A Comprehensive Perspective on Treating Victims of Human Trafficking
Kathryn Marburger, Sheri Pickover
Providing treatment to survivors of human trafficking requires mental health professionals to understand complex layers of multiple traumas. These layers include an understanding of how trafficking occurs; what gender, ages, sexual orientations, life circumstances, and ethnicities are most at risk to be trafficked; the lasting impact of trafficking on human development, mental health, and family relationships; and the stigma victims face from their own families, communities, and mental health providers. These survivors suffer from physical ailments and post-traumatic stress disorder, and they are at high risk for developing comorbid disorders such as depression and addiction disorders. Integrated treatment options to alleviate these concerns, including cognitive behavioral therapy, trauma-focused therapy, ecologically focused therapy, and family therapy, are presented.
Keywords: human trafficking, trauma, post-traumatic stress disorder, addiction disorder, sexual orientation
Human trafficking is often referred to as modern-day slavery and is found in every corner of the globe (Cecchet & Thoburn, 2014; Department of Homeland Security [DHS], n.d.; Gerassi, 2015; Hardy et al., 2013; Hodge, 2014; Litam, 2017; Polaris, n.d.-b; Sanchez & Stark, 2014; Zimmerman & Kiss, 2017). The United Nations defines trafficking as:
the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or
use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or
of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the
consent of a person having control over another person, for the purpose of exploitation. (Office of the
High Commissioner for Human Rights, 2000, article 3, para. 1)
The International Labour Office (2017) has estimated that 40.3 million people are victims of modern-day slavery throughout the world. This means that one person in every 1,000 is being victimized through modern-day slavery. Offering high rewards with minimal risk, human trafficking is a profitable and fast-growing criminal enterprise. Human trafficking profits surpass illegal arms trafficking and are second only to drug trafficking (Busch-Armendariz et al., 2014; Greer & Davidson Dyle, 2014; UNICEF USA, 2017). The International Labour Office (2014) has estimated that the profits from human trafficking are $150 billion a year, of which $99 billion comes from sexual exploitation.
The DHS reported that the crime of human trafficking is often hidden in plain sight in both legal and illegal industries; victims can be any gender, sexual orientation, age, and nationality, including documented or undocumented immigrants (DHS, n.d.; Rothman et al., 2017). However, statistics on human trafficking within the United States are lacking (DHS, n.d.; Gerassi, 2015; Miller-Perrin & Wurtele, 2017; Varma et al., 2015), and a uniform system of collecting data to identify victims currently does not exist, which increases the difficulty of obtaining accurate data (Gerassi, 2015; Miller-Perrin & Wurtele, 2017). Additional factors that contribute to the underreporting of human trafficking include legal and social services that are not readily accessible to victims, fear of punishment from traffickers, and fear or distrust of law enforcement. Moreover, some victims may not even recognize themselves as being the victims of human trafficking (De Chesnay, 2013; Miller-Perrin & Wurtele, 2017).
Human trafficking is a crime that inflicts complex layers of trauma on victims and survivors. The goal of this article is to provide mental health professionals with a systemic view of this crime from various perspectives so that they can implement wraparound-focused treatment plans. The perspectives adopted include how individuals become trafficked, sociocultural factors, the impact on the victims’ development and mental health, family relationships, and the stigma victims face from communities and their families. Having knowledge of these complex factors will allow mental health professionals to devise trauma-sensitive approaches to treat survivors of human trafficking. For the purpose of this paper, the term victims refers to individuals who are actively under the control of the trafficker, and the term survivors refers to individuals who are no longer being exploited.
Sexual exploitation and forced labor are two of the most common forms of human trafficking (Busch-Armendariz et al., 2014; De Chesnay, 2013; Greer & Davidson Dyle, 2014; Hodge, 2014; Martinez & Kelle, 2013; Miller-Perrin & Wurtele, 2017; U.S. Department of State, 2017). Human Rights First (2017) reported that 19% of human trafficking victims are trafficked for sex, and yet sex trafficking accounts for 66% of trafficking profits worldwide. Sex trafficking includes a wide variety of traditionally accepted forms of labor, including commercial sex, exotic dancing, and pornography. It is a form of oppression placing men, women, and children throughout the world at risk of sexual exploitation (Litam, 2017; Polaris, n.d.-a; Zimmerman & Kiss, 2017).
Traffickers treat victims’ bodies as resources to be used and repeatedly sold for money or goods such as pornography, cigarettes, drugs, clothing, and shelter (Busch-Armendariz et al., 2014; Greer & Davidson Dyle, 2014; Litam, 2017; Miller-Perrin & Wurtele, 2017; Sanchez & Stark, 2014). International trafficking often receives more attention; however, most trafficking occurs domestically within the same country (Martinez & Kelle, 2013; Zimmerman & Kiss, 2017). Furthermore, trafficking does not have to include crossing a state line, nor does it necessarily involve moving locations (Busch-Armendariz et al., 2014). Domestic minor sex trafficking is flourishing in every region, state, and community in the United States (Countryman-Roswurm & Bolin, 2014), with Midwestern cities showing increased rates of recruitment; such cities have access to several highways to transport victims to destination cities, including Detroit, Chicago, and Las Vegas, where demand for sexual exploitation is highest (Litam, 2017).
Sex trafficking has been linked not only to escort and massage services, strip clubs, and pornography, but also to major sporting events, entertainment venues, truck stops, business meetings, and conventions (Busch-Armendariz et al., 2014; Hardy et al., 2013; Litam, 2017). As long as demand exists, the opportunity for traffickers to sell victims is limitless. The internet increases the convenience and reduces the risk for traffickers and consumers. For instance, although Backpage.com was shut down by the U.S. government in 2017 for participating in and profiting from sex trafficking advertisements, and other websites like Craigslist began to censor and remove sex advertisements (Anthony et al., 2017; Leary, 2018; Peterson et al., 2019), numerous websites are used by traffickers not only to lure victims but also to advertise and sell to consumers. These websites include Eros.com, Bedpage.com, and social media platforms such as Instagram, Facebook, Twitter, Tinder, and Grindr (Jordan et al., 2013; Litam, 2017; Moore et al., 2017; O’Brien, 2018). The physical and psychological abuse victims experience from both traffickers and consumers leaves victims traumatized (Graham et al., 2019; Greer & Davidson Dyle, 2014; Litam, 2017; Moore et al., 2017; Zimmerman & Kiss, 2017).
The Victims of Trafficking
One out of every four victims of human trafficking is a child (International Labour Office, 2017), and these children are often found in the child welfare and juvenile justice systems, and runaway and homeless youth shelters (Moore et al., 2017; U.S. Department of State, 2017). In 2016, it was estimated that one out of six runaways was a victim of sex trafficking and 86% had been in foster care or social services when they ran away (Polaris, n.d.-a). Runaway youth are usually approached by traffickers within 48 hours of living on the street (Jordan et al., 2013). Traffickers recruit runaway or homeless children into trafficking rings, exposing them to extreme forms of abuse that result in many being killed from the violence inflicted or from diseases acquired through sexual abuse (Litam, 2017).
Sex trafficking is prevalent throughout the world, affecting men, women, children, families, and communities. Individuals also are trafficked for various other purposes, including domestic service, agricultural work, commercial fishing, the textile industry, construction, mining, factory work, and petty crime (U.S. Department of State, 2017; Zimmerman & Kiss, 2017). Although men have been confirmed to be victims in all areas of trafficking, they are disproportionately subjected to forced labor, whereas women and children account for the majority of sexually exploited victims (International Labour Office, 2017). Although trafficking occurs in all parts of the world and can affect anyone, several factors increase the risk of trafficking, including gang activity, a history of childhood abuse, and poverty. Substance abuse also plays a key role (De Chesnay, 2013; Moore et al., 2017; O’Brien, 2018).
Substance abuse within families is a risk factor for children becoming the victims of trafficking (Hardy et al., 2013; Miller-Perrin & Wurtele, 2017). Parents or other family members with an addiction can force youth into sexual exploitation, selling or trading them to support their drug addiction (De Chesnay, 2013; Litam, 2017). Traffickers often force substance use on victims in order to control and sexually exploit them (De Chesnay, 2013; Gerassi, 2015; Hodge, 2014; Hom & Woods, 2013; Litam, 2017; Moore et al., 2017). Substance abuse also may be a way for trafficking victims to cope with the abuse they endure (Miller-Perrin & Wurtele, 2017).
Trafficking victims who engage in substance abuse usually experience detrimental personal outcomes, including an increased likelihood of engaging in high-risk behaviors (i.e., unprotected sex), infection from needles, and overdosing (Gerassi, 2015; Zimmerman et al., 2011). They often commit drug-related crimes for their trafficker and are therefore at risk of arrest and conviction for prostitution and drug offenses (Litam, 2017; Miller-Perrin & Wurtele, 2017; Zimmerman et al., 2011). Arrests, drug charges, substance abuse, and violent clients can trap trafficking victims in a vicious circle of re-traumatization by their traffickers, their potentially abusive consumers, and the criminal justice system (Gerassi, 2015; Zimmerman et al., 2011).
Impact on Physical and Mental Health
A concern for children who fall prey to sex trafficking is the impact these experiences have on their development. Not only are victims affected by educational deprivation, but trafficking also causes serious harm to their psychological, spiritual, and emotional development (Miller-Perrin & Wurtele, 2017; Rafferty, 2008; Sanchez & Stark, 2014). Child victims suffer from an increased risk of several emotional problems such as guilt, shame, anxiety, hopelessness, and loss of self-esteem (Miller-Perrin & Wurtele, 2017; Rafferty, 2008). Some of the mental health consequences for child victims include depression, dissociation, post-traumatic stress disorder (PTSD), eating disorders, somatization, poor attachment, antisocial behaviors, substance use disorders, self-harm, and suicidality (Kiss et al., 2015; Miller-Perrin & Wurtele, 2017; Rafferty, 2008). Furthermore, because of the exposure to the violence and sexual assault linked to trafficking, child victims have been found to be at higher risk of sexually transmitted infections, reproductive health problems from unsafe abortions, fractures, genital lacerations, malnutrition, and dental problems (Miller-Perrin & Wurtele, 2017).
Trafficking poses significant risk to child victims’ long-term mental health. Survivors trafficked in childhood report a high prevalence of mental health problems such as depression, anxiety, and PTSD. These mental health problems also affect adult victims (Hom & Woods, 2013; Oram et al., 2016). Among women who have survived trafficking, there are increased rates of anxiety and stress disorders, disassociation, depression, personality disorders, low self-esteem, suicidal ideation, and poor interpersonal relationships (Sanchez & Stark, 2014). Additionally, somatic symptoms such as headaches, fainting, and memory problems are commonly reported among women who are victims of trafficking (Oram et al., 2016). A high prevalence of sexually transmitted infections has been reported in both men and women (Hom & Woods, 2013; Oram et al., 2016; Sanchez & Stark, 2014). Borschmann et al. (2017) found high rates of self-harm among adult victims of human trafficking.
Pregnancy is a common occurrence for trafficked women (Bick et al., 2017; Gerassi, 2015; Hom & Woods, 2013; Oram et al., 2016; Sanchez & Stark, 2014). Several barriers to maternity services have been identified for pregnant victims, including traffickers preventing women from seeking care and the victims feeling reluctant because they might not have valid documents (Bick et al., 2017). Additionally, children and family members are often used by traffickers to threaten and coerce victims, which further isolates victims and distances them from their families (Hardy et al., 2013; Hodge, 2014; Juabsamai & Taylor, 2018; Sanchez & Stark, 2014).
Sex trafficking often involves the exploitation of victims by force, and the brutal nature of the crime can cause complex mental health problems for victims (Gerassi, 2015; Greer & Davidson Dyle, 2014; Hodge, 2014; Hom & Woods, 2013; Litam, 2017). Victims endure high levels of trauma, and survivors show increased rates of depression, anxiety, PTSD, and substance use disorders (Gerassi, 2015). The goal of traffickers is to physically and psychologically break victims down into subservience (Hodge, 2014). Not only are victims forced to engage in humiliating sexual acts and use substances, but traffickers also use recurrent beatings, rape, and even murder as tactics to control their victims (De Chesnay, 2013; Gerassi, 2015; Hodge, 2014; Hom & Woods, 2013; Litam, 2017). Victims may believe that the traffickers have their best interests in mind and develop significant bonds with their traffickers, similar to Stockholm syndrome, and may be reluctant to escape (De Chesnay, 2013; Hodge, 2014; Hom & Woods, 2013; Litam, 2017). In addition, victims of sexual exploitation have not only endured physical and emotional abuse from their traffickers, but there also is a strong correlation with childhood abuse (Gerassi, 2015; Miller-Perrin & Wurtele, 2017). However, issues of physical and mental health tend to be exacerbated by issues of economic deprivation and racial inequality. These factors may act as a catalyst for putting individuals more at risk of human trafficking (Greer, 2013).
Sex traffickers often target vulnerable individuals, including runaway and homeless youth; victims of domestic abuse or sexual assault; victims of war; and individuals who experience social discrimination, including gender, racial, ethnic, and socioeconomic inequality (Anthony et al., 2017; Miller-Perrin & Wurtele, 2017). For example, LGBTQ homeless youth account for 20% of the homeless youth population in the United States, yet 58.7% of homeless LGBTQ youth are victims of sex trafficking (Martinez & Kelle, 2013). Martinez and Kelle (2013) further noted that this figure is significantly higher than the 33.4% of the heterosexual homeless youth. Furthermore, LGBTQ youth are more than seven times more likely to experience acts of violence than their cisgender peers (Anthony et al., 2017). Trafficking often affects victims of poverty. Studies of sexual exploitation and domestic sex trafficking also have reported higher rates of violence against women of color, especially African American women, and undocumented immigrants (Gerassi, 2015; Zimmerman & Kiss, 2017).
Finally, individuals with intellectual disabilities are at risk because of an unfamiliarity with sexual activities and an inability to understand the nature of sexual abuse and exploitation (Reid, 2018). As a result, such individuals are at a higher risk of becoming victims of trafficking (Greer & Davidson Dyle, 2014; Hodge, 2014; Miller-Perrin & Wurtele, 2017; Reid, 2018).
Women who have been victims of trafficking have often been found to come from abusive households (Gerassi, 2015; Hom & Woods, 2013; O’Brien, 2018; Oram et al., 2016). As a result, once victims are free from their traffickers, they have often been found to not only lack social support but also lack basic needs such as shelter and financial support (Hom & Woods, 2013; Le, 2017; Oram et al., 2016). Reconciliation with supportive family often plays a key role for trafficking survivors; however, because of stigma, some victims are met with shame and judgment from their families and are not welcomed (Hom & Woods, 2013; Juabsamai & Taylor, 2018; McCarthy, 2018; Zimmerman & Kiss, 2017).
Unfortunately, it is not uncommon for victims to be exploited by someone they know and love. Oftentimes a trafficker is a family member, intimate partner, friend, or acquaintance (Gerassi, 2015; Hardy et al., 2013; Hom & Woods, 2013; Le, 2017; Miller-Perrin & Wurtele, 2017; Moore et al., 2017), which further complicates survivors’ ability to establish trusting relationships. Moreover, law enforcement may charge adult victims with prostitution. Not only is the victim caught in legal limbo, but they are re-victimized by law enforcement (Sanchez & Stark, 2014). Finally, female survivors who socialize with men after being freed from their traffickers have reported being triggered with memories of their abusive experiences, further affecting their ability to develop healthy, stable relationships and social support (Hom & Woods, 2013).
Victims of human trafficking have often been robbed of their identities, had their self-esteem demolished, and already experienced physical and psychological abuse before they became victims of human traffickers. Once they leave their traffickers, survivors have a variety of immediate, short-, and long-term needs that must be addressed to help promote resiliency while they are reintegrating into the community (Busch-Armendariz et al., 2014; Graham et al., 2019; Hom & Woods, 2013; Le, 2017; McCarthy, 2018; O’Brien, 2018; Twigg, 2017). Immediate needs include ensuring safety; finding medical care, food, shelter, clothing, and counseling; and acquiring identiﬁcation, language interpretation services, and legal and immigration assistance (Busch-Armendariz et al., 2014; Graham et al., 2019; Hom & Woods, 2013; McCarthy, 2018; Polaris, n.d.-a; Twigg, 2017). Education, employment, and establishing friendships have been identified as vital ongoing needs to successfully alleviate stress while reintegrating into the community (Hom & Woods, 2013; McCarthy, 2018; O’Brien, 2018; Polaris, n.d.-a; Twigg, 2017). However, it is important to note that survivors are often met with substantial challenges while seeking basic services. For instance, many programs may be underfunded or ill-equipped to handle the high demand for services (Polaris, n.d.-a). This reaffirms the crucial need to meet survivors with empathetic and nonjudgmental attitudes to help prevent re-victimization and a return to traffickers (Anthony et al., 2018; Hodge, 2014; Hom & Woods, 2013; McCarthy, 2018).
Family support can provide survivors with significant protection while reintegrating into the community. Reconnecting with family typically increases the likelihood of a sustainable return process (McCarthy, 2018; Twigg, 2017). However, reconciliation might require a careful approach, as the process can be met with difficulties, including stigma, dysfunctional family environments, or the family’s direct involvement with the victim’s trafficking (Le, 2017; McCarthy, 2018; Twigg, 2017; Zimmerman & Kiss, 2017). In some cases, shame within a cultural context is a prohibitive factor for many to return to their families because of the association with prostitution or having been trafficked (Hom & Woods, 2013). As a result, it is necessary to provide comprehensive, culturally sensitive interventions for trafficking survivors (Hodge, 2014; Hom & Woods, 2013; Le, 2017; McCarthy, 2018). Family continues to be essential to survivors’ sense of identity, and, upon return, cultural beliefs and values that previously formed their self-concept remain influential to survivors (Le, 2017). Many women have noted that marriage and children play an integral role in successfully reintegrating into their community and gaining acceptance from family members (McCarthy, 2018). However, issues of economic deprivation and racial inequality act as a barrier to successful community reintegration and put an individual at higher risk for trafficking (Greer, 2013).
This brief literature review has confirmed that victims of human trafficking suffer from a wide array of mental health concerns, including PTSD, depression, anxiety, and substance abuse, and from stigma associated with being victims of human trafficking. Mental health treatment should address these complex concerns and provide for comprehensive assessment and treatment planning.
Working with trafficked clients poses a series of challenges for counselors because an intervention modality specific to sex-trafficked survivors has yet to be developed (Hopper et al., 2018; Jordan et al., 2013). Treatments are borrowed from evidence-based interventions initially developed for PTSD, domestic violence, and captivity, and a holistic approach is essential (De Chesnay, 2013; Hom & Woods, 2013; Jordan et al., 2013). Four essential practices for providers include ensuring safety and conﬁdentiality, engagement of trauma-informed care, performing a comprehensive needs assessment, and delivery of comprehensive case management that coordinates physical and mental health and legal services. As a result of the multiple traumas trafficking victims endure, the path to restoring wellness is often long and complex, requiring additional time and patience from mental health counselors (Hodge, 2014; Hom & Woods, 2013).
Mental health counselors should conduct a needs assessment to identify the physical, emotional, and spiritual needs of trafficking survivors (Hodge, 2014; Hom & Woods, 2013). Survivors are often in need of medical treatment, as traffickers do not bother with preventative care or what they may consider minor treatment and only allow victims to seek treatment when a condition interferes with earning money (De Chesnay, 2013). Similarly, survivors are often resistant to seek help from mental health providers because of fear of physical violence or threats of retaliation from their traffickers if they disclose their circumstances (De Chesnay, 2013; Hodge, 2014; Litam, 2017). Survivor-centered approaches are recommended initially to acknowledge and validate the survivor’s experience, give the survivor control, and build a sense of safety and trust (Hodge, 2014; Hom & Woods, 2013; Twigg, 2017).
However, after months or years of abuse, trafficking survivors often need a wide array of services to meet their distinctive needs (Hodge, 2014; Hom & Woods, 2013; McCarthy, 2018; Polaris, n.d.-a). The U.S. government has enacted several policies to help victims of trafficking, including the Victims of Trafficking and Violence Protection Act of 2000, which allows victims who have been trafficked from abroad to be issued visas, enabling them to reside in the United States (Davy, 2016; Hodge, 2014). Survivors need to be met with nonjudgmental attitudes, acceptance, understanding, and genuine concern, and they should be slowly encouraged to take on risks associated with leaving their traffickers (Hodge, 2014; Hom & Woods, 2013; McCarthy, 2018). Providing survivors with emotional support and encouragement opposes the isolated world created by their trafficker. Survivors have explained that street outreach programs can play an essential role in establishing contact, allowing victims to become aware of the resources available and begin breaking down the sense of isolation (Hom & Woods, 2013). Additionally, it is vital to empower survivors so that they can understand they are in control (Anthony et al., 2018; Hodge, 2014; Hom & Woods, 2013; Twigg, 2017). Research on resiliency has found creativity, humor, flexibility, and movement are important factors in improving self-esteem, prosocial behaviors, and hope among traumatized individuals (Litam, 2017).
Counselors working with trafficking survivors should be equipped to use several trauma-sensitive interventions to assist with the individual needs of each survivor (Busch-Armendariz et al., 2014; De Chesnay, 2013; Hardy et al., 2013; Hodge, 2014; Hom & Woods, 2013; Litam, 2017; Miller-Perrin & Wurtele, 2017; Twigg, 2017). Trauma-sensitive interventions recognize safety as the foundation for working with individuals to end self-harm, develop trusting relationships, overcome obstacles, leave dangerous situations, and promote wellness (Hopper et al., 2018). Although it may be painful for trafficking survivors to verbalize their traumatic experiences, creative therapies offer alternative methods of communication and expression (De Chesnay, 2013; Litam, 2017).
Although evidence-based practices for treating sex-trafﬁcking survivors are not widespread, counseling techniques exist that have been shown to be effective with child sex abuse victims, including trauma-focused cognitive behavioral therapy and dialectical trauma-focused cognitive behavior therapy (De Chesnay, 2013; Twigg, 2017). Similarly, participating in group counseling can empower survivors of sex trafficking and provide them with an opportunity to share their experiences, generating a sense of community and support (Hopper et al., 2018). Peer support has been noted to be a vital component of intervention, both as a motivating factor to remain in treatment and as help in the prevention of survivors returning to their traffickers (De Chesnay, 2013; Litam, 2017; Twigg, 2017). Furthermore, discussing stigmatized topics within group settings can help reduce shame, as it is common for trafficked survivors to feel that no one else has gone through similar situations (Hickle & Roe-Sepowitz, 2014; Litam, 2017). Having a setting to address the shame can help survivors recognize the commonality of their experiences and build support (Countryman-Roswurm & Bolin, 2014; Litam, 2017).
As human trafficking affects individuals, families, and communities, it is necessary to adopt treatment models that engage families and communities as well as individual-based treatment models. Twigg (2017) found that survivors require and benefit from therapeutic support in order to achieve successful family and community reunification. However, like individual treatment, family therapy models specific to human trafficking survivors do not exist, but current family therapy models developed around trauma could be adapted for use with human trafficking survivors. Apsche et al. (2008) developed Family Mode Deactivation Therapy, a cognitive behavior family therapy model for use with youth and families in residential treatment that uses ongoing assessment and community skill development to reduce the behavioral symptoms associated with trauma. The researchers found this model reduced recidivism more effectively than a non–family-based approach. Hughes (2017) developed an attachment-focused family treatment for children who have experienced developmental trauma. This two-phase treatment provides therapy to a caregiver first, then transitions to joint sessions to reframe the trauma experience.
Similarly, using ecologically based family therapy with individuals involved in sex trafficking has been found to improve outcomes for sobriety and depression (Murnan et al., 2018). Agani et al. (2010) recommended the use of the linking human systems community resilience model, which is based on transgenerational and ecosystemic structural family therapies. This model focuses on identifying the strengths of community and family members, bringing them together to encourage their competency and using community leaders to solve problems. Other novel approaches to working with survivors of crime include the Family Group Project, which involves group therapy aimed at recreating a family environment to re-integrate survivors into the community (Allen et al., 2015).
A Survivor’s Story
Research provides one perspective on the plight of human trafficking victims and survivors, but a first-person account provides insight to the worldview of an actual survivor. One of the authors met with a human trafficking advocate in order to gain further perspective on the needs of survivors. The advocate, who requested that the author provide no identifying information beyond her gender, disclosed during the interview that she was a survivor who had been trafficked by her husband. Her trafficker had been blackmailing a John, a term commonly used for an exploitive consumer. She was arrested during a raid and remained in jail for 3 months because she refused to say anything. She explained that it took her a year to build up the strength and courage to testify in court because her trafficker blackmailed her. He threatened to tell her family about the exploitative acts and substance use, which he forced her to engage in. He would say, “Do you really want your family to know what you have been up to?” However, once her family was notified of her predicament, she reported that her family members provided emotional support. She explained that it was through their support she was able to come forward and testify.
Although she came forward and testified against her trafficker, she was not viewed as a victim, and she was charged with prostitution. As she explained, advocates are trying to change the legislation and work with police in her local area so that human trafficking victims are not charged with crimes. For instance, not only was she charged with prostitution, but she also had to pay the John $3,000, the money her trafficker had stolen from him. Despite never having seen the money, she was ordered to repay it and was placed on a repayment schedule. Even more disheartening, her trafficker made a plea deal and did not have to repay any money and the charges of trafficking were dropped. All these events provide an example of how the legal system can re-victimize a survivor. Although she had been the victim of trafficking, which stigmatized her, she also was told that she owed money to someone her trafficker had stolen from, thus re-victimizing her.
The charge of prostitution remained on her record and became something she had to explain to potential employers. With the support of her family and by attending therapy, she was able to rebuild her life. She had a bachelor’s degree in social work when she met her ex-husband and was able to obtain her limited license. She decided to pursue a master’s degree and was once again faced with the challenge of disclosing the charge on her record and reliving the trauma of explaining what happened. The first university she applied to denied her application, and this placed her in a deep depression; however, she was accepted at another university and after graduating became an advocate for survivors of human trafficking. She also shared that although it took time to be able to trust someone again, she has established an intimate relationship and will soon be married.
Counselors treating a human trafficking survivor need to develop a wide-ranging view of assessment, treatment, case management, support, advocacy, and termination from counseling. Human trafficking survivors suffer from a complex variety of developmental, mental health, and social issues that require counselors to not only engage the individual in treatment, but also to act as an advocate against stigma within their family and the community.
The myriad of issues faced by these individuals, from navigating the criminal justice system, coping with multiple layers of physical and emotional trauma, overcoming substance abuse, overcoming family and community alienation, coping with dual stigmas of human trafficking and mental health diagnoses, to finally reintegrating into daily work and life, require counselors to be vigilant in the assessment process. Counselors need to consider assessment an ongoing extensive process that should occur throughout every session and focus not just on mental health needs, but also on physical health and basic needs, and career support. Counselors will need to assess risk of the individual returning to the trafficker and have referrals ready to help the client stay safe. Human trafficking survivors will need a counselor able to quickly identify short-term crisis needs during long-term treatment.
When entering the treatment phase, counselors need to research multiple treatment modalities that may not directly relate to human trafficking but may support the client. For example, a counselor will need to navigate working with substance use, trauma, family issues, and career concerns. Counselors will need to widen their view of their role within the therapeutic relationship. Human trafficking survivors may require case management services more than long-term counseling when first entering care, yet the need to build a strong therapeutic relationship is paramount for ongoing treatment. The counselor should consider taking on the case management role as needed to promote consistency in the treatment process. As an advocate, the counselor will need to engage multiple individuals and systems into the treatment process to ensure comprehensive care. Counseling skills aimed at engaging families, law enforcement personnel, legal personnel, and medical professionals in treatment are essential for treating survivors. Counselors would also benefit from strength-based approaches with this population, as research indicates survivors most benefit from being able to identify their own qualities of self-protection and resiliency, which empowers their recovery process. This empowerment also allows for a supportive termination process, ensuring that the survivor has ongoing access to a support network in order to facilitate long-term recovery.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
Agani, F., Landau, J., & Agani, N. (2010). Community-building before, during, and after times of trauma: The application of the LINC model of community resilience in Kosovo. American Journal of Orthopsychiatry, 80, 143–149. https://doi.org/10.1111/j.1939-0025.2010.01017.x
Allen, D. F., Carroll, M. A., Allen, V. S., Bethell, K. Y., & Manganello, J. A. (2015). Community resocialization via instillation of family values through a novel group therapy approach: A pilot study. Journal of Psychotherapy Integration, 25(4), 289–298. https://doi.org/10.1037/a0039563
Anthony, B., Amatullah, A. H., Anderson, J., Arias, E. F. P., N.M.B., Crisp, J. D., Crosson, L., D’Souza, H., Fasthorse, H., Hollis, J., John, D., Johnson, D., Johnson, N., Liles, T., Lipenga, F., Lundstrom, M., Marty, R., McCarty, T., Moninda, Morrissey, A., . . . Woworuntu, S. (2018). On-Ramps, intersections, and exit routes: A roadmap for systems and industries to prevent and disrupt human trafficking. https://polarisproject.org/wp-content/uploads/2018/08/A-Roadmap-for-Systems-and-Industries-to-Prevent-and-Disrupt-Human-Trafficking.pdf
Anthony, B., Penrose, J. K., Jakiel, S., Couture, T., Crowe, S., Fowler, M., Keyhan, R., Sorensen, K., Myles, B., & Badavi, M. A. (2017, March). The typology of modern slavery: Defining sex and labor trafficking in the United States. https://polarisproject.org/wp-content/uploads/2019/09/Polaris-Typology-of-Modern-Slavery-1.pdf
Apsche, J. A., Bass, C. K., & Houston, M.-A. (2008). Family mode deactivation therapy as a manualized cognitive behavioral therapy treatment. International Journal of Behavioral Consultation and Therapy, 4(2), 264–277. https://doi.org/10.1037/h0100848
Bick, D., Howard, L. M., Oram, S., & Zimmerman, C. (2017). Maternity care for trafficked women: Survivor experiences and clinicians’ perspectives in the United Kingdom’s National Health Service. PLOS ONE, 12(11), e0187856. https://doi.org/10.1371/journal.pone.0187856
Borschmann, R., Oram, S., Kinner, S. A., Dutta, R., Zimmerman, C., & Howard, L. M. (2017). Self-harm among adult victims of human trafficking who accessed secondary mental health services in England. Psychiatric Services, 68(2), 207–210. https://doi.org/10.1176/appi.ps.201500509
Busch-Armendariz, N., Nsonwu, M. B., & Heffron, L. C. (2014). A kaleidoscope: The role of the social work practitioner and the strength of social work theories and practice in meeting the complex needs of people trafficked and the professionals that work with them. International Social Work, 57, 7–18. https://doi.org/10.1177/0020872813505630
Cecchet, S. J., & Thoburn, J. (2014). The psychological experience of child and adolescent sex trafficking in the United States: Trauma and resilience in survivors. Psychological Trauma: Theory, Research, Practice, and Policy, 6, 482–493. https://doi.org/10.1037/a0035763
Countryman-Roswurm, K., & Bolin, B. L. (2014). Domestic minor sex trafficking: Assessing and reducing risk. Child and Adolescent Social Work Journal, 31, 521–538. https://doi.org/10.1007/s10560-014-0336-6
Davy, D. (2016). Anti–human trafficking interventions: How do we know if they are working? American Journal of Evaluation, 37, 486–504. https://doi.org/10.1177/1098214016630615
De Chesnay, M. (2013). Psychiatric-mental health nurses and the sex trafficking pandemic. Issues in Mental Health Nursing, 34, 901–907. https://doi.org/10.3109/01612840.2013.857200
Department of Homeland Security. (n.d.). Blue campaign: What is human trafficking? https://www.dhs.gov/blue-campaign/what-human-trafficking
Gerassi, L. (2015). From exploitation to industry: Definitions, risks, and consequences of domestic sexual exploitation and sex work among women and girls. Journal of Human Behavior in the Social Environment, 25, 591–605. https://doi.org/10.1080/10911359.2014.991055
Graham, L. M., Macy, R. J., Eckhardt, A., Rizo, C. F., & Jordan, B. L. (2019). Measures for evaluating sex trafficking aftercare and support services: A systematic review and resource compilation. Aggression and Violent Behavior, 47, 117–136. https://doi.org/10.1016/j.avb.2019.04.001
Greer, B. T. (2013). Hiding behind tribal sovereignty: Rooting out human trafficking in Indian country. The Journal of Gender, Race & Justice, 16, 453–482.
Greer, B. T., & Davidson Dyle, S. (2014). Balancing the equity of mental health injuries: Examining the “trauma exception” for sex trafficking T-VISA applicants. International Journal of Migration, Health and Social Care, 10(3), 159–191. https://doi.org/10.1108/IJMHSC-11-2013-0042
Hardy, V. L., Compton, K. D., & McPhatter, V. S. (2013). Domestic minor sex trafficking: Practice implications for mental health professionals. Affilia, 28, 8–18. https://doi.org/10.1177/0886109912475172
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(2), 99–113.
Hodge, D. R. (2014). Assisting victims of human trafficking: Strategies to facilitate identification, exit from trafficking, and the restoration of wellness. Social Work, 59(2), 111–118. https://doi.org/10.1093/sw/swu002
Hom, K. A., & Woods, S. J. (2013). Trauma and its aftermath for commercially sexually exploited women as told by front-line service providers. Issues in Mental Health Nursing, 34(2), 75–81.
Hopper, E. K., Azar, N., Bhattacharyya, S., Malebranche, D. A., & Brennan, K. E. (2018). STARS experiential group intervention: A complex trauma treatment approach for survivors of human trafficking. Journal of Evidence-Informed Social Work, 15(2), 215–241. https://doi.org/10.1080/23761407.2018.1455616
Hughes, D. (2017). Dyadic developmental psychotherapy (DDP): An attachment-focused family treatment for developmental trauma. Australian and New Zealand Journal of Family Therapy, 38, 595–605. https://doi.org/10.1002/anzf.1273
Human Rights First. (2017). Human trafficking by the numbers. http://www.humanrightsfirst.org/sites/default/files/TraffickingbytheNumbers.pdf
International Labour Office. (2014). Profits and poverty: The economics of forced labour. http://www.ilo.org/wcmsp5/groups/public/—ed_norm/—declaration/documents/publication/wcms_243391.pdf
International Labour Office. (2017). Global estimates of modern slavery: Forced labour and forced marriage. http:/www.ilo.org/wcmsp5/groups/public/@dgreports/@dcomm/documents/publication/wcms_575479.pdf
Jordan, J., Patel, B., & Rapp, L. (2013). Domestic minor sex trafficking: A social work perspective on misidentification, victims, buyers, traffickers, treatment, and reform of current practice. Journal of Human Behavior in the Social Environment, 23, 356–369. https://doi.org/10.1080/10911359.2013.764198
Juabsamai, K. J., & Taylor, I. (2018). Family separation, reunification, and intergenerational trauma in the aftermath of human trafficking in the United States. Anti-Trafficking Review, 10, 123–138. https://doi.org/10.14197/atr.201218108
Kiss, L., Yun, K., Pocock, N., & Zimmerman, C. (2015). Exploitation, violence, and suicide risk among child and adolescent survivors of human trafficking in the Greater Mekong Subregion. JAMA Pediatrics, 169(9), e152278–e152278. https://doi.org/10.1001/jamapediatrics.2015.2278
Le, P. D. (2017). “Reconstructing a sense of self”: Trauma and coping among returned women survivors of human trafficking in Vietnam. Qualitative Health Research, 27, 509–519.
Leary, M. G. (2018). The indecency and injustice of section 230 of the Communications Decency Act. https://scholarship.law.edu/cgi/viewcontent.cgi?article=1990&context=scholar
Litam, S. D. A. (2017). Human sex trafficking in America: What counselors need to know. The Professional Counselor, 7, 45–61. https://doi.org/10.15241/sdal.7.1.45
Martinez, O., & Kelle, G. (2013). Sex trafficking of LGBT individuals: A call for service provision, research, and action. The International Law News, 42(4), 1–6.
McCarthy, L. A. (2018). Life after trafficking in Azerbaijan: Reintegration experiences of survivors. Anti-Trafficking Review, 10, 105–122. https://doi.org/10.14197/atr.201218107
Miller-Perrin, C., & Wurtele, S. K. (2017). Sex trafficking and the commercial sexual exploitation of children. Women & Therapy, 40, 123–151. https://doi.org/10.1080/02703149.2016.1210963
Moore, J. L., Houck, C., Hirway, P., Barron, C. E., & Goldberg, A. P. (2017). Trafficking experiences and psychosocial features of domestic minor sex trafficking victims. Journal of Interpersonal Violence. https://doi.org/10.1177/0886260517703373
Murnan, A., Wu, Q., & Slesnick, N. (2018). Effects of ecologically-based family therapy with substance-using, prostituting mothers. Journal of Family Therapy, 40, 557–583. http://doi.org/10.1111/1467-6427.12187
O’Brien, J. E. (2018). “Sometimes, somebody just needs somebody—anybody—to care:” The power of interpersonal relationships in the lives of domestic minor sex trafficking survivors. Child Abuse & Neglect, 81, 1–11. https://doi.org/10.1016/j.chiabu.2018.04.010
Office of the High Commissioner for Human Rights. (2000). Protocol to prevent, suppress and punish trafficking in persons, especially women and children, supplementing the United Nations convention against transnational organized crime. https://www.ohchr.org/Documents/ProfessionalInterest/ProtocolonTrafficking.pdf
Oram, S., Abas, M., Bick, D., Boyle, A., French, R., Jakobowitz, S., Khondoker, M., Stanley, N., Trevillion, K., Howard, L., & Zimmerman, C. (2016). Human trafficking and health: A survey of male and female survivors in England. American Journal of Public Health, 106, 1073–1078. https://doi.org/10.2105/AJPH.2016.303095
Peterson, M., Robinson, B., & Shih, E. (2019). The new virtual crackdown on sex workers’ rights: Perspectives from the United States. Anti-Trafficking Review, 12, 189–193. https://doi.org/10.14197/atr.2012191212
Polaris. (n.d.-a). Myths, facts, and statistics. https://polarisproject.org/myths-facts-and-statistics
Polaris. (n.d.-b). Human trafficking. https://polarisproject.org/human-trafficking
Rafferty, Y. (2008). The impact of trafficking on children: Psychological and social policy perspectives. Child Development Perspectives, 2, 13–18.
Reid, J. A. (2018). Sex trafficking of girls with intellectual disabilities: An exploratory mixed methods study. Sexual Abuse, 30(2), 107–131. https://doi.org/10.1177/1079063216630981
Rothman, E. F., Stoklosa, H., Baldwin, S. B., Chisolm-Straker, M., Kato Price, R., & Atkinson, H. G. (2017). Public health research priorities to address U.S. human trafficking. American Journal of Public Health, 107, 1045–1047. https://doi.org/10.2105/AJPH.2017.303858
Sanchez, R., & Stark, S. W. (2014). The hard truth about human trafficking. Nursing Management, 45, 18–23. https://doi.org/10.1097/01.NUMA.0000440630.41142.66
Twigg, N. M. (2017). Comprehensive care model for sex trafficking survivors. Journal of Nursing Scholarship, 49(3), 259–266. https://doi.org/10.1111/jnu.12285
UNICEF USA. (2017, January 13). What fuels human trafficking? https://www.unicefusa.org/stories/what-fuels-human-trafficking/31692
U.S. Department of State. (2017). Trafficking in persons report. https://www.state.gov/wp-content/uploads/2019/02/271339.pdf
Varma, S., Gillespie, S., McCracken, C., & Greenbaum, V. J. (2015). Characteristics of child commercial sexual exploitation and sex trafficking victims presenting for medical care in the United States. Child Abuse & Neglect, 44, 98–105. https://doi.org/10.1016/j.chiabu.2015.04.004
Zimmerman, C., Hossain, M., & Watts, C. (2011). Human trafficking and health: A conceptual model to inform policy, intervention and research. Social Science & Medicine, 73, 327–335.
Zimmerman, C., & Kiss, L. (2017). Human trafficking and exploitation: A global health concern. PLOS Medicine, 14(11), e1002437. https://doi.org/10.1371/journal.pmed.1002437
Kathryn Marburger is a graduate student at the University of Detroit Mercy. Sheri Pickover, PhD, LPC, is an associate professor at Central Michigan University. Correspondence can be addressed to Sheri Pickover, 195 Ojibway Court, Mt. Pleasant, MI 48859, email@example.com.