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.
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. As a safety measure, many providers working with victims of trafficking do not publish their physical location or address, similar to domestic violence shelters (Clawson, Small, Go & Myles, 2004).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.
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.
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.
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.