Human Sex Trafficking in America: What Counselors Need to Know

Feb 10, 2017 | Volume 7 - Issue 1

Stacey Diane A. Litam

The social justice issue of human sex trafficking is a global form of oppression that places men, women and children at risk for sexual exploitation. Although a body of research exists on the topics of human trafficking, literature specific to the mental health implications for counselors working with this population is limited. Counselors should increase their awareness of the vulnerabilities that place persons at risk of becoming trafficked. Additionally, obtaining a deeper understanding of the indicators and processes through which persons become trafficked is necessary in order to provide appropriate services. Counselors should learn how force, fraud and coercion influence the wellness of trafficked persons. The following article provides an overview of the relevant information pertinent to sex trafficking and addresses the counseling implications for working with sex trafficked survivors.

Keywords: human sex trafficking, sexual exploitation, social justice, trafficked survivors, oppression

The sexual exploitation of men, women and children through sex trafficking continues to occur in the United States and across the globe at an increasingly alarming rate. Despite misconceptions that sex trafficking requires transportation across state or country borders, the majority of victims are domestically trafficked within their own country by persons of the same nationality (Shelley, 2010; U.S. Department of State, 2009). Rates of forced labor are unknown and notoriously difficult to obtain due to methodological deficiencies (Fedina, 2015) and issues related to reporting and victim identification (Chesnay, 2013; Hyland, 2001; Laczko & Gramegna, 2003). However, the International Labour Organization (n.d.) estimates 27 million people become trafficked annually—4.5 million of whom are victims of forced sexual exploitation. Children and adolescents are exceptionally vulnerable to forced entry into the sex trade. The National Center for Missing and Exploited Children (2014) reported that 1 in 5 runaways are at risk for forced sexual exploitation. This represents an increase from an estimated 1 in 6 in 2014 (Polaris, 2016). Additionally, a study conducted by Estes and Weiner (2002) estimated that 326,000 youth are at risk for child trafficking. Counselors must become educated in recognizing the signs of trafficked persons, vulnerabilities to becoming trafficked, and the processes by which persons are forced into sexual exploitation in order to obtain a deeper understanding of the client’s worldview and provide appropriate support.

Existing literature addressing the mental health needs of sex trafficked survivors remains extremely limited (Hossain, Zimmerman, Abas, Light, & Watts, 2010; Tsutsumi, Izutsu, Poudyal, Kato, & Marui, 2008). Instead, the current body of research has focused on the sexual consequences of trafficking-related health issues such as sexually transmitted infections and rates of HIV among trafficked women in Asia (Beyrer, 2001; Beyrer & Stachowiak, 2003; Silverman et al., 2006; Silverman et al., 2007). The following article provides a brief overview of the definition, terms and processes associated with human trafficking. Next, the vulnerabilities and signs that a person has been or is currently being trafficked are presented. Finally, we address the clinical implications of working with trafficked survivors and identify trauma-sensitive interventions. Although female pronouns are used in this article, this detail is not intended to minimize the fact that many cisgender men, as well as lesbian, gay, bisexual and transgender persons, become victims of forced sexual exploitation (Martinez & Kelle, 2013; Oram, Stöckl, Busza, Howard, & Zimmerman, 2012).

Definition, Terms and Processes of Sex Trafficking

Despite the growing awareness of modern day slavery, the act of human trafficking is not a new phenomenon. In Imperial Rome, it has been estimated that between 30–40% of the Roman population was comprised of slaves trafficked from nearby countries such as Thrase, Gaul, Britain and Germany (Collingridge, 2006). In fact, during the height of the Roman Empire, wars were fought solely to procure more slaves (Cahill, 1995; Goldsworthy, 2006). Human trafficking was not limited to European countries. Beginning in 1619, both White and African slaves were taken from their countries and imported to Virginia to help construct the colonies (D. Davis, 2006; Jordan & Walsh, 2007). Human trafficking and modern day slavery are acts of social injustice that have historically exploited men, women and children.

According to the Trafficking Victims Protection Act (U.S. Department of State, 2000), the act of human trafficking refers to the recruitment, harboring, transportation, provision or obtaining of a person for commercial sex through force, fraud or coercion, or in which the person induced to perform a sex act is under 18 years of age. Despite common misconceptions, for an act to be considered sex trafficking, forced movement across the state is not required (U.S. Department of State, 2000). Sex trafficking includes a wide variety of traditionally accepted forms of labor, including commercial sex, exotic dancing and pornography (Logan, Walker, & Hunt, 2009). The following sections address the three components of control associated with human trafficking, namely force, fraud and coercion. Specific strategies used by traffickers to obtain and maintain control also are described.

Force

As defined by the United States Department of Health and Human Services (2012), force pertains to the physical restraint or serious physical harm that traffickers use to obtain and maintain control. According to Chesnay (2013), methods of force are typically used to break down the victim’s spirit. Examples of force as a means of control include rape, physical violence, intimidation, physical confinement and restricted freedom (Williamson & Prior, 2009; Zimmerman et al., 2008). Traffickers may introduce an addiction to an illicit substance or use existing drug or alcohol addictions to force persons into exploitative circumstances (Raphael & Ashley, 2008; Raymond et al., 2002; Whitaker & Hinterlong, 2008; Williamson & Prior, 2009; Zimmerman, 2003). According to findings by Whitaker and Hinterlong (2008), victims’ resistance often leads to additional or more forceful control mechanisms used by traffickers. For example, traffickers may initially use physical or sexual violence and increase the severity (e.g., burning or torturing victims) when disobeyed. Additionally, Whitaker and Hinterlong discovered the presence of gendered patterns of control or the concept that different strategies are used when eliciting compliance from men and women (e.g., use of threats to community members and drug addiction in men, and threats to family relationships and references about the world being dangerous in women). It is important to note that not all trafficked persons experience physical suffering (Aradau, 2004; Belser, 2005).

Fraud

     Fraud, or the use of false promises to lure persons into the human trafficking industry, is another method used by traffickers to control and exploit their victims (United States Department of Health and Human Services, 2012). Although fraud is typical in labor trafficking scenarios (e.g., women are offered appealing job opportunities overseas as a nanny or model and then forced into prostitution upon arrival), this tactic also is employed within sex trafficking scenarios (Belser, 2005; Whitaker & Hinterlong, 2008). Traffickers may recruit children from low-income families by promising parents that their children will be safer, better cared for and taught a useful skill or trade (Albanese, 2007; U.S. Department of State, 2009). Once recruited, victims enter into debt bondage and are promised freedom upon repayment to traffickers for their services (Williamson et al., 2010). Unfortunately, the result of debt bondage is a never-ending cycle from which victims cannot escape (Chesnay, 2013). Upon incurring a debt, persons in forced labor scenarios become trapped as traffickers enforce high interest rates, withhold payment, and charge for miscellaneous expenses such as the cost for food, transportation, condoms, and other supplies (International Labour Organization, 2005). Albanese (2007) described one case in which traffickers used fraud after recruiting two girls from Vancouver, British Columbia, and transporting them to Hawaii. In this scenario, the traffickers withheld the girl’s passports and threatened to circulate photographs of them engaging in sex acts in order to obtain their compliance. For many victims of forced labor, fraud is a strategy used by traffickers to exploit dreams or hope for a better life (U.S. Department of State, 2009).

Coercion

     Coercion, or using threats of physical harm or physical restraint against a person, is another context of control associated with human trafficking (United States Department of Health and Human Services, 2012). Coercion can take the form of direct physical violence or be psychological in nature (Logan et al., 2009; U.S. Department of State, 2009). In many cases, traffickers coerce victims by threatening to harm their families if they do not comply with their demands (Whitaker & Hinterlong, 2008; Williamson & Prior, 2009). Coercive tactics can directly exploit cultural beliefs, such as the case described by Whitaker and Hinterlong (2008) in which a victim believed she had to obey a trafficker because he kept a lock of her hair. Homeless youth who lack resources (e.g., food, protection, drugs) become coerced by adults that provide shelter and later demand “payment” in the form of sex (Hagan & McCarthy, 1997, p. 48). Although some victims are controlled by traffickers, others are coerced into sexual exploitation by boyfriends, girlfriends and friends (Hagan & McCarthy, 1997; Widom & Kuhns, 1996). Traffickers may coerce their victim’s compliance through the use of a grooming process (Herman, 1992) in which a connection is forged between victims and their traffickers in order to produce intense loyalty (Priebe & Suhr, 2005). When threats, force or coercion is used for the purpose of exploitation, victim consent is not relevant (Logan, 2007).

     The grooming process. The seasoning, or grooming, process refers to the progression of power used by traffickers to control their victims and, in some cases, forge a trauma bond (Smith, Vardaman, & Snow, 2009). Similar to “Stockholm syndrome,” in which hostages relate to and defend their captors (Smith et al., 2009), trauma bonding is a form of coercive control in which traffickers instill a sense of fear as well as gratitude for being allowed to live (United States Department of Health and Human Services, 2012). As outlined by O’Connor and Healy (2006), the grooming process stages are ensnaring, creating dependence, taking control, and total dominance. During the ensnaring phase, traffickers begin to identify themselves as a trustworthy and valuable person in the victim’s life (O’Connor & Healy, 2006). Traffickers may provide favors, purchase expensive gifts, show affection and enter into a romantic relationship with the victim (Albanese, 2007). For many adolescents, this façade may represent the only affirming, reliable and secure relationship in their lives, and victims quickly find themselves emotionally invested. Next, traffickers create dependence. During this process, victims gradually become separated from their families and friends (O’Connor & Healy, 2006). Traffickers may convince victims that other persons in their lives are unreliable or untrustworthy. At the completion of this stage, victims begin to rely solely on their traffickers for support and become isolated from their previous lives (O’Connor & Healy, 2006). The taking control stage is characterized by a shift in the traffickers’ behavior from caring and supportive to controlling and possessive (O’Connor & Healy, 2006). The trafficker may begin to use threats, violence and drugs as methods of control and dictate whom the victim sees and where she goes (Whitaker & Hinterlong, 2008). At the end of this stage, traffickers may test the victims’ commitment to the relationship and demand that they begin selling commercial sex to prove their love (O’Connor & Healy, 2006). Once victims have become completely dependent on their traffickers and are convinced that the easiest way to earn money and maintain their relationships is through selling sex, total dominance has been achieved (O’Connor & Healy, 2006). Although the grooming process outlined by O’Connor and Healy is a helpful model that represents how many persons become trafficked, these series of stages may not occur in every case. Persons may enter the commercial sex trade through a variety of avenues, and their experiences of becoming trafficked may be consistent with, or distinct from, O’Connor and Healy’s model.

Contexts of Control

Just as variability exists within the stages of grooming, different factors influence whether the grooming process itself results in victim compliance. Traffickers use a variety of recruitment techniques and forms of exploitation to obtain and maintain control (Shelley, 2010). Contexts of control acknowledge the complex associations that influence the relationship between victim and trafficker (Whitaker & Hinterlong, 2008). These factors include the individual resiliencies of trafficked persons, the grooming process, and the methods of force, fraud and coercion used by traffickers (Whitaker & Hinterlong, 2008). According to Whitaker and Hinterlong (2008), the four contexts of control include control-seeking, control mechanisms, controllability and resistance. The context of control-seeking refers to the trafficker’s desire to limit the victims’ choices in order to increase the likelihood that their desires are met (Whitaker & Hinterlong, 2008). Traffickers with higher rates of control-seeking seek more power over victims’ behaviors, appearance and travel (Whitaker & Hinterlong, 2008). They may determine what victims wear, control how they interact with buyers, confine persons to specific locations, identify and enforce a mandatory amount of earnings per day, or withhold passports, money and identifying documents (Whitaker & Hinterlong, 2008; Zimmerman, 2003). Traffickers use control mechanisms (e.g., threats of violence, debt bondage, psychological intimidation and acute violence) to obtain and maintain control of victims, and they may vary depending on the victims’ level of controllability, or capacity to resist due to their social or financial context, cultural or personal beliefs, physical limitations, or other deficiencies (Shelley, 2010; Whitaker & Hinterlong, 2008). Thus, a trafficker may attempt to recruit a young woman by showering her with expensive gifts and affection, but if she demonstrates a low level of controllability (e.g., she has a strong support system, is financially stable, has high self-efficacy), the control mechanisms are less effective (Whitaker & Hinterlong, 2008). Controllability can be further delineated into six subdomains: social, financial, physical, cultural, psychological and institutional (Whitaker & Hinterlong, 2008). Persons with a strong combination across these six subdomains have lower controllability levels and are less likely to become trafficked through the grooming process (Whitaker & Hinterlong, 2008). Because trafficked people are unable to predict or manage events that influence their health and safety, the methods of control in human trafficking are parallel to the characteristics of abuse described in the literature on torture (Saporta & Van der Kolk, 1992).

Vulnerabilities and Risk Factors

     The market for commercial sex represents a diverse avenue that incorporates a wide spectrum of activities and transactions across many settings (Anderson & O’Connell Davidson, 2003). Although survivors of human trafficking are not limited to race, ethnicity, age, gender or socioeconomic status, vulnerabilities such as location, poverty, sexual minority status and childhood trauma history, among other factors, influence higher rates for potential sexual exploitation (Albanese, 2007;  Bales, 2007; Hyland, 2001; Kidd & Liborio, 2011; Martinez & Kelle, 2013). The following section outlines a variety of risk factors that have been linked to entrance into the sex trafficking trade.

Location as Risk Factor

Within the global human trafficking industry, there are origin and destination countries that influence the direction of movement and likelihood that persons become victims of forced sexual exploitation (Bales, 2007). Often, third world countries are origin countries characterized by locations with a large supply of available victims (Bales, 2007). The country may be in a state of conflict and social unrest or have high rates of poverty, government corruption and a lack of viable employment opportunities (Bales, 2007). Because trafficking is strongly linked to rates of poverty and minimal employment opportunities (Loff & Sanghera, 2004), many people willingly go with traffickers believing they will receive better opportunities abroad and can send money home to their families (Chung, 2009). Once recruited from origin countries, survivors are transported to destination countries, characterized by locations with high demand for commercial sex (Bales, 2007). Some locations, such as the United States, are bidirectional countries, in which victims are both recruited and put to work (Farr, 2005).

Although many persons become trafficked across international borders, the majority of victims in the United States are trafficked domestically (U.S. Department of State, 2009), with an increase of minors recruited from the Midwest (Williamson & Prior, 2009). In a study of 13 youth involved with forced sexual exploitation, respondents explained that recruitment occurred on the streets, while walking to friends’ houses, with peers, at corner stores, at malls, at their own homes, and waiting to meet with a probation officer outside the juvenile justice center (Williamson & Prior, 2009). In most cases, youth were approached by someone they knew, a mutual acquaintance, or people they recognized from their community (Williamson & Prior, 2009). Thus, counselors need to become familiar with recruitment cities, destination cities and bidirectional cities (Williamson & Prior, 2009). Recruitment and destination cities respectively refer to locations where persons are obtained and transported to meet the growing demand for commercial sex (K. Davis, 2006). Although victims may become recruited and forced into sexual exploitation in any city across the United States, smaller cities in the Midwest have been linked to increased rates of recruitment (K. Davis, 2006). Recruitment cities share similar characteristics, such as access to numerous highways that facilitate victim transportation to destination cities where demand for commercial sex is greatest (K. Davis, 2006). Once obtained, victims are transported to high-demand locations such as Chicago, Detroit and Las Vegas (Wilson & Dalton, 2007. Additional factors that seem to link location to sex trafficking exist. Previous studies have found increased rates of commercial sexual exploitation in areas with higher ratios of females to males (Rao & Presenti, 2012), in places with legalized prostitution (Cho, Dreher, & Neumayer, 2013), and within areas characterized by large populations of transient males such as military personnel, truckers, tourists, and conventioneers (Estes & Weiner, 2002; Farley & Kelly, 2000).

Interpersonal and Intrapersonal Risk Factors

     In addition to location, other vulnerabilities to becoming trafficked exist, including individual, family, peer-related and environmental factors (Williamson & Prior, 2009). Persons from any socioeconomic background, race or ethnicity may become trafficked (McClain & Garrity, 2010). A study exploring the shared characteristics of adolescent females in the commercial sex industry identified low IQ scores and multiple mental health disorders as common factors (Twill, Green, & Traylor, 2010). History of risky or deviant behavior exposes adolescents to increased risk for becoming trafficked. For example, adolescents selling, buying and using drugs all increase the likelihood of crossing paths with a trafficker (McClain & Garrity, 2010; Walsh & Donaldson, 2010). Additional risk factors such as poverty, unemployment, isolation, low self-efficacy, drug addiction and history of physical and sexual abuse have been linked with entrance into the sex trafficking industry (Bales, 2007; Kidd & Liborio, 2011). Although not all trafficked persons have histories of childhood abuse (Chudakov, Ilan, Belmaker, & Cwikel, 2002), persons forced into sexual exploitation have commonly experienced violence prior to becoming trafficked, which increases their vulnerability to entering the sex trafficking trade and influences the greater likelihood of developing future mental health concerns (Hossain et al., 2010).

Homelessness and Sexual Minority Status as Risk Factors

Runaway, homeless or throwaway children are recruited into trafficking rings and exposed to extreme forms of abuse (Estes & Weiner, 2002). Many are killed as a result of violence or from diseases incurred from their sexual victimization (Estes & Weiner, 2002; Mitchell, Finkelhor, & Wolak, 2010). Adolescents are typically approached by traffickers within 48 hours of living on the street (Jordan, Patel, & Rapp, 2013). Traffickers are predatory in nature and adept at identifying vulnerable persons in need of safety, security and protection (Albanese, 2007; Jordan et al., 2013). LGBT persons are especially at risk of forced sexual exploitation due to increased rates of high-risk behaviors and homelessness (Martinez & Keele, 2013). According to the National Coalition for the Homeless (2009), sexual minority youth are twice as likely to experience sexual abuse before the age of 12 and are 7.4 times more likely to become victims of sexual violence. Counselors working with LGBT adolescents must assess their clients’ histories and explore whether they have engaged in survival sex or substance abuse or have been homeless. Survival sex is characterized by the exchange of sexual acts for shelter, food, money, protection, favors or other resources (Estes & Weiner, 2002; Williams & Frederick, 2009). It is important to note that persons from stable families may become trafficked. Young women may go willingly with friends to parties and become enamored with charming men involved in the sex trafficking trade or become flattered by the attentions of predatory older men (Chesnay, 2013). According to a study conducted by Raphael and Myers-Powell (2010) that interviewed 25 ex-pimps in Chicago, the prime candidate for recruitment was a blonde runaway.

Social Media and Internet Use as Risk Factor

Free access and anonymity with the Internet has created greater opportunity for offenders to purchase sex online where a wider variety of options exist (Chung, 2009; McCarthy, 2010; Raphael & Myers-Powell, 2010). Social media Web sites such as Myspace, Twitter and Facebook have been identified as a frequent tool used by traffickers to recruit adolescents into the sex trafficking trade (Demir, 2010; Jordan et al., 2013; Raphael & Myers-Powell, 2010; Williamson & Prior, 2009). Offenders cited the use of social media Web sites to contact, groom and connect with their victims, whereas online advertisement Web sites such as Craigslist were used to sell their victims (Raphael & Myers-Powell, 2010).

Adolescents with low levels of self-efficacy may be at increased risk for victimization due to higher rates of social media use. According to the Pew Research Center (2013), 74% of adults online use social networking sites, with young adults ages 18 to 29 representing the vast majority of social media users. Research exploring the relationship between social media use and the well-being of young adults has yielded significant findings that promote a deeper understanding of how traffickers select and recruit victims online. A study conducted by Meier and Gray (2014) linked photo activity on Facebook with greater than ideal internalization and self-objectification. Michikyan, Subrahmanyam, and Dennis (2014) additionally discovered that young adults experiencing emotional instability were more strategic in their online self-presentation, presumably to seek reassurance. Social networking site use also has been found to increase levels of self-efficacy, satisfy a need for belonging and improve self-esteem in college-aged students (Gangadharbatla, 2008). Upon examination of these pre-existing vulnerabilities, counselors can acquire a deeper understanding of how the grooming process may result in trauma bonds and entrance into the sex trafficking trade. For at-risk adolescents that lack a strong support system, experience low levels of self-efficacy and seek affirmation through their social media presence, online connections with traffickers may satisfy their deep desires for validation. Because traffickers are predatory in nature and gravitate toward vulnerable persons with low self-efficacy and high rates of controllability, counselors working with adolescents and young adults should provide education on topics related to Internet safety and the consequences of promoting a sexually suggestive online presence.

Possible Signs of Trafficking

Counselors working with at-risk populations (e.g., clients with addictions, and a history of homelessness and trauma) must recognize the possible signs that clients are being trafficked. Because many victims remain invisible to law enforcement (Hyland, 2001) and counselors, the identification and treatment of victims represents one of the greatest challenges in working with this population (McClain & Garrity, 2010). According to Polaris (2015), a variety of indicators exist that may suggest forced exploitation.

Signs of Trafficking in Mental Health Settings

Counselors and other helping professionals should assess clients for signs of trafficking, including instances in which clients are under 18 and providing commercial sex acts, have a controlling older boyfriend, work excessively long or unusual hours, or have few personal possessions (Polaris, 2015). Within behavioral health settings, clients may present as fearful, anxious, depressed, submissive or tense with avoidant eye contact (Polaris, 2015). Trafficked persons rarely seek counseling independently and have likely endured intense, ongoing victimization and may present with depression, dissociative reactions, suicidal ideation, post-traumatic stress disorder, feelings of guilt,  shame and self-mutilation (Chesnay, 2013). Clients also may have histories of solicitation charges, substance use issues, or a need for safe and stable housing, lack a strong support system, and have visible bruises or branding (Chesnay, 2013; Hyland, 2001; Jordan et al., 2013). Branding refers to a method of identification used by traffickers to indicate ownership and may be tattoos or carvings (Jordan et al., 2013; Shared Hope International, 2016). It is the author’s experience that some clients that become addicted to opiates by their oppressors are forced to inject in locations on their bodies that will not detract from their overall marketability as a reusable commodity. In many cases, these locations include the inner thighs or between the fingers or toes. As one anonymous survivor (a client of the author) explained, “Nobody is going to buy someone with track marks.” A trend exists in which offenders trafficking drugs are beginning to traffic people (Shelley, 2010). Whereas drugs can be sold once, people can be sold repeatedly and thus represent a more profitable and less risky business venture (Neville & Martinez, 2004; Shelley, 2010).

Signs of Trafficking in Medical Settings

Trafficked persons may present in health care settings, although these instances occur at a low rate. Persons are only allowed to seek medical attention when traffickers believe their condition prevents monetary gain, at which point they can become disposable (Chesnay, 2013; Neville & Martinez, 2004). Medical issues associated with trafficked survivors within health care settings may include sexually transmitted infections, pregnancy, history of unsafe abortions, chronic pain, malnutrition, substance use issues, and sleep deprivation (Chesnay, 2013; Estes & Weiner, 2002). Counselors and medical professionals may additionally note that trafficked survivors struggle during a mental status exam (Chesnay, 2013). Due to a combination of working long hours, exhaustion, and frequent transportation to and from locations, trafficked persons may respond incorrectly to questions regarding time, place and person (Chesnay, 2013).

Signs of Trafficking in School Settings

School counselors need to be mindful of signs that students are being trafficked. Adolescents may be trafficked out of their own homes and transported to and from school by their oppressor (U.S. Department of Education, 2013). Possible signs that students are being trafficked within educational settings include references to frequent travel to other cities, signs of bruising, presence of depression, anxiety, or fear, coached or rehearsed responses to questions, and inappropriate dress based on weather conditions (U.S. Department of Education, 2013). Additionally, school counselors need to be mindful of children who have significantly older boyfriends or girlfriends, describe concern for the safety of family members if they disclose, or care for children that are not family members (U.S. Department of Education, 2013). When a child is being sex trafficked, they may be absent from school or miss periods of time while being sold to other communities (Williamson & Prior, 2009).

Challenges of Working With Trafficked Clients

Counselors may experience feelings of frustration and helplessness upon discovery that clients are rarely willing to leave their traffickers despite their dire situations. It is important to remember that many adolescents who become sex trafficked experience neurological effects from childhood physical, emotional and sexual trauma that inhibits their abilities to make pragmatic choices or escape their traffickers (Reid & Jones, 2011). The presence of chronic fear can inflict barriers to cognitive processing and decision making, which explains why some survivors do not escape when the opportunity arises (Loewenstein, Weber, Hsee, & Welch, 2001; Logan, Walker, Jordan, & Leukefelt, 2006). Due to the familiarity of unhealthy relationships and the lack of self-efficacy required to pursue change, childhood victims of sexual trauma are more likely to accept situations characterized by abuse (Reid & Jones, 2011). Counselors are encouraged to seek supervision, connect with colleagues and practice regular self-care routines in order to avoid experiencing burnout, secondary trauma, and compassion fatigue when working with this population.

Counselors working with trafficked clients are often faced with a series of challenges since an intervention modality specific to sex trafficked survivors has not yet been developed (Jordan et al., 2013). Although a small body of research exists on the health consequences associated with human trafficking, limited research has explored the mental health consequences of trafficking (Hossain et al., 2010; Tsutsumi et al., 2008). Current treatments are borrowed from evidence-based interventions originally developed for post-traumatic stress disorder and survivors of domestic violence, slavery and captivity (Jordan et al., 2013).

Assess Client’s Current State

Whether providing individual or group counseling to sex trafficked clients, several treatment considerations should be examined. First, counselors should assess whether the client is currently being trafficked or whether a sex trafficking history exists. Naturally, the counselor’s role will differ significantly depending on the client’s present situation. In the author’s experience, clients that are currently trafficked rarely seek mental health services independently. Instead, clients may present to counseling as the result of court mandates associated with drug or solicitation charges. Clients that are currently trafficked often resist help from mental health providers and avoid reporting due to well-founded fears of physical violence or threats of retribution if they disclose their situation (Flores, 2010). Therefore, building strong rapport with sex trafficked clients is critical (Chesnay, 2013). Because of the fraud and deception used by traffickers during the grooming process, many trafficked persons demonstrate marked difficulty with trusting others (Belser, 2005). It is essential that counselors build trust with the client by demonstrating unconditional positive regard, empathy and authenticity. Counselors may support clients by developing individualized safety plans and sharing valuable resources (e.g., The National Human Trafficking Hotline: 1-888-373-7888). Once a strong therapeutic relationship has been established, counselors may begin pursuing a variety of counseling goals, including psychoeducation, supporting clients through the stages of personal change, engaging in group counseling, medication management, addressing substance use issues, and promoting reintegration through education and job training.

Counselors working with sex trafficked survivors must assess whether the client has access to necessary resources, including housing, food, water, shelter and medicine. Ensuring that survivors are equipped with safe and stable homes minimizes the likelihood that they are simply returning to the same endangering conditions (Feingold, 2005). Counselors should work with sex trafficked clients to explore the circumstances that increased their risk for sexual exploitation. Once the situations are identified, counselors must work collaboratively with clients to create a sustainable maintenance promotion plan. Chesnay (2013) explained that once basic physiological needs and safe housing are obtained, mental health professionals can begin reframing the client’s worldview from “victim” to “survivor” to “thriving survivor.”

Asking Helpful Questions

In addition to taking the client’s trafficking situation into consideration, it is important to remain mindful of the language used when working with this population. Clients will rarely, if ever, identify with the term trafficked and also are likely to struggle with identifying their partner and protector as a pimp or trafficker (Chesnay, 2013). Trafficked clients may explain that they are working to help their boyfriends (Priebe & Suhr, 2005). Counselors and other mental health professionals are encouraged to accept the client’s identified terms and work within their individual framework (Chesnay, 2013).

Providing psychoeducation on the process, rates and prevalence of sex trafficking may be beneficial for clients to promote insight. Educational modalities that shift pertinent information from general to specific may be helpful in gradually exposing clients to difficult concepts. Counselors should work collaboratively with clients to identify salient issues and validate their experiences to promote recognition and exploration on the effects of trafficking. Counselors may use statements such as, “Many young adolescents living on the streets feel scared and find someone to protect and care for them. I wonder whether this is true for you?” Or, “Some people care so much about their partners that they feel obligated to prove their love and begin doing things they are not really comfortable with. I am curious whether this has been your experience as well?” Offering opportunities for clients to disclose information in a safe, nonjudgmental and accepting environment can increase client insight, promote counselor awareness of client history and facilitate therapeutic growth. Additionally, counselors should determine whether clients have access to safe and stable housing. If basic physiological needs are not met, clients may struggle to focus on higher order needs such as developing a safety plan or emotion regulation.

Assess Client’s Stage of Change

For clients that are currently trafficked, the stages of change outlined by Norcross, Krebs, and Prochaska (2011) may be a helpful tool for examining clients’ willingness to engage in counseling. Clients in the precontemplation stage may respond positively to counseling strategies aimed at increasing education and awareness. When clients present in the stage of contemplation, counselors may be most supportive by exploring client ambivalence. Counselors may facilitate costs and benefits analyses with the client regarding their current predicaments. Regardless of the client’s stage of change it is important that counselors do not force the client to leave their oppressor. This may put the client, their families and other loved ones at risk (Flores, 2010). Instead, counselors must listen, affirm and provide the client with resources such as the trafficking hotline and empower them to call when ready. It is important that counselors assess the severity and duration of trafficking-related abuse and recognize how these experiences influence recovery time (Hossain et al., 2010). In a sample of 204 trafficked girls and women, the presence of sexual violence during a trafficking experience had an independent effect on mental health symptoms (Hossain et al., 2010). Hossain and colleagues (2010) concluded that persons trafficked for longer periods of time have an increased likelihood of abusive episodes and prolonged feelings of entrapment, alienation, loss of control, humiliation and helplessness—all of which are associated with developing mental health disorders in the future. Counselors can better accommodate the needs of persons that have been trafficked for longer periods of time by providing longer duration post-trafficking care.

Assess Entrance Into Trafficking

Other treatment considerations pertain to the process through which clients became trafficked. Clients recruited and controlled through a grooming process may struggle to identify their captors as oppressors due to the presence of a trauma bond (United States Department of Health and Human Services, n.d.). Cases also exist in which clients have been trafficked by family members or sold to traffickers by their parents (Shelley, 2010). In some instances, adolescents and children are forced into sexual exploitation by their parents or siblings in order to support drug addictions or to avoid financial burdens (Estes & Weiner, 2002). One survivor, a client of the author, reported that a family member diagnosed with schizoaffective disorder trafficked her for a period of 2 months. The client described how the family member would hold a firearm to his neck and threaten to commit suicide if she did not provide him with heroin. The client explained how she felt forced to complete commercial sex acts with drug dealers, as this strategy was the quickest and easiest way to obtain illicit substances within her impoverished community. Counselors should work to identify their biases regarding how persons are trafficked, and by whom, in order to identify survivors and provide appropriate services.

Counseling Sex Trafficked Clients

     Counselors working with sex trafficked survivors should be prepared to employ a variety of trauma-sensitive interventions to support the individual needs of each client. Trauma-sensitive interventions identify safety as the foundation for working with persons to eliminate self-harm, develop trustworthy relationships, overcome challenges, promote wellness and remove themselves from dangerous situations (Najavits, 2002). Helping traumatized clients to regain a sense of control is critical (Goodman & Calderon, 2012). For example, counselors may use mindfulness-based activities such as body scans and body awareness exercises to help clients differentiate between current and past experiences (Rothschild, 2000). Counselors can use other mindfulness techniques, such as focusing on the present and emphasizing the mind-body connection, to help clients identify and reduce the somatic symptoms of arousal when no threats are present (Goodman & Calderon, 2012). Finally, counselors can help clients practice imagining, and returning attention to, comforting images to increase their sense of safety and decrease arousal (Goodman & Calderon, 2012). Ideally, counselors will empower their clients to redefine their lives not by their pasts, but by their futures (Chesnay, 2013).

Creative Interventions

     Creative-based interventions are especially powerful with sex trafficked clients because they provide opportunities for clients to make choices. For clients who have long been told what to do and have lived according to their trafficker’s demands, the presentation of choices and sense of control may represent an exciting and difficult challenge. Creative arts interventions have received a great deal of empirical support for clients presenting with trauma. Research that investigated resiliency has identified the importance of creativity, humor, flexibility, and movement as effective interventions to improve traumatized clients’ self-esteem, hope and prosocial behaviors (Johnson, Lahad, & Gray, 2009; Lahad, 2000; Raynor, 2002). Additionally, therapeutic art has been shown to be efficacious for work with clients presenting with emotional disturbances, grief and loss, low self-efficacy, depression, post-traumatic stress disorder, anxiety, and feelings of guilt and shame (Johnson et al., 2009; Slayton, D’Archer, & Kaplan, 2010). Creative interventions can be used to help clients reframe ideas, shift perspectives, externalize emotions and gain deeper understanding of events (Bradley, Whiting, Hendricks, Parr, & Jones, 2008). According to Lev-Weisel (1998), clients that struggle to find words to describe their traumatic experiences may prefer creative interventions as a means of expression. Counselors can integrate the use of creative and expressive interventions using mandalas or other art mediums to support clients in promoting openness while providing a sense of structure. Future areas of research are needed to determine the efficacy of creative interventions specific to clients with a history of sex trafficking.

Cognitive Behavioral Therapies

     Clients with a history of sex trafficking can benefit from cognitive behavioral therapies due to their internalization of derogatory labels (Hickle & Roe-Sepowitz, 2014). Counselors working with trafficked clients can identify and challenge these labels in order to decrease the presence of shame and other meta-emotions (e.g., anger at oneself for feeling shame). Additional evidence-based counseling interventions that may be useful for sex trafficked client populations include Eye Movement Desensitization and Reprocessing with adults (Maxfield, 2003; Shapiro, 1989) and trauma-focused cognitive behavioral therapy with children (Cohen, Berliner, & Mannarino, 2010; Cohen, Mannarino, Berliner, & Deblinger, 2000). The use of dialectical trauma-focused cognitive behavioral therapy is effective with both children (Racco & Vis, 2015) and adults with histories of trauma and post-traumatic stress disorder (Wagner, Rizvi, & Harned, 2007). Although trauma-focused cognitive behavioral therapy and dialectical trauma-focused cognitive behavioral therapy have not been tested specifically for sex trafficked populations, research indicates that these modalities are successful in helping children overcome histories of trauma and abuse (Classen, Koopman, Nevill-Manning, & Spiegel, 2001; Cohen & Mannarino, 1997). Future research studies should investigate the efficacy of cognitive behavioral therapies with sex trafficking survivors in order to standardize appropriate treatment methods for this unique population.

Group Counseling

     Providing survivors of forced sexual exploitation with an opportunity to participate in group counseling can empower persons to share similar experiences while creating a sense of community and support (Hickle & Roe-Sepowitz, 2014). Peer support is a crucial component for treatment since bearing witness to the similar lived experiences of other survivors provides a unique dimension of support and sense of universality (Chesnay, 2013). Counselors working with trafficked persons may focus on accomplishing a variety of treatment goals, including feeling identification, establishing safety, addressing substance use, countering internalized stigma and labels, providing psychoeducation and establishing healthy boundaries. Shame can be reduced by prompting discussions about taboo and stigmatizing topics within group settings (Hickle & Roe-Sepowitz, 2014). Many trafficked survivors have upheld the belief that they are the only ones who have been trafficked by parents, have engaged in survival sex, or who have been forced into sexual exploitation by boyfriends or girlfriends. According to Estes and Weiner (2002), boys that performed oral sex on adult males as a result of forced sexual exploitation experienced a profound sense of shame. Addressing these foci of shame can help clients recognize the universality of their experiences, build rapport with peers and facilitate trust in the group setting. Counselors should listen openly to the client’s stories of shame and receive them with empathy in order to dispel their negativistic beliefs. Psychoeducation within group settings can be used to explain how traffickers use coercion and other techniques to recruit young women (Hickle & Roe-Sepowitz, 2014).

Expressive techniques that allow group members to process trauma experiences without dissociating from the event are beneficial in promoting therapeutic growth (Hickle & Roe-Sepowitz, 2014). Clients can use markers, colored pencils and other artistic mediums to draw, color or write on an outlined body where they feel specific emotions such as pain, shame, anger, fear and guilt (Hickle & Roe-Sepowitz, 2014). Words and pictures from magazines also can be used to represent emotions or past and present states of mind and facilitate the healing process. The author has facilitated mask exercises within group settings to support trafficked clients in identifying and processing their ideal and actual selves. Once completed, the pictures and masks can be processed with other group members and similar or different experiences, emotions and challenges can be discussed.

Conclusion

Although social and cultural norms, poverty, gendered inequality and childhood history represent important vulnerability factors, the social injustice known as sex trafficking could not occur without the demand for sexual exploitation (Matheson & Finkel, 2013). A deeper understanding is needed to comprehend how persons become trafficked (Whitaker & Hinterlong, 2008). Additionally, a dearth of research remains that identifies specific evidence-based and trauma-sensitive modalities developed specifically for sex trafficked survivors (Chesnay, 2013; Jordan et al., 2013). The experiences, challenges and reflections of the author have been presented with the intention of providing education, support and guidance to other counselors serving this unique population. Regardless of which counseling tools are used, establishing and building a strong therapeutic alliance is a valuable tool that counselors can employ to support sex trafficked persons (Chesnay, 2013). Although challenging at times, establishing rapport requires a nonjudgmental attitude and a willingness to bear witness to clients’ experiences, without pointing out what survivors could have done differently (Chesnay, 2013).

It is important to remember that trafficked persons are often survivors of long-term childhood trauma characterized by instability within the home, childhood sexual trauma and community violence (Bales, 2007; Hossain et al., 2010; Kidd & Liborio, 2011; Williamson & Prior, 2009). Many adolescents were targeted, recruited and trafficked due to pre-existing vulnerabilities and high controllability factors (Whitaker & Hinterlong, 2008). Counselors are tasked with a unique position to provide corrective relational experiences characterized by the nonjudgmental acceptance, support and affirmation desperately needed by this population. Fewer resources and services exist for trafficked survivors than for victims of any other crime (Clawson, Dutch, & Cummings, 2006). Counselors should connect sex trafficked survivors to necessary social service supports, including case management services, safe and stable housing, and services aimed at supporting the successful reintegration of clients into the community through education and job training (Williamson & Prior, 2009). Future areas of research should explore the profiles of traffickers and standardize how mental health and medical providers can better identify, serve, protect, and support trafficked survivors (Bales, 2005). Finally, counselors are called to continue promoting awareness on the prevalence and signs of sex trafficked survivors. Increasing awareness and decreasing demand for sexually exploited persons are the fundamental steps necessary to end the human rights violation of sex trafficking (Chung, 2009; Kotrla, 2010).

Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest

or funding contributions for the development

of this manuscript.

References

Albanese, J. (2007). Commercial sexual exploitation of children: What do we know and what do we do about it? Retrieved from http://www.ncjrs.gov/pdfFiles1/nij/215733.pdf

Anderson, B., & O’Connell Davidson, J. (2003). Is trafficking in human beings demand driven? A multi-country pilot study. Retrieved from https://www.compas.ox.ac.uk/media/ER-2004-Trafficking_Demand_Driven_IOM.pdf

Aradau, C. (2004). The perverse politics of four-letter words: Risk and pity in the securitisation of human trafficking. Millennium Journal of International Studies, 33, 251–277.

Bales, K. (2005). Understanding global slavery: A reader. Berkeley, CA: University of California Press.

Bales, K. (2007). What predicts human trafficking? International Journal of Comparative and Applied Criminal Justice, 31, 269–279. doi:10.1080/01924036.2007.9678771

Belser, P. (2005). Forced labor and human trafficking: Estimating the profits. Retrieved from http://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?article=1016&context=forcedlabor

Beyrer, C. (2001). Shan women and girls and the sex industry in Southeast Asia: Political causes and human rights implications. Social Science & Medicine, 53, 543–550.

Beyrer, C., & Stachowiak, J. (2003). Health consequences of trafficking of women and girls in Southeast Asia. The Brown Journal of World Affairs, 10, 105–117.

Bradley, L. J., Whiting, P., Hendricks, B., Parr, G., & Jones, E. G., Jr. (2008). The use of expressive techniques in counseling. Journal of Creativity in Mental Health, 3, 44–59.

Cahill, T. (1995). How the Irish saved civilization: The untold story of Ireland’s heroic role from the fall of Rome to the rise      of Medieval Europe (The Hinges of History). New York: Random House.

Chesnay, M. D. (2013). Psychiatric-mental health nurses and the sex trafficking pandemic. Issues in Mental Health Nursing, 34, 901–907. doi:10.3109/01612849.2013.857200

Cho, S. Y., Dreher, A., & Neumayer, E. (2013). Does legalized prostitution increase human trafficking? World                    Development, 41, 67–82.

Chudakov, B., Ilan, K., Belmaker, R. H., & Cwikel, J. (2002). The motivation and mental health of sex workers.                 Journal of Sex and Marital Therapy, 28, 305–315. doi:10.1080/00926230290001439

Chung, R. C-Y. (2009). Cultural perspectives on child trafficking, human rights & social justice: A model for psychologists. Counselling Psychology Quarterly, 22,85–96.

Classen, C., Koopman, C., Nevill-Manning, K., & Spiegel, D. (2001). A preliminary report comparing trauma-focused and present-focused group therapy against a wait-listed condition among childhood sexual abuse survivors with PTSD. Journal of Aggression, Maltreatment & Trauma, 4, 265–288.

Clawson, H. J., Dutch, N., & Cummings, M. (2006). Law enforcement response to human trafficking and the implica-tions for victims: Current practices and lessons learned. Retrieved from http://www.ncjrs.gov/pdffiles1/nij/grants/216547.pdf

Cohen, J. A., Berliner, L., & Mannarino, A. (2010). Trauma focused CBT for children with co-occurring trauma and behavior problems. Child Abuse & Neglect, 34, 215–224.

Cohen, J. A., & Mannarino, A. P. (1997). A treatment study for sexually abused preschool children: Outcome during a one-year follow-up. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 1228–1235.

Cohen, J. A., Mannarino, A. P., Berliner, L., & Deblinger, E. (2000). Trauma-focused cognitive behavioral therapy for children and adolescents: An empirical update. Journal of Interpersonal Violence, 15, 1202–1223.

Collingridge, V. (2006). Boudica: The life and legends of Britain’s warrior queen. Woodstock, NY: Overlook Press.

Davis, D. B. (2006). Inhuman bondage: The rise and fall of slavery in the New World. New York, NY: Oxford University Press.

Davis, K. Y. S. (2006). Human trafficking and modern day slavery in Ohio. Washington, DC: Polaris Project. Retrieved from http://www.ccv.org/wp-content/uploads/2010/04/Ohio-Report-on-Trafficking.pdf

Demir, O. O. (2010). Methods of sex trafficking: Findings of a case study in Turkey. Global Crime, 11, 314–335.
doi:10.1080/17440572.2010.490636

Estes, R. J., & Weiner, N. A. (2002). The commercial sexual exploitation of children in the U.S., Canada, and Mexico. Retrieved fromhttp://abolitionistmom.org/wp-content/uploads/2014/05/Complete_CSEC_0estes-weiner.pdf

Farley, M., & Kelly, V. (2000). Prostitution: A critical review of the medical and social sciences literature. Women & Criminal Justice, 11(4), 29–64.

Farr, K. (2005). Sex trafficking: The global market in women and children. New York, NY: Worth.

Fedina, L. (2015). Use and misuse of research in books on sex trafficking: Implications for interdisciplinary

research, practitioners, and advocates. Trauma, Violence, and Abuse, 16, 188–198. doi:10.1177/1524838014523337

Feingold, D. A. (2005). Human trafficking. Foreign Policy, 150, 26–30.

Flores, T. (2010). The slave across the street: The true story of how an American teen survived the world of human trafficking. Boise, ID: Ampelon.

Gangadharbatla, H. (2008). Facebook me: Collective self-esteem, need to belong, and internet self-efficacy as predictors of the iGeneration’s attitudes toward social networking sites. Journal of Interactive Advertising, 8(2), 1–28.

Goldsworthy, A. (2006). Caesar: Life of a colossus. New Haven, CT: Yale University Press.

Goodman, R. D., & Calderon, A. M. (2012). The use of mindfulness in trauma counseling. Journal of Mental Health Counseling, 34(3), 254–268.

Hagan, J., & McCarthy, B. (1997). Mean streets: Youth crime and homelessness. Cambridge, England: Cambridge University Press.

Herman, J. L. (1992). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. New                         York, NY: Basic Books.

Hickle, K. E., & Roe-Sepowitz, D. E. (2014). Putting the pieces back together: A group intervention for sexually exploited adolescent girls. Social Work with Groups, 37, 99–113. doi:10.1080/01609513.2013.8233838

Hossain, M., Zimmerman, C., Abas, M., Light, M., & Watts, C. (2010). The relationship of trauma to mental disorders among trafficked and sexually exploited girls and women. American Journal of Public Health, 100, 2442–2449.

Hyland, K. E. (2001). Protecting human victims of trafficking: An American framework. Berkeley Women’s Law Journal, 16, 29–71.

International Labour Organization. (n.d.). Forced labour, modern slavery and human trafficking. Retrieved from http://www.ilo.org/global/topics/forced-labour/lang–en/index.htm

International Labour Organization. (2005). Global report on forced labour in Asia: Debt bondage, trafficking and state-

            imposed forced labour. Retrieved from http://www.ilo.org/global/about-the-ilo/newsroom/news/WCMS_07

5504/lang–en/index.htm

Johnson, D. R., Lahad, M., & Gray, A. (2009). Creative therapies for adults. In E. B. Foa, T. M. Keane, M. J. Fried-

man, & J. A. Cohen (Eds.), Effective treatments for PTSD. Practice guidelines from the International Society for Traumatic Stress Studies (pp. 479–490). New York, NY: Guilford Press.

Jordan, D., & Walsh, M. (2007). White cargo: The forgotten history of Britain’s white slaves in America. New York: New York University Press.

Jordan, J., Patel, B., & Rapp, L. (2013). Domestic minor sex trafficking; A social work perspective on misidentifi-cation, victims, buyers, traffickers, treatment, and reform of current practice. The Journal of Human Behavior in the Social Environment, 23, 356–369.

Kidd, S. A., & Liborio, R. M. C. (2011). Sex trade involvement in Sao Paulo, Brazil, and Toronto, Canada: Narra-tives of social exclusion and fragmented identities. Youth & Society, 43, 982–1009.

Kotrla, K. (2010). Domestic minor sex trafficking in the United States. The National Association of Social Workers, 55, 181–187.

Laczko, F., & Gramegna, M. A. (2003). Developing better indicators of human trafficking. The Brown Journal of World Affairs, 10, 179–194.

Lahad, M. (2000). Darkness over the abyss: Supervising crisis intervention teams following disaster. Traumatology, 6, 273–293.

Lev-Weisel, R. (1998). Use of drawing technique to encourage verbalization in adult survivor of sexual abuse. The Arts in Psychotherapy, 25, 257–262.

Loewenstein, G., Weber, E. U., Hsee, C. K., & Welch, N. (2001). Risk as feelings. Psychology Bulletin, 127, 267–286.

Loff, B., & Sanghera, J. (2004). Distortions and difficulties in data for trafficking, The Lancet, 363, 566.

Logan, T. (2007). Human trafficking in Kentucky. Retrieved from http://www.cdar.uky.edu/CoerciveControl/docs/Human%20Trafficking%20in%20Kentucky.pdf

Logan, T. K., Walker, R., & Hunt, G. (2009). Understanding human trafficking in the United States. Trauma, Violence, and Abuse, 10(3), 3–30. doi:10.11777/15249=838008327262

Logan, T. K., Walker, R., Jordan, C. E., & Leukefelt, C. (2006). Women and victimization: Contributing factors, inter-ventions, and implications. Washington, DC: American Psychological Association.

Martinez, O., & Kelle, G. (2013). Sex trafficking of LGBT individuals: A call for service provision, research, and action. International Law News, 42(4), 1–6.

Matheson, C. M., & Finkel, R. (2013). Sex trafficking and the Vancouver winter Olympic games: Perceptions and preventative measures. Tourism Management, 36, 613–628.

Maxfield, L. (2003). Clinical implications and recommendations arising from EMDR research findings. Journal of Trauma Practice, 2, 61–81.

McCarthy, J. A. (2010). Internet sexual activity: A comparison between contact and non-contact child pornography offenders. Journal of Sexual Aggression, 16, 181–195.

McClain, N. M., & Garrity, S. E., (2010). Sex trafficking and the exploitation of adolescents. The Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40, 243–252. doi:10.1111/j.1552-6909.2011.01221.x

Meier, E. P., & Gray, J. (2014). Facebook photo activity associated with body image disturbance in adolescent girls. Cyberpsychology, Behavior, and Social Networking, 17, 199–206. doi:10.1089/cyber.2013.0305

Michikyan, M., Subrahmanyam, K., & Dennis, J. (2014). Can you tell who I am? Neuroticism, extraversion, and online self-presentation among young adults. Computers in Human Behavior, 33, 179–183.

Mitchell, K. J., Finkelhor, D., & Wolak, J. (2010). Conceptualizing juvenile prostitution as child maltreatment:

Findings from the national juvenile prostitution study. Child Maltreatment, 15, 18–36. doi:10.1177/1077559509349443

Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York, NY: Guilford Press.

National Center for Missing and Exploited Children. (2014). Child sex trafficking. Retrieved from http://www.missingkids.com/1in6

National Coalition for the Homeless. (2009). LGBT Homeless. Retrieved from http://www.nationalhomeless.org/factsheets/lgbtq.html

Neville, S., & Martinez, S. (2004). The law of human trafficking. What legal aid providers should know. Clearing-house Review Journal of Poverty Law and Policy, 37, 551–556.

Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of Clinical Psychology, 67, 143–154. doi:10.1002/jclp.20758

O’Connor, M., & Healy, G. (2006) The links between prostitution and sex trafficking: A briefing handbook. Retrieved from http://www.catwinternational.org/Home/Article/175-the-links-between-prostitution-and-sex-trafficking-a-briefing-handbook

Oram, S., Stöckl, H., Busza, J., Howard, L. M., & Zimmerman, C. (2012). Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: Systematic review. PLOS Medicine, 9(5), 1–13. doi:10.1371/journal.pmed.1001224

Pew Research Center. (2013). Social networking fact sheet. Retrieved from http://www.pewinternet.org/fact-sheets/social-networking-fact-sheet

Polaris. (2015). Recognize the signs. Retrieved from https://polarisproject.org/recognize-signs

Polaris. (2016). 2015 NHTRC annual report. Washington, DC: Author. Retrieved from https://humantrafficking

hotline.org/resources/2015-nhtrc-annual-report

Priebe, A., & Suhr, C. (2005). Hidden in plain view: The commercial sexual exploitation of girls in Atlanta. Atlanta, GA: The Atlanta Women’s Agenda.

Racco, A., & Vis, J.-A. (2015). Evidence based trauma treatment for children and youth. Child and Adolescent Social Work Journal, 32, 121–129.

Rao, S., & Presenti, C. (2012). Understanding human trafficking origin: A cross-country empirical analysis. Feminist Economics, 18, 231–263.

Raphael, J., & Ashley, J. (2008). Domestic sex trafficking of Chicago women and girls. Retrieved from http://www.icjia.state.il.us/assets/pdf/ResearchReports/Sex%20Trafficking%20Report%20May%202008.pdf

Raphael, J., & Myers-Powell, B. (2010). From victims to victimizers: Interview with 25 ex-pimps in Chicago. Retrieved from https://law.depaul.edu/about/centers-and-institutes/schiller-ducanto-fleck-family-law-center/Documents/interview_ex_pimps.pdf

Raymond, J. G., D’Cunha, J., Dzuhayatin, S. R., Hynes, H. P., Rodriguez, Z. R., & Santos, A. (2002). A comparative study of women trafficked in the migration process: Patterns, profiles, and health consequences of sexual exploita-tion in five countries (Indonesia, the Philippines, Thailand, Venezuela, and the United States). Belgium: Coalition Against Trafficking in Women. Retrieved from http://www.catwinternational.org/Content/Images/Article/96/attachment.pdf

Raynor, C. M. (2002). The role of play in the recovery process. In W. N. Zubenko & J. A. Capozzoli (Eds.), Children and disasters: A practical guide to healing and recovery (pp. 124–134). New York, NY: Oxford University Press.

Reid, J. A., & Jones, S. (2011). Exploited vulnerability: Legal and psychological perspectives on child sex traffick-ing victims. Victims & Offenders, 6, 207–231. doi:10.1080/15564884.2011.557327

Rothschild, B. (2000). The body remembers. New York, NY: W. W. Norton.

Saporta, J. A., & Van der Kolk, B. A. (1992). Psychobiological consequences of trauma. In M. Basoglu (Ed.), Torture and its consequences: Current treatment approaches (pp. 151–181). Cambridge, England: Cambridge University Press.

Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress, 2, 199–223. doi:10.1002/jts.2490020207

Shared Hope International. (2016). Trafficking terms. Retrieved from http://sharedhope.org/the-problem/traffick

ing-terms

Shelley, L. (2010). Human trafficking: A global perspective. New York: Cambridge Universitiy Press

Silverman, J. G., Decker, M. R., Gupta, J., Maheshwari, A., Patel, V., & Raj, A. (2006). HIV prevalence and pre-dictors among rescued sex-trafficked women and girls in Mumbai, India. Journal of Acquired Immune Deficiency Syndromes, 43, 588–593.

Silverman, J. G., Decker, M. R., Gupta, J., Maheshwari, A., Willis, B. M., & Raj, A. (2007). HIV prevalence and predictors of infection in sex-trafficked Nepalese girls and women. Journal of the American Medical Association, 298, 536–542.

Slayton, S. C., D’Archer, J., & Kaplan, F. (2010). Outcome studies on the efficacy of art therapy: A review of find-ings. Art Therapy: Journal of the American Art Therapy Association, 27(3), 108–119.

Smith, L., Vardaman, S., & Snow, M. (2009). The national report on domestic minor sex trafficking: America’s prostitu-ted children. Retrieved from https://sharedhope.org/wp-content/uploads/2012/09/SHI_National_Report_on_DMST_2009.pdf

Tsutsumi, A., Izutsu, T., Poudyal, A. K., Kato, S., & Marui, E. (2008). Mental health of female survivors of human trafficking in Nepal. Social Science & Medicine, 66, 1841–1847.

Twill, S. E., Green, D. M., & Traylor, A. (2010). A descriptive study on sexually exploited children in residential treatment. Child & Youth Care Forum, 39, 187–199. doi:10.1007/s10566-010-9098-2

U.S. Department of Education. (2013). Human trafficking of children in the United States: A fact sheet for schools. Re-trieved from https://www2.ed.gov/about/offices/list/oese/oshs/tipfactsheet91913.pdf

U.S. Department of Health and Human Services. (2012). Fact sheet: Human trafficking. Retrieved from http://www.acf.hhs.gov/endtrafficking/resource/fact-sheet-human-trafficking

U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. (n.d.). Human trafficking into and within the United States: A review of the literature. Retrieved from http://aspe.hhs.gov/hsp/07/humantrafficking/litrev/index.pdf

U.S. Department of State. (2000). Victims of trafficking and violence protection act of 2000. Retrieved from http://www.state.gov/j/tip/laws/61124.htm

U.S. Department of State. (2009). Trafficking in persons report 2010. Washington, DC: Author. Retrieved from http://www.state.gov/g/tip/rls/tiprpt/2010.

Wagner, A. W., Rizvi, S. L., & Harned, M. S. (2007). Applications of dialectical behavior therapy to the treatment of complex trauma-related problems: When one case formulation does not fit all. Journal of Traumatic Stress, 20, 391–400.

Walsh, S. M., & Donaldson, R. E. (2010). Invited commentary: National safe place: Meeting the immediate needs of runaway and homeless youth. Journal of Youth and Adolescence, 39, 437–445.
doi:10.1007/s10964-010-9522-9

Whitaker, M. P., & Hinterlong, J. (2008). Contexts of control: Modern slavery in the United States. Social Develop-ment Issues, 30(3), 27–41.

Widom, C. S., & Kuhns, J. B. (1996). Childhood victimization and subsequent risk for promiscuity, prostitution, and teenage pregnancy: A prospective study. American Journal of Public Health, 86, 1607–1612.

Williams, L. M., & Frederick, M. E. (2009). Pathways into and out of commercial sexual victimization of children: Understanding and responding to sexually exploited teens. Lowell, MA: University of Massachusetts Lowell. Retrieved from http://faculty.uml.edu/lwilliams/Williams%20Pathways%20Final%20Report%202006-MU-FX-0060%2010-31-09L.pdf

Williamson, C., Karandikar-Chheda, S., Barrows, J., Smouse, T., Kelly, G., Swartz, G., . . . Tame, C. (2010). Ohio trafficking in persons study commission research and analysis sub-committee report on the prevalence of human trafficking in Ohio. Retrieved from http://docplayer.net/12555115-Ohio-trafficking-in-persons-study-commission-research-and-analysis-sub-committee-report-on-the-prevalence-of-human-trafficking-in-ohio.html

Williamson, C., & Prior, M. (2009). Domestic minor sex trafficking: A network of underground players in the Midwest. Journal of Child & Adolescent Trauma, 2, 46–61.

Wilson, J. M., & Dalton, E. (2007). Human trafficking in Ohio: Markets, responses, and considerations. Retrieved from http://www.rand.org/pubs/monographs/2007/RAND_MG689.pdf

Zimmerman, C. (2003). The health risks and consequences of trafficking in women and adolescents: Findings from a European study. London, England: London School of Hygiene & Tropical Medicine. Retrieved from http://www.lshtm.ac.uk/php/ghd/docs/traffickingfinal.pdf

Zimmerman, C., Hossain, M., Yun, K., Gajdadziev, V., Guzun, N., Tchomarova, M., . . . Watts, C. (2008). The
health of trafficked women: A survey of women entering posttrafficking services in Europe. American Journal of Public Health, 98, 55–59.

Stacey Diane A. Litam is a doctoral candidate at Kent State University and a mental health counselor at Moore Counseling and Mediation Services Inc. Correspondence can be addressed to Stacey Litam, Moore Counseling and Mediation Services, 4600 Carnegie Avenue, Cleveland, Ohio 44103, slitam@kent.edu.