Human Trafficking Into and Within the United States: A Review of the Literature

By:
Heather J. Clawson, Nicole Dutch, Amy Solomon, and Lisa Goldblatt Grace

Introduction

This paper presents a comprehensive review of current literature on human trafficking into and within the United States.  This review of the literature is part of a larger study funded by the U.S. Department of Health and Human Services (HHS), Office of the Assistant Secretary for Planning and Evaluation, to examine how HHS programs are currently addressing the needs of victims of human trafficking, including domestic victims, with a priority focus on domestic youth.  This study is also structured to identify barriers and promising practices for addressing the needs of victims of human trafficking, with a goal of informing current and future program design and improving services to this extremely vulnerable population.

While historically there have been inconsistencies and disagreements regarding the definition of human trafficking among politicians, practitioners, and scholars (Laczko & Gramegna, 2003; Richard, 1999), for the purpose of this literature review, the legal definition of human trafficking set forth in the Trafficking Victims Protection Act of 2000 (TVPA) will be used. In the TVPA, Congress defines severe forms of trafficking in persons as:

1. Sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age; or
2. The recruitment, harboring, transportation, provision or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery (8 U.S.C. § 1101).

To conduct a comprehensive review of the literature associated with the trafficking of foreign nationals into the United States and of U.S. citizens and legal permanent residents within the country,[1] we performed multiple searches of the literature using Google and EBSCOhost® search engines. In particular, within the EBSCOhost search engine, we searched the following databases: Academic Search Elite, PsycINFO, PsycARTICLES, ERIC, and PsycEXTRA.[2] Our initial searches featured a wide array of directly related terms, including: trafficking in persons, human trafficking, trafficking/youth/adult, international trafficking, domestic trafficking, sex trafficking, sexual exploitation, child prostitution, commercial sexual exploitation of children, forced labor, labor trafficking, labor exploitation, minor (persons younger than age 18) trafficking victims, debt bondage, domestic servitude, involuntary servitude, and modern day slavery. Most of the research, particularly research published in peer-reviewed journals, was limited to qualitative and quantitative studies of the scope of the problem (i.e., who is vulnerable to trafficking and the characteristics of those who are trafficked).  Information on the needs of trafficking victims and the services provided to this population was limited to information contained in Federal reports, non-peer reviewed journals, manuals and fact sheets, Web sites for advocacy organizations and nongovernmental organizations (NGOs) working with trafficking victims, recently published books on trafficking, and personal communications with direct service providers and trafficking survivors.  Given the state of the field, with the limited research that is available on this issue, personal communication was relied on for many portions of this review to supplement the available literature.  Only first names are used in the citations, to protect the identity of the survivors interviewed for this study.

To collect more rigorous information on promising or effective practices or strategies for serving victims of human trafficking, we expanded our search to related disciplines and victim populations, including: prostitution,[3] torture victims, refugees, asylum seekers, homeless/runaway/throwaway youth, juvenile justice system, adolescent substance abuse, child and adolescent mental health, trauma, co-occurring disorders, domestic violence and sexual assault, and child protective services.  The search criteria were refined further by specifically seeking literature related exclusively to adults (women and men) and minors (girls and boys).  This search revealed significantly more research-focused articles evaluating substance abuse, domestic violence, mental health, and trauma-related services for adults and youth in general.  While not specific to human trafficking, information obtained from these latter searches provides important context about key service delivery systems needed by victims of human trafficking.  It should be noted, however, that even with a broader search, very little information was available regarding the specific needs of and service response for victims of labor trafficking.  This is a significant gap in the literature that is only recently being addressed through calls for research by Federal agencies focused on labor trafficking and, in particular, male victims of labor trafficking.

The results of this comprehensive review are organized by the following key questions:

• What is human trafficking?
• How prevalent is human trafficking into and within the United States?
• Who are the victims of human trafficking?
• What are the needs of victims of human trafficking?
• How are victims identified?
• What services are victims of human trafficking eligible to receive?
• What are the barriers to and challenges in accessing and providing services?
• What are promising practices for serving victims of human trafficking?

This review of the literature provides one of the first comprehensive syntheses of information available on human trafficking into and within the United States.

What is Human Trafficking?

The crime of human trafficking affects virtually every country in the world (Europol, 2005; Miko, 2000) and has been associated with transnational criminal organizations, small criminal networks and local gangs, violations of labor and immigration codes, and government corruption (Richard, 1999; U.S. Government Accountability Office, 2006).  Historically, trafficking has been defined most often as the trade in women and children for prostitution or other immoral purposes (Europol, 2005).  More recently trafficking has been defined to include other types of force, fraud, or coercion beyond sexual exploitation.  It has been further clarified that victims do not need to be transported across international or other boundaries in order for trafficking to exist.  In 2000, the international community developed and agreed to a definition for trafficking in persons that can be found in Article 3 of the United Nations Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children:

Trafficking in persons shall mean the recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power, or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation.  Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude or the removal of organs (Europol, 2005, p. 10).

At the same time, the U.S. Congress defined and classified human trafficking into two categoriessex trafficking and labor traffickingin the TVPA.  As stated previously, sex trafficking involves the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act in which a commercial sex act is induced by force, fraud, or coercion, or in which the person forced to perform such an act is younger than age 18.  A commercial sex act means any sex act on account of which anything of value is given to or received by any person.  Types of sex trafficking include prostitution, pornography, stripping, live-sex shows, mail-order brides, military prostitution, and sex tourism.  Labor trafficking is defined in the TVPA as the recruitment, harboring, transportation, provision, or obtaining of a person for labor services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.  Labor trafficking situations may arise in domestic servitude, restaurant work, janitorial work, sweatshop factory work, migrant agricultural work, construction, and peddling (8 U.S.C. § 1101). 

Human trafficking is synonymous with trafficking in persons and has commonly been referred to as modern day slavery.  Under the U.S. definition, transportation or physical movement of the victim does not necessarily need to be present in order for the crime to occur; instead, it is the presence of exploitation (force, fraud, or coercion) that indicates whether a trafficking crime has occurred.  The TVPA and subsequent reauthorizations not only provide a standard legal definition of the crime of human trafficking but also offer a framework for current and future U.S. anti-trafficking efforts.  It addresses the prevention of trafficking, protection and assistance for victims of trafficking, and prosecution and punishment of traffickers (U.S. Government Accountability Office, 2006).  While most of the anti-trafficking efforts within the United States have historically focused on trafficking of foreign nationals into the country, the 2005 reauthorization of the TVPA highlighted the need to address the trafficking of U.S. citizens and permanent residents, in particular minor victims of sex trafficking or the prostitution of minors, within U.S. borders (22 U.S.C §7103).

How Prevalent Is Human Trafficking Into and Within the United States?

Trafficking into the United States

The data and methodologies for estimating the prevalence of human trafficking globally and nationally are not well developed, and therefore estimates have varied widely and changed significantly over time.  The U.S. State Department has estimated that approximately 600,000 to 800,000 victims are trafficked annually across international borders worldwide and approximately half of these victims are younger than age 18 (U.S. Department of State, 2005, 2006, 2007).  Additionally, the U.S. State Department has estimated that 80 percent of internationally trafficked victims are female and 70 percent are trafficked into the sex industry (U.S. Department of State, 2005).  In comparison, the International Labor Organization has estimated that at any given time, 12.3 million people are in forced labor, bonded labor, forced child labor, sexual servitude, and involuntary servitude (International Labor Organization, 2005).  Other estimates of global labor exploitation range from 4 million to 27 million (U.S. Department of State, 2006, 2007).

Initial estimates cited in the TVPA suggested that approximately 50,000 individuals were trafficked into the United States each year.  This estimate was subsequently reduced to 18,00020,000 in the U.S. Department of States June 2003 Trafficking in Persons Report, and in its 2005 and 2006 reports, altered again to an estimate of 14,50017,500 individuals trafficked annually into the United States.

According to official administrative data, since 2001, the U.S. Department of Justice has prosecuted 360 defendants in human trafficking cases, and secured 238 convictions (U.S. Department of Justice, 2007).

Additionally, as of June 2007, 1,264 foreign nationals (adults and children) have been certified by the U.S. Department of Health and Human Services as victims of human trafficking, eligible to receive public benefits.  Of these, 1,153 are adults, with 69 percent female victims.  Of the 111 minor victims certified, 82 percent were female.  For some victim service providers and NGOs, these figures are not considered representative of the actual number of human trafficking victims in the country.  They believe that many victims go unreported (and uncounted) because they do not want to cooperate with law enforcement and, therefore, are never reported to authorities or receive Federal assistance (Caliber Associates, 2007).

Trafficking within the United States

To date, estimates of human trafficking have focused almost exclusively on international trafficking victims (Laczko & Gozdziak, 2005), and this holds true for the United States as well.  Only a recent estimate of minors at risk for sexual exploitation comes close to estimating U.S. domestic trafficking.  Between 244,000 and 325,000 American youth are considered at risk for sexual exploitation, and an estimated 199,000 incidents of sexual exploitation of minors occur each year in the United States (Estes & Weiner, 2001).  These figures, however, are limited estimates of youth at risk for human trafficking and do not address adult U.S. citizens trafficked into the sex industry or American children and adults trafficked for labor.  We can, however, turn to estimates of other at-risk populations, such as runaway/throwaway youth, youth exploited through prostitution, and child labor, to gain a better sense of the potential prevalence of domestic trafficking, or at least the numbers of people at high risk of trafficking.

Given the correlations between runaway/throwaway youth and minors exploited through prostitution (Estes & Weiner, 2001), findings from the Second National Incidence Studies of Missing, Abducted, Runaway, and Thrownaway Children can offer additional information about the possible prevalence of minors trafficked or at risk of being trafficked domestically into the commercial sex industry (Hammer, Finkelhor, & Sedlak, 2002).  For example, in 1999, 1,682,900 youth had a period of time in which they could be characterized as a runaway or throwaway youth; 71 percent of these youth were considered at risk for prostitution (Estes & Weiner, 2001).

Data reported by the runaway and homeless youth programs supported by funding from the Family and Youth Services Bureau (FYSB) within HHS provide additional information about this at-risk youth population.  In 2007, 50,718 youth received services from FYSB-funded runaway and homeless programs (U.S. Department of Health and Human Services, n.d.).  Of these youth, 54 percent were female.  Additionally, 770,223contacts (distribution of written materials, health and hygiene products, and/or food and drinks) were made with youth through street outreach programs.  It is unclear, however, whether these numbers include duplicate counts (e.g., youth receiving services multiple times from one or more service providers), which is a problem often inherent in administrative data (Gozdziak & Collett, 2005).  In addition, it is not known how many street youth do not come into contact with service providers.

National juvenile arrest data provide another glimpse of the potential magnitude of the domestic trafficking of youth.  Nationwide in 2003, 2,220,300 juveniles were arrested, 11 percent fewer than in 1999 (U.S. Department of Justice, 2004).  During 2003, 1,400 youth were arrested for prostitution and commercialized vice.  Of these youth, 69 percent were female and 14 percent were younger than age 15.  Unlike overall juvenile arrest rates, these numbers increased 31 percent between 1994 and 2003.

Notwithstanding these general data, there is no clear consensus on the numbers of girls versus boys exploited through prostitution nationwide.  The differential treatment of boys and girls, coupled with the differences in the circumstances under which they prostitute (including location), make these statistics extremely difficult to interpret.

As with most other data related to human trafficking, there are huge gaps between estimates of prevalence or populations at risk and individuals actually identified as trafficking victims or enrolled in government programs.  Better data and research are needed to begin distinguishing among possible reasons for the gaps between prevalence estimates and administrative data.

In addition to domestic sex trafficking, American minors and adults are likely trafficked for forced labor; however, children are generally preferred to adults in the labor world as they are more easily controlled, cheaper, and less likely to demand better working conditions (Herzfeld, 2002).  Unfortunately, we know even less about labor trafficking, both into and within the United States, than we do about sex trafficking.  There is evidence that forced child labor exists in the African and Latin American regions and also in more developed countries such as the United States (International Labor Organization, 2002). An International Labor Organization study indicated that girls are more likely to be trafficked for commercial sexual exploitation and domestic services, and boys tend to be trafficked for forced labor in commercial farming, petty crimes, and the drug trade.

A review of the data on child labor, however, provides some insight into the potential for labor trafficking within the United States.  Data from the National Longitudinal Survey of Youth 1997 (NLSY97) show substantial work activity among 14- and 15-year-old children (Bureau of Labor Statistics, 2001).  Employment among 14- and 15-year olds was concentrated in a small number of industries, with restaurants and supermarkets the most common industries in which youth were employed.  Babysitting and yard work were by far the most common freelance jobs youth reported having worked. NLSY97 figures and those of the Child Labor Coalition (CLC) indicate that youth employment is growing in the United States.  The CLC estimated there are 5.5 million youth between the ages of 12 and 17 employed across the United States.  This estimate was derived from the NLSY97 data. The CLC (2007) also estimates there are 500,000 U.S. children working in various agricultural settings, with most being members of minority groups. In addition to agricultural work, the CLC estimates 50,000 children are involved in street peddling, including peddling magazines, candy, and other consumer goods.  Many teens become involved, believing peddling is a good way to make money, and do not realize the dangers associated with these activities.  The CLC indicates that youth peddlers work long hours with little pay, in extreme temperatures, and with no access to bathrooms, water, or food; work for activities or prizes they never receive; and work alone in strange neighborhoods or cities.  Youth peddlers also may be abandoned or deserted if they do not meet their quota for the day, or may be forced to walk home for angering the crew leader.  Many parents are also unaware of these dangers and believe they are allowing their children to work for respected and legitimate companies.

In FY 2004, the U.S. Department of Labor found 1,087 minors employed in violation of Hazardous Occupation Standards.  During the same period, the Wage and Hours Division reported 5,840 children were employed in violation of child labor laws.  Both sets of figures represent reductions from prior years; however, advocates contend that the reductions are the result of reduced Federal enforcement, not declining use of child labor.  This assumption is partly due to the fact that there are only 34 Department of Labor employees assigned to monitor this area, or one per every 95,000 child laborers.  The advocates contention is supported by the U.S. Government Accountability Office (2002).  These child labor estimates represent a proportion of the population that may be at risk for labor trafficking within the United States, and should be explored further from the perspective of domestic labor trafficking.

Despite these various estimates, we are still uncertain about the actual prevalence of human trafficking into and within the United States for several reasons.  First, given the covert character of the crime, accurate statistics on the nature, prevalence, and geography of human trafficking are difficult to calculate (Clawson, Layne, & Small, 2006).  Trafficking victims are guarded closely by their captors, many victims lack accurate immigration documentation, trafficked domestic servants remain invisible in private homes, and private businesses often act as a front for a back-end trafficking operation.  These factors make human trafficking a particularly difficult crime to identify and count.  Additionally, available data are often non-comparable and contain duplicate counts, are limited to information on women and children trafficked for sexual exploitation and not other forms of human trafficking, and are often inconsistently or inaccurately recorded due to differing definitions and beliefs among service providers and law enforcement about who is a victim of human trafficking (Clawson, Layne, & Small, 2006).

Despite these challenges, steps are being taken to improve the methods used to estimate human trafficking (Clawson, Layne, & Small, 2006) and improve the reliability and validity of the data.  For example, Massachusetts created the Child Sexual Exploitation Database through the SEEN Coalition (formerly the Teen Prostitution Prevention Project) in Suffolk County.  Through increased awareness and a new reporting system, better data are available on the number of prostituted teens in the area.  In 2003, for example, only five prostituted teens were recorded by Suffolk County, but by September 2005, the number jumped to 59.  Of those 59, 58 were female, one was male, and none identified as transgender.  Providers in Boston believe this jump may be attributed to increased awareness by those coming in contact with youth (including law enforcement, health care, and child protective services) as well as a more effective identification and referral mechanism, particularly of female minors exploited through prostitution.  However, to date, there has been no analysis that documents whether these increasing numbers reflect improved awareness and identification, or an actual increase in the incidence of minor prostitution (Teen Prostitution Prevention Project, 2006).

Obtaining more stable and reliable estimates is key to helping Federal, State, and local governments appropriately allocate resources and develop programs and strategies to prevent human trafficking, prosecute traffickers, and protect and serve victims of this crime.

Who Are the Victims of Human Trafficking?

Commonalities Among Victims

While current stereotypes often depict the victims of human trafficking as innocent young girls who are seduced or kidnapped from their home countries and forced into the sex industry (Bruckert & Parent, 2002), it is not just young girls who are trafficked.  Men, women, and children of all ages can fall prey to traffickers for purposes of sex and/or labor.  Victims may be trafficked into the United States from other countries or may be foreign citizens already in the United States (legally or illegally) who are desperate to make a living to support themselves and their families in the United States or in their home countries (Florida University Center for Advancement of Human Rights, 2003).

Regardless of sex, age, immigration status, or citizenship, certain commonalities exist among victims of trafficking (for both sex and labor), such as their vulnerability to force, fraud, or coercion (Protection Project, 2002).  Traffickers prey on those with few economic opportunities and those struggling to meet basic needs.  Traffickers take advantage of the unequal status of women and girls in disadvantaged countries and communities, and capitalize on the demand for cheap, unprotected labor and the promotion of sex tourism in some countries (Aronowitz, 2001; Miller & Stewart, 1998).  Victims of human trafficking, both international and domestic, share other characteristics that place them at risk for being trafficked.  These include poverty, young age, limited education, lack of work opportunities, lack of family support (e.g., orphaned, runaway/throwaway, homeless, family members collaborating with traffickers), history of previous sexual abuse, health or mental health challenges, and living in vulnerable areas (e.g., areas with police corruption and high crime) (Salvation Army, 2006).

Victims of international trafficking may be trying to escape from internal strife such as civil war and economic crises (Aiko, 2002).  Many international trafficking victims originate from poor countries where human trafficking has become a significant source of income (Newman, 2006).  Traffickers exploit conditions in impoverished countries in Asia, Eastern Europe, Africa, and Latin America that offer few employment opportunities and are characterized by high rates of organized crime and violence against women and children, discrimination against women, government corruption, political instability, and armed conflict (Bell, 2001; U.S. Department of State, 2005).  Many trafficking victims are merely trying to remove themselves from unstable or unsatisfactory living conditions.  According to the latest figures from HHS (as reported in the DoJ Annual Report to Congress), of those certified as victims of human trafficking in 2006, the countries of origin with the highest populations of victims were El Salvador (28%) and Mexico (20%) (U.S. Department of Justice, 2007).

Traffickers often deceive their victims through false promises of economic opportunities that await them in more affluent destination countries, such as the United States.  Thus routes of trafficking often flow from less developed countries to neighboring countries or industrialized nations with higher standards of living (Miko, 2000).

Many of those who accept offers from traffickers find themselves in situations where their documents are destroyed, their families are threatened with harm, or they are bonded by a debt they will not be able to repay (Human Trafficking Organization, 2006).  Traffickers use threats, intimidation, and violence, as well as deception and trickery, to force or lure victims to engage in sex or labor in slavery-like conditions.

Victims of labor trafficking may be promised well-paying jobs, yet once in the destination country they find themselves trapped in substandard living and working conditions.  In these situations, abuse can range from the imposition of excessive working hours to verbal and physical abuse to sexual harassment and sexual attacks, and may extend to forcing the worker into the sex trade (International Organization on Migration, 2005).  Migrants residing illegally in destination countries, such as the United States, are more exposed to this kind of abuse (Tuller, 2005).  However legal citizens also can be subjected to such exploitation (International Organization on Migration, 2005).  In the United States, vulnerable workers have been recruited from homeless shelters and elsewhere, transported to isolated labor camps, and ultimately exploited and abused.  According to some experts in the labor movement, the power differential between a farm worker and an employer can create a situation that may escalate into exploitation, regardless of the immigration status of the worker (Bales, 2004; Zeitlin, 2006). 

Minor Victims of Domestic Sex Trafficking

Minors, including American children, are among the most vulnerable populations.  A look at the characteristics of minors exploited through prostitution and prostituted adults who were recruited as minors (Raphael, 2004) provides useful information to help answer the question, Who are the victims of domestic sex trafficking?  Minors are deceived, manipulated, forced, or coerced into prostitution every day.  Nationally, the average age at which girls first become exploited through prostitution is 1214 years old, but direct service providers around the country report they have been encountering increasingly younger victims over the past decade (Estes & Weiner, 2001; Lloyd, 2005; Spangenberg, 2001).  For example, service providers in New York City report that the average age that girls enter prostitution has dropped from 14 to 13 or 12 years of age in recent years (Spangenberg, 2001).  The average age that boys and transgender youth begin prostitution is even younger: 1113 years old (Estes & Weiner, 2001).

In terms of race and ethnicity, all subgroups of adolescents are at risk for prostitution.  The vast majority of male and female adolescents arrested for prostitution are White or Black (Flowers, 2001).  The only specific research conducted on a subpopulation of exploited minors shows that African-American girls and women are arrested in prostitution at a far higher rate than girls and women of other races involved in the same activity (Flowers, 2001; MacKinnon & Dworkin, 1997).  Although it appears that no socioeconomic class is immune to domestic trafficking, Estes and Weiner (2001) acknowledge that poverty (as noted previously for victims of trafficking in general) places adolescents at increased risk of exploitation. Though their sample was small (10 boys), Lankenau, Clatts, Welle, Goldsamt, and Gwadz  (2005) found that 100 percent of a studys subjects were born into homes characterized as poor or working class.  The correlation between poverty and trafficking has been corroborated by qualitative reports from law enforcement, social service providers, and others working in the anti-trafficking movements (Clawson & Dutch, 2008).  Further, Lloyd (2005) states that low-income girls are at greater risk of recruitment and may find it harder to exit.

One common characteristic or risk factor for prostituted girls is a history of childhood sexual abuse.  In 20 recent studies of adult women who were sexually exploited through prostitution, the percentage of those who had been abused as children ranged from 33 percent to 84 percent (Raphael, 2004).  For example, a study of 106 adult women in Boston who were incarcerated for prostitution-related offenses or had ever been arrested for prostitution-related offenses found that 68 percent of the women reported having been sexually abused before the age of 10 and almost half reported being raped before the age of 10 (Norton-Hawk, 2002).  Other smaller studies of prostituted girls affirm these figures.  For example, the Huckleberry House Project in San Francisco reported that 90 percent of the girls involved in prostitution had been sexually molested (Harlan, Rodgers, & Slattery, 1981).  Two other studies of juveniles estimated the percentage of girls engaged in prostitution who had a history of sexual abuse to be between 70 percent and 80 percent (Bagley & Young, 1987; Silbert & Pines, 1982).

Research has demonstrated that the younger a girl is when she first becomes involved in prostitution, the greater the likelihood that she has a history of childhood sexual abuse and the greater the extent of the abuse (Council for Prostitution Alternatives, 1991).  Further, the history of childhood trauma experienced by most girls involved in prostitution includes abuse that is chronic in nature and takes the form of physical abuse, emotional abuse, and/or sexual abuse by multiple perpetrators (Farley & Kelly, 2000). A 1994 National Institute of Justice report (as cited in Spangenberg, 2001) states that minors who were sexually abused were 28 times more likely to be arrested for prostitution at some point in their lives than minors who were not sexually abused.

In addition to a history of childhood abuse, prostituted girls are likely to experience other forms of family disruption.  Multiple studies suggest that girls involved in prostitution are more likely to come from homes where addiction was present (Raphael, 2004).  For example, one study of 222 women in Chicago involved in prostitution found 83 percent had grown up in a home where one or both parents were involved in substance abuse (Center for Impact Research, 2001).  Further, prostituted girls are more likely to have witnessed domestic violence in their home; specifically, girls are likely to have seen their mother beaten by an intimate partner (Raphael, 2004).

Some literature has begun to recognize a correlation between school-related problems, most notably learning disabilities, and sexual exploitation.  Current research does not allow us to distinguish whether the learning disability was present before or is a consequence of the exploitation.  However, the later the disability is diagnosed and an appropriate educational plan put in place, the greater the likelihood of the girl experiencing failure in school and/or low self-esteem, making her vulnerable to exploitation (Harway & Liss, 1999).

Another risk factor that emerges for youth at risk for exploitation through prostitution is the loss of a parent through death, divorce, or abandonment.  For example, in two separate studies of adolescent girls involved in prostitution, a third of the sample had a deceased mother (Norton-Hawk, 2002; Raphael & Shapiro, 2002).  This familial disruption often results in the childs involvement in the child welfare system, involving placement in foster care or group homes.  One study in Canada of 47 women in prostitution found that 64 percent had been involved in the child welfare system, and of these, 78 percent had entered foster care or group homes (Nixon, Tutty, Downe, Gorkoff, & Ursel, 2002).  The themes of trauma, abandonment, and disruption, begun in childhood, are central to the narratives of adolescent girls trafficked into commercial sexual exploitation.  Girls describe having had a profound sense of being alone without resources:  They [the women and girls] described their isolation, lack of connectedness, and feelings of separation as the single most important factor in making them vulnerable to prostitution to begin with (Rabinovitch, 2003).

The prostitution of boys is not as visible as that of young girls (McKnight, 2006).  According to Flowers (1998), boys primarily sell their bodies to survive financially, explore their sexuality, and/or make contact with gay men, with money a major motivator to continue prostituting.  Young prostituted males are also more likely to be involved in criminal or delinquent behaviors in addition to prostitution (Flowers, 1998); however, they are arrested much less frequently (McKnight, 2006).  McKnight also states that boys are more likely than girls to leave home due to a feeling of being unwanted or misunderstood regarding their sexual orientation.  Similar to girls, however, most boys exploited through prostitution come from dysfunctional homes and a large percentage have been the victim of some kind of abuse in the past (Flowers, 1998).

Other Populations at Risk for Trafficking: Runaway and Homeless Youth

According to the Federal Bureau of Investigation (FBI) Uniform Crime Reports (2006), across the United States 36,402 boys and 47,472 girls younger than age 18 were picked up by law enforcement and identified as runaways.  Girls who run from their homes, group homes, foster homes, or treatment centers, are at great risk of being targeted by a pimp (or trafficker) and becoming exploited.  Research consistently confirms the correlation between running away and becoming exploited through prostitution.  Researchers have found that the majority of prostituted women had been runaways; for example, 96 percent in San Francisco (Silbert & Pines, 1982), 72 percent in Boston (Norton-Hawk, 2002) and 56 percent in Chicago (Raphael & Shapiro, 2002).  Among prostituted youth (both boys and girls), up to 77 percent report having run away at least once (Seng, 1989).  Experts have reported that within 48 hours of running away, an adolescent is likely to be approached to participate in prostitution or another form of commercial sexual exploitation (Spangenberg, 2001); however, no definitive published research substantiates this claim.

Like girls, boys exploited through prostitution are most often runaways or throwaways (Flowers, 2001; Lankenau et al., 2005; Moxley-Goldsmith, 2005). For example, one study found that two-thirds of males exploited through prostitution had run away from home prior to becoming involved (Allen, 1980).  While many of the factors leading to a young person leaving home are similar for boys and girls, it is estimated that between 40 and 50 percent of boys exploited through prostitution had been thrown out of their homes because of sexual identity issues (Earls & David, 1989; Seattle Commission on Children and Youth, 1986).  Approximately 2535 percent of prostituted boys self-identify as gay, bisexual, or transgender/transsexual (Estes & Weiner, 2001).  Further, regardless of the boys self-identification, at least 95 percent of all prostitution engaged in by boys is provided to adult men (Estes & Weiner, 2001).  Regardless of their sex, when minors leave their homes, it is to protect themselves, often because they view living on the streets as either less dangerous or no more dangerous than staying at home (Hyde, 2005; Martinez, 2006).

Once on the street, homeless youth are at risk for being victimized because they lack the funds, interpersonal and job skills, and support systems necessary to survive on their own (Martinez, 2006).  Having often come from chaotic families, runaways tend to lack strategies for problem solving, conflict resolution, and meeting basic needs such as food, clothing, and shelter (Martinez, 2006; Robertson & Toro, 1999; Whitbeck, Hoyt, & Yoder, 1999).  Some minors turn to substance abuse, crime, and survival sex to meet their basic needs (Greene, Ennett, & Ringwald, 1999; Riley, Greif, Caplan, & MacAulay, 2004; Robertson & Toro, 1999).  Furthermore, exposure to the dangers of the street makes them more visible and vulnerable to traffickers, and their risky lifestyles and routines put them at greater risk of being victimized (Kipke, Simon, Montgomery, Unger, & Iversen, 1997; MacLean, Embry, & Cauce, 1999; Tyler, Cauce, & Whitbeck, 2004).

Most runaway/throwaway youth are likely to run to and congregate in urban areas, so it is not surprising that there is general consensus that a greater percentage of minors are exploited in the U.S. sex industry in urban areas, though they may be brought from suburban and rural areas (Flowers, 2001). However, an increase in minor arrests in suburban counties/areas and rural areas has experts speculating that the increase is indicative of an expansion of prostitution beyond city limits (Flowers, 2001).  While these data are somewhat outdated, anecdotal evidence from service providers indicates that this trend continues (A. Adams, personal communication, March 2006; N. Hotaling, personal communication, June 2006).  However, further research is needed to determine whether the increase in suburban arrests is due to better identification or an actual increase in incidence.

What Are the Needs of Victims of Human Trafficking?

Needs of International Victims

An examination of the services provided to international victims of human trafficking (adults and children) reveals emergency, short-term, and long-term needs (Caliber Associates, 2007; Clawson, Small, Go, & Myles, 2004).  Some victims initially may present to a service provider with basic needs for safety, housing, food, and clothing.  In fact, the need for safe and secure housing and overall support and advocacy are primary needs for virtually all victims of trafficking.

These basic needs often are accompanied by an immediate need for legal assistance/representation to handle issues related to immigration status, provide legal representation that may be required in an ongoing investigation and prosecution of the trafficking case, or provide counsel in a civil lawsuit against the trafficker or in a potential custody case (Caliber Associates, 2007; Florida University Center for Advancement of Human Rights, 2003).  Interviews with service providers and NGOs reveal that beyond these common immediate needs, the needs of victims are as diverse as the countries from which the victims originate.  Additionally, during the course of working with victims, their needs are likely to change (Caliber Associates, 2007).

A needs assessment conducted with service providers working with victims of human trafficking identified a broad range of victims needs, including emergency, transitional, and permanent housing; food/clothing; medical services (including dental care); advocacy (moral/emotional support), legal services; transportation; and information/referral services (e.g., rights as a victim of human trafficking, available services) (Clawson et al., 2004).  For international victims, more often than not, there is a need for language assistance, often requiring an interpreter/translator to help the victim communicate with first responders and those trying to provide assistance.  Only after these immediate needs have been met can a victim benefit from treatment for depression, trauma, re-traumatization, and other issues (Misra, Connolly, Klynman, & Majeed, 2006).

Addressing the symptoms exhibited by victims of human trafficking is critical to their long-term recovery.  Victims of human trafficking have been described as exhibiting symptoms and needs for service similar to torture victims, victims of domestic violence/sexual assault, battered immigrant women, migrant workers, refugees, and asylum seekers (Clawson et al., 2004).  Like torture victims, victims of human trafficking (both sex and labor trafficking) often experience post-traumatic stress disorder (PTSD), depressive disorder, other anxiety disorders, and substance abuse (De Jong, et al, 2001; Shrestha, Sharma, Van Ommeren, Regmi, Makaju, et al., 1998).  Specific symptoms exhibited by victims can include nightmares, difficulty concentrating, becoming easily upset, and having difficulty relaxing.  Victims can frequently feel sad or angry, have difficulty thinking, experience feelings of hopelessness, and demonstrate sleep disorders.  The trauma itself also may manifest as physical symptoms, such as headaches, chest pain, shaking, sweating, and dizziness (Center for Victims of Torture).

Beyond trauma-recovery services, long-term service needs include permanent housing, legal assistance, job training, job placement, education, family reunification (within the United States), and repatriation (in some cases).  For some victims, in particular victims of labor trafficking, the victim may have a need for long-term medical care to address physical disabilities resulting from the abuse and/or harsh labor conditions under which the person was forced to work (Bales, 2004; Caliber Associates, 2007).  Based on research on the needs of unaccompanied refugee minors, minor international trafficking victims may experience depression and feelings of isolation, but given their culture, they may not know how to express or describe what they are feeling.  They may display psychosomatic symptoms; experience high levels of anxiety (especially if language obstacles and cultural differences exist between the minor and the caregiver); experience survivor guilt (victims feel they do not deserve to be alive and in a safe place when friends, siblings, or other family members are suffering); exhibit behavioral problems, including aggression; and question their ethnic identity (Ryan, 1997).

Intensive case management and medical, mental health, and social services are important for responding to the needs of these children.  Additionally, educating and training foster care families about the dynamics of human trafficking, the needs of victims, and the symptoms of trauma are also needed to ensure appropriate placement for children in need of homes.  Given the complex needs of international victims of human trafficking, it is not surprising that providers report working with clients for more than a year and often for several years, frequently on an intermittent basis.  This makes sustained progress challenging (Caliber Associates, 2007; Clawson et al., 2004).

Needs of Domestic Victims

Information specifically documenting the needs of victims of human trafficking is limited and has focused primarily on international victims.  However, research on prostitution and on homeless and runaway youth can provide some insights about the needs of domestic trafficking victims and can help increase understanding about the similarities and differences across the victim types.

Girls and women escaping prostitution report housing (both transitional and long-term) as an urgent need (Commercial Sexual Exploitation Resource Institute, 1998).  Substance abuse treatment and mental health counseling are also common needs among this population.  The use of substances and subsequent drug addiction is well documented among homeless youth exploited through prostitution.  One study found that more than 75 percent of these youth abuse alcohol or drugs, while virtually all admit to some level of use (Yates, Mackenzie, Pennbridge, & Swofford, 1991).  These rates were notably higher than among homeless youth not exploited through prostitution (R. Lloyd, personal communication, May 2007).  While it is important to note that a significant percentage of girls enter prostitution with no history of drug or alcohol abuse (Farley & Kelly, 2000), some studies suggest that girls who become exploited through prostitution are likely to have begun using substances at an earlier age than their at-risk peers who do not become exploited in this way (Inciardi, Pottieger, Forney, Chitwood, & McBride. 1991; Nadon, Koverola, & Schludermann, 1998).  Substance abuse is also a rampant problem among the male population.  For example, one study found that 77 percent of the boys exploited through prostitution were regular users of marijuana (Harlan et al., 1981).  Another study found that 42 percent of the prostituted boys could be classified as heavy drinkers or alcoholics and 29 percent were regular users of hard drugs (Allen, 1980).  In 1989, the County of Los Angeles found that of all the runaway youth, both boys and girls, seeking medical assistance, 75 percent of those exploited through prostitution had a substance abuse problem compared with 36 percent of those youth not being prostituted (Klain, 1999).  Both girls and boys also present with medical needs.  Females trafficked in the sex trade have increased risk of cervical cancer and chronic hepatitis as well as HIV (Farley et al., 2003), thus requiring immediate and potentially long-term medical care.  Boys are at particularly high risk of contracting HIV due to high rates of unprotected anal sex with adult men as well as frequent intravenous drug use (Flowers, 2001).

Rates of mental health problems are similar between girls and boys, though girls have been studied far more extensively (Flowers, 2001; Klain, 1999; Lankenau et al., 2005; Moxley-Goldsmith, 2005).  Adolescent girls suffer severe emotional and physical consequences as a result of domestic trafficking. Survivors of prostitution demonstrate a high rate of dissociative disorders, self-destructive behaviors (including cutting), suicide attempts, and clinical depression (Farley, 2003; Farley & Kelly, 2000; Giobbe, 1993; Lloyd, 2005; Nixon et al., 2002).  Additionally, as a result of the chronic trauma, prostituted girls often develop symptoms congruent with PTSD.  One international study of prostituted children and adults, including male prostitutes, in five countries found that almost three-fourths met the diagnostic criteria for PTSD (Farley, Barel, Kiremire, & Sezquin, 1998; Silbert & Pines, 1981).  The clinical manifestations of PTSD can limit an individuals ability to function effectively, decreasing the likelihood that he or she can take advantage of available resources and possibly minimizing any likelihood of leaving prostitution (Valera, Sawyer, & Schiraldi, 2001).

As with all victims of human trafficking, adolescent girls may display symptoms of Stockholm syndrome, otherwise most frequently seen among prisoners of war and torture victims (Graham & Wish, 1994).  As a means of emotional and physical survival, the captive (the girl) identifies with her captor. She expresses extreme gratitude over the smallest acts of kindness or mercy (e.g., he does not beat her today), denial over the extent of violence and injury, rooting for her pimp, hypervigilence regarding his needs, and the perception that anyone trying to persecute him or help her escape is the enemy.  She may lash out at law enforcement or anyone else attempting to help her exit, and insist that she is fine and happy in her current situation. Further, the manifestations of her trauma may make her reticent to trust those outside the Life who state they are trying to help her (Friedman, 2005; Raphael, 2004).

While presented here as separate needs or conditions, recognition of co-occurring disorders among adolescent victims of trafficking and the need for integrated treatment approaches, specifically for trauma, substance abuse, and mental health disorders, has gained momentum over the past 510 years (Austin, Macgowan, & Wagner, 2005; Battjes et al., 2004; Dasinger, Shane, & Martinovich, 2004; Dennis et al., 2002, 2004; Godley, Jones, Funk, Ives, & Passetti, 2004; Robbins, Bachrach, & Scapocznik, 2002).  A number of studies indicate high rates of co-occurring disorders among adolescents.  In one clinical study of youth in the mental health system, for example, about half had a co-occurring substance abuse disorder (Greenbaum, Foster-Johnson, & Petrilla, 1996).  In the substance abuse system, estimates are even higher that as many as 7590 percent of drug abusing adolescents having a co-morbid mental health disorder (Eisen, Youngman, Grob, & Dill, 1992; Grella, Hser, Joshia, & Rounds-Bryant, 2001).  Mood disorders (especially depression and anxiety), conduct disorders, and attention deficit hyperactivity disorder are most often cited as co-occurring with substance abuse disorders in adolescents (Crowley & Riggs, 1995; Wise, Cuffe, & Fischer, 2001).  Given the high documented rates of co-morbidity in substance abusing clinical populations, Grella et al. (2001, p. 391) concluded that adolescent drug treatment programs should assume that co-morbidity among their patients is the norm, rather than the exception.

The needs of homeless and runaway youth parallel the needs of victims of human trafficking (international and domestic).  These include the need for food, clothing, and housing; medical care; alcohol and substance abuse counseling and treatment; mental health services; education and employment assistance; and legal assistance (Robertson & Toro, 1999).  In two studies, homeless youth reported wanting assistance with life skills training (Aviles & Helfrich, 2004; DeRosa et al., 1999).  Other important service needs are assessment and treatment for exposure to trauma (Dalton & Pakenham, 2002; Steele & OKeefe, 2001) and risk of suicide (Martinez, 2006).

Overall, the needs of victims of human trafficking, whether international or domestic, sex or labor trafficking, can be characterized as complex, requiring multiple and comprehensive services and treatment representing a continuum of care (emergency, short-term, and long-term assistance) that can last for several years.

How Are Victims Identified?

Although victims of human trafficking are difficult to identify because of the hidden nature of the crime, many sectors of U.S. communities have the potential to come in contact with them.  For example, victims of trafficking are at risk for the same types of injuries as victims of domestic violence and rape.  They frequently contract sexually transmitted infections or become pregnant.  Therefore, health clinic workers or emergency room personnel are often first responders and should be trained to assess whether someone is a victim of human trafficking (Hughes, 2003).  In addition, female trafficking victims may be able to gain admission to, and potentially could be identified through, battered women and homeless shelters.  For this reason, several domestic violence and sexual assault coalitions have issued guidelines for battered women service providers on identifying and serving victims of trafficking (Dabby, 2004; Salvation Army, 2006).  Social workers, mental health professionals, and school personnel are also at times on the front line of encountering and identifying potential victims.  Community-based organizations, faith leaders, and citizens can also be in a position to identify victims of trafficking.  As public awareness of the problem has grown, victim referrals from these groups to NGOs and service providers have increased significantly (Caliber Associates, 2007).

Perhaps the greatest chance of identifying victims lies with law enforcement.  Most victims of human trafficking who have been referred to NGOs and other service providers have been initially identified by Federal and local law enforcement (Caliber Associates, 2007).  Additionally, many of the documented cases of domestic trafficking have been the result of law enforcement task force investigations.  For example, the U.S. Department of Justice has attempted to address identification and outreach to victims of domestic sex trafficking through the FBIs Innocence Lost program, which was launched in 2003.  The FBI established 14 task forces in cities with the most reports of prostituted youth; currently, task forces are in 27 cities.  In more than two and one half years, 300 child victims have been rescued.  The program also has resulted in 241 investigations and reported more than 662 arrests, 151 informations/indictments, and 100 convictions (Federal Bureau of Investigation, 2005).  Similar multidisciplinary anti-trafficking task forces have been funded in 42 communities across the country with the goal of identifying, investigating, and prosecuting cases and providing the protection and services needed by victims (U.S. Department of Justice, 2006).  According to a Department of Justice press release in 2005, indictments were made against 31 individuals in four U.S. Districts (the Middle District of Pennsylvania, the District of New Jersey, the Eastern District of Michigan, and the District of Hawaii) that included charges of transportation of minors to engage in prostitution and sex trafficking of children.  A challenge for these task forces is the inconsistency in the definition of human trafficking.  There does not seem to be a consensus within law enforcement as to whether a minor involved in prostitution is a victim or an offender (Finkelhor & Ormrod, 2004).

Law enforcement personnel report often coming in contact with victims of human trafficking through the investigation of other crimes (Clawson, Dutch, & Cummings, 2006; Venkatraman, 2003).  Victims of sex trafficking have the greatest chance of being identified through arrests made by law enforcement pursuant to State prostitution and commercial vice statutes.  Uniform Crime Reports estimate that in 2005, there were 84,891 arrests for adult prostitution or commercialized vice.  National Incident-Based Reporting System (NIBRS) data from 13 States found slightly more arrests of males for prostitution than females.  The arrest rate (a standard measure of the percent of reported cases where an arrest was made) was high for these crimes (85% for males and 82% for females), although it is not known what percent of individuals involved in prostitution actually come to the attention of police.

A significant challenge to identifying victims of human trafficking is that many have historically been, and in some instances continue to be, viewed as criminals (e.g., undocumented immigrants, prostitutes) and subject to arrest, detention, and/or deportation.  But under the TVPA, these individuals previously identified as criminals should be identified and treated as trafficking victims.  This change is important and challenging for Federal, State, county, and local law enforcement and prompts the need for adequate and ongoing education, training, and commitment at all levels of these agencies.  This shift in focus has not been achieved consistently, due in part to the decentralized structure of our law enforcement system with more than 13,000 local police departments alone in the United States (Bureau of Justice Statistics, 2003).  Further complicating this systemic and conceptual shift is the fact that some individuals, such as adults engaged in commercial sex activity without the elements of force, fraud, or coercion, may not be considered victims of trafficking.  Ideally, every law enforcement officer would have the proper training and tools (e.g., common screening questions and protocols) to be able to correctly apply the trafficking law, make the proper distinctions, and refer trafficking victims for health and human services.

What Services Are Victims of Human Trafficking Eligible to Receive?

Services for Adult Victims

Prior to the passage of the TVPA in 2000, NGOs and other service providers with scarce resources struggled to piece together the comprehensive services needed by victims of human trafficking (Clawson, Small, Go, & Myles, 2004).  Under the TVPA, the U.S. government designated HHS, along with the Office for Victims of Crime (OVC) at the Department of Justice, as the primary Federal agency responsible for helping international victims of human trafficking become eligible for benefits and services, and allocated some resources for service delivery.  One responsibility of HHS is to certify international victims of trafficking once they have been identified.  This certification provides a victim of trafficking who is not a U.S. citizen or lawful permanent resident with the appropriate documentation allowing eligibility for a special visa, refugee benefits, and other refugee services that are not available to citizens and lawful permanent residents.  U.S. citizens who find themselves victims of trafficking do not need to be certified in order to be eligible for mainstream benefits, such as Temporary Assistance for Needy Families (TANF), Medicaid, and the Supplemental Nutrition Assistance Program (formerly known as the Food Stamp Program).  As U.S. citizens, they already are eligible for such services.  However, anyone applying for mainstream benefits such as these must do so through the State in which they reside and must meet the eligibility requirements for each program (e.g., be single mothers with children, disabled, or meet other criteria, and have low income).  Variations in State application processes, documentation requirements (e.g., birth certificate, drivers license), and the movement of victims once they are rescued may make it difficult for victims to access these services (Holcomb, Tumlin, Koralek, Capps, & Zuberi, 2003).

To receive certification, an international adult must first be determined to be a victim of a severe form of trafficking, as defined by the TVPA, and be willing to assist in the investigation of the traffickers.  Following this determination by law enforcement, victims must complete a bona fide application for a T-visa or be awarded continued presence by a U.S. Immigration and Customs Enforcement official (8 U.S.C. 1101 a15T 2000), which allows them to legally, albeit temporarily, reside in the United States.  T-visas were established under the TVPA and allow international victims of trafficking to become temporary residents of the United States. Once a T-visa is obtained, a victim may remain in the United States for up to 3 years.  At the end of this time period, the victim may be eligible for permanent resident status (Protection Project, 2002).  Continued presence is a discretionary status provided by the U.S. Department of Homeland Security, generally for a period of 1 or 2 years and can be renewed.

Certified adult victims are eligible to receive federally funded services and benefits similar to refugees.  Some of the refugee-specific services that victims of trafficking are eligible to receive through HHS and NGOs are Refugee Cash and Medical Assistance, housing or shelter assistance, food assistance, income assistance, employment assistance, English language training, health care assistance, mental health services, and assistance for victims of torture. Other non-refugee specific benefit programs that certified victims may apply for are TANF, which provides a cash benefit and work opportunities for needy families with children younger than age 18, and Medicaid, which provides public health insurance for needy people with low income and limited resources (22.U.S.C. §7105(b)(1)).

Victims also are eligible for the Department of Labors One-Stop Career Center System, which offers free job search and employment centers that provide information and assistance for people who are looking for a job or who need education and training to obtain a job.  It also provides support services such as transportation, child care, and housing.  Other programs available to victims who meet standard income and eligibility requirements of each program include the Supplemental Nutrition Assistance Program, Supplemental Security Income, State Childrens Health Insurance Program, Job Corps, public housing, and State-specific programs (U.S. Department of Justice, 2006).

The process for obtaining certification and thus access to services can be lengthy, since it often takes law enforcement agencies a while to formally determine that a person meets the statutory criteria to be considered a victim of a severe form of trafficking (Caliber Associates, 2007).  During this waiting period, international victims, in most cases, are not eligible for either refugee-specific or mainstream services.  For this reason, OVC began administering comprehensive service grants to communities to provide pre-certification services to international victims of human trafficking who were pursuing certification and cooperating with law enforcement.  Additionally, HHS extended the parameters of its direct services (now per capita services) funding to cover the period of pre-certification.  The Per-Capita Victim Services contract is designed to centralize services while maintaining a high level of care for victims of human trafficking through anytime, anywhere case management.  Working with the HHS ongoing Rescue and Restore public awareness campaign, subcontractors are reimbursed for the services actually provided to each human trafficking victim.  The contract also streamlines support services to help victims gain timely access to shelter, job training, and health care.  Pre-certification services parallel most of the certification services, including housing, food/clothing, advocacy, legal assistance, medical/dental care, language services (e.g., interpreters/translators), mental health counseling, education, and job training (U.S. Department of Justice, 2006).  Most of these services are provided in response to emergency or immediate needs, which can be several.  Most international victims become certified before their long-term needs, such as permanent housing and employment, develop (Caliber Associates, 2007).

For some international victims, including those who decide not to cooperate with law enforcement, NGOs and service providers seek alternative remedies to meet their needs.  This has included filing for U-visas[4] and accessing services under the Violence Against Women Act, seeking asylum for the victim, and for some agencies, tapping non-federal or unrestricted funding streams to provide ad hoc services (Caliber Associates, 2007).

Services for Minor Victims

Unlike adults, minor victims of human trafficking do not need to be certified in order to receive services and benefits, as they are eligible for benefits through the Office of Refugee Resettlement within the HHS Administration for Children and Families (22.U.S.C. §7105(b)(1)).  Similar to international adult victims, international minor victims of trafficking (younger than age 18) do not need to be certified, but instead receive a letter of eligibility from HHS and are then eligible to apply for a similar range of services as refuges, including the Unaccompanied Refugee Minor Program.  The Unaccompanied Refugee Minor Program originally was designed to provide resettlement services to those refugee minors located both in the United States and abroad without a parent or guardian, and to provide a linguistically and culturally appropriate alternative to the mainstream Federal/State foster care and adoption system.  This program assists with the development of skills minors need to enter adulthood and achieve economic and social self-sufficiency.  According to each States law, victims receive the full range of assistance, care, and services to which all children in the State are entitled.  In addition, a legal authority is designated to act on behalf of the minor in the absence of the minors parents.  This includes English language training, career planning, health/mental health needs, socialization skills/adjustment training, residential care, education/training, and ethnic/religious preservation.  Reunification with parents or other family also is encouraged when available and appropriate, and attempts to trace family are conducted in coordination with local refugee resettlement agencies.  Most children in the Unaccompanied Refugee Minor program are placed in licensed foster homes, although other settings, including therapeutic foster care, group homes, residential treatment centers, and independent living programs, may be utilized depending on the needs of the minor (U.S. Department of Health and Human Services, 2007).

Although some research suggests services available for minor victims are meeting some of their needs (Bales & Lize, 2004; Caliber Associates, 2007), larger, long-term studies are needed to confirm early findings.

What Are the Barriers to and Challenges in Accessing and Providing Services?

There are many barriers to and challenges in responding to the needs of victims of human trafficking.  Some of these barriers result from an overall lack of knowledge about human trafficking and lack of public awareness of the issue, and differing definitions and perceptions regarding who is a victim (Clawson et al., 2004).  To compound the problem, research has suggested that trafficking victims are often reluctant to identify themselves as victims; therefore, self-referrals are less common than with other types of crime (Richard, 1999).  Victims of human trafficking are also a hard-to-find, hard-to-reach population.  Many victims have been taught to fear law enforcement authorities and NGOs, often because of their experiences with corrupt law enforcement personnel or authorities in their countries of origin (Bales, 2004).  Additionally, victims are often reluctant to come forward because they fear retribution from their traffickers and fear arrest and deportation.

Despite the definition offered by the TVPA, inconsistencies still exist in how law enforcement and service providers define victims and handle cases, presenting a primary barrier to identification.  For example, there is no nationwide consensus regarding the treatment of juveniles engaged in prostitution (whether they should be considered victims or offenders).  Data from the FBIs NIBRS 19972000 (prior to the TVPA) were analyzed, looking at a sub-sample of 241 prostitution arrests involving juveniles nationwide (Finkelhor & Ormrod, 2004).  Of these incidents, 229 juveniles were counted as offenders and 61 as victims.  Further, boys were more likely than girls to be considered offenders.  As boys most often do not have the formal coercion of a pimp, this may account for them being more frequently labeled as offenders rather than victims.  In addition, law enforcement may fail to record a prostitution offense at all, believing it is in the adolescents best interest to be released or charged with another offense (e.g., disorderly conduct, trespassing).  Law enforcement also may be affected by other issues, such as the demeanor of the adolescent, the officers sympathy for a particular teenager, or specific law enforcement policies in a jurisdiction (Finkelhor & Ormrod, 2004).

The stigma associated with sexual exploitation in general, and prostitution in particular, also increases the difficulty in identifying victims.  Both international and domestic victims of sex trafficking are not likely to disclose their involvement in prostitution to providers, especially law enforcement, due to their own sense of shame and fear of the response (Lloyd, 2005; Raphael, 2004; U.S. Department of Justice, 2002).  Further, the power of the traffickers or pimps seduction and manipulation, as well as the manifestations of Stockholm syndrome,  render some victims less likely to see themselves as victims and more likely to protect their perpetrator at all costs (Caliber Associates, 2007; Lloyd, 2005; Raphael, 2004).

For international victims, and perhaps some domestic victims, other significant challenges to accessing services include cultural and language barriers.  Victims may not learn about available services if information about these services is not provided in their native language.  Additionally, some victims may be illiterate in their native language.  While most service providers engage an interpreter/translator to assist with communication, the presence of a third party can make it more difficult for the provider (often the case manager) to develop a relationship of trust with the victim.  Cultural differences also can interfere with the ability to provide or receive services and lead to culturally inappropriate services, insensitive responses, and/or misinterpretation of behavior or actions.  For example, victims unwillingness to look directly at the person speaking to them may be misinterpreted by providers as a sign that someone is hiding something or not telling the truth rather than understood as a sign of respect, as is the case in some cultures.  Basic logistical barriers, including lack of familiarity with the community, transportation, or child care, can prevent victims from accessing available services (Clawson et al., 2004).

Studies of runaways provide useful insights about why these youth do not use available services and programs or discontinue using them (De Rosa et al., 1999; Martinez, 2006).  Reported barriers included restrictive rules at shelters; concerns regarding confidentiality, including concerns about being reported to child protective services; lack of age-appropriate therapeutic groups; lack of culturally appropriate services; inability to establish trust with staff members due to high staff turnover; and the need for emotional, financial, and other support that will help empower these victims to leave the streets and exploitation (Aviles & Helfrich, 2004; Dalton & Pakenham, 2002).  With the exception of the last barrier, the barriers described here are similar to concerns expressed by international trafficking victims during individual interviews conducted as part of a larger evaluation of comprehensive services for victims of human trafficking (Caliber Associates, 2007). 

Seeking some services may have potential legal ramifications for victims.  As is the case with adult victims of domestic violence, the legal consequences of being identified with a substance abuse or mental health disorder can be profound for an immigrant illegally in this country.  An international trafficking victim may fear that the problem will be documented and negatively affect a future immigration hearing or a possible custody case (Caliber Associates, 2007). 

With minors (but also with many adults), one of the greatest barriers is persuading a victim to commit to substance abuse and/or mental health treatment.  Research indicates that most adolescents do not present themselves for substance abuse treatment voluntarily and therefore have low motivation for treatment; they are either mandated to services or enter as a result of family pressure (Melnik, DeLeon, Hawke, Jainhill, & Kressel, 1997; Noel, 2006).  Studies also document higher rates of attrition in adolescent programs compared to adult programs (Dobkin, Chabot, Maliantovitch, & Craig, 1998; Noel, 2006; Siegal, Rapp, Fisher, Cole, & Wagner, 1993; Spooner, Mattick, & Noffs, 2001).  Both research and program administrators identify demographics (younger age, ethnic minority status, female gender, and being pregnant and parenting), substance use severity, mental health symptoms, and motivation/treatment readiness as the leading predictors of dropping out of treatment (Gainey, Wells, Hawkins, & Catalano, 1993; Grella et al., 2001; Haller, Miles, & Dawson, 2002; McCaul, Svikis, & Moore, 2001; McComish, Greenberg, Ager, Chruscial, & Laken, 2000).

Additionally, the complex needs of victims of human trafficking can create tremendous challenges for providers trying to deliver integrated services (Caliber Associates, 2007; Van Leeuwen, 2004).  Common difficulties cited include lack of adequate resources to provide intensive case management and follow-on/aftercare services for extended periods of time (Dennis, 2006); lack of training about how to gain victims trust, effective outreach methods, cultural competency, and/or confidentiality (Bird, 1999; Clawson et al., 2004); and staff inability to identify and respond to the co-occurrence of emotional and behavioral problems (especially among adolescents) (Mark et al., 2006).  Other agency problems include ineffective coordination of services across agencies (Clawson, Dutch, & Cummings, 2006), safety concerns for victims and staff (Clawson et al., 2004), insufficient monitoring of service quality (Lyons & Rogers, 2004), and a general lack of services in the surrounding community.  Services that are particularly lacking include appropriate interpreters/translators, secure housing, and affordable medical/dental care (Clawson et al., 2004).

What Are Promising Practices for Serving Victims of Human Trafficking?

There is little literature on effective programs and services specifically for victims of human trafficking.  In fact, what is known is limited to a couple of recent studies that examined services for international victims of human trafficking (Bales & Lize, 2004; Caliber Associates, 2007) and anecdotal information from providers and victims.  Information from more than a decade of work with victims of domestic violence, prostitution, homeless and runaway youth, and victims experiencing trauma in general provide most of the groundwork that requires further exploration, application, and assessment with victims of human trafficking.

Despite the lack of rigorous evaluations of effective practices and programs, providers nationwide have begun to agree on some promising practices in the field of human trafficking and, in particular, in working with prostituted minors (A. Adams, personal communication, March 2006; Caliber Associates, 2007; N. Hotaling, personal communication, June 2006; National Center for Missing and Exploited Children, 2002; K. Seitz, personal communication, October 2006; R. Lloyd, personal communication, May 2007).  These ideas can be organized into two categories: components of promising services/strategies and continuum of care.

Components of Promising Services/Strategies

While little evidence exists to support the effectiveness of specific interventions or services for victims of human trafficking, it is possible to identify certain components of promising services and strategies based on the observations and experiences of service providers working with trafficking victims and similar populations.

Safety Planning

Physical and emotional safety is a theme throughout the various programs serving victims of human trafficking (international or domestic, adult or child).  Similar to battered women, victims are often at greatest risk for harm by their trafficker (or pimp) when they leave their situation.  Because traffickers may be involved in organized crime, local gangs, or trafficking networks, the risk may be even greater for a victim of human trafficking (Salvation Army, 2006).  Agencies must ensure that they are maximizing the safety of victims and that providing or referring to services does not further jeopardize victims physical well-being.  Protecting the safety of staff working with victims also is important and safety plans should be developed for both victims and staff.[5] As a safety measure, many providers working with victims of trafficking do not publish their physical location or address, similar to domestic violence shelters (Clawson, Small, Go & Myles, 2004).  Frequently, case managers and other providers are involved in outreach activities, which potentially place them at greater risk for visibility and harm.  When in the field, outreach workers should not appear as a threat to a pimp or trafficker (e.g., by trying to ostentatiously convince a girl to exit), and therefore must be creative about how and when they reach out to victims or potential victims (O. Briceno, personal communication, June 2006).  For example, street outreach teams at The Paul & Lisa Program are specifically trained to carefully observe and assess a girls situation on the street prior to taking any precipitous actions (National Center for Missing and Exploited Children, 2002; The Paul & Lisa Program, 2006).

Security also becomes a concern when providing housing for victims.  Similar to battered womens shelters, safety must be a priority not only for the victim and staff but also for the other residents (A. Adams, personal communication, March 2006; Children of the Night, 2006).  Clear communication of shelter rules (e.g., use of telephone, disclosure of location, precautionary measures for entering and leaving facility) and strict enforcement of those rules are necessary for the safety of everyone.

Another safety consideration is whether the victim has been exposed to infectious diseases such as tuberculosis, HIV, and typhus (Salvation Army, 2006) and the risk of exposure to others.  This should be determined as part of an initial assessment or screening of the victim.

Collaboration

Because trafficking victims needs are complex and extensive, it is impossible for a single agency to respond effectively to this population.  Some NGOs and providers are able to offer core services in-house (e.g., case management, social services, legal assistance).  However, many other services needed by victims can only be obtained through collaboration with other providers.  These providers include domestic violence/sexual assault shelters, health/dental clinics, counseling services (including mental health and substance abuse treatment), legal advocates/immigration attorneys, language translation services, and food banks.  (A. Adams, personal communication, March 2006; Caliber Associates, 2007; N. Hotaling, personal communication, June 2006; MacInness, 1998; National Center for Missing and Exploited Children, 2002; K. Seitz, personal communication, October 2006).

The value of a collaborative approach to meeting the needs of victims of human trafficking is supported by the development of HHS anti-trafficking community coalitions, OVCs comprehensive service initiatives, and multidisciplinary anti-trafficking task forces across the country that require collaboration among Federal, State, and local law enforcement, attorneys, other government agencies (e.g., Department of Labor, social service agencies), NGOs, and victim service providers (Caliber Associates, 2007; U.S. Department of Justice, 2006).  The Florida Coalition Against Domestic Violence carries out a multidisciplinary response to human trafficking, adapted from its coordinated community response model to assist victims of domestic violence and sexual assault.  According to members of the coalition, Multidisciplinary coordinated community response is one of the best ways for communities to respond to victims of trafficking.  Just as with domestic violence survivors, trafficked persons have a variety of needs.  Developing a community response to human trafficking requires the collaboration of many persons, agencies and organizations (Florida Coalition Against Domestic Violence, 2004, p.14).

Other collaborations exist throughout the United States and Canada, including the SEEN Coalition of the Suffolk County (MA) Childrens Advocacy Center.  With a collective goal of increasing awareness and identification of services to adolescents exploited through prostitution, project partners launched Multidisciplinary Team Guidelines in October 2006.  These guidelines ensure that within 48 hours of any agency identifying a girl or boy being exploited through prostitution, representatives from all relevant agencies (including law enforcement, child protective services, medical providers, and district attorneys) convene to jointly ensure the victims immediate safety needs are met and to plan for longer term needs and recovery.  Although the model is predicated on a victims choice about exit and planning, the team convenes to exchange information and provide support, whether or not the victim is ready to receive these services.  If the victim is not ready to receive services, the collaboration ensures that follow-up takes place (Teen Prostitution Prevention Project, 2006).

The Southern California Regional Sexual Assault and Exploitation Felony Enforcement (SAFE) team is a task force of Federal, State, and local investigators and prosecutors who are physically located together for the purpose of investigating cases of child sexual exploitation.  Each agency contributes important resources such as investigative expertise.  Members are deputized as U.S. marshals and operate under a formal memorandum of understanding.  The SAFE team meets biweekly and compiles monthly summaries of cases and activities, including any training received by members.  Based on these summaries, statistics on the number of investigations and their outcomes are tracked.  Street work and reverse stings are the primary means used to investigate the prostitution of children.  Community policing techniques also are used to build rapport with runaway, homeless, or street youth, enabling law enforcement to work with them to identify and apprehend pimps, customers, and others who exploit the youth.  The task force works closely with victim service providers, child protective services, childrens advocacy centers, and youth shelters (National Center for Missing and Exploited Children, 1999).

One review found that to be most effective, collaborations and relationships among agencies must be clear and established before a victim is in need of assistance (Braun, 2003).  While task forces and collaborations continue to emerge as promising practices in addressing trafficking and meeting the needs of victims, no rigorous assessment of their success has been conducted to date.

Relationship Development/Consistency

As is commonly recognized among providers serving adult women, Making connections and building relationships have proven to be crucial first steps in moving out of prostitution (Rabinovitch, 2003).  Girls and women in the Life have been systematically isolated from the straight world.  Girls and women report going months or even years without talking with anyone outside the sex trade (Audrey M., personal communication, December 2006; N. Hotaling, personal communication, June 2006; Michelle S., personal communication, December 2006).  Research, predominantly focused on adult women, has shown that supportive relationships are a key factor in exiting the Life (Hedin & Mansson, 2003; MacInness, 1998; Raphael, 2004).  This relationship building requires consistency over time, coupled with a nonjudgmental approach and significant perseverance on the part of providers.  Considerable time and repeated contacts may be necessary before a relationship has been built sufficiently for a girl to accept services designed to empower her to leave the Life (Audrey M., personal communication, December 2006; Hotaling, Burris, Johnson, Yoshi, & Melbye, 2003; Massachusetts Department of Social Services, 2006; Michelle S., personal communication, December 2006; National Center for Missing and Exploited Children, 2002; Rabinovitch, 2003; R. Lloyd, personal communication, May 2007).

Significant hurdles must also be overcome in establishing a relationship with victims of international trafficking.  In addition to language and cultural differences, many victims may not trust the provider and may not understand or believe the provider is willing to help.  According to one victim of international labor trafficking, she had been taught not to trust people and therefore was suspicious of offers to help, expecting she would have to give something in return (Caliber Associates, 2007).

NGOs and other providers have found that working with international victims requires significant patience and consistency.  Turnover, especially among case managers or other key providers, can cause setbacks in a victims recovery.  Through adequate education, training (including cultural sensitivity training), support (including emotional and psychological support), and caseload management, many agencies have experienced success in retaining case managers (Caliber Associates, 2007).

Culturally Appropriate Service Provision

Racial and/or cultural issues are important when dealing with all victim populations (Carter, 2003; Rabinovitch, 2003).  For example, according to Breaking Free, a program focused on African-Americans in Minnesota and serving prostituted women, The services that black women need may seem to be the same as those required by white women.  However, because of the repeated and sustained harms of racism, the needs of African-American women are significantly different (Carter, 2003).  Similarly, just because a group of women or men were involved in the same trafficking case does not mean they will have the same experience.  Service providers working with victims of international human trafficking have encountered cultural issues that can affect service delivery (e.g., dietary needs, religious practices, and behavior).  A recent evaluation of a comprehensive initiative in Los Angeles explored some of the challenges encountered by international victims from different cultures living in the same house (a shelter designed specifically for victims of trafficking).  The women experienced problems and conflict, but through cultural sensitivity workshops, cultural events (e.g., hosting cultural dinners, celebrating holidays), and efforts to foster open dialogue and communication, the women were able to form relationships and overcome some of the cultural barriers even though they often did not speak the same language (Caliber Associates, 2007).

To deliver culturally appropriate services and support, providers must be aware of cultural differences and develop an understanding of culture.  The Center for Victims of Torture (2006) provides the following guidelines for developing cultural understanding for victims of torture.  These are largely applicable for providing services to international trafficking victims:

• Learn to identify and articulate ones own cultural beliefs, practices, and assumptions.
• Investigate ways to address cultural differences or similarities among provider, survivor, and interpreter (if used).
• Learn from multiple sources and perspectives about the countries, cultures, and subcultures of survivors the provider is serving.
• Assess and address culturally relevant variables such as spirituality and religious practices, family and social roles, stages of resettlement and/or acculturation.
• Use tools designed for cross-cultural dialogue.
• Ask survivors what their culture means to them.
• Find out who the survivor was before the torture.

Similar guidelines emerged from an evaluation of programs for unaccompanied refugee minors (Ryan, 1997).  These guidelines can help promote culturally appropriate services and better respond to the needs of victims of human trafficking.

Trauma-Informed Programming

All victims of human trafficking share the experience of trauma.  While each victim may respond differently, trauma is a constant among all victims and therefore should be considered in any comprehensive service plan.  For example, the literature on prostitution indicates that focused support related to recovery from trauma is fundamental to a successful exit from prostitution. Adult womens programs, such as the Standing Against Global Exploitation Project, Inc. (SAGE) STAR program, specify that trauma recovery is a lifelong process and imperative for every survivor of prostitution.  This includes being able to acknowledge and share the harsh realities of their lives in prostitution without fear of shaming, confrontation, or minimization: Like Vietnam veterans, women in prostitution must overcome public denial about the truth of their experiences (Hotaling et al., 2003).  Well-established adolescent programs serving exploited girls also make trauma recovery a key component of treatment.  This may include individual therapy, group therapy, or art therapy in an atmosphere of love, support, and unconditional acceptance.  Further, providers use a variety of grounding techniques to assist girls who experience flashbacks and other symptoms of trauma (B. Everts, personal communication, November 2006; Girls Educational & Mentoring Services, 2006; Nixon et al., 2002).

Given that girls may heal and develop through connections to others, and that trauma from prostitution is relational in nature, a gender-specific trauma recovery program should focus on the need for healing connections in the face of the complex relationships that girls bring into treatment. As explained in relation to traumatized girls in the juvenile justice system, [Gender-specific trauma recovery programs] should help girls negotiate gender and family roles, determine appropriate boundaries in relationships, and avoid conflict and violence in [intimate] relationships (Hennessey, Ford, Mahoney, Ko, & Siegfried, 2004).  These considerations also apply to victims of international trafficking.

According to Harris and Fallot (2001), providers often need to make fundamental changes in their attitudes, beliefs, and practices related to understanding trauma and its impact in order to be more successful in meeting the needs of their clients.  The following concepts are key to making services trauma-informed and more effective:  

• Understanding trauma is a defining and core life event with a complex course that can shape a survivors sense of self and others, rather than a discrete event with predictable and immediate impact. 
• Understanding the consumer/survivors complaints and symptoms are coping mechanisms and original sources of strength within a relational approach to solutions that may no longer be effective, rather than viewing them as problems within an individualized view of the solutions.
• Understanding the primary goals of services are empowerment and recovery (growth, mastery, and efficacy) which are prevention-driven, limited by survivor self-assessment and recovery needs, and requiring both the consumer and provider to assume shared risks, rather than the primary goals being stability and absence of symptoms, a crisis orientation, time-limited by economic and administrative needs, and oriented to minimizing provider liability.
• Understanding the service relationship is collaborative, with the survivor and provider having equally valuable knowledge, rather than viewing it as hierarchical with the provider having superior knowledge.  This equal relationship ensures survivors are active planners and participants in ensuring their safety and developing services.  This approach places a priority on choice and control and trust developed over time, rather than treating the survivor as a passive recipient where safety and trust are assumed from the outset.

Characteristics of trauma-informed services also include universal screening and assessment for trauma; training all staff about trauma and its impact (especially the multiple and complex interactions of trauma and drug/alcohol use); hiring staff members who are knowledgeable about trauma dynamics; reviewing agency policies and procedures to identify any that are potentially harmful to trauma survivors (Carmen et al., 1996); and recognizing that ancillary services, including safe housing, parenting and other life skills, health care, legal services, and vocational supports, are critical to comprehensively meeting the needs of individuals who have experienced trauma (Finkelstein, VandeMark, Fallot, Brown, Cadiz, & Heckman, 2004).

Providing a context for bonding and a sense of safety through group processes is essential in a trauma-informed approach.  Other trauma-specific elements include helping clients develop new coping skills, find meaning in their lives, and see the correlation between their traumatic experiences and other symptoms they may have (Gatz et al., 2007).  Integrating these elements into comprehensive services, along with the changes in beliefs, attitudes, and practices outlined above, is necessary for a trauma-informed approach to services.

Research conducted by Elliott, Bjelajac, Fallot, Markoff, and Reed (2005) suggests that service systems that do not follow a trauma-informed approach or do not have an understanding of the impact of trauma, can unintentionally create a destructive or negative environment.  Many common practices in service settings can trigger trauma reactions, creating an unsafe place for survivors (Harris & Fallot, 2001).  For example, a group home may send youth to their rooms as a punishment for misbehavior; imposing this punishment on victims of trafficking can result in the youth feeling a sense of confinement and trigger a traumatic reaction.  Systems and providers that are unaware of these trauma-related issues may not serve their clients effectively (Elliott et al., 2005).  Continuing research is needed to evaluate the trauma-informed approach in order to better understand its effects on work with survivors of trauma, particularly victims of human trafficking.

Involving Survivors of Trafficking in Developing and Providing Services

Helping traumatized minor or adult females who have been trafficked develop trust with a provider is always challenging.  In particular, the shame associated with the Life, manifestations and symptoms of PTSD, and allegiance to the perpetrator often can make trust building an enormous hurdle (A. Adams, personal communication, March 2006; B. Everts, personal communication, November 2006; N. Hotaling, personal communication, June 2006; National Center for Missing and Exploited Children, 2002; K. Seitz, personal communication, December 2006).  Therefore, some advocates and service providers believe that the most successful programs serving young women exiting prostitution need to incorporate a peer-to-peer counseling model and often hire survivors to provide either some or all of the services to clients (N. Hotaling, personal communication, June 2006).  As stated in a report of the Massachusetts Department of Social Services (2006), Often children identify others who have been in the Life as the easiest and most comfortable adults with whom to talk about and to understand their own situations, and they need the non-judgmental support, understanding and help of adult survivors in order to successfully transition to a new life beyond sexual exploitation.  Rabinovitch and Strega (2004) add, Peer-led services reduce or remove the cultural and language barriers that most sex trade workers experience when trying to communicate with those whose education about the trade has been academic and professional.  Talking with peers, or even talking to a non-peer in a predominantly peer-led setting, lessens sex trade workers fears of confessing to a stigmatized identity and producing in service providers a range of reactions from horror to titillation. 

One example of youth survivors engaged in helping other youth is the Young Womens Empowerment Project (YWEP) in Chicago.  YWEP employs adolescent girls who have exited prostitution or are still engaged in prostitution and are willing to attend a 16-session training to conduct outreach and education to peers.  The girls receive a stipend for their time.  They operate under a harm reduction model and are offered a range of supports at a drop-in center (e.g., hygiene products, a place to rest) (Young Womens Empowerment Project).  The Young Womens Leadership Project in Detroit similarly employs girls with a history of some type of high-risk activity to provide street outreach to their at-risk peers (Alternatives for Girls, 2006).

SAGE is another organization that employs a peer-to-peer treatment model.  In an address to the United Nations, Hotaling (2000) remarked, The personal knowledge and experience possessed by many of the staff enables [sic] us to effectively provide support and engender trust without re-traumatizing even the most fragile of clients. By using a peer empowerment model, Hotaling indicates that SAGE has seen dramatic decreases in PTSD, depression, suicide, re-victimization, and recidivism in the clients they serve.  In addition, SAGE has seen increases in client self-esteem, confidence, and overall health.  Clients have benefited from this model by being able to take charge of their lives, obtain and keep legal jobs, advance in education, and recover from substance abuse.

More service providers who work with victims of international human trafficking are starting to engage survivors in programming.  The Coalition to Abolish Slavery and Trafficking (CAST) has developed a survivors of trafficking council that assists in program decision-making and provides peer-to-peer and group mentoring and support to current clients.  The survivors are individuals who graduated from the social services program offered by CAST.  Interviews with survivors suggest that involving survivors, when they are ready, in the care of others can be beneficial to both the survivor and the victim (Caliber Associates, 2007).  Some programs have formed communities of survivors to serve as peer groups, assisting other victims in rebuilding their sense of personal efficacy.  Part of the success of these groups involves allowing victims to set the agenda for meetings and focus on what is most important to them.  Activities have included computer training, language classes, ethnic celebrations, and even writing plays about their personal experiences.  Other programs assign survivors of labor trafficking as peer counselors to work one-on-one with victims to help stabilize their life and offer opportunities for survivors to become involved in education and outreach activities (Bales & Lize, 2004).

An important element of including survivors in program development and implementation is that they can speak about their own experiences, sharing strengths while acting as role models to reduce instances of relapse.  Elliott et al. (2005) state that, Like the concept of sponsorship in AA, a trauma survivor can help another one through this transition.  Allowing survivors to work with others gives them the chance to return the help they received, with the added result of boosting self-esteem.

That survivors are ideally suited to reach their peers has been demonstrated over time with other populations of traumatized individuals, including addicted individuals, individuals with HIV, and Vietnam veterans (as cited in Hotaling et al., 2003).  This non-traditional approach to service provision (in contrast to following a traditional clinical model) has gained increasing support across the United States:  When working with traumatized, politically disenfranchised, and stigmatized individuals, service providers must avoid traditional therapeutic neutrality and clearly support those they work with. (Hotaling et al., 2003).  Many agree (though do not universally practice) that survivors may be in the best position to assist peers, working in collaboration with clinicians and other necessary supports.  However, there is limited research on the impact of peer models on recovery.

Continuum of Care

While objective measurement of successful reintegration of a trafficking victim is difficult to achieve, service providers nevertheless have moved ahead and adapted their services to meet the needs of victims.  It is difficult for trafficking victims to successfully reintegrate into society, and it is also difficult for providers and researchers to develop standards of measurement that would indicate such reintegration.  As already discussed, both international and domestic victims have diverse needs and can require assistance and support over a significant period of time, thereby requiring a continuum of care.  Providers have conceptualized this continuum of care as having three phases: crisis intervention and assessment, comprehensive assessment and case management, and social reintegration (Bales & Lize, 2004).  The goal is to help the victim progress along the continuum that begins at crisis or the need for emergency assistance and moves to a position of safety (all within phase 1).  With ongoing assessment and intervention to address existing and emerging needs, the victim can move to stability in phase 2.  Finally, victims (now often referred to as survivors) can integrate into their environment and begin to thrive.  Among the best evidence of the success of offering a continuum of care and becoming reintegrated is in a survivors report, I work like a normal person, and they treat me like a normal personWhen youre in the kind of situation we were in, you feel like the world has ended.  And once youre back here on the outsideEverything is different now.  Just imagine if you were reborn.  Thats what its like (Bales & Lize, 2004).  A continuum of services appears to be central to successfully engaging and supporting all victims of human trafficking.  This continuum echoes the Exit Counseling Model developed by MacInness (1998), which illustrates the importance of beginning trust building and engagement with prostituted youth and moving toward stabilization and support.

Given the complex needs of victims of human trafficking and the challenges and barriers to providing them services, several key components seem to be required in a continuum of care for this population.

Identification

Successful identification of victims of human trafficking can be facilitated by increased education and training on the crime of human trafficking, the rights of victims, how to respond to victims, the needs of victims, and available resources (Clawson et al., 2004).  Additionally, the use of standard protocols to screen for victims of human trafficking (including questions to ask and techniques for interviewing victims) is essential to successful identification and ultimately cooperation from victims (Clawson, Dutch, & Cummings, 2006).  Since passage of the TVPA and increased funding to NGOs, law enforcement, and other service providers, the availability of protocols for identifying and responding to human trafficking victims has grown substantially.  Commonly referenced resources include the HHS Rescue & Restore Campaign Outreach Kits (www.acf.hhs.gov/trafficking/), Hiding in Plain Sight: A Practical Guide to Identifying Victims of Trafficking in the U.S. (www.uri.edu/artsci/wms/hughes/hiding_in_plain_sight.pdf), WHO Ethical and Safety Recommendations for Interviewing Trafficked Women (Zimmerman & Watts, 2003), and the Domestic and Sexual Violence Advocate Handbook on Human Trafficking (Florida Coalition Against Domestic Violence, 2004).

While protocols have been developed to determine if a foreign national is a potential victim of human trafficking, there are few published assessment protocols with questions to determine potential victims of domestic trafficking. While some agencies that conduct outreach to this population (e.g., prostituted children/adults) have developed their own assessment tools, there are no published protocols for use by medical providers, child protection workers, and others as there are for international trafficking and domestic violence victims.  For example, SAGE uses an assessment tool within the juvenile justice system which remains unpublished and unavailable for review (N. Hotaling, personal communication, June 2006).

To assist with identification, the HHS Office of Refugee Resettlement has established the Campaign to Rescue and Restore Victims of Human Trafficking. This public awareness campaign has established Rescue and Restore coalitions composed of social service providers, law enforcement, academics, students, and other key stakeholders in 24 cities, regions, and States.  The goal of these community action groups is to raise awareness of human trafficking and build local anti-trafficking networks.  The Office of Refugee Resettlements street outreach grants facilitate identification of victims through direct outreach to individuals involved in or at-risk for trafficking. Additionally, the agency funds the National Human Trafficking Resource Center a toll-free hotline (888-373-7888) where community members, law enforcement, social service providers, victims of human trafficking, and others can report incidents of human trafficking, receive technical assistance, and obtain referrals for a variety of services (U.S. Department of Health and Human Services, 2009)

Like coalitions, multidisciplinary teams and task forces are promising approaches to effective identification.  Through ongoing communication and sharing of information, coordinated outreach, and service follow-through, these entities are better positioned to identify and respond to all victims of human trafficking than single agencies operating in isolation (Clawson, Dutch, & Cummings, 2006).  Coordinating the identification process also helps protect victims by not requiring them to tell their story repeatedly to different providers.  Anti-trafficking task forces funded by the Bureau of Justice Assistance and OVC, other State anti-trafficking task forces and community coalitions, and the Innocence Lost task forces are making inroads in addressing the challenges of identifying victims and coordinating communications and services (Clawson, Dutch, & Cummings, 2006; U.S. Department of Justice, 2006).  The number of Department of Justice anti-trafficking task forces increased from 22 at the end of FY 2004 to 32 at the end of FY 2005.  In Houston Texas, the task force helped rescue and provide assistance to almost 100 victims of trafficking, and 10 defendants have been convicted on trafficking charges in cases involving forced prostitution and forced labor (U.S. Department of Justice, 2006).  Additionally, Northeastern University, in conjunction with the National Institute of Justice, conducted a study to address how law enforcement defines human trafficking, the number of investigations conducted, the extent of reporting, the nature of coordination with other agencies, and what are considered best practices in responding to human trafficking (Northeastern University, Institute on Race and Justice, 2006).

Various States are using other mechanisms to ensure providers respond quickly and victims have access to services.  In Suffolk County, Massachusetts, all providers (including law enforcement, medical providers, and school-based personnel) are instructed to file a 51A report of child sexual abuse to the Massachusetts Department of Social Services if they have sufficient reason to believe that an adolescent is being exploited through prostitution.  The provider files on behalf of the youth against an unknown perpetrator (i.e., pimp) when more information on the pimp is not available.  This report is screened out by the Department of Social Services if the perpetrator is not a family member and is sent to the district attorneys office as a discretionary referral.  An assistant district attorney and a victim/witness advocate are assigned immediately and the Multidisciplinary Team Guidelines take effect (Teen Prostitution Prevention Project, 2006).  While a multidisciplinary approach to identification has been shown to be promising, more research on effective models of identification (including assessment tools) should be conducted.

Another promising strategy for identification and tracking is the use of a centralized database with information from diverse sources.  While little progress has been made in this area with regard to tracking victims of international trafficking (Clawson, Layne, & Small, 2006), some success has been experienced in addressing child sexual exploitation.  For example, in both Suffolk County and Fulton County, Georgia, the Childrens Advocacy Center has spearheaded a child sexual exploitation database (Priebe & Suhr, 2005; Teen Prostitution Prevention Project, 2006).  In Georgia, 14 different agencies make referrals to this database, named Child Abuse Case Tracking Information System, which tracks both the victims and their exploiters (Priebe & Suhr, 2005).

Outreach and Education

Outreach and education to communities about the crime of human trafficking and the needs of victims are important when it comes to identifying victims.  The most significant outreach campaign associated with human trafficking is the Rescue and Restore Victims of Human Trafficking public awareness campaign supported by HHS.  As a result of this nationwide campaign, local coalitions are being established, local and national media coverage of human trafficking is taking place, and national partnerships are being formed.  Campaign materials have been distributed, particularly to intermediaries or first responders most likely to come into contact with victims.  These include law enforcement agencies, social service providers, health care professionals, faith-based organizations, domestic violence prevention groups, homeless assistance professionals, and child protective services (U.S. Department of Health and Human Services, 2009).  However, the impact of this nationwide campaign has not been formally assessed.

Other examples exist of promising outreach activities being conducted by NGOs and local programs.  These strategies include conducting global television campaigns to combat human trafficking (Vital Voices, 2003); developing public service announcements for ethnic radio, television, and newspapers; posting billboards in ethnic communities and garment districts; and distributing flyers (in multiple languages) and other items (e.g., Band Aids^®, matchbooks) at laundromats, ethnic supermarkets, beauty parlors, and other establishments that victims may be allowed to visit (Clawson et al., 2004; Raymond & Hughes, 2001).  Victim service providers report increases in calls to crisis hotlines and referrals from community-based organizations and good samaritans following such outreach efforts (Caliber Associates, 2007).

Countries around the world also are conducting outreach to increase public awareness of human trafficking.  Colombia and Ecuador are relying on the entertainment industry for delivering anti-trafficking messages.  In Colombia, the United Nations Office of Drugs and Crime worked with the producer of the popular soap opera Everybody Loves Marilyn to incorporate a storyline that dramatized the plight of a trafficking victim. The widely viewed Spanish language television series, broadcast throughout Colombia and exported to Venezuela, Ecuador, and the United States, is being used to educate a large segment of the population.  It is also intended to attract the attention of potential victims and educate them about the methods used to deceive victims and the abuse they could face from a trafficker. 

In Ecuador, volunteers from the National Institute for Children and Family worked with visiting international musician Ricky Martin, his charitable foundation, and Colombian entertainer Carlos Vives to disseminate anti-trafficking messages and information that reached approximately 24,000 people attending their concerts in Quito and Guayaquil (U.S. Department of State, 2006).  These represent innovative ideas for outreach to a wide audience.

Other street outreach efforts are also underway.  Outreach workers should be well-trained and understand the inherent safety concerns (see Safety Planning section).  Further, they must be willing to build a relationship with a victim repeatedly, for as long as necessary (MacInness, 1998).  Relevant to domestic sex trafficking, many agencies provide drop-in centers, as part of their continuum of care efforts, to meet the short-term needs of exploited youth (e.g., food, hygiene products) and to build relationships aimed at long-term change (O. Briceno, personal communication, June 2006; Girls Educational & Mentoring Services, 2006; N. Hotaling, personal communication, June 2006; Priebe & Suhr, 2005). Outreach services must be offered in a non-judgmental, careful way so trust can begin to be built.  As previously stated, developing a trusting relationship with a victim of human trafficking can be extremely difficult for a variety of reasons, including the victims trauma history, threats to safety from the trafficker (pimp), distrust, and possibly prior negative experiences with authorities or the system.

These same recommendations for effective and appropriate outreach are highlighted in the literature related to runaway and homeless youth.  The Substance Abuse and Mental Health Services Administrations Treatment Improvement Protocol 32: Adolescent Substance Abuse Treatment suggests that outreach is a primary intervention strategy for engaging homeless youth (U.S. Department of Health and Human Services, 1999a).  Youth workers should meet young people on the street, developing trusting relationships over time and encouraging and facilitating youth access to treatment.  In a 1998 survey of health providers for homeless Australian youth, outreach workers highlighted the importance of a non-judgmental approach as well as the importance of maintaining client confidentiality and anonymity, noting that youth would go without treatment if they suspected that outreach workers were connected to police or protective services (Harrison & Dempsey, 1998).   

In addition, Slesnick, Meyers, Meade, and Segelken (2000) describe an engagement process specifically for substance abusing runaways that draws upon the success of the Szapocznik et al.  (1988) and Szapocznik, Kurtines, Santisteban, and Rio (1990) Strategic Structural Systems Engagement (SSSE) approach and the Meyers and Smith (1997) Community Reinforcement and Family Therapy (CRAFT) intervention.  Both models engage a client in treatment through a family member or significant other.  Using the SSSE model, Szapocznik et al. found that 93 percent of substance abusers and their families became engaged in treatment, compared to 42 percent of those entering treatment without families. Primary components of the combined SSSE and CRAFT intervention include approaching the runaway youth and engaging him or her in a non-threatening manner, identifying and addressing his or her treatment motivators and barriers, and negotiating with the counselor about treatment.  Additionally, the intervention involves contacting parents to gain their approval, informing them about the treatment, engaging them in treatment, addressing their treatment motivators and concerns, and negotiating with them about treatment. Each stage in the engagement process includes developmentally appropriate and motivational techniques specific to the population. Components of these approaches may be more applicable for victims of domestic trafficking than international trafficking given the need to involve a family member or significant other.

Prevention

To date, there is no documented best practices research related to the prevention of human trafficking.  However, the incorporation of a prevention component into the TVPA suggests the importance of this element of service.  Additionally, the literature on treatment of domestic sex trafficking victims consistently points to the importance of prevention education (Girls Educational & Mentoring Services, 2006; National Center for Missing and Exploited Children, 2002; Priebe & Suhr, 2005).  The Paul & Lisa Program, The Center to End Adolescent Sexual Exploitation (CEASE), and Girls Educational & Mentoring Services (GEMS) use a well-constructed prevention program for middle school and/or high school youth.  The Alternative for Girls, an agency in Detroit, has several components, including a prevention program that involves weekly meetings and activities for at-risk girls.  Nationwide, most agencies such as schools and child welfare agencies are not engaging in such primary prevention, and those engaged in secondary and tertiary prevention lack an evidence-based curriculum to meet their goals.

The My Life, My Choice Project in Massachusetts is an example of a program designed to offer primary, secondary, and tertiary prevention to a population of particularly vulnerable girlsthose in group care settings.  Co-written by a clinician and a survivor, the group work component of the My Life, My Choice Project of the Home for Little Wanders uses a 10-session curriculum presented in weekly 1.25 hour modules.  The sessions include material on dispelling myths and stereotypes about prostitution, awareness of recruitment tactics by pimps, information on sexual health, understanding the link between substance use and prostitution, resource lists, strategies for increasing safety in the Life, and an overarching emphasis on improving self-esteem.  In addition, throughout the 10 weeks, participants hear both written and live testimony by women who have been in the Life.  The sessions include interactive activities (e.g., games, role plays), art, music, reading, and journaling.  Initial participant feedback on the My Life, My Choice group work component has shown a positive impact on the young women involved (Goldblatt-Grace, personal communication, December 2006).

Intensive Case Management

Given their complex needs, victims of human trafficking can be expected to encounter a range of law enforcement, social service providers, medical professionals, counselors, legal advocates, and shelter personnel, which can be a daunting experience, especially for international and minor victims.  In response, service providers have adopted intensive case management approaches to working with these victims.  The case managers broad range of responsibilities can include assessing service needs; providing victims with information about their rights to services, establishing a comprehensive service plan with victims, identifying and making referrals for services, coordinating services, sometimes accompanying victims to appointments, advocating on behalf of victims to other providers and agencies, providing emotional and moral support to victims, and often keeping victims informed of progress on their legal case, T-visa, and other applications (e.g., Social Security card, and work permit).  The role of the case managers is critical.  Not only are they responsible for supporting the victim but also, by the nature of their work, they support other providers and agencies by enabling law enforcement officials, attorneys, counselors, and others to focus on their services for the victim (Caliber Associates, 2007; Salvation Army, 2006).

As part of service coordination, the case manager also is responsible for ensuring regular communication and information sharing (without violating confidentiality) among providers working with victims.  Intensive case management often requires expansion of the traditional service delivery role of a case manager and widening the network of providers.  For example, evaluation of services provided to torture victims confirms that coordinated care that takes a holistic approach to treatment, while often challenging, is essential to meeting the medical, psychological, and social needs of victims (Center for Victims of Torture, 2006; Program for Torture Victims, 2006). 

In fact, the case management approach demonstrated by nurses working with torture victims appears to mirror the intensive case management model being used with victims of trafficking.  Nursing case management is a process of ensuring that individual survivors receive appropriate health care services both within the torture treatment center or primary care facility and in the larger community.  The case manager coordinates and monitors the clinical services the survivor receives to ensure the individuals unique health care needs are met.  Responsibilities of the nursing case manager include:

• Health care service planning and resource identification.
• Linking clients to needed services and coordinating individual client care in the community health care system.
• Client advocacy and problem solving with the health care system.
• Monitoring service delivery.
• Evaluating services.

Nurses also educate survivors about accessing and navigating the U.S. health care system, including gaining information about patient rights (Center for Victims of Torture, 2006).

An examination of well-established programs for girls who have been exploited through prostitution also highlights the importance of comprehensive case management (A. Adams, personal communication, March 2006; Girls Educational & Mentoring Services, 2006; N. Hotaling, personal communication, June 2006; National Center for Missing and Exploited Children, 2002).  Some of these case management teams (e.g., SAGE, CEASE) collaborate with the juvenile justice system, combining outreach, advocacy, and case management.  Others offer case management services through a drop-in center (e.g., A Way Back). Still others (e.g., GEMS) offer both.  The most important aspect of case management appears to be the quality of the relationship between the case manager and the victim, and the case managers ability to access a wide range of resources on behalf of the victim.  A case managers first priorities must be helping the client achieve physical safety and meet basic needs (such as food, clothing, and housing) (A. Adams, personal communication, March 2006; O. Briceno, personal communication, June 2006; Girls Educational & Mentoring Services, 2006; N. Hotaling, personal communication, June 2006; National Center for Missing and Exploited Children, 2002).  The Unaccompanied Refugee Minor Program requires this type of intensive case management and is a primary reason that international minor victims of trafficking are served under this system.

According to Healey (1999), the criminal justice system also follows a case management approach in working with released offenders.  Several programs working with the criminal justice population employ a holistic service approach that addresses multiple issues, including unemployment, homelessness, and substance abuse, that could contribute to an offender relapsing.  As with the models already described, the activities of the case manager in the criminal justice field include engaging the client in the treatment process, assessing client needs, developing a service plan, linking the client with appropriate services, monitoring client progress, intervening with sanctions when necessary, and advocating for the client when needed.

Many experts, program directors, and case managers support intensive case management as a tool for the criminal justice field; however, some obstacles exist.  Poorly designed programs can be less effective and make it difficult for case managers to establish relationships with other service providers. Overburdened case managers can affect program outcomes as well; managing too many cases with too few resources makes it difficult for case managers to spend the time needed with each client.  Another obstacle cited by Healey (1999) is the transfer of offender treatment information.  Case managers must pass along basic offender information and treatment plans to another agency or case manager providing care.  Ensuring the documentation arrives at the receiving agency before the offender can be challenging.

While the effectiveness of intensive case management has not been documented fully, the work of Cauce et al. (1994) lends evidence to the success of intensive mental health case management for homeless adolescents.  Preliminary data from 115 adolescents indicated that after 3 months of treatment, youth randomly assigned to intensive case management did somewhat better in treatment than those in basic or regular case management in terms of self-reported aggression, general externalizing behaviors, and satisfaction with quality of life.  However, young people in both groups reported improvements while receiving services.  Case management continues to be used by the trafficking, medical, criminal justice, mental health, and domestic violence fields, as well as by those working with victims of torture (Bennett, Stoops, Call, & Flett, 2007; Center for Victims of Torture, 2006; Healey, 1999; Lattimore, Broner, Sherman, Frisman, & Shafer, 2003; Salvation Army, 2006).

Comprehensive Services

The complex needs of victims of human trafficking appear to require a comprehensive approach to service delivery that includes the provision of core services such as housing, legal assistance, medical assistance, social services, trauma therapy, and substance abuse treatment. 

Housing/Shelter Services

Since there are so few shelters across the country that serve only victims of trafficking, most victims are placed in shelter or housing programs that traditionally serve victims of domestic violence and sexual assault.  Shelters that have been successful in serving both domestic and international victims of human trafficking have adjusted their programs for this population.  These adjustments have included:

• Extending the length of stay for victims in emergency and transitional housing.  Compared to victims of domestic violence, victims of human trafficking may take longer to secure a job and obtain affordable housing due to their certification and/or documentation status, which can affect their ability to work legally in the country, as well as other barriers to work (e.g., physical disabilities, lack of English language skills, lack of employable skills).  Additionally, when victims can work, many feel the need to send money to their families and are therefore unable to save money for housing as other victims might.
• Relaxing rules about mandatory participation in group activities and counseling.  Language barriers, lack of social support, and other factors may make it difficult for trafficking victims to engage in traditional requirements of communal living, such as communal meals, participation in support groups, and sharing living space with women of different ethnic, cultural, and religious backgrounds.
• Providing more intensive case management.  Most victims of human trafficking require more intensive and specialized case management given the complexity of their needs, including their legal status.
• Interacting with Federal (and local) law enforcement.  While many domestic violence shelters work closely with law enforcement, the circumstances of a trafficking case may require more frequent visits by law enforcement to the shelter.  The implications of these visits to other shelter occupants can be disruptive and need to be carefully considered.

In emergencies, domestic violence shelters may be called upon to provide shelter for minor victims.  In some cases, this is not possible because shelters are not equipped to serve children.  In most cases, housing for minor victims of international human trafficking is provided through the Unaccompanied Refugee Minor Program.  These children often are placed in foster care or group homes.  Domestic violence and sexual assault shelters are not used to house male victims of trafficking.  Instead, these victims often are referred to homeless shelters, shelters run by NGOs and faith-based organizations, or are put in hotels or temporary housing paid for by the service provider (Salvation Army, 2006).

Literature regarding adult women exiting prostitution emphasizes the importance of a therapeutic housing community to prevent relapse and build stability (Carter, 2003; Hotaling et al., 2003; Rabinovitch, 2003; Raphael, 2004).  Any housing program designed to support this population must take into account the myriad ways in which the self-esteem of the women and girls has been diminished.  Edwina Gately of Chicagos Genesis House described the importance of the physical space in this way: If you offer space, you are using the space to give every version of the message that you can give; that is, these people who are coming to this space are worth something (Raphael, 2004).  Housing or shelter programs for adolescents who are leaving prostitution are traditionally small (610 beds) and provide a comprehensive array of services, including mental health services, family support services, education support, career planning, life skills education, and recreational programming.  Children of the Night in Los Angeles accepts both boys and girls while others (including SAGE House in San Francisco and Angelas House in Atlanta) serve only girls.  The Paul and Lisa Program does not offer a group home setting but rather facilitates appropriate housing using existing resources (including specialized foster homes) (National Center for Missing and Exploited Children, 2002).  While some variations in housing programs exist, all tend to be grounded in an understanding of the trauma history of residents and the survival and coping skills learned in the Life (such as manipulation and dissociation), which must be unlearned and replaced in order for the adolescents to heal (A. Adams, personal communication, March 2006; Children of the Night, 2006; N. Hotaling, personal communication, June 2006).

Legal Services

The legal needs of most international and domestic victims can be extensive. Attorneys are needed to explain to victims their legal options and rights; educate victims about the U.S. legal system; represent victims in legal hearings (e.g., detention/deportation hearings); complete applications for certification, T-visas, U-visas, or derivative visas for family members; and assist with gaining permanent resident status, as well as assist with the repatriation process (Florida Immigrant Advocacy Center, 2006; Salvation Army, 2006).  The most pressing concern for victims is often their immigration status, followed by their ability to reunite with their families and children.  Many victims of domestic trafficking have had multiple contacts with the juvenile and/or criminal justice systems and may have been identified as the result of an arrest for prostitution, panhandling, or other crimes.  Thus, they also usually need legal representation in juvenile or criminal proceedings and, in many cases, family hearings.

Attorneys who work with victims of human trafficking who do not have the support of a case manager must be prepared to assist them with a wide range of needs, including lack of adequate housing, unemployment, isolation, medical problems, or lack of transportation.  Working in collaboration and close communication with a case manager can be beneficial to both the attorney and the victim.  The attorney should recognize that until their legal cases are resolved, some victims cannot move forward with their lives (Caliber Associates, 2007; Center for Victims of Torture, 2006).

Attorneys also should recognize that the trauma suffered by victims may influence their ability to participate in legal proceedings.  For example, fear of authority figures (including the victims own attorney), immigration officials, law enforcement, and judges may interfere with the attorney-victim relationship or the victims ability to go forward with the legal case.  Establishing a trusting relationship will take time and require patience on the part of the attorney (Caliber Associates, 2007).

There are a few comprehensive documents available to assist attorneys working with victims of human trafficking: Identification and Legal Advocacy for Trafficking Victims (2nd Edition) (NYC Anti-trafficking Network Legal Committee, 2005) and the Guide for Legal Advocates Providing Services to Victims of Human Trafficking (United States Conference of Catholic Bishops, 2004). 

Medical Services

Victims of human trafficking present with a range of medical needs.  Service providers have reported the following needs for medical services:  basic physical exams; gynecological exams; tests for infectious diseases; treatment for stomach problems and headaches (often symptomatic of an emotional problem); chronic back, hearing, cardiovascular, or respiratory problems; and eye and dental care (Caliber Associates, 2007). 

Work with torture victims indicates that medical treatment is essential to their physical and psychological healing.  Lingering body pains and physical symptoms often create daily reminders of past torture.  Medical providers play an important role in clarifying the nature of physical symptoms in torture survivors and alleviating their complaints.  A similar need appears to present in victims of human trafficking and requires educating victims about the association between stress and symptom exacerbation so they do not perceive their treatment as ineffective and understand that their increased symptoms will diminish gradually (for example, if they are receiving treatment for the trauma) (Center for Victims of Torture, 2006).  Of those seeking treatment, some will require one treatment, some will require intermittent treatment at various periods in their life, and others will require ongoing services, particularly those who suffer from a physical disability resulting from the trafficking experience.

Through their research, Willis and Levy (2002) found that prostituted minors are at high risk for many infectious diseases, including HIV.  The risk of prostituted minors contracting HIV depends on the local prevalence of HIV infection in sex workers, access to condoms, and attitudes of clients toward the use of protection.  Minors involved in prostitution are also at high risk of contracting STDs other than HIV, as well as transmitting these diseases to others (e.g., their children and clients).  They are also more likely to develop drug-resistant forms of the STDs.  Willis and Levy found that minors are at higher risk than their adult counterparts because they have less power to ensure their clients use condoms.

Most other research on the prevalence of HIV and STDs in trafficking victims has focused on international victims and those trafficked outside of the United States.  For example, a study conducted on the prevalence of HIV in sex-trafficked Nepalese girls and women found that among 287 victims, 109, or 38 percent, tested positive for HIV (Silverman et al., 2007).  Silverman et al. also found that girls trafficked prior to age 15 were at higher risk of being infected with HIV, with 20 of 33, or 60.6 percent, infected among this age group in the study sample.

Another study conducted by the United Nations Development Programme (2006-2007) focused on trafficking in India and the links between HIV and trafficking.  This study explored four categories of trafficking victims: sex workers, domestic workers, forced labor, and street-based workers.  The study found that many of those involved in the study were unaware they should always use a condom to prevent the spread of HIV.  Additionally, only 19 to 28 percent of the studys respondents in the sex worker category were aware of sexually transmitted diseases; percents were even lower for respondents in the other categories.  Awareness of HIV was highest among those in the forced labor category, ranging from 47 to 71 percent for the various age groups compared to 28 to 38 percent among those in the sex worker category.

Given the limited research done in this area, there is more to study about the health implications of human trafficking and the medical needs of all types of victims.

Social Services

Providing social services is essential to meeting the needs of victims.  These services help stabilize victims by offering opportunities for educational, personal, and economic advancement.  Obtaining an education, developing life and social skills, learning a new language, gaining job skills, and obtaining employment are essential for a victim to be able to reintegrate into society.  Through social services, victims can become personally and economically independent.  For international victims, they can also learn about the new culture in which they are living (Caliber Associates, 2007).  Despite the importance of social services for victims of human trafficking, there are currently no published studies that identify promising or best practices in this area. 

A report (Thompstone, n.d.) was developed that discusses the need for a Quality of Care Standard (QCS) across all services, specifically one that recognizes the need for homes that provide recovery services for minor victims of commercial sexual exploitation and trafficking.  However, the report does not indicate what might be the best or promising practices for social services.  Since there is no universal or commonly agreed to QCS, some countries, such as Cambodia, have created their own QCS to regulate services to minors.  Standards that can be adopted by other countries include: (1) all children trafficked for sexual purposes shall have equal access to education programs, regardless of citizenship; (2) care plans shall be developed and case records shall be maintained in care homes for all children; and (3) repatriation schemes will include child protection mechanisms to ensure that child victims of trafficking are returned to a place of safety.  According to this report, within direct service programs, the role of QCS is to facilitate the full recovery and social integration of the survivors.

Trauma Therapy

While the availability of a wide range of mental health services is important, the focus of this review is on trauma therapy because all victims of human trafficking have experienced some form of trauma.  Although some victims are hesitant at first to access trauma therapy or mental health services, making them accessible throughout the continuum of care is important.  It may take months or even years for a victim to accept counseling (Caliber Associates, 2007).

According to the literature, trauma recovery models begin with pretreatment assessment and a critical understanding of a victims current safety risk.  Once the victims immediate safety is established, a trained clinician can begin to address the trauma issues and their related symptoms, begin any appropriate family work, and treat any co-occurring disorders (Mahoney, Ford, Ko, & Siegfried, 2004).  Trauma treatment research and studies of manualized treatment options, especially for working at the intersection of trauma and co-occurring disorders in adolescents, are quite limited.  While the literature is extensive on PTSD in children and youth, no published literature is available on controlled adolescent intervention studies with sufficient sample size to be generalizable.  Furthermore, especially for minors with multiple and intersecting challenges (like those of young victims of human trafficking), there has been criticism that the current treatment literature is too narrowly focused on symptom reduction rather than on measures of functioning (including health, academic performance, peer networks, and family relationships) (Feeny, Foa, Treadwell, & March, 2004).

The evaluation literature on trauma treatment is more advanced in the adult arena than for adolescents, especially since the publication of a number of articles based on the Women, Co-Occurring Disorders and Violence (WCDV) study funded by the Substance Abuse and Mental Health Services Administration (Elliot et al., 2005; Finkelstein et al., 2004; Giard et al., 2005; Huntington, Moses, & Vaysey, 2005; Morrissey et al., 2005; Noether et al., 2005). This was the first large-scale, multi-site study investigating promising treatment models for women with histories of traumatic violence and substance use and mental health disorders.  The study framework and some of its trauma interventions are particularly relevant to victims of human trafficking.

Research has provided strong support for several trauma-specific interventions (such as cognitive behavioral therapies, eye movement desensitization and reprocessing, and trauma-focused educational groups).  The strongest evidence for adults supports the efficacy of cognitive behavioral therapies in reducing PTSD symptoms (Feeny et al., 2004; Foa & Rothbaum, 1998).  Cognitive behavioral therapy (along with exposure therapy) also shows promise in child and adolescent populations in reducing PTSD symptoms (National Institute of Mental Health, 2001).  Also promising are early findings on the effectiveness of integrated models of adult trauma treatment in substance abuse settings, particularly in reducing substance abuse, general mental health problems, and PTSD symptoms (Brady et al., 2001;

Fallot & Harris, 2004; Najavits, Weiss, Shaw, & Muenz, 1998; Rosenberg et al., 2001; Zlotnick, Najarvits, Rhsenow, & Johnson, 2003).

At least two of the group trauma-specific integrated models of treatment examined in the WCDV study have been modified for adolescents (Seeking Safety and the Trauma Recovery and Empowerment Model), while a number of others are under development (Mahoney et al., 2004; Rivard et al., 2004).

Seeking Safety is the first of the modified adolescent versions to undergo a randomized, controlled trial exploring the impact of this 25-session, manualized intervention for mental health, trauma symptoms, and substance use in youth[6] (Najavits, Gallop, & Weiss, 2006).  The sample size for this study was quite small (N=33) and included outpatient adolescent girls with PTSD (the most frequent trauma category was sexual abuse) and substance use disorders (with cannabis and alcohol the most frequently used substances).  Despite the small sample, participants showed significantly better outcomes post-treatment than the treatment-as-usual group, including decreased substance use, trauma-related symptoms, and improvement on cognitive measures related to substance use disorders and PTSD.  While quite preliminary, the authors believe these early results are especially hopeful because they suggest that the highly prevalent co-occurrence of PTSD and substance use disorders may be amenable to early changean important finding because the usual trajectory of these disorders persists into adulthood (Ouimette & Brown, 2002).

While it has not been part of a rigorous evaluation of services, a comprehensive initiative for victims of human trafficking in Miami has observed significant recovery (including a decrease in recovery time) among victims, especially minors, who receive trauma therapy.  In one case, after participating in therapy, not only had the individuals mental state improved but her physical state also improved (Caliber Associates, 2007).  The therapy incorporated many non-Western techniques into the treatment, such as breathing exercises and physical therapy and massage.  These services were well received by international victims.  This is consistent with treatment programs and results observed among victims of torture (Center for Victims of Torture, 2006).

Not only is trauma therapy important for victims overall well-being, but addressing the trauma also may help their legal case.  Information on torture victims has demonstrated that the symptoms of trauma may interfere with clients ability to participate in their case.  For example, victims may have difficulty remembering details of events.  Their emotional reactions when recounting traumatic events may seem inappropriate.  They may avoid discussing the torture or other traumatic events or begin missing appointments with their attorney (or other services) when they anticipate the discussion will be too painful.  Additionally, victims may not recount the torture events in a linear fashion; they may jump from one event to the next or omit details.  This may be particularly true for individuals for whom torture started at an early age.  Therefore, helping a victim recover from trauma, although a lengthy process, may also prove beneficial to the prosecution of these cases (Center for Victims of Torture, 2006).

Substance Abuse Treatment

Limited information is available regarding substance abuse treatment for adult victims of human trafficking.  One explanation given by a service provider for this absence is the belief that victims are reluctant to divulge this problem for cultural reasons as well as concern that by acknowledging they have a problem, they may be jeopardizing their credibility as a witness in their trafficking case, their immigration case, or a future custody case (Caliber Associates, 2007).  Likewise, research specific to substance abuse in minor trafficking victims is also extremely limited.  However, there is some general research on adolescent treatment programs that might provide some guidance about effective substance abuse services for minor trafficking victims.

Adolescent treatment for substance abuse must be tailored to the unique challenges and developmental needs of that population (Hser et al., 2001; Physician Leadership on National Drug Policy, 2002).  Additionally, the earlier treatment is received, the shorter the course of substance abuse.  While encouraging, the problem is that fewer than 1 in 10 adolescents with substance abuse or dependence problems receives treatment (Dennis, 2006).

Research also has found that gender differences in the use of substances have implications for effective treatment design (Amaro, Blake, Schwartz, & Flinchbaugh, 2001).  For example, a factor to be considered when designing effective treatment programs specifically for girls includes the need to improve a girls self-image, including body image and self esteem/efficacy.  There are, however, other factors that are important to consider when designing treatment programs for adolescents in general.  These include developing life skills in areas such as intrapersonal competencies, problem-solving, and self-assertion; promoting healthy life styles; improving family functioning, including families with adolescent parents; treating the long-lasting effects of sexual abuse; and addressing racial and ethnic differences in risk factors through culturally tailored approaches.

The number of studies evaluating adolescent substance abuse treatment programs has increased significantly in recent years, with major methodological advances, especially exploring new manualized therapies (Dennis, 2002; Dennis et al., 2002).  While there is no evidence that one particular treatment format or modality is appropriate for all adolescents, key elements of effective interventions have been described in a number of articles and reports (Brannigan et al., 2004; Dennis, 2006; Mark et al., 2006; Physician Leadership on National Drug Policy, 2002).  These elements reflect the components of effective services and strategies reviewed previously:

Comprehensive assessment and treatment matching, including mental health and medical problems, learning disabilities, family functioning, and other key aspects of adolescents lives.

• Comprehensive and integrated treatment approach, addressing the broad range of needs rather than concentrating only on curtailing substance abuse. These may include individual or group targeted sessions to address victimization, anger management, depression, medication management, educational deficits, and health care.
• Family involvement in treatment, maintaining close links with family, school, and where necessary the juvenile justice system.
• Wraparound services, including transportation, case management, and care coordination.
• Recreational activities and exposure to non-using activities.
• Developmentally appropriate programs designed specifically for adolescents.
• Engagement and retention based on developing trust between the teen and therapist or counselor.
• Qualified staff trained in adolescent development, co-occurring disorders, substance abuse, and addiction.
• Gender and cultural competence, addressing the unique needs of girls and boys, as well as cultural differences.
• Continuing care, including relapse prevention, aftercare, referral to community resources, and follow-up.

Given the percentage of minors in prostitution who develop substance abuse issues, any programming, at least for minor victims of domestic sex trafficking, should include access to substance abuse treatment (A. Adams, personal communication, March 2006; B. Everts, personal communication, November 2006; N. Hotaling, personal communication, June 2006; National Center for Missing and Exploited Children, 2002; K. Seitz, personal communication, December 2006).

Conclusion

Despite increased attention to the problem of human trafficking into, and most recently within, the United States, knowledge and understanding of the issue remains fairly limited (Albanese, Donnelly, & Kelegian, 2004; Derks, Henke, & Vanna, 2006).  Research on trafficking has focused primarily on estimating the scale of the problem, mapping routes, and reviewing policies and legal frameworks (Gozdziak & Collett, 2005). 

Very little is known about the prevalence of trafficking and the number of victims; characteristics of the victims and perpetrators; the long-term impacts of human trafficking on victims, their families, and communities; the effectiveness of anti-trafficking programs; and best practices in meeting the complex needs of victims.  More specifically:

• There is little literature on effective programs and services designed specifically for victims of human trafficking.  Information from more than a decade of work with victims of domestic violence, prostitution, homeless and runaway youth, and victims experiencing trauma in general provide most of the general groundwork summarized here, and there is a need for research that explores the applicability and effectiveness of these approaches with victims of human trafficking.
• While there is little hard evidence to support the effectiveness of specific interventions or services for victims of human trafficking, it is possible to identify components or characteristics that seem promising in services and strategies for trafficking victims and similar populations based upon the limited information available.
• In looking at promising models to assist victims in their recovery, indications are that survivors may be in the best position to assist peers, working in collaboration with clinicians.  However, there is limited research evidence about the impact of peer models on recovery.
• With limited research, more needs to be learned about the health implications of human trafficking and the medical needs of all types of victimsmales, females, adults, and children.
• Trauma treatment research and studies of manualized treatment options, especially those programs working at the intersection of trauma and co-occurring disorders in adolescents, are quite limited.  While the literature is extensive on PTSD in children and youth, no published literature is available on controlled studies of adolescent interventions.
• Limited information is available regarding substance abuse treatment for adult victims of human trafficking.
• Research specific to substance abuse in minor trafficking victims is also extremely limited.

What is known about victims of human trafficking is focused primarily on the trafficking of international women into the United States for sexual exploitation, with little attention to domestic trafficking, minor victims, and in particular, male victims of sex and labor trafficking.

However, a richer source of information based on more rigorous research studies can be found in related fields, as demonstrated in the current literature review.  Inferences can reasonably be made from what is known about victims of domestic violence, torture victims, child sexual exploitation and prostitution, and runaway and homeless youth, and what we expect to find from similar studies of international and domestic victims of human trafficking.  In the absence of existing studies, conclusions can be drawn only from overviews, commentaries, and anecdotal observations and experiences of providers and others in the field (Gozdziak & Collet, 2005).

The challenges associated with combating human trafficking and protecting victims are overwhelming but manageable.  Many NGOs feel that a multi-dimensional approach to addressing trafficking should include not only legislative initiatives and crime prevention, but also social welfare, job training, rights protection, and development initiatives in the source, transit, and destination countries and locales (Caliber Associates, 2007; Richard, 1999).  Effective strategies should be comprehensive and provide for collaboration among governments, governmental agencies, NGOs, advocacy groups, service providers, survivors, and affected communities (Miller & Stewart, 1998).  Intensive case management, comprehensive services provided through partnerships, and ongoing outreach and education most likely will produce an effective response to the needs of victims.  Ongoing communication with existing programs and documentation and assessment of their activities will offer valuable lessons for the field.  NGOs working with different groups of trafficking victims (e.g., sex trafficking or labor trafficking, males or females, adults or minors) and populations with similar needs (e.g., torture victims, refugees, minor prostitutes, runaway and homeless youth, victims of domestic violence) represent an untapped wealth of practical knowledge and expertise on how to develop appropriate assistance and treatment programs for trafficking victims and survivors.  More research is needed to document these evolving approaches and strategies, provide results that will inform and strengthen the response by sectors already involved in combating trafficking, and serve as best practices for those communities wanting to replicate this work.

Federal and State laws addressing specifically the crime of human trafficking are less than a decade old, and while some of the literature for this review was drawn from prostitution research or other related fields, much remains to be learned about persons who are trafficked into and within the United States.

This review of the literature, along with a series of issue briefs and the final study report, can be downloaded from the following Web sites:

http://aspe.hhs.gov/hsp/07/HumanTrafficking/
http://www.icfi.com/markets/social-programs/

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Endnotes

[1] For the purposes of this literature review, the foreign nationals who are trafficked into the United States are referred to as international victims and the United States citizens and permanent residents trafficked within the United States are referred to as domestic victims.

[2] Academic Search Elite offers full text for more than 2,000 serials, including more than 1,500 peer-reviewed titles. This multidisciplinary database covers virtually every area of academic study. More than 100 journals have PDF images back to 1985. This database is updated daily via EBSCOhost.

PsycINFO, from the American Psychological Association (APA), contains nearly 2.3 million citations and summaries of scholarly journal articles, book chapters, books, and dissertations, all in psychology and related disciplines, dating as far back as the 1800s. Ninety-seven percent of the covered material is peer-reviewed. Journal coverage, which spans 1887 to the present, includes international material selected from more than 2,100 periodicals in more than 25 languages.

PsycARTICLES, from the APA, is a definitive source of full-text, peer-reviewed scholarly and scientific articles in psychology. The database contains more than 45,000 articles from 57 journals, 46 published by the APA and 11 from allied organizations. It includes all journal articles, letters to the editor, and errata from each journal. Coverage spans 1985 to the present.

ERIC, the Educational Resource Information Center, contains more than 2,200 digests along with references for additional information and citations and abstracts from more than 1,000 education and education-related journals.

PsycEXTRA, produced by the APA, is a bibliographic and full-text companion to the scholarly PsycINFO database. The document types include technical, annual, and government reports; conference papers; newsletters; magazines; newspapers; consumer brochures; and more. It contains more than 85,000 records with nearly a quarter million full-text pages.

[3] The term human trafficking is not used in many studies about the prostitution of minors. However, the prostitution of minors is, by statutory definition, a form of sex trafficking and prostituted minors are victims of trafficking. Thus the literature related to this problem is included in this review.

[5] Visit www.safehorizon.org for a sample safety planning guide.

[6] For details on the treatment, see www.seekingsafety.org.

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