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Article

Traumatic Associations amongst Men and Women Selling Sex in the Philippines

by
Lianne A. Urada
1,2,*,
Jasmine H. Ly
1,
Nymia Pimentel Simbulan
3,4,
Laufred I. Hernandez
3 and
Elizabeth E. Reed
5
1
School of Social Work, San Diego State University, San Diego, CA 92182, USA
2
Center on Gender Equity and Health, Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, CA 92093, USA
3
Department of Behavioral Sciences, College of Arts and Science, University of the Philippines, Manila 1000, Philippines
4
College of Public Health, University of the Philippines, Manila 1000, Philippines
5
School of Public Health, San Diego State University, San Diego, CA 92182, USA
*
Author to whom correspondence should be addressed.
Trauma Care 2022, 2(2), 330-340; https://doi.org/10.3390/traumacare2020027
Submission received: 1 June 2021 / Revised: 5 April 2022 / Accepted: 19 May 2022 / Published: 2 June 2022
Review Reports Versions Notes

Abstract

:
Background: The present study explores trauma-related factors (human trafficking or physical or sexual violence during transactional sex) associated with interest in future community mobilization around health and human rights. Community mobilization among persons selling sex aims to help participants overcome trauma and increase self-reliance through peer advocacy and collective action for improved human conditions. However, how violence and human trafficking impact community mobilization participation among men and women selling sex is less known. Methods: The current study uses data (n = 96) from the baseline survey of participants in the pilot Kapihan community mobilization intervention, which recruited 37 men and 59 women from Metro Manila, Philippines. Multiple logistic regression was used to analyze factors (violence, human trafficking) independently associated with the desire to participate in community mobilization, adjusting for socio-demographic variables. Results: An increased interest in participating in community mobilization around health and human rights was significantly associated with having experienced physical or sexual abuse in the sex trade (AOR = 10.86; CI 1.48–79.69) and less history of trafficking (AOR = 0.14; 95% CI 0.02–0.97), adjusting for age, gender, income, number of children, and whether they considered group goals or had previously participated in community mobilization. Conclusion: Understanding the impact of experiences with physical and sexual violence and human trafficking on health and human rights mobilization participation can inform the design and recruitment for future community-based interventions. Further investigation needs to explore why experiences with human trafficking, having more children, or being a woman lessened the desire to mobilize in this Philippines context. Findings imply that trauma may be more complex. More work is needed to better identify interventions for those with a history of being trafficked or victimized by physical or sexual violence during transactional sex exchanges.

1. Introduction

Persons selling sex are vulnerable to trauma, violence, abuse, and exploitation. Globally, women who trade sex for something of monetary value (transactional sex) experience a high incidence of physical and sexual abuse [1,2,3,4]. Variance in severity and forms of violence amongst those trading sex often depends upon factors in their environment (e.g., street-based, brothel-based) and the policing of persons selling sex [5]. Furthermore, victims of sex trafficking and exploitation (defined as force, coercion, or deception into selling sex) have an increased risk for depression and post-traumatic stress disorder [6,7], substance abuse [6], and intimate-partner violence [6]. Although much of the literature focuses on women, a growing body of literature also focuses on men who trade sex, including men who have sex with other men. For example, men who sell sex (i.e., sex exchanges with other men) are vulnerable to increased risk of HIV infections [8], stigma, criminalization, and discrimination [9,10,11,12], physical and sexual violence [2,4].
In the Philippines, economic, physical, or psychological abuse was associated with suicide attempts and psychological distress among women in a population-based study [13]. Poorer households increased the likelihood of encountering forced first sexual intercourse [14]. In the Philippines, extreme poverty exacerbated by environmental disasters such as typhoons has led to greater violence against women [15]. Kidney donation coercion is another common form of coercive trafficking [16].
Previous studies in the Philippines reveal the prevalence of human trafficking endured by those who sold sex [17]. Eleven percent of those working in the bars/nightclubs/massage establishments in Metro Manila, Philippines, reported being trafficked into their first jobs [18]. Being trafficked was associated with current drug use, less availability of condoms at their establishment, and increased peer support for practicing safe behaviors. At the same time, other studies found that being forced/deceived into their jobs was highly associated with inconsistent condom use and lack of condom negotiation [19]. In addition, women and girls in the Philippines were more likely to be recruited by an agency whose agents went to the rural areas than by a friend/acquaintance or job advertisement [20]. However, how violence and human trafficking have impacted community mobilization efforts among men and women selling sex in the Philippines is less known.
Community mobilization is a “capacity-building process through which individuals, groups, or organizations plan, carry out, and evaluate activities to improve their health and other needs [21,22].” It is a structural intervention that contributes to the empowerment of individuals and groups to take action to affect change. The community mobilization process aims to help participants overcome their barriers, increase self-reliance, and decrease sexual violence victimization through collective action [23]. Many studies focus on one or a few aspects of community mobilization, such as collectivization. Collectivization includes a strong sense of action, agency, collective efficacy, collective identity [24], and collective ownership [25]. Another aspect of community mobilization is community engagement, which includes community identity, collective action, and community empowerment [25]. Many interventions are empowerment-based; participants come together to collectively create programs to address their needs and priorities to create positive outcomes [26,27,28].
Community mobilization interventions differ from traditional methods in that the participants coalesce as a community to design, implement and assess the programs [24,28]. These types of interventions also use advocacy and economic strategies [29]. For example, many critical community mobilization programs for people selling sex revolved around HIV prevention. Implemented in India, the Avahan program [23,24] and the Sonagachi Project [26,29,30], known as the Durbar intervention [29], are widely cited. In the Avahan intervention, half of the participants reported feeling confident that they could work together to address problems the group experienced, and more than half would speak up for their rights [24]. Participation in community mobilization efforts in Durbar also helped individuals gain critical resources such as pride, self-esteem, a sense of personal autonomy, and financial independence [30]. In addition, the Durbar intervention included advocacy and organization revolving around promoting the participants’ rights.
Increasing evidence shows that community mobilization interventions effectively produce positive health outcomes for individuals trading sex. However, much of the research on community mobilization focuses on female participants with limited evidence of similar effects among male participants. Furthermore, many mobilization interventions with this population focus on HIV prevention and measure outcomes such as increased condom utilization or HIV testing. However, little research examines whether participation in community mobilization interventions influences future engagement in human rights activities for individuals trading sex or whether trauma-related factors may hinder their participation. In this paper, we define community as those trading sex on the street or in entertainment establishment venues and the community of peers and organizations who outreach to them to reduce their vulnerabilities to violence victimization.
Using data from a community mobilization intervention with women and men trading sex in Metro Manila, Philippines [31], the present study explores the association between trauma-related factors (abuse, human trafficking) and the likelihood of mobilizing around their human rights. We further predicted that increased knowledge of human rights positively correlates with a future interest in participating in mobilization or organization. Individuals who think about the group goals of individuals trading sex are more likely to be interested in future mobilization activities.

2. Materials and Methods

The current study uses data from the baseline survey pilot Kapihan intervention conducted in the Philippines’ Metro Manila area [31]. The Kapihan intervention aimed to reduce HIV risk and increase HIV testing. It included a four-hour intervention and a self-administered pre-and post-intervention survey completed on the same day as the intervention. During the intervention, the participants received HIV and STI education, condom demonstrations, and research results on ethics research, which focused on consent and disclosure. Following the education section of the intervention were discussions on human rights legislation, work-related risks (i.e., violence), and goals at both the individual level and community level. Pre- and post-test measures included the participants’ demographic information, HIV risk behaviors, violence experiences, history of sex trafficking, knowledge of HIV and other STIs, human rights, and research ethics. (Refer to [31] for further methods).
Between August and November 2013, 37 males and 59 females who had traded commercial sex within six months of the study were recruited from a suburb of Metro Manila, Philippines. Researchers from the United States worked with collaborators from local non-government organizations, government organizations, and peer-led youth organizations. Collaborators included a peer organization with some members formerly involved in trading sex. The participants in this study were approached and recruited by peer outreach workers through purposeful sampling based on established relationships with the peer outreach workers. Participants provided informed consent after being read the instructions on the consent by the group facilitators (to aid those who might have trouble reading). The University of California San Diego Institutional Review Board approved the protocols for the study.

2.1. Measures

This study uses the following measures and hypotheses not conducted previously. The dependent (outcome) variable was the participants’ willingness to engage in future organizing around human rights, measured by the (Y/N) answer to the question “Would you participate in an organization that addresses health and human rights in the next three months?” The independent variables were the participants’ previous community mobilization experience, human rights knowledge and reproductive rights knowledge, and thoughts on community goals. Previous experience in community mobilization was measured by the (Y/N) answer to the question, “Have you participated in community mobilization activities around your health and human rights in the past six months?” Knowledge of human and reproductive rights was measured using a 1 to 10 scale, with 1 meaning nothing and 10 meaning a great deal. They were asked, “How much do you know about human rights for [persons trading sex] or entertainers, women, and youth?” and “How much do you know about reproductive health rights (e.g., family planning, contraceptives, condoms)?” Thoughts on community goals were measured using a 1 to 10 scale for the question “How much have you thought about the goals of female entertainers or [persons trading sex] as a community or group?”.
Covariates were substance use, experiences of violence or abuse during transactional sex, human trafficking experience, and socio-demographic information. Substance use was measured by (Y/N) answers to “Have you used drugs in the past three months?” Incidents of physical or sexual violence during transactional sex were measured by responding “physical abuse or violence” or “sexual abuse” to the question “Have you ever experienced the following violence or abuse against you as an entertainer or [from trading sex on the street]?” Socio-demographic variables included age, gender, education, occupation location, marital status, income, and the number of children. Human trafficking was measured by the question, “Have you ever been trafficked (tricked or forced) into being an entertainer or trading sex on the street?”.

2.2. Data Analysis

The current study conducted bivariate descriptive statistics using chi-square statistics to determine whether individuals with previous community mobilization experience were more likely to want to engage in future organizing around human rights. T-test statistics were used to determine whether individuals with more knowledge of human and reproductive rights or who considered group goals were more willing to participate in future human rights organizing. Next, multiple logistic regressions, using a forward stepwise approach, revealed independent associations between abuse and trafficking and the desire to participate in future mobilization, adjusting for previous experience with community mobilization, visualization of goals as a group, knowledge of human and reproductive rights, and other variables (i.e., location of selling sex, recent drug use, age, gender, occupation, marital status, and their number of children).

3. Results

A total of 96 participants were included in this cross-sectional analysis. Almost two-thirds (63.4%) of the participants were female, over half were either married or living with a partner (53.8%), and three-quarters worked on the street instead of in venue-based locations such as a bar. The participants’ median age was 23 years old, education level (10 years), daily income (500 pesos), and their number of children (1). Furthermore, two-thirds of the participants experienced physical or sexual abuse, and one-third reported being trafficked. Nearly one-fifth (18%) of participants reported recent drug use. Three-quarters had not previously participated in community mobilization activities.
Table 1 examines socio-demographic and socio-behavioral characteristics associated with interest in future participation in an organization that addresses health and human rights. Chi-square analyses did not reveal significant differences in participation in organization associated with gender (X2 = 0.01, p > 0.05), marital status (X2 = 0.59, p > 0.05), work location (X2 = 1.55, p > 0.05), previous experiences of abuse (X2 = 2.78, p > 0.05), trafficking (X2 = 1.26, p > 0.05), and community mobilization activities (X2 = 3.55, p > 0.05), or recent drug use (X2 = 0.01, p > 0.05). Independent samples t-tests demonstrated no significant differences in future participation associated with age (t = −0.49, p > 0.05), years of education (t = −0.79, p > 0.05), daily income (t = −1.61, p > 0.05), or number of children (t = −0.94, p > 0.05).
Independent samples t-tests revealed significant differences in future organization interests (Table 2). More abuse and fewer trafficking experiences were significantly associated with a desire to mobilize, as were male gender and having fewer children. Results demonstrated that participants who reported thinking more about the goals of entertainers or persons trading sex as a community or group were more likely to be willing to participate in an organization addressing their health and human rights (t = −5.60, p < 0.01). Similarly, those who reported having more health and human rights knowledge also were more likely to be interested in future organizing (t =−2.43, p < 0.05). Reproductive rights knowledge was not associated with interest in health and human rights organization (t = −1.75, p > 0.05).
In logistic regression models, previously experienced abuse (AOR = 10.86; CI 1.48–79.69), and less history of trafficking (AOR = 0.14; 95% CI 0.02–0.97), were significantly associated with interest in future participation in health and human rights organization, as well as community mobilization experience (AOR = 41.75; 95% CI 1.96–891.19), thinking about the goals of the community/group (AOR = 2.12; 95% CI 1.37–3.28), and adjusting for other factors: older age, more income, male gender (AOR = 0.11; 95% CI 0.01–0.08), and less number of children (AOR = 0.28; 95% CI 0.12–0.66) which were significantly associated with more desire to mobilize. Participants who thought about the goals of the group or community had two and a half times the odds of being interested in future health and human rights organizations. Before this intervention, those who experienced community mobilization had more than a hundred times the odds of being interested in future organizing than participants without previous experience. Male participants had nearly twenty-five times the odds of being interested in health and human rights than female participants. Knowledge of health and human rights became statistically insignificant in association with the desire to mobilize in adjusted models.

4. Discussion

Over 80% of the participants trading sex in this Metro Manila-based Philippines study expressed interest in participating in an organization addressing health and human rights in the future, with two-thirds having never engaged in mobilization activities in the past. Participants who reported being trafficked into selling sex had lower odds of being interested in future participation in health and human rights organizations but nearly 11 times higher odds if they were previously ever abused when they sold sex. This study provides insight into factors associated with willingness to participate in health and human rights mobilization among men and women trading sex, such as thinking about community goals, history of community mobilization participation, human trafficking and abuse, gender, and the number of children.
The present study found that trafficked participants had lower odds of willingness to participate in health and human rights organizations in the future. A possible explanation is that trafficked individuals may be unwilling to participate in organizations out of fear or lack of trust or hope. For example, many individuals trafficked into selling sex have experienced the severest forms of physical or sexual violence [32,33,34], contributing to feelings of fear, powerlessness, and unwillingness to participate in human rights organizations. In addition, the psychological states of human trafficking survivors in the Philippines have been documented [35]. In addition, non-government organizations in the Philippines have long helped those selling sex with HIV prevention interventions [36]; few, however, focus specifically on human trafficking survivors [34]. More research needs to explore how human trafficking survivors feel about community mobilization efforts or those currently human trafficked.
In contrast, participants who reported experiencing physical or sexual abuse while trading sex had over ten times the odds of intending to participate in organizing around health and human rights. Individuals are especially vulnerable to experiencing abuse or violence from their clients or police enforcement while trading sex [37,38,39]; there is a strong need for community mobilization and human rights efforts to address the issue of violence. In addition, some community mobilization efforts have occurred in other national contexts where women who sold sex mobilized for changes in police practices [40,41].
Participants in the present study who considered the goals of a community/group were twice as likely to be interested in future mobilization. A possible explanation is that participants who think about group goals may be more likely to identify as part of the group. They may also have been exposed to or reached by (no matter how limited) education activities conducted by NGOs. Other research has demonstrated that group membership or collective identity is positively associated with action and participation [42,43]. Future research incorporating more detailed scales about goal formation, group identity, and human rights participation is needed. Respondents who reported thinking of the goals of persons who sell sex may have been made aware of these goals in their involvement in community mobilization and organizations. They may have realized certain objectives when engaging in community mobilization and collective action. Moreover, they may have seen strength in numbers. These results corroborate previous findings that persons involved in community mobilization would engage in future organizing efforts [44].
Furthermore, compared to participants with no prior experience, those who had participated in community mobilization activities before this study were much more likely to be interested in future organization participation. These findings support the literature on community mobilization, which has intervened against several health and human-rights-related issues such as violence against women and the HIV epidemic [28,45,46,47,48]. HIV prevention interventions involving community mobilization have effectively improved collectivization outcomes for persons trading sex in other global contexts. For example, women selling sex were more likely to have consistently used condoms with their occasional and regular sexual partners if they had higher self-reported collective efficacy levels than those with lower levels [29,42]. Furthermore, increased exposure to community mobilization has been associated with increased consistent condom utilization [27,29].
In the Philippines, the women’s movement has been relatively active in mass mobilization and organizing activities covered by print, audio-visual, and even social media [49]. In many instances, these collective actions have brought positive results for the organization [49]. Recognizing the value of community mobilization may also be attributed to the participants’ exposure to the mass media, particularly among the women participants.
However, men were more likely to be interested in future mobilization than women in this study. A possible explanation of this finding is that men could have fewer concerns or more time to engage in community mobilization than women. For example, men who trade sex in the Philippines are usually establishment-based or freelancers (street walkers), or both simultaneously [50]. Usually, they sell sex due to financial necessity [50]. Some in the present study had female marriage partners and supported their families.
On the other hand, women may have multiple burdens, such as being a breadwinner, mothers, or caretakers of other family members. However, little research has examined gender differences in participation rates in health and human rights organizations and community mobilization activities. Further study comparing men and women trading sex could help explain this variation in their potential to participate in human rights efforts.
Another key finding was that participants with children had lower odds of being interested in participation in mobilization activities. One possibility is that taking care of a family may limit the amount of time and energy spent on other health and human rights activities. For example, they may feel their involvement may impact their family, including their children, especially if they are the primary breadwinners. Participation may also lead to their children or other family members learning about the participants’ involvement in selling sex. Finally, participants may fear that they or their children may be stigmatized [30].
A limitation of this study is that participants were willing to attend a group intervention in the first place. Therefore, the participants were probably more likely to be interested in future organizing around their health and human rights than those who did not attend. Another limitation is that the number of participants with previous experiences of abuse or trafficking may be higher than what they reported in this study. Human trafficking victimization and violence are likely to be under-reported due to stigma or lack of knowledge or recognition of abuse or exploitation. Furthermore, the study was not a randomized controlled trial. Instead, the analysis was based on self-reported measures and a cross-sectional design. Some measures contained one item. Future research should also develop scales to describe and measure constructs such as human trafficking better. The results of this study may not be generalizable to all street and venue-based individuals engaged in trading sex in the Philippines. There may also be variations in rural and urban areas. The participants in this sample may have different views today than when this study took place before any political administration changes.

5. Conclusions

This study found several factors associated with community mobilization interest among men and women selling sex in the Philippines: abuse and less experience with trafficking, previous mobilization, and thinking about goals as a community or group. On the other hand, having more children, being female, and having experiences with human trafficking were associated with less desire to mobilize. These findings have important implications for future research on individuals trading sex. Understanding the factors associated with increased participation in health and human rights organizations can inform the design and recruitment for future community-based interventions.
The community mobilization intervention for those in the present study specifically educated the participants on human rights laws that could help mitigate some of the abuse they experienced. For example, programs in the Philippines have focused on strengthening the core workplace skills of human trafficking survivors to reduce their re-entry into sex trafficking [51].
The findings of this research can inform the development of policies that help vulnerable populations in the Philippines safely seek help for trauma, abuse, and trafficking. One way to do this is by being aware of their reluctance to engage in community mobilization efforts when they have histories of being trafficked. Likewise, vulnerable men and women caught up in illicit substance use as a way of coping may fear harsh consequences when seeking help. Extra caution may be needed when tailoring interventions for these populations. On the other hand, those victimized by physical and sexual abuse when trading sex were more likely to mobilize if given the opportunity. Persons selling sex in the Philippines may not be aware of policies that protect them from trafficking and abuse. Humane ways of addressing trauma among these populations are urgently needed.

Author Contributions

Conceptualization, L.A.U. and J.H.L.; methodology, L.A.U.; software, L.A.U.; formal analysis, J.H.L. and L.A.U.; investigation, J.H.L. and L.A.U.; data curation, L.A.U.; writing—original draft preparation, J.H.L. and L.A.U.; writing—review and editing, L.A.U., E.E.R., N.P.S. and L.I.H.; supervision, L.A.U.; project administration, L.A.U.; funding acquisition, L.A.U. All authors have read and agreed to the published version of the manuscript.

Funding

The original data collection was supported by funding from the Fordham University HIV and Drug Abuse Prevention Research Ethics Training Institute Research (research project award to PI Urada) supported by National Institutes of Drug Abuse Grant #R25 DA031608 (Celia B. Fisher, Ph.D., Principal Investigator), the National Institutes of Drug Abuse (Grant #K01DA036439 PI: Urada), and the University of California Los Angeles International Institute.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) of the University of California San Diego (protocol code 111058 and date of approval 072916).”

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The de-identified data presented in this study are available on request from the corresponding author. Data are not publicly available due to the vulnerability of this population.

Acknowledgments

The authors would like to acknowledge the research staff, peer educators, and participants in the Philippines for contributing to the project.

Conflicts of Interest

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

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Table
Table 1. Socio-demographic and socio-behavioral characteristics are associated with interest in future participation in health and human rights organizations (n = 96).
Table 1. Socio-demographic and socio-behavioral characteristics are associated with interest in future participation in health and human rights organizations (n = 96).
N (%)Participate in an Organization Addressing Health and Human Rightsp-Value
Median (Range)Yes (n = 78)No (n = 18)
Gender
Male37 (38.5)29 (37.2)8 (44.4)0.93
Female59 (61.5)49 (62.8)10 (55.6)
Marital Status 0.44
Married or Living with Partner50 (53.8)40 (51.9)10 (62.5)
Single/Other43 (46.2)37 (48.1)6 (37.5)
Work Location 0.21
Street70 (75.3)56 (72.7)14 (87.5)
Venue-based23 (24.7)21 (27.3)2 (12.5)
Experienced Abuse (physical, sexual) 0.1
Yes61 (63.5)53 (71.4)8 (50.0)
No35 (36.5)25 (28.6)10 (50.0)
Experienced Trafficking 0.26
Yes33 (37.6)26 (33.3)7 (38.9)
No63 (62.4)52 (67.9)11 (61.1)
Drug Use in the Past 3 Months 0.93
Yes16 (18.0)13 (16.9)3 (18.8)
No73 (82.0)60 (77.9)13 (81.3)
Community Mobilization Experience 0.06
Yes24 (25.0)23 (29.5)1 (.06)
No72 (75.0)55 (70.5)17 (94.4)
Age23 (15–48)25.6 (7.9)24.6 (7.4)0.63
Income (pesos)500 (0–10,000)1063.1 (1594.1)637.5 (769.1)0.11
Years of Education10 (1–16)9.2 (3.0)8.6 (2.8)0.44
Number of Children1 (0–6)1.2 (1.4)1.5 (1.3)0.36
Knowledge of Health and Human Rights5.2 (3.3) *5.4 (3.4)3.7 (2.3)0.02 ***
Knowledge of Reproductive Rights6.0 (3.4) **6.3 (3.3)4.6 (3.5)0.1
Had Thought About the Goals of the Group/Community4.9 (3.2)5.5 (3.1)2.3 (1.8)0.001 ****
* 91 observations, ** 92 observations, *** p < 0.05, **** p < 0.001.
Table
Table 2. Factors independently associated with interest in future participation in health and human rights organizations (n = 96).
Table 2. Factors independently associated with interest in future participation in health and human rights organizations (n = 96).
Adjusted Odds Ratio (AOR)95% CI
Experienced Abuse10.861.48–79.69 *
Experienced Trafficking0.140.02–0.97 *
Considered Goals of the Group/community2.121.37–3.28 ***
Previous Community Mobilization Participation around Health and Human Rights41.751.96–891.19 *
Number of Children0.280.12–0.66 **
Gender0.110.01–0.80 *
Age1.191.03–1.38 *
Income1.001.00–1.00
* p < 0.05, ** p < 0.01, *** p < 0.001.
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Urada, L.A.; Ly, J.H.; Simbulan, N.P.; Hernandez, L.I.; Reed, E.E. Traumatic Associations amongst Men and Women Selling Sex in the Philippines. Trauma Care 2022, 2, 330-340. https://doi.org/10.3390/traumacare2020027

AMA Style

Urada LA, Ly JH, Simbulan NP, Hernandez LI, Reed EE. Traumatic Associations amongst Men and Women Selling Sex in the Philippines. Trauma Care. 2022; 2(2):330-340. https://doi.org/10.3390/traumacare2020027

Chicago/Turabian Style

Urada, Lianne A., Jasmine H. Ly, Nymia Pimentel Simbulan, Laufred I. Hernandez, and Elizabeth E. Reed. 2022. "Traumatic Associations amongst Men and Women Selling Sex in the Philippines" Trauma Care 2, no. 2: 330-340. https://doi.org/10.3390/traumacare2020027

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