of the agreed guidelines and asked to remove it from the study.

During the optional video conference call, participants had the alternate choice to

participate audio only with no video. The video conference call used the program Zoom, which included end to end encryption. The meeting was password protected and was locked once participants joined. The meeting was recorded. Because it was stored on Zoom cloud, which is not HIPAA compliant, participants were instructed to use their research identification numbers and not reveal their personal identifying information.

Two years after the conclusion of the study, audio recordings will be destroyed. At conclusion of the study the Photovoice photos were removed from Pennbox. Participants were given printed copies of their photographs.

There is no confirmed benefit to participate in this study. However, participants are making a contribution to understand how services are effective for survivors of sex trafficking survivors and what factors help sex trafficking survivors find physical and mental stability. Therefore, this study may benefit them indirectly. This research may influence how to make services available and useful for survivors of sex trafficking. We also hope that sharing experiences through words and/or photography was empowering for the participants. In fact, many commented on how powerful and healing the experience was for them, particularly by being involved with the Photovoice project.

Vulnerable Population

By definition, victims of human trafficking have previously experienced undue influence and coercion. Therefore, it must be considered that the impact of their exploitation includes continued vulnerability to coercion. To seek maximum protection of this vulnerability, the primary researcher formed a Survivor Advisory Council for consultation. This council was comprised of individuals who are domestic sex trafficking survivors and survivor leaders within the field of anti-human trafficking advocacy and aftercare work. Their feedback based on personal and professional experiences was incorporated to aim for a survivor-centered research study.

complex trauma, including human sex trafficking and commercial sexual exploitation. The survivors were supported throughout the interview and the Photovoice project to insure their wellbeing and their ongoing freedom in participation. The primary researcher was prepared to offer necessary support during the interviews and provide appropriate resources should they be needed. Finally, privacy and confidentiality was protected throughout the process including private interview settings, utilizing identification numbers for clients rather than their names, and maintaining all information on a secure computer file.

Institutional Review Board