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

08/30/2009

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.

Components of Effective Programming for At-Risk Youth
  • Small group setting
  • Relaxed and casual environment
  • Interactive and experiential
  • Driven/informed by participants rather than the group leader
  • Language to which young people can relate
  • Videos or other visual material

(Harrison & Dempsey, 1998)

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).

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