Dignity: A Journal on Sexual Exploitation and Violence Volume 1 | Issue 1 Article 7 November 2016 Predictors of Readiness to Exit Commercial Sexual Exploitation Among Women in India and the U.S. Bincy Wilson University at Bufalo, bincywil@bufalo.edu homas H. Nochajski University at Bufalo, thn@bufalo.edu Follow this and additional works at: htp://digitalcommons.uri.edu/dignity Part of the Gender and Sexuality Commons, and the Social Work Commons Recommended Citation Wilson, Bincy and Nochajski, homas H. (2016) "Predictors of Readiness to Exit Commercial Sexual Exploitation Among Women in India and the U.S.," Dignity: A Journal on Sexual Exploitation and Violence: Vol. 1: Iss. 1, Article 7. Available at: htp://digitalcommons.uri.edu/dignity/vol1/iss1/7 his Research and Scholarly Article is brought to you for free and open access by DigitalCommons@URI. It has been accepted for inclusion in Dignity: A Journal on Sexual Exploitation and Violence by an authorized administrator of DigitalCommons@URI. For more information, please contact digitalcommons@etal.uri.edu. Predictors of Readiness to Exit Commercial Sexual Exploitation Among Women in India and the U.S. Abstract Exiting commercial sexual exploitation (CSE) is a diicult and prolonged process. his study examines the predictors of readiness to exit CSE, using the stages of change model as an underlying framework, among women in India (n=163) and the U.S. (n=87). Constructs such as years of schooling, residence, unemployment, age of entry, causes of entry, types of exploitation, addictions, presence of perpetrator, culture – individualistic and collectivistic, stigma, social support, empowerment, and current involvement in CSE were assessed. Results of a multi-group analysis indicated signiicant diferences in the relationships between readiness to change and the predictor measures. For the Indian sample, years of schooling, economic conditions/abuse/runaway behavior as reasons for entry, individualistic and collectivistic culture approaches, and stigma were associated with readiness to change. For the U.S. sample, living by oneself, abuse/runaway behavior as reasons for entry, indoor experiences of exploitation, substance abuse problems, collectivist cultural approach, social support, and current involvement in CSE were associated with readiness to change. However, some similarities were also found. he indings suggest that service provision must focus on addressing the constructs that increase the readiness to exit, while also being culturally competent. Keywords Commercial sexual exploitation, predictors of exit, multi-group, cross-cultural Creative Commons License his work is licensed under a Creative Commons Atribution-Noncommercial-No Derivative Works 4.0 License. Acknowledgements Fahs Beck Foundation Gender Institute, University at Bufalo hree referees reviewed this article using a double-blind review process. With the permission of the reviewers and the authors, Dignity thanks them for their time and expertise. hey are: Sven-Axel Mansson, Professor Emeritus, Social Work, Malmo University, Sweden; Joan A. Reid, Assistant Professor, Criminology and Co-Director and Psychotherapist, Restoring Innocence Lost Counseling Collaborative, University of South Florida, USA; and Pravin Patkar, Adjunct Professor, Amrita University, India. his research and scholarly article is available in Dignity: A Journal on Sexual Exploitation and Violence: htp://digitalcommons.uri.edu/dignity/vol1/iss1/7 Wilson and Nochajski: Predictors Volume , Issue , Article , PREDICTORS OF READINESS TO EXIT COMMERCIAL SEXUAL EXPLOITATION AMONG WOMEN IN INDIA AND THE UNITED STATES Bi cy Wilso University of Bufalo Tho as H. Nochajski University of Bufalo ABSTRACT Exiting commercial sexual exploitation (CSE) is a difficult and prolonged process. This study examines the predictors of readiness to exit CSE, using the stages of change model as an underlying framework, among women in India (n= ) and the U.S. (n= ). Constructs such as years of schooling, residence, unemployment, age of entry, causes of entry, types of exploitation, addictions, presence of perpetrator, culture – individualistic and collectivistic, stigma, social support, empowerment, and current involvement in CSE were assessed. Results of a multi-group analysis indicated significant differences in the relationships between readiness to change and the predictor measures. For the Indian sample, years of schooling, economic conditions/abuse/runaway behavior as reasons for entry, individualistic and collectivistic culture approaches, and stigma were associated with readiness to change. For the U.S. sample, living by oneself, abuse/runaway behavior as reasons for entry, indoor experiences of exploitation, substance abuse problems, collectivist cultural approach, social support, and current involvement in CSE were associated with readiness to change. However, some similarities were also found. The findings suggest that service provision must focus on addressing the constructs that increase the readiness to exit, while also being culturally competent. KEYWORDS commercial sexual exploitation, predictors of exit, multi-group, cross-cultural C OMMERCIAL SEXUAL EXPLOITATION (CSE) of women and girls is a global social justice issue, which reflects violence against women and amounts to gross violation of human rights (Barry, ; Leidholdt, ). For the purposes of the current study, the focus is on women who were trafficked/forced into prostitution, meaning that the women did not freely choose the sex trade, circumstances forced them into the industry, whether it was the result of economic conditions, some form of abuse, or drug addiction, or direct coercion, societal pressure, religion, or family. According to a recent global estimate on forced labor, the total number being forcibly sexually exploited at any given time is . million; with percent being female (International Labor Organization [ILO], ). Another international organization that assists victims of such crime around the globe reports two-thirds being female and percent subjected to CSE (International Organization for Migration [IOM], ). Although these figures are an estimate of Published by DigitalCommons@URI, 2016 1 Dignity: A Journal on Sexual Exploitation and Violence, Vol. 1, Iss. 1 [2016], Art. 7 the magnitude of the problem, they reflect the preponderance of females among those being commercially sexually exploited. In this study we examine the exit process from CSE in two countries, India and the United States (U.S.), which are major source, transit, and destination countries for trafficking for the purpose of CSE (United States Department of State [USDS], ). In India, it is estimated that million women and girls are commercially sexually exploited, of which % are children, and a vast majority are Indian citizens (Ministry of Women and Child Development, Government of India [MWCD], ). National-level data on sex trafficking cases in the U.S. between revealed % were female, % involved U.S. citizens, and % involved minors (Banks & Kyckelhahn, ). Apart from the similarity in the magnitude of the problem within the borders in both countries, these two countries also reflect differing cultural approaches. The U.S. reflects an individualistic cultural approach while India reflects a collectivistic one. Therefore, an examination of predictors of exit from CSE within these two countries would enable us to identify the cultural nuances involved in the exiting process. Studies documenting the experiences of women in CSE describe the overwhelming presence of violence, victimization, captivity, criminalization, and commoditization (Gupta, Raj, Decker, Reed, & Silverman, ; Panchanadeswaran et al., ; Raphael & Shapiro, ; Williamson & Folaron, ). The traumatic experience is not limited to while in the sex industry, but also prior to entering it, and continuing to have a debilitating impact on the lives of victims even after exit (as reviewed in Wilson & Butler, ). Most often, women are left with a range of health consequences, psychological illnesses, emotional problems, addictions to substances, stigma, and difficulties envisioning themselves in and transitioning into mainstream society (Farley et al., ; Jackson, Bennett, & Sowinski, ; Raymond et al., ; Sallmann, ; Zimmerman et al., ). The extant research on CSE has focused on identifying the characteristics of individuals in CSE and the factors causing entry into CSE (Estes & Weiner, ; Dandona et al., ; Kramer & Berg, ; Vindhya & Dev, ), experiences while in CSE (Farley et al., ; Hossain, Zimmerman, Abas, Light, & Watts, ; Panchanadeswaran et al., ; Raphael & Shapiro, ), addictions to substances (Bowser, Ryan, Smith, & Lockett, ; Yahne, Miller, Irvin-Vitela, & Tonigan, ), and HIV/AIDS and other STI concerns among this population (Gupta, Reed, Kershaw, & Blankenship, ; Halli, Ramesh, O’Neil, Moses, & Blanchard, ; Shannon, Bright, Gibson, & Tyndall, ; Surratt & Inciardi, ). However, the understanding of exit from CSE has seen limited published research, with the little that does exist, being qualitative in nature and conducted predominantly in the West (Dalla, ; Mansson & Hedin, ; Oselin, ; Sanders, ), and a handful of studies conducted in non-western countries (Learmonth, Hakala & Keller, ; Manopaiboon et al., ). The process of exit from CSE is often understood as a difficult and prolonged process that may involve numerous exit-re-entry-exit cycles (Dalla, ; Manopaiboon et al., ; Mansson & Hedin, ; Sanders, ; Saphira & Herbert, ). During this process, women experience multiple barriers and have a high probability of returning back into the sex industry (Dalla, ; Manopaiboon et al., ; Mansson & Hedin, ). Baker, Dalla and Williamson ( ) have integrated various exit models in an attempt to understand exiting from prostitution, comparing more general approaches provided by Prochaska, DiClemente and Norcross’s ( b) Stages of Change model and Fuchs Ebaugh’s ( ) Role Exit http://digitalcommons.uri.edu/dignity/vol1/iss1/7 2 Wilson and Nochajski: Predictors Model, to those more specific to CSE as seen in Mansson and Hedin’s ( ) Breaking the Matthew Effect and Sander’s ( ) Becoming an ex-sex worker. This comprehensive integrated model views exit from CSE as occurring in stages, involving immersion, awareness, planning, initial exit, reentry and final exit, and lays the foundation for our understanding of exit as a continuous dynamic process rather than as a single event. Within the context of the integrated model proposed by Baker and colleagues ( ), is the concept of readiness to change. While not directly referred to, the explanation of the model infers that this is a critical element that helps determine whether an individual continues to move forward or may revert/relapse back into the sex trade. This construct of readiness to change is a product of the Stages of Change model put forward by Prochaska and DiClemente ( a) and is an indication of the dynamic elements within the change process (Prochaska, DiClemente, & Norcross, b). The measurement of readiness to change is considered a more critical indicator of an individual’s motivation to change, than is the actual measurement of stages (Carey, Purnine, Maisto, & Carey, ). While the stages of Change model has been used in research studies to predict women leaving abusive relationships and staying away from abuse within the context of intimate partner violence (Burke, Mahoney, Gielen, McDonnell, & O’Campo, ), entering substance abuse treatment programs (Brown, Melchior, Slaughter, & Huba, ), recovering from substance abuse issues (Heather, Hönekopp, & Smailes, ; Teater & Hammond, ), and understanding the process of recovery among survivors of childhood sexual abuse in therapy (Koraleski & Larson, ), the integrative model of Baker and colleagues ( ) has not yet been tested. Within the context of the current paper, we consider elements that Baker and colleagues identified as having been important to exiting the sex trade, and how these relate to readiness to change. Thus, assessing a woman’s readiness to exit CSE would help in identifying the factors that are associated with and that facilitate their movement along the continuum of exiting. Factors Associated ith Bei g i CSE An international report on re-trafficking into CSE has identified women coming from economically deprived backgrounds, with limited education and inability to find and sustain employment, as being more vulnerable to being re-trafficked, with a vast majority being trapped in CSE (IOM, ). On more than one occasion, women who were rescued and assisted by IOM in the past, re-enter the sex industry for lack of other viable options. Poor socio-economic backgrounds, unemployment or lack of sustainable income, limited or lack of education, and presence of perpetrators have been identified as factors causing entry into CSE, in both India and the U.S. (Belcher & Herr, ; Clarke, Clarke, Roe-Sepowitz, & Fey, ; Gupta et al., ; Kennedy, Klein, Bristowe, Cooper, & Yuille, ; Kramer & Berg, ; Vindhya & Dev, ). Research studies conducted in the West have explored the relationship between many of these precipitating factors and their association with remaining in the sex industry. For instance, entering CSE at an early age has not only a debilitating impact on the development of the individual (Clarke et al., ), but is also associated with staying in the sex industry for a longer duration (Cobbina & Oselin, ; Roe-Sepowitz, , see also Dandona et al., in India). Women in indoor forms of CSE are older at the age of entry, spend a longer time in the sex industry, are slightly more educated and therefore able to transition into more skilled jobs post exit, as compared to those in outdoor forms who are younger at Published by DigitalCommons@URI, 2016 3 Dignity: A Journal on Sexual Exploitation and Violence, Vol. 1, Iss. 1 [2016], Art. 7 the age of entry, and report limited education (Sanders, ). Addiction to substances, which could arise either prior to or post entry into CSE, also acts as a barrier during their exit process from CSE (Kurtz, Surratt, Kiley, & Inciardi, ; Romero-Daza, Weeks, & Singer, ). However, the impact of these factors on the exit process remains largely unstudied, especially within different cultural contexts. Culture is an integral part of society that provides information to individuals within a society on what has worked in the experience of the society and is useful in transmitting such knowledge to future generations (Triandis, ). Culture is said to influence the personality of individuals (as reviewed in Triandis & Suh, ). In an individualistic society such as the U.S., the focus is on independence, competitiveness, self-reliance, and in primarily valuing one’s personal achievement or well-being, where the self is independent of the in-group. However, in a collectivistic society such as India, individuals are traditionalists, emphasizing ingroups (such as family, tribe) cohesion and interdependence, and subordination of personal needs and goals while prioritizing those of the in-groups. Therefore, it is imperative to not only identify the factors that influence the exit process within these distinct cultures (as knowledge obtained from an individualistic society cannot be generalized to the phenomenon within a collectivist society), but to also understand the impact of culture itself on the exit phenomenon. Women in the sex industry often encounter tremendous stigma from the society, which acts as a barrier preventing them from approaching social service agencies, health and mental health care, and accessing the support available to facilitate exit (Bindel, ; Kurtz et al., ; Sallmann, ; Suresh, Furr, & Srikrishnan, ). Even after exiting CSE and attempting to mainstream into societies, some have reported enormous challenges adjusting to life post exit due to the high level of social stigma attached to their involvement in the sex industry and different standards of cultural expectations from women (Hennink & Simkhada, ; Mansson & Hedin, ; Vindhya & Dev, ). Thus, it is important to examine the impact of stigma on the process of exit within different cultural contexts. Supportive relationships have been identified as being not just a protective factor against intimate partner violence (Bybee & Sullivan, ) but also a critical factor in mobilizing women to leave the sex industry (Dalla, ; Hedin & Mansson, ). It refers to both informal (family, friends) and professional (staff of organizations) support that women might have access to while in the sex industry (Hedin & Mansson, ). Qualitative research has observed that a healthy supportive relationship has encouraged women to exit CSE, while relationships with greater dependency needs often latch on as parasites for their own survival and forces the women’s continued exploitation in CSE (Dalla, ; Manopaiboon et al., ; Raghavan & Pawar-Kate, ). This aspect needs to be further explored within larger samples, to establish its association with exiting CSE. Empowerment is considered an essential factor in recovery oriented programs and systems, as it operationalizes and measures personal empowerment (Rogers, Ralph, & Salzer, ). Empowerment theory has been used with women in substance abuse, sexual assault, and domestic violence programs to understand the process of change (Busch & Valentine, ; Campbell et al., ; Gibson, ). Empowerment is the process by which the powerless gain greater control over various circumstances in their lives (Kabeer, ; Pradhan, ). It reflects greater self-confidence, inner transformation of one’s consciousness, decision-making power, and outrival of systemic sources of subordination. However, this construct has not been assessed among women exiting CSE. http://digitalcommons.uri.edu/dignity/vol1/iss1/7 4 Wilson and Nochajski: Predictors Research among women escaping intimate partner violence has identified that higher social support and access to resources is associated with higher overall quality of life (Bybee & Sullivan, ), which is a significant negative predictor of reabuse (Tan, Basta, Sullivan, & Davidson, ). Studies have used quality of life as a measure to assess the performance of various groups in clinical settings (Stevanovic, ). Quality of life refers to the degree of enjoyment and satisfaction that women experience in various areas of life (such as physical health, mood, work, and sexual life among others). Thus, within the context of women exiting CSE, assessing the impact of quality of life on women’s readiness to exit would better assist in understanding the process of recovery. Curre t Study In the current study, we will address two important limitations of past research. First, to date, no known studies have identified the predictors of exit from CSE in a quantitative manner. Second, the knowledge base on the process of exit from CSE has been limited to the West. Using readiness to change and the integrative model of Baker et al. ( ), we sought to identify some of the critical factors associated with exit from CSE. Also, the global and international nature of CSE of women makes it imperative to understand and address this phenomenon keeping in mind varied socio-cultural contexts. Thus, our sample consisting of women in/exiting CSE from two culturally distinct countries would be able to begin building a culturally competent knowledge base in this field. The two main goals of this study are: (i) identifying the factors that predict readiness to exit CSE among women, and (ii) examining if these predictors differed across cultures (India and the U.S.). Given the relative lack of known research identifying the predictors of exit from CSE, we included factors that are associated with entering or remaining in the sex industry, such as years of schooling, dependents, marital status, residence, job situation, current involvement in CSE, age of entry, causes of entry, time in CSE, types of exploitation, addictions, presence of perpetrator, culture, stigma, social support, empowerment and quality of life as predictors. METHOD Paricipa ts The study consisted of women participants ( from India and from the U.S.). The two eligibility criteria being the women had to be in either of the three phases - currently in, exiting, or already exited from CSE and who were receiving, or had received services from social service organizations that served victims of CSE. A total of agencies from the U.S (specifically in California - San Francisco, Oakland, San Jose, Los Angeles and San Diego) and India (Bangalore, Goa, Mumbai, Delhi and Kolkata), distributed evenly across both counties, participated in the study. All the participants were included in the study. The mean age of the participants was . years (SD = . ) in India, and . years (SD = . ) in the U.S., with ages ranging from to years. Information on ethnicity was gathered only for the U.S. sample since this variable was not relevant in India. In the U.S., the highest represented ethnicity was African American (n = , %), followed by Caucasian (n = , %), Hispanic/Latino (n = , %), Bi-racial (n = , %), Native American (n = , %), and Asian/Pacific Islander (n = , %). In Published by DigitalCommons@URI, 2016 5 Dignity: A Journal on Sexual Exploitation and Violence, Vol. 1, Iss. 1 [2016], Art. 7 India, information was gathered on religious affiliation since this was more relevant in terms of the Indian census classification. The vast majority was Hindu (n = , %), followed by Muslim (n = , %) and two ( %) Christians. Procedures The participating agencies were identified through web searches, personal contacts and snowball sampling techniques. Out of the agencies that were approached, the proportion that participated was / in India and less than / in the U.S. The staff at these agencies was requested to make announcements during group activities or individual counseling sessions, conducted routinely within the agency, to ascertain the willingness of women to participate in the proposed study. Additionally flyers were used within agencies, especially in the U.S., to recruit women, but in India this was not used due to the low level of literacy among this population. Another mode of recruitment adopted was the snowball sampling technique – by requesting the women who did participate in the study to inform their peers in/exiting CSE about the study. The women who expressed their interest in the study were then directed to the researcher by the staff. Data was collected using a survey questionnaire, between January and August , after obtaining approval from the researcher’s university Institutional Review Board (IRB). A survey questionnaire was developed primarily in English, and translated into two Indian languages - Hindi and Kannada (and back translated), for the purpose of administration in India. Participants were compensated Rs. in India, and $ in the U.S. for completing the survey. In India, factoring in the low level of literacy among women in CSE, as well as their level of comfort, all questionnaires were administered in an interview format, by the researcher (the principal investigator). Although this method of administration was expensive, time consuming (average - minutes per participant), and subject to investigator effect, it ensured that participants had a clear understanding of the questions, a high response rate was achieved. In the U.S., different options, such as paperbased, or telephone-based, were offered for filling out the questionnaire. In some organizations, the researcher was permitted to be present while the women were filling out the survey to clarify any concerns they may have had, while in other organizations, the staff preferred either directly handing the questionnaire to the women, who would complete and return to the staff, or administering them over the telephone. Measures Readiness to change. A standardized instrument, namely the University of Rhode Island Change Assessment (URICA) (McConnaughy, Prochaska, & Velicer, ) was used to measure and determine readiness to change in the process of exit from CSE. This is a -item scale consisting of four -item subscales - precontemplation, contemplation, action, and maintenance. The initial instructions informed the participants to consider involvement in the sex industry as the focus for all questions. A sample item for pre-contemplation is, “I’m not the problem one. It doesn’t make much sense for me to be here”; a sample for contemplation is, “I think I might be ready for some self-improvement”; a sample for action is, “I am doing something about the problems that had been bothering me”; and a sample for maintenance is, “I may need a boost right now to help me maintain the changes I’ve already made”. The original -point Likert scaling format was converted into a -point format ( = Strongly Disagree to = Strongly Agree) for effectiveness and to elicit a definitive answer. The reliability coefficients for the four subscales were http://digitalcommons.uri.edu/dignity/vol1/iss1/7 6 Wilson and Nochajski: Predictors . ,. ,. , and . , for the pre-contemplation, contemplation, action and maintenance subscales, respectively. The readiness to change score (RCS) for each individual was obtained by summing up the scores on the items for contemplation, action and maintenance subscales and subtracting the scores on items for pre-contemplation subscale (Carey et al., ). Age of entry. Participant age of entry was determined by self-report, where they were asked to indicate the age at which they were first commoditized for sexual purposes. For those who were unable to provide an exact number, an approximate age was obtained. Causes of entry. Participants were asked to indicate the cause of their entry into CSE by either checking from the list of causes provided or by specifying any additional cause that is not mentioned at the end of the options. Although the responses were grouped into causes, for purposes of the current study, these were collapsed into economic conditions (also includes poverty, survival sex), running away behavior (includes running away from home and foster care), abuse (experience of child physical or sexual abuse, other trauma, or being addicted), and being coerced for various reasons (sold, forced, abducted, societal practices, pimped, lack of support). Since the participants checked multiple causes of entry, each of these four causes were used in the study and were treated as a dichotomous variable where = Yes and = No. Time in CSE. Participant time spent in CSE was determined by self-report, where they were asked to indicate the duration of time in terms of years, months or days, which was later converted as a fraction of years. Participants who had already exited CSE, provided the duration of time between their entry and exit, and for those who were still in the sex industry, the duration was determined as the difference between the age of entry and their current age. Types of exploitation. Participants were asked to indicate the various settings within which they were commercially sexually exploited, by providing multiple choices, and a blank space at the end of the options to specify any additional types that were not listed. The responses were grouped into three categorical variables (Outdoor, Indoor, Both) based on the responses. Outdoor types included street prostitution while indoor types included brothels, escort services, massage parlors, dance bars, strip clubs, peep shows, and pornography; and both were individuals that indicated experiencing both types of exploitation. For purposes of the current study because they could check both outdoor and indoor types, these were used as the measures in subsequent analyses. Addictions. Simple Screening Instrument for Substance Abuse (SSI-SA, Center for Substance Abuse Treatment, ) was used to assess addiction to substances (alcohol, drugs, or tobacco) during the past months. The SSI-SA is a -item scale, and uses a dichotomous response format ( = Yes or = No). A sample item is, “Have you tried to cut down or quit alcohol, drugs or other substances of your choice?” The total score on all the items provides the individual’s degree of risk associated with their addiction. The overall reliability of this measure for this study was ∝ = . . Perpetrator presence. The presence of a perpetrator was assessed with the following item “Do you have to give money earned to another individual?” The response was coded into a dichotomous format ( = Yes and = No). Published by DigitalCommons@URI, 2016 7 Dignity: A Journal on Sexual Exploitation and Violence, Vol. 1, Iss. 1 [2016], Art. 7 Culture – individualistic and collectivistic. A standardized instrument, namely, the Horizontal and Vertical Individualism and Collectivism Scale (HVICS) (Triandis & Gelfand, ) was used to measure the influence of cultural orientation on the respondent’s exit process. HVICS has been tested across different individualistic and collectivistic societies including the U.S. and India. This is a -item scale using a -point Likert scaling format ( = Strongly Disagree to = Strongly Agree), with two constructs – individualism and collectivism having items each. A sample item for individualism is, “I would rather depend on myself than others.” In terms of collectivism, a sample item is “The well being of my co-workers is important to me.” The reliability for the individualism subscale was . , while for the collectivism subscale it was . . Perceived stigma. Sex Worker Stigma Index (SWSI; Liu et al., ) was used to measure how the perceived stigma among women in CSE impacts their exit process. SWSI was developed and tested in India among women in CSE. This is a item scale, using a -point Likert scaling format ( = Strongly Disagree to = Strongly Agree), and comprising two domains - perceived stigma from community, and one’s family ( items each). A sample item is, “I feel that if I disclosed my identity to some people they would not talk to me anymore.” The overall reliability of the scale for this study was ∝ = . . Social support and satisfaction with social support. The social support system variable was measured through a -item scale called Social Support QuestionnaireShort Form (SSQ-SF) (Sarason, Sarason, Shearin, & Pierce, ). Each question consists of two-parts - the first part assesses the number of available individuals (not exceeding nine) that the respondent feels they could turn to in times of need in a variety of situations. A sample is, “Whom can you really count on to be dependable when you need help?” The second part measures the respondent’s degree of satisfaction with the perceived support available in that particular situation, where they indicate their satisfaction on a -point Likert scale ( = Very Dissatisfied to = Very Satisfied). Cronbach’s ∝ for this measure in the current study was . for social support and . for satisfaction with social support. Empowerment. A -item Empowerment Scale (Rogers, Chamberlin, Ellison, & Crean, ) was employed to measure the level of subjective feelings of empowerment on a -point Likert scale ( = Strongly Disagree to = Strongly Agree). Although the instrument had subscales, for the purpose of this study, only the total score was obtained, by adding the scores on items of self-esteem/self-efficacy, community activism and autonomy, righteous anger, and optimism and control over the future, and subtracting the scores on items of power-powerlessness subscale. A sample item is, “I have a positive attitude toward myself.” Cronbach’s ∝ for the powerless subscale was . , while for the other items, the alpha was . . Quality of life. Quality of Life Enjoyment and Satisfaction Questionnaire (QLES-Q) (Endicott, Nee, Harrison, & Blumenthal, ), a -item scale was used to measure quality of life. The last two items on this scale which were standalone items were not administered, as they were not relevant for the final scoring, making it a -item scale in this study. A sample item is, “Taking everything into consideration, during the past week how satisfied have you been with your physical health?” Responses were scored on a -point scale ( = Not at all satisfied to = Very satisfied), where higher scores indicate better enjoyment and satisfaction with life. Cronbach’s ∝ for this measure in the current study was . . Currently in CSE. This dichotomous variable asked the participants to indicate if they were currently involved in CSE, which was coded as = Yes and = No. Some http://digitalcommons.uri.edu/dignity/vol1/iss1/7 8 Wilson and Nochajski: Predictors of the respondents who did not choose either of these options, rather mentioned that there involvement in CSE was on a decline, were also included in the ‘Yes’ category. Years of schooling. The educational qualification of individuals, a continuous variable, was obtained by asking the participants to either provide their degree or years of schooling completed. All values in this variable were converted into numeric values based on the degree completed. Dependents. This was a continuous variable, where the respondents were asked to indicate the number of individuals that were dependent on them, including children. Marital status. Participants were asked to indicate their marital status by either choosing an option from the multiple choices provided, or by using the blank space to enter any additional status that may not be included in the list. The responses were coded as a dichotomous variable where, = Single (Single/Divorced/Separated/Widow/Abandoned) and = With Someone (Married/In relationship). Residence. Participants were asked to indicate their residence by either choosing an option from the multiple choices provided, or by using the blank space to enter any additional information that may not be included in the list. The responses were coded as a categorical variable where, = Supervised (Shelter/Transitional home), = Oneself and = Unstable (living with someone else, family, friends, partner or in a hotel). Job situation. Participants were asked to indicate their current job situation by choosing from a set of options provided or by filling in any additional information that may not be listed in the blank space at the end. The responses were coded as a dichotomous variable where, = Employed (legally employed either full time or part time), = Unemployed (living in shelter with no job, house wife, living on welfares, still in the sex industry which is not legal employment). A alysis For analysis, all the data obtained from India and the U.S. was coded and entered into the IBM Statistical Package for Social Sciences (SPSS) . An initial analysis was performed to determine the pattern of missing data. The results revealed that the U.S. sample had more missing data compared to the Indian sample, which may be due to the difference in the manner of survey administration in both countries. An overall missing value analysis conducted on all key variables of the study suggested a few missing cases in some predictor variables (i.e. years of schooling [n= , %], dependents [n= , %], current job situation [n= , %], age of entry [n= , %], time in CSE [n= , %], and types of exploitation [n= , %]), which were excluded for the purpose of bivariate analysis. However, to identify predictors, multivariate regression analysis was performed in MPlus (Muth9n & Muth9n, ), using full-information maximum likelihood (FIML) estimation due to the missing cases ( to percent). FIML imputes the values of the missing items based on all other variables being used in the analysis (similar outcomes to that of multiple imputation). Descriptive statistics including means, standard deviations, minimums, maximums, frequencies and percentages were computed for all variables. This revealed differences in the mean and standard deviation values for each country and therefore, bivariate analyses were conducted to identify their significance. Chi-square Published by DigitalCommons@URI, 2016 9 Dignity: A Journal on Sexual Exploitation and Violence, Vol. 1, Iss. 1 [2016], Art. 7 and cross tabulations for categorical variables and t-tests for continuous variables were performed. To ascertain effect sizes, square of Cramer’s V (ES) for categorical and Cohen’s d for continuous variables were computed. We then ran bivariate analyses looking at the relationships between our identified predictor measures and readiness to change variable. This was done for the overall sample and within the India and US samples as well. Measures showing significant relationships with readiness to change were then used in the overall analysis. Multivariate regression analyses were done on MPlus by running a multigroup procedure to test whether the parameters differed for the Indian and US participants. All predictors were entered into the model and assessed for significance within Indian and U.S. sample. The benefit of doing this analysis in MPlus is that it accounts for the missing cases found in certain key variables in the U.S. sample by imputing the value. The Wald statistic was used to assess differences in parameters. Initially an overall assessment was made, and then separate assessments were done for each parameter in the analysis. The R square for each sample along with the associated p-value was also ascertained to determine the significance of the variance accounted for by the predictor variables. RESULTS Descripi e A alyses A comparison of the frequencies and percentages for all categorical variables in the study between women in India (n = ) and the U.S. (n = ) are summarized in Table . There were no significant differences in marital status and job situation between the two groups of women. However, there were significant differences in the other variables. Residential status revealed a significant difference )= . ,p<. , ES = . ] with half the women in India living by [ ( , n = themselves as compared to % of U.S. women living in unstable housing arrangements (i.e., living with someone else, family, partner, or in a hotel). More than half the women in both India and U.S. had exited CSE, with the percentage of women )= . ,p<. , ES = having exited in the U.S. being significantly [ ( , n = . ] than those in India. All four causes of entry explored in this study suggest a significant difference between the two groups of women. The proportion of women identifying economic conditions as a cause of their entry into CSE was significantly higher [ ( , n = )= . ,p=. , ES = . ] in India to enter as a function of some type of abuse [ ( , n = )= . ,p=. , ES = . ]. The likelihood of entry being a func)= tion of runaway behavior was also higher in the U.S. than India [ ( , n = . ,p=. , ES = . ]. Finally, the likelihood of being forced into the sex trade was significantly higher for women in India than the U.S. [ ( , n = )= . , p<. , ES = . ]. The types of exploitation encountered by individuals while in CSE revealed significant differences between the countries. The participants in India were more likely to have experienced indoor forms of exploitation (i.e. brothels, dance bars, lodge based prostitution), than the U.S. participants [ ( , n = ) = . , p<. , ES = . ]. The women in the U.S. were more likely than the women from India to have experienced outdoor forms of exploitation (i.e. street prostitution [ ( ,n= )= . ,p<. , ES = . ]. http://digitalcommons.uri.edu/dignity/vol1/iss1/7 10 Wilson and Nochajski: Predictors TABLE . Differences Between India and the U.S. Sample on Categorical Independent Variables India, n = Variable n (%) n (%) Marital status Residence Job situation Currently in CSE*** Causes of entry Types of exploitation Perpetrator presence*** Note: *p < . , **p < . U.S., n = Single ( ) ( ) With someone ( ) ( ) Supervised ( ) ( ) Oneself*** ( ) ( ) Unstable*** ( ) ( ) Employed ( ) ( ) Unemployed ( ) ( ) Yes ( ) ( ) No ( ) ( ) Economic conditions** ( ) ( ) Running away behavior* ( ) ( ) Abuse*** ( ) ( ) Forced/Coerced*** ( ( ) Outdoor*** ( ) ( ) Indoor*** ( ) ( ) Both* ( ) ( ) Yes ( ) ( ) No ( ) ( ) ) , ***p < . There was also a significant difference between the countries, in the number of individuals who identified the presence of a perpetrator, while in the sex industry, [ ( , n = )= . ,p<. , ES = . ]. The Indian sample was split into equal halves between having and not having a perpetrator, while a majority of the U.S. sample identified as not having a perpetrator. A comparison of the means and standard deviations for all continuous variables in the study between women in India (n = ) and the U.S. (n = ) are summarized in Table . There were no significant differences in age of entry, time in CSE, and quality of life between the two groups of women. However, there were significant differences for the years of schooling, with women in India being significantly lower than women in the U.S. [t ( )= . ,p<. , d = . ]. The number of individuals dependent on these women for their survival was significantly higher [t ( )= . ,p<. , d = . ] in India than in the U.S. The women in the U.S. had a significantly higher mean score on addictions [t ( )= . ,p< . , d = . ], social support [t ( ) = . , p = . , d = . ], satisfaction with social support [t ( )= . ,p=. , d = . ], and empowerment [t ( ) = . , p<. , d = . ] as compared to their counterparts in India. However, the women in India were significantly higher on culture – individualistic [t ( ) = . , p = . , d = . ] and perceived stigma [t ( ) = . , p < . , d = . ] compared to their counterparts in the U.S. Published by DigitalCommons@URI, 2016 11 Dignity: A Journal on Sexual Exploitation and Violence, Vol. 1, Iss. 1 [2016], Art. 7 TABLE . Differences between India and U.S. sample in the descriptive statistics (N = Variable India, n = U.S., n = M (SD) M (SD) Age at time of interview . ( . ) Years of Schooling*** . ( . ) Dependents*** . ( . ) Age of entry . . ( . Substance Abuse*** . ( . ( . . ( . ) . ( . Time in CSE . ) ) ) ) ( . ) . ( . ) . ( . ) . ( . ) Culture – Individualistic* . ( . ) . ( . ) Culture – Collectivistic . ( . ) . ( . ) Perceived stigma*** . ( . ) . ( . ) Social support** . ( . ) . ( . Satisfaction with social support** . ( . ) . ( . ) Empowerment*** . ( . . ( . Quality of life . ( . ) . ( Note: *p < . , **p < . ) ) ) ) . ) , ***p < . Bi ariate Relaio ships ith Readi ess to Cha ge The results for the bivariate associations are shown in Table . We conducted three sets of correlations, one for the overall sample (n= ), and then one for each of the countries (U.S. n = , India n = ). For the overall sample, there were significant positive relationships with readiness to change for years of schooling, unstable housing, abuse as a reason for entry, substance abuse, a collectivist approach, number of supports, and empowerment. While negative relationships existed for the number of dependents, living by oneself, entry due to economic conditions, being coerced into the sex trade, and indoor exploitation experiences. For just the India sample, there were significant positive relationships for years of schooling, an individualist approach, a collectivist approach, perceived stigma, number of supports, and empowerment. Negative associations were present for age of entry into the sex trade and economic conditions for entry. Finally for the U.S. sample, there were significant positive associations for substance abuse, a collectivist approach, and still being involved in the sex trade. Negative associations were present for living by oneself and entry due to running away behavior. http://digitalcommons.uri.edu/dignity/vol1/iss1/7 12 Wilson and Nochajski: Predictors TABLE . Correlations of Potential Predictors with Readiness to Change Predictor Variable Overall (n= Years of Schooling . *** Dependents -. ** ) India (n = . ) US (n = ** ) . -. -. Single . -. . Professional Supervision . . . + ** -. -. * * -. . -. -. Oneself -. Unstable Housing . Unemployed -. Age entry into Sex Trade -. Time in Sex Trade . . . Presence of perpetrator -. . . -. ** . Reasons for Entering Economic Conditions -. Runaway -. Abuse . ** . Coerced/Forced -. ** . -. Work Outdoors . + . -. Work Indoors -. ** -. . Substance Abuse . *** . Individualist Approach * -. . -. Collectivist Approach . . Number of Supports . *** Satisfaction with Support . -. ** ** -. . *** . * . ** . + . *** -. . Quality of Life -. . -. Still in Sex Trade -. . . ;*p<. . . Empowerment +p<. ; ** p < . * . . -. ** . + . *** Perceived Stigma ** * -. * ; *** p < . Regressio A alyses The next analysis was focused on identifying which of the identified measures remained significant when controlling for the other predictors. Only those measures that showed significant associations with readiness to change in the overall analysis or in the separate runs for India and the U.S. were used in MPlus version . to run a multi-group model, looking to assess whether the specific measures would show similar relationships in the U.S. and Indian samples. The initial run assessed whether the overall model significantly varied for the two groups. We then assessed each specific measure to determine if the parameters differed for the two samples. Results are shown in Table . Published by DigitalCommons@URI, 2016 13 Dignity: A Journal on Sexual Exploitation and Violence, Vol. 1, Iss. 1 [2016], Art. 7 TABLE . Multigroup Regression Analyses Results Predicting Readiness to Change Predictor Variable India (n = Years of Schooling ( %CI) ( % CI) . ( . . ( . to . (- . Age entry into Sex Trade - . ( . ) (- . to . ) ( . ) to - . ( . to . ( . )** ( . (- . ) . )+ ) to . (- . )+ (- . ( . ) . (- . to . ) (- . - . Substance Abuse . (- . - . (- . Collectivist Approach ( . Perceived Stigma ( . ( . (- . . (- . ) . ) (- . ( . ) to . ( . ( . ) ) ( . (- . ( . )*** to . - . ( . (- . to . ( . ) ) ( . . ,p=. . ,p=. ) ) . ,p=. . ,p=. . ,p=. . )+ ) )** to . ( . ) ) . ,p=. )*** ( . ) to . . ,p=. ) ( . ) to . . ,p=. . ,p=. ( . ) . ,p=. . ,p=. . ,p=. )* ( . (- . ) ) ( . - . . ) to . . ( . ) . to . (- . ) ) ( . . ,p=. )* ( . . to . ) (- . ( . to . ) )*** ) to . )+ to - . -. )** . to ( . ,p=. ) ) ( . . ( . ) to . . ) to . to . . . to . to . . ) . ) ( . - . ,p=. ) to . to - . ( . to . . . . ,p=. ) (- . http://digitalcommons.uri.edu/dignity/vol1/iss1/7 - . ,p=. )** to . . ; ** p < . to - . (- . (- . ;*p<. . ( . ) Work Outdoors +p<. ) - . (- . Still in Sex Trade ( . ) (- ( . ) - . Empowerment ) . ( . (-. Number of Supports to . - . ) -- . . Individualist Approach ) to . (- . Abuse Work Indoors (- . ) (- . Coerced/Forced )*** ) to . - . Runaway ( . ) Wald – parameter Difference test (- . Reasons for Entering Economic ) beta (SE) - . Unstable Living Situation US (n = beta (SE) ( . Living By Oneself ) ) to . ) ( . to ) . )** ; *** p < . 14 Wilson and Nochajski: Predictors The comparison test for the overall model was significant, Wald = . , df = ,p=. , indicating that the beta coefficients for the two countries differed. Evaluating the specific coefficients for significant differences between the countries showed living by oneself, indoor types of exploitation, and currently still in the sex trade as having significant differences, and scores on the entry due to running away behavior and individualist approach showing marginal differences. For the living by oneself comparison, while the slopes were negative for both the U.S. and Indian samples, the slope was steeper for the U.S. sample than for the Indian sample, with the coefficient for the U.S. sample being significant. The coefficient for runaway showed a similar pattern. The results for still involved in the sex trade, showed differences in terms of the slopes, with the Indian sample showing a non-significant but negative slope, while the U.S. showed a significant positive slope, suggesting that those who had already exited scored higher on the readiness to change measure, whereas for the Indian sample readiness to change did not depend on whether they had exited or still remained in the sex trade. The indoor exploitation measure also showed different types of slopes for the two countries. The Indian sample showed a non-significant but negative slope, while the U.S. showed a marginal positive slope. So, readiness to change was lower for the women in India but higher for the women in the U.S. who participated with the indoor types of exploitations. Finally, for the individualist approach score, both the U.S. and Indian samples showed negative slopes, however, the slope for the Indian women was steeper and significant, where the slope for the U.S. women was not significant. Except for indoor types of exploitation and still being in the sex trade, the directions of relationships for living by oneself, running away as a reason for entry and individualist approach were similar for the two samples. So, even though the overall test suggested a significant difference between the two countries, there were some similarities as well. In terms of the specific findings for the Indian sample there were significant positive relationships with readiness to change for years of schooling, being abused as a reason for entry into the sex trade, the collectivist approach, and stigma. Thus, higher education, childhood abuse as a reason for entry, more focus on others, and greater feelings of stigma associated with working in the sex trade all resulted in greater readiness to change scores. Additionally, there were significant negative relationships between readiness to change and economic conditions as a reason for entry, runaway behavior as a reason for entry, and an individualist approach. So, readiness to change was lower if economic conditions or being a runaway were reasons for entry into the sex trade. Likewise, in contrast to a collectivist approach, higher scores on the individualist approach resulted in lower readiness to change scores. The R-Square for the Indian sample was . , indicating that the model accounted for percent of variance in readiness to change. Results for the U.S. sample showed significant negative relationships with readiness to change for living by oneself and runaway behavior as a reason for entry. In addition, there were significant positive relationships with readiness to change for substance abuse, collectivist approach, number of supports, and still being in the sex trade, and a marginal positive association for abuse as a reason for entry and indoor forms of exploitation. The R-Square for the U.S. sample was . , indicating that the model accounted for percent of variance in readiness to change. Published by DigitalCommons@URI, 2016 15 Dignity: A Journal on Sexual Exploitation and Violence, Vol. 1, Iss. 1 [2016], Art. 7 DISCUSSION The findings of this study, constitutes a contribution to the sparse knowledge base in the area of exiting CSE. Capturing the phenomenon of readiness to exit from CSE as a continuous variable, and using the existing standardized measures of readiness to change score, has broadened its purview without having to re-invent the wheel. Assessing readiness to change even among women who have already exited recognizes exiting behavior as a dynamic process, and their vulnerability to re-enter for various reasons (lack of employment, need for resources). In addition, there has been minimal work exploring possible differences in the experience for women in different countries, which the current study addresses by including two samples, Indian and U.S. The variables used as predictors for the readiness to change score were not evaluated in prior research as being related to readiness to change in the process of exit from CSE. Some of these factors – such as age of entry into CSE (Cobbina & Oselin, ; Roe-Sepowitz, ), cause of entry (Joffres et al., ; Williamson & Folaron, ), time spent in CSE (Gupta et al., ; Sanders, ), types of exploitation (Cusick, Brooks-Gordon, Campbell, & Edgar, ; Raphael & Shapiro, ), addictions (Panchanadeswaran et al., ; Vaddiparti et al., ), presence of perpetrator (Gupta et al., ; Kennedy et al., ), stigma (Jackson et al., ; Sallmann, ), and social support (Dalla, ; Hedin & Mansson, ) - were characteristics associated with women in/exiting CSE. The other factors, although not directly associated with women in CSE, either predicted reduction of abuse among victims of intimate partner violence – in the case of quality of life (Tan et al., ) and empowerment (Busch & Valentine, ), or influenced change in the personality of an individual – in the case of culture (Triandis & Suh, ). Therefore, these variables were selected to understand its impact on readiness to exit CSE across different cultures. The percentage of women having exited being significantly higher in the U.S. could be attributed to the participation of organizations that mostly provided exit services. Although efforts were made to include organizations that promote staying in the sex trade in the U.S., like in India, there were only a couple of them with very few participants. However, in India the participating organizations were more balanced comprising of both type of organizations – those that did provide exit specific services and those that promoted staying in the sex trade. Another interesting finding was the proportion of women entering sex trade due to economic condition and force being higher in India, and entering due to abuse and running away behavior being higher in the U.S. which is consistent with the literature in both countries (Kramer & Berg, ; Vindhya & Dev, ). The lack of difference in the bivariate analyses of age of entry, and time in CSE between Indian and U.S. samples reflect the ubiquitous nature of the exploitation of individuals in CSE, regardless of women belonging to a developed or developing nation, or individualistic or collectivistic societies. Moreover, the average age of entry being years with nearly half the women ( %) entering as minors, and the average time spent in CSE being years is consistent with a comprehensive study conducted by Farley and colleagues ( ) across nine different countries. This underscores the challenges involved in exiting CSE and the need for more interventions. Test of differences for the overall model indicated that the beta coefficients for the two countries differed significantly. When considering differences in direction of the coefficients, we found that having experienced indoor forms of exploitation, http://digitalcommons.uri.edu/dignity/vol1/iss1/7 16 Wilson and Nochajski: Predictors and being still active in the sex trade as the measures that showed different signs for the beta coefficients. The readiness to change being higher and marginally significant for those in indoor form of exploitation in the U.S. sample is observed in a qualitative study, where women in indoor forms of CSE were slightly more educated and therefore able to transition into more skilled jobs post exit, as compared to those in outdoor forms (Sanders, ). In all other cases, such as living by oneself, running away as a reason for entry and individualistic approach, signs of the coefficients were in the same direction indicating that although the impact on readiness to change was the same for both samples, it was more significant for one of the sample. Results for the Indian sample showed that education level was positively associated with readiness to change. This is consistent with the extant literature that describes the characteristics of women currently in CSE in India as lacking, or having minimal years of schooling (Dandona et al., ; Vindhya & Dev, ). Perceived stigma associated with working in the sex trade was also positively associated with readiness to change, while economic conditions as a reason for entry, and an individualist approach were negatively associated with readiness to change for the Indian sample. In contrast, for the U.S. sample substance abuse problems, number of social supports, still being involved in the sex trade and indoor forms of exploitation showed positive aspects, while living by oneself was negatively associated with readiness to change. Hotaling, Burris, Johnson, Bird, and Melbye ( ), describing their experience of serving women in CSE in the U.S., emphasize the importance of stabilizing the latter by first offering safe housing and de-addiction services, followed with access to a support group during their recovery process, which has been established in the current study as factors predicting their readiness to exit. However, there were a few measures that impacted readiness to change in both the U.S. and India. The collectivist approach was similar and significant in both the U.S. and Indian samples, suggesting that taking more of a focus on others than the self may be more likely to result in a greater likelihood of readiness to change behavior regardless of where the women resided. Studies exploring the impact of culture on personality have described that a collectivistic cultural approach nurtures individuals’ belongingness to a group or community from which they draw strength and are influenced (Triandis & Suh, ). This can be understood within the context of women exiting CSE and receiving services from social service organizations, as having a good peer network that positively influences and motivates them during their exit, which is essential to women in sex industry who are otherwise ostracized by society in both countries. Similarly, abuse as a reason for entry was positively associated with readiness to change in both countries, suggesting that in these cases with proper support the individual can decide to change without being influenced by external factors such as economic conditions. Another interesting finding was that running away behavior as a reason for entry of women into CSE had a negative relationship with readiness to change in both countries. Women who run away may not have sufficient self-efficacy around surviving without being involved in the sex industry. Therefore, from an intervention standpoint, it is important to increase their belief in oneself to be able to survive and sustain through viable alternate mechanisms. The literature in the U.S. has identified run away behavior as having a strong impact on entry into CSE (McClanahan, McClelland, Abram, & Teplin, ; Reid, ; Roe-Sepowitz, ), but this study has furthered that understanding by suggesting that it also Published by DigitalCommons@URI, 2016 17 Dignity: A Journal on Sexual Exploitation and Violence, Vol. 1, Iss. 1 [2016], Art. 7 reduces women’s readiness to exit, thus underscoring the importance of addressing the entry factors during the exit process. Li itaio s a d Future Direcio s Although the findings of this study are promising, there are a number of limitations that warrant consideration. The hard-to-reach nature of women currently in/exiting or already exited CSE makes it difficult to adopt random sampling techniques. Therefore, the study approached these women through social service organizations that provided services to women in/exiting CSE, which limits the generalizability of the findings of this study to only those that have access to organizations assisting them. Thus, the current sample may not be representative of the experiences of all women exiting CSE. Future research may benefit from recruiting women exiting CSE through other means without ever approaching any social service organizations, and assess if their experience differs significantly from these findings. Additionally, the findings of this study cannot be generalized to juveniles, male, or transgender populations exiting CSE. Also, the data obtained from the U.S. was only from organizations within the state of California, thereby limiting the ability to generalize these findings to the entire country. Future research may benefit from use of stratified sample considering the vast heterogeneity in the universe of research area. The variation in the method of survey administration in India (interview mechanism), and the U.S. (paper-based), may have had an impact on the responses and completion rates. The data obtained in this study is cross-sectional, which precludes understanding how the constructs are chronologically associated with each other. Future research could conduct a longitudinal study by observing individuals throughout their recovery process. This may be achievable for organizations working with this population by doing a series of self-reported tests at different intervals along the continuum of the exit process. This would assist in the identification of variables that truly impact the exit, and the various exit trajectories and the associated characteristics. The overall sample size for the survey being small was a limitation, causing low power issues. The number of parameters used in the study would have benefitted from a larger representation of women, especially in the U.S., which limited to some extent, the ability to infer meaningful cross-cultural understanding. Nevertheless, given that contemporary research exploring the process of exit among women from CSE is still nascent, this study is a first important step towards understanding the predictors that facilitate readiness to exit and assist in developing interventions. This study also examined for the first time some of the associations between variables for women exiting CSE in both India and the U.S. This meant that there was no extant literature to confirm or explain some of the significant outcomes. For example, the individualistic cultural approach had a significant negative impact on the readiness to exit among women in India, while the collectivistic cultural approach had a significant positive impact on the readiness to exit among women in both the U.S. and India. Although on the surface this signifies that collectivistic approach is better for women in both societies during the process of exit, future research can substantiate these findings. Additionally, future work must also explore the impact of other factors such as psychological (depression, anxiety, post traumatic stress disorder), health (fear of contracting sexually transmitted illness such as HIV/AIDS), social customs (religious/non-religious), displacement of red http://digitalcommons.uri.edu/dignity/vol1/iss1/7 18 Wilson and Nochajski: Predictors light areas by real estate market, and legalization lobby on the readiness to exit CSE. Pracice I plicaio s Our findings present a number of possible implications for clinicians, therapists and social service providers working with women in/exiting CSE. Readiness to change score can be used as an indicator to gauge women’s readiness to exit from CSE and provide services specific to their stage along the continuum of exit. The service provision must be directed towards increasing the individual’s readiness to change, while simultaneously being culturally competent. Although there were similarities in the experiences of women in CSE in the two countries, the inherent cultural differences within the society must be considered for service provision to be effective. Services for women in/exiting CSE in India must focus on providing education, working with family members to reduce their dependency on these women, focusing on early intervention programs, addressing the causes of entry such as economic conditions/abuse/running away behavior that leads women into CSE, shifting focus from individualistic to collectivistic approach and addressing their perceived stigma. Services in the U.S. must offer safe residential services, address entry factors such as running away behavior/abuse, especially work among those in indoor forms of exploitation, provide de-addiction treatment (especially since the women in the U.S. have significantly high risk towards addictions), and create positive support networks and collectivistic approach that would facilitate recovery. A collectivistic cultural approach and being a part of a healthy network could positively impact readiness to exit for women in both countries, which must be addressed by service providers. CONCLUSION The current study sheds light on the phenomenon of exit from CSE among women within two culturally distinct countries, India and the U.S. The study identified that variables such as years of schooling, living by oneself, age of entry, causes of entry – economic condition/ abuse/ runaway/ force, types of exploitation – indoor/ outdoor, substance abuse, culture – individualistic and collectivistic, perceived stigma, social support, empowerment, and current involvement in CSE, account for significant variance in the readiness to exit CSE among women in both countries. Addressing some of these variables with significant impact on readiness to change during service provision also has a direct impact on the exit process. However, although some of these predictors were similar across cultures, there were also differences observed between the individualistic (U.S.) and collectivistic (India) societies. Research on the process of exit from CSE is still in its nascent stage. Identifying significant predictors of exit from CSE would assist organizations in offering more effective services and intervening in more finessed ways among both, women in the sex industry, as well as those who are in the process of exiting, and assist in truly liberating those commercially sexually exploited through appropriate and culturally competent services. Published by DigitalCommons@URI, 2016 19 Dignity: A Journal on Sexual Exploitation and Violence, Vol. 1, Iss. 1 [2016], Art. 7 ACKNOLWEGMENTS Fahs Beck Doctoral Dissertation Grant Program, Gender Institute, University at Buffalo. Three referees reviewed this article using a double-blind review process. With the permission of the reviewers and the authors, Dignity thanks them for their time and expertise. They are: Sven-Axel Mansson, Professor Emeritus, Social Work, Malmo University, Sweden; Joan A. Reid, Assistant Professor, Criminology and Co-Director and Psychotherapist, Restoring Innocence Lost Counseling Collaborative, University of South Florida, USA; and Pravin Patkar, Adjunct Professor, Amrita University, India. AUTHOR BIOGRAPHIES Bincy Wilson, Ph.D., is a social science researcher who is passionate about gender justice and empowerment of women and children. She has years of practice and academic experience working on issues related to commercial sexual exploitation of women and children in international settings. She has a doctorate degree in Social Welfare from School of Social Work, State University of New York, U.S. She started her career working with a grassroots level NGO in Goa, India combating trafficking of women and girls for commercial sexual exploitation by providing rehabilitation, protection and rescue services to victims, followed with providing Eye Movement Desensitization and Reprocessing (EMDR) therapy in individual and group settings to address the trauma of victims of sex industry in the USA. The wider social welfare community recognizes her expertise, both popular media which has featured her work in news and radio programs, as well as the academic community where she serves as an invited reviewer for peer-reviewed journals. She is also a member of the Cadre of Experts that serves on the American Psychology Association (APA) Task Force on Trafficking of Women and Girls. Currently, she works for an international child rights organization (Terre des Hommes Netherlands), in India overseeing programs related to child trafficking and migration, and commercial sexual exploitation of children (CSEC) in India, Nepal and Sri Lanka. Thomas H. Nochajski, Ph.D., is a research professor at the University at Buffalo School of Social Work, an associate research scientist at RIA, as well as an associate research scientist at the Center for Health and Social Research. He has over years of experience doing research and has been principal investigator or co-principal investigator n several National Institute of Health (NIH) and foundation funded grants. His work focuses on all aspects of prevention of alcohol and drug problems (primary, secondary and tertiary), which includes how mental health and other behavioral risk factors influence treatment and prevention outcomes. Nochajski also has experience with instrument development around screening and assessment issues for various groups. He has also engaged in numerous evaluations of existing programs, including drug courts, mental health programs, drinking driver programs, substance use treatment and other types of programs for criminal justice groups. His most recent work focuses on trauma and trauma-informed care. RECOMMENDED CITATION Wilson, Bincy & Nochajski, Thomas H. ( ). Predictors of readiness to exit commercial sexual exploitation among women in India and the United States. Dignity: A Journal of Sexual Exploitation and Violence. Vol , Issue , Article . Available at http://digitalcommons.uri.edu/dignity/vol /iss / /. http://digitalcommons.uri.edu/dignity/vol1/iss1/7 20 Wilson and Nochajski: Predictors REFERENCES Baker, L. M., Dalla, R. L., & Williamson, C. ( ). Exiting prostitution: An integrated model. Violence Against Women, ( ), . Banks, D., & Kyckelhahn, T. ( ). 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