The Trafficking Protocol by United Nations (2000) titled Protocol to Prevent, Suppress and Punish Trafficking in Persons, especially Women and Children, Supplementing the United Nations Convention Against Organised Crime, known to provide the first official legal definition states trafficking in persons as “the recruitment, transportation, transfer, harboring 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.”

Although actual numbers of trafficking victims are difficult to determine due to methodological flaws in data definition and collection (United States Government Accountability Office, 2006), estimates indicate that in 2009, 12.3 million individuals worldwide were in situations of forced and/or bonded labor, and forced sexual exploitation (U.S. Department of State, 2010). Each year approximately 800,000 women, men, and children are trafficked transnationally with an approximate 80% of victims being identified as women and 50 % as children (U.S. Department of State, 2006), and many more are trafficked within their home country.  Given the significantly high percentage of those trafficked estimated to be women and girls, the United Nations has called for a gender-based approach to combat trafficking crimes (United Nations, 2002).

Trafficking patterns are complex and dynamic but generally reflect disparities in the economic and other social and structural inequalities. While historically it has been largely believed that victims move from poorer regions to more prosperous areas, global trafficking patterns indicate that essentially every nation may function as a region of origin and destination (Monzini, 2004). Trafficking as both a national and international phenomenon is acknowledged by the United Nations (UN Office on Drugs and Crime 2006a).  This awareness however is not reflected in United Nations’ Trafficking Protocol, which states that it will only apply to ‘offences that are transnational in nature’ (UN General Assembly 2000a, Article). It is suggested that the politics of nationalism and those confirming the stereotypes about poor cultures and societies may play a role in the western focus on third world countries as the primary focus of trafficking. Given the nearly half of those trafficked are being reported as domestic and the increasing trend of intra-national trafficking, this lack of focus on it and an exclusive focus on transnational trafficking is misleading and warrants further investigation.

Findings from the Trafficked Persons Report 2010 suggest that persons from Africa are mostly trafficked to Western Africa and Western Europe.  The majority of trafficked persons from Asia originate from the Commonwealth of Independent States and Southeast Asia.  Within Europe, most individuals are trafficked from Central and Eastern Europe to Western Europe.  In general, trafficked individuals from the Commonwealth of Independent States are moved to Western Europe and North America. North America is reported to be an area of destination with persons primarily coming from the Commonwealth of Independent States, Asia, Latin America and the Caribbean; yet, some research also reveals that children may be trafficked from the United States to other industrialized countries for the purpose of sexual exploitation (Estes & Weiner, 2001).  Australia (Oceana) primarily is a destination for Southeast Asian trafficking victims (UNODC, 2006).

The United States is the second largest region of destination for trafficked women and children, with prevalence rates varying between 14, 500 to 50,000 trafficked victims annually (U.S. Department of the State, 2004; Mizus, Moody, Privado, & Douglas, 2003; Raymond, Hughes, & Gomez, 2001).  Each year, as many as 60% of trafficked victims into the United States are females and almost 50% are children (Mizus et al., 2003).  The United States is also home to the largest internet and child pornography market worldwide (Hodge, 2008).  Women and girls who are trafficked may be sexually exploited, forced to work in domestic services, factories, farm labor, or as mail order brides (Bales, Fletcher, & Stover, 2004).  They may be coerced into trafficking or deceived in their home country about the alleged wealth of opportunities in the United States.  They may be smuggled or enter the U.S. legally, with tourist or educational visas provided by their traffickers. Typically, women enter into an agreement of debt bondage with their traffickers to repay transportation costs (Hodge, 2008; Raymond et al., 2001).  There have also been reports of women entering the U.S. as military wives who are subsequently exploited in prostitution (Moon, 1997 as cited in Raymond et al.).  Regardless of whether trafficked women and girls are U.S. citizens, residents or foreign born, their traffickers create dependent relationships that result in extreme power differentials.

At greatest risk for domestic trafficking are immigrants, ethnic minority groups, adolescents, and runaway or homeless youth (Clawson, Dutch, Solomon, & Grace, 2009; Estes & Weiner, 2001; Logan, Walker, & Hunt, 2009; Raymond et al., 2001). Thus an emphasis on an analysis of class, race, ethnicity, immigrant rights, in addition to gender is warranted. Females from ethnic and racial minority backgrounds have increasingly been targeted by traffickers (Monzini, 2004).  Other risk factors for domestic minors for exploitation by traffickers include having lower socio-economic status, as well as living in unstable family environments and having a history of childhood abuse (Clawson et al., YEAR).  Data also indicates that homeless youth are especially vulnerable to victimization due to a lack of support systems and economic means (Martinez, 2006).

Whether intra-national or international, trafficking is an industry characterized by the dynamics of economic profit gains dependent on the market supply and demand. Within the international trafficking paradigm, nations that primarily sell “labor” are often states in transition or conflict. In contrast, many of the buyer nations are highly industrialized and characterized by higher standards of living.  It is suggested that women and girls are trafficked within and across national borders to meet local demands. The prevalence of high levels of intra-nation trafficking both within the U.S. and many western countries debunks the myth of trafficking being a phenomenon only in the developing countries. A dominant discourse on trafficking has tended to dismiss the women’s rights violations. For example, descriptions of trafficking occurring “only in countries where civil liberties and human rights are not valued” (Winterdyk & Reichel, 2010) and others that presents stereotypes of women from poor countries as weak and without agency.  Such a view often ignores the complexity of underlying factors contributing to trafficking of women and prevent an effective resolution to this serious issue of human right violations.

Economic and social inequalities are among the leading contributing factors to human trafficking. A thorough understanding and analysis of the underlying causes and contributing factors to the economic and social inequalities and resulting vulnerable circumstances of trafficked victims for being targeted is essential for those committed to the prevention of human trafficking. To begin, it is important to underscore the economic gains of human trafficking as a significant incentive fueling the sales and purchases of human bodies.  According to the US Federal Bureau of Investigation (2006), human trafficking generates about nine billion in U.S. dollars per year.  According to the US National Intelligence Council Trafficking of women is estimated to be worth four billions dollars and likely the second most profitable criminal activity after drug trafficking. Given the significance of gender, race, class discrimination and violence, and immigration status and migrant rights, feminist and international relations perspective is identified to a useful theoretical framework by Heredia (2007). However, it is often neglected in the understanding and policy making that is driven by law enforcement, national security, immigration and border control and less with the human rights of the victimized women.

A comprehensive understanding of the global and local oppressive structures and systems that facilitate labor abuses, unsafe migration, and exploitation of trafficked women before and after being trafficked reveals a complex intersectionality of gender, race, culture, globalization, socioeconomic and political conditions, transitions and conflict, often as a result of geopolitical struggles for resources and power.  Trafficking is fostered by poverty, which is heightened by the social gender inequalities, as well as the corrupt forces embedded often in government and society, both locally and globally.  It is important to note that even post-conflict zones such as Bosnia-Herzegovina that are occupied by international troops and non -profit organizations, have become trafficking destinations (Cameron & Newman, 2008). Some research suggests military presence and occupation from the industrialized countries in developing countries create conditions in which trafficked women are sought and provided.

Given structural factors of oppression, including economic, social, ideological and geopolitical forces (Newman and Cameron, 2008), women and girls are especially vulnerable to victimization in trafficking.  Given economic disadvantages experienced by many women, there is a documented “feminization of poverty” alongside with other forms of discriminations of racial, ethnic or religious nature which further alienate and place women at risk of trafficking (UN Special Rapporteur on Violence Against Women, 2001).  Frequently, women and girls face a lack of education, resources, and choices at home, and they essentially move from one environment of poverty and exploitation to similar situations in the hands of traffickers (Cameron & Newman, 2008).  In many regions, gender-bias and patriarchal family structures exacerbate the vulnerabilities of women for trafficking. Traffickers, at the same time, take advantage of the gendered perceptions of ‘female skills:’ They may target women and girls for prostitution or brides, while men and boys are more often exploited as farm laborers or trafficked for adoption (Cameron & Newman, 2008).

Although there is a dearth of research on the impact of race-based discrimination on trafficking, it has been considered a risk factor for trafficking that expresses itself in a range of ways, at home and in regions of destination.  Some women may be more inclined to migrate and more susceptible to coercion by traffickers because of limited access to opportunities provided to their group of ethnic membership (Cameron & Newman, 2008).  For example, in some South- American countries indigenous people have been found to be at highest risk for trafficking (International Labour Organization, 2002).  Discriminatory policies such as non-citizenship rights for some populations may also increase one’s risk.  Although there has been disagreement whether caste-based discrimination may be considered a form of racism (Cameron & Newman), in many countries, belonging to a lower caste puts women and girls at a disadvantage for opportunities, and in turn, at higher vulnerability for economic exploitation and trafficking. Reports from Nepal, for example, indicate that the majority of the 12,000 children that are trafficked annually are from lower castes (Kumar, Subedi, Gurung, & Adhikani, 2001).

Women and children are not only at heightened risk for becoming victims of trafficking due to discrimination in their home communities, but global consumerism and frequent racial stereotypes in the region of destination increase their risk.  Frequently, racist and xenophobic frameworks may be used to justify the demand for ethnic minority “workers.”  A report prepared for the International Organization of Migration found that in Thailand, for example, Burmese trafficked workers were perceived as desirable due to alleged personality characteristics of being obedient and hard-working.  In Sweden, there was an increased demand for women and girls from the Baltic area because of their supposed need for “social and economic aid,” whereas Swedish study participants indicated a dislike for hiring Muslim or gypsy groups as domestic workers (Anderson & O’Connell Davidson, 2003).  The global sex industry operates on similar racist principles: In India, clients favored engaging with women they perceived to be of “higher racial/national” status such as European women and lighter skinned women from the Nepali area, followed by “dark-skinned local workers and […] women and girls from the Nat Bedia population.”

Commercial Sexual Exploitation (CSE) takes several forms. These include sexual servitude such as prostitution, servile marriage, and other sex- related activities such as pornography, exotic dancing, entertainment, and escort services (Logan et al., 2009). As the ILO reports, there are an estimated 1.7 million victims of such practices consisting of mostly women and children forced into prostitution. In the industrialized world, the victims trafficked from other countries are foreign women and girls who have been recruited by traffickers under false pretenses. They are often promised jobs employment as waitresses, cleaners, or maids, and upon arrival are forced into sex work and made to work off fraudulent debts, such as fees of travel agents, smugglers and labor contractors. These debts typically vary from US $3,000 to $60,000. Some trafficked women and girls are held in confinement, but most are forced into prostitution and sex-related activities through threats, beatings and/or retention of identity documents.  The ILO estimates that world profits from trafficked victims forced into sex trades amount to US $33.9 billion annually, with almost half realized in industrial nations, including the United States—and with an estimated average annual turnover of US $100,000 per individual victim per year (Belser, 2005).

Logan (2009) found that poverty, personal characteristics and isolation increased women and girls’ vulnerability to forced CSE. Lack of education, language proficiency or knowledge about legal rights or ways to seek help also may trap people into being trafficked for sex. Fear, lack of knowledge about alternatives, isolation, and physical and psychological confinement are factors that keep people entrapped (Logan et al., 2009).  Fear factors include implicit and explicit sexual violence, and fear of deportation and being jailed and of law enforcement in general. Traffickers use violence and restrict victims’ contacts with the outside world to isolate them, which reduces both the opportunity and the will to resist. Extreme forms of abuse, like chaining someone for use as a sexual slave, and the psychological coercion and confinement through verbal degradation, threats, abuse and humiliation are powerful tools that traffickers use to keep women and girls trapped (Logan et al.).

In recent years, the Internet and computer have revolutionized communications in the world’s wealthiest nations and increasingly in the world’s poorest as well. American Internet usage reaches at least 70 percent of the population (Internet World Stats, 2007). This pervasive presence makes the Internet a major tool in the marketplace of commercial sexual exploitation, and a key gateway for viewers to become buyers in the sex markets (Shared Hope International, 2006).  Alongside legitimate entertainment, the pornography industry has grown exponentially as cyberspace opportunities have expanded. At the same time, mainstream culture has become more and more tolerant of pornography, a phenomenon reinforced by the sexual objectification of women and girls in television shows and other mass media. Such trends encourage the public perception that some forms of the sex industry are not harmful, that some participants enjoy their victimization, and that men’s engagement in the industry is inevitable and may actually support women’s “career goals” (Lloyd, 2011).

Literature suggests that anti-trafficking efforts have perhaps overemphasized trafficking for sex which has led to reduced focus on the exploration of the factors related to other forms of forced labor. Economic exploitation takes the form of domestic labor, domestic servitude, factory labor or sweatshop work, restaurant work, agricultural labor and forced labor in other sectors (Logan, 2007). The International Labour Organization (ILO) finds that a substantial majority of the approximately eight million people in forced labor in non-sex trades are located in Asia in the largest regional concentration. In South Asia, ‘bonded labor’ in the agricultural sector accounts for some six million individuals, those who lose their freedom of movement or their freedom of employment as a result of debt and the obligation to reimburse this debt through labor. Most such laborers are forced to work on agricultural land and provide free labor to influential landlords as a means of paying off a debt that is often fraudulent, and sometimes inter-generational (Belser, 2005).

In the industrialized world, most cases of forced labor involve migrant workers in the labor-intensive segments of agriculture, where labor costs in comparison to production costs are kept low to maximize profits. In the United States, it is estimated that over a million farm workers are employed every week. In the summer, this number climbs to 1.2 million (U.S. Department of Agriculture, 2003). The ILO estimates that yearly earnings of forced workers are subsistence level at best, often ranging in the vicinity of US $10,000 - 15,000 in the industrialized world including the United States. It is often much lower in resource poor nations. The U.S. Bureau of Labor Statistics (2003) estimated that non-unionized workers in the agricultural sector earned approximately US $365 weekly with no benefits.  In garment industry sweatshops and other low-wage sectors, earnings are similar to those in the agricultural sector. The garment industry in particular is known for instances of holding workers in servitude for decades, with long work hours in conditions of extreme food deprivation, and use of beatings and physical restraints (U.S. Department of Justice, 2003). Considering only profits from people trafficked into forced economic exploitation, the total amounts to approximately US $3.8 billion, with US $2.2 billion generated in the industrial world (Belser, 2005).

Given that trafficking in the form of commercial sexual exploitation and forced labor exploitation is a lucrative business, it is not surprising that many governments are slow to enforce criminal penalties against traffickers or provide legal services and other assistance for victims.   Many governments have proven reluctant to take meaningful action against what may amount to large sectors of their economies.  Even in the United States, which ostensibly has stronger protections for minors than many other societies, entry into the commercial sex industry typically starts between the ages of 10 and 14, among runaways or “throwaways” from unstable families or foster homes (Raymond, 1998). The juvenile system is not set up to offer real protections to non-criminal runaway children, and they easily fall prey to pimps and others in the sex industry. Some are lured, coerced, isolated and threatened to participate in sex-related activities such as child pornography or nude dancing, and then groomed, often by older predatory men, into prostitution as they reach their later teens or 18 years of age. The well-documented seamlessness of the transition from child to adult CSE renders moot the arguments for legalization and illuminates the sophistry of differentiating adult from child prostitution, prostitution from trafficking, sex work from coercion and exploitation, and other such distinctions (Farley, 2009).

Given the powerful social, economic and political institutions driving these industries, combating them requires not only tougher laws, progressive legislative efforts, and public education; it requires societal reexamination of cultural tolerance of the mistreatment, degradation and humiliation of women and girls. Countering commercial sexual exploitation also necessitates the sacrifice of economic incentives and demands the dismantling of institutions that promote oppression as legitimate business.  As Farley (2003) notes, trafficking dehumanizes, commodifies and fetishizes women and girls. While other types of gender-based violence such as incest, rape, sexual harassment, stalking, battering, verbal abuse and humiliation are all points on a continuum of violence, they do not constitute an enormous source of revenue (Farley, 2003).

There is a power imbalance where the trafficker possesses the economic power to treat another human as a commodity and to keep the profits. There is no element of consent, voluntariness, pleasure or personal desire of the victim in this transaction.

Roughly three percent of the global population, numbering approximately 192 million people, live outside of their place of birth or are classified as migrants (IOM, 2008). The vulnerability of migrants worldwide to challenges in social and economic life is great. Host countries that receive migrants have varying policies and levels of openness to newcomers entering their borders. Since 1996 IRAIRA (Illegal Immigration and Immigrant Responsibility Act), and more so since September 11, 2001, the United States currently imposes fairly restrictive standards for immigrants entering the borders. Given current policies prioritizing the removal (deportation) of undocumented immigrants, regardless of their circumstances for being in the US, the recognition of victims of labor or commercial sexual exploitation as “trafficked persons” poses a formidable challenge. Most may be overlooked as “illegal criminal aliens” unauthorized to work in the United States.

In the United States, the implications of immigration and national security policy play a large role in the safety and protections afforded to survivors. Current priorities of the Department of Homeland Security are focused on the removal of undocumented peoples or people who have crossed U.S. borders without authorization (without a visa). More often than not, ”trafficked” persons fall under this category and may not be assessed or regarded as “crime victims” by law enforcement by virtue of being undocumented. Being undocumented, for example is considered a felony offense and victims and perpetrators alike may be treated as law breakers in a global level. The majority of people who experience crimes of “trafficking” may never be categorized as a victim of the crime – unless they are minors, at which point certain mandatory reporting and protective systemic mechanisms are automatically engaged.

Typical immigration conditions of trafficked persons include being brought into the host country:  Without inspection (no visa), with falsified immigration papers, as a tourist, student or other visa, on a Fiance visa (eg: cases involving women “purchased” over the internet as “picture brides” or “mail order brides”, on special visas issued by a Governmental Department (eg: as the domestic worker for Diplomat or Expatriate), on a binding worker visa with an employer or other agency some of which may promise adjustment of status to legal permanent residency after a period of time (e.g.,nurses from Philippines or Nigeria entering into a contract with a Nursing Home, or construction workers brought in to work in the Gulf Coast and upon arrival find themselves working for meager or no wages and living in squalid conditions).

In the United States, the Department of Homeland Security enacted a Detention and Removal Strategic Plan, named Operation Endgame that took effect in 2003 (Barry, 2008). Its mission is to eliminate an estimated 12 million immigrants living and working in the U.S. within 10 years. In 2008 alone, Immigration Customs Enforcement officials have deported 349, 041 immigrants. This is an increase from 288,663 in 2007 and 174,000 in 2004. One issue that all immigrants who are trafficked have in common is the trauma impact on their psyche, spirit and bodies. This also includes trauma from interfacing with ICE officials and witnessing the violent arrests and detention of loved ones. Another commonality is that their newness to this country leaves immigrants unarmed with adequate or accurate information about rights, laws, resources and supportive community. New immigrants are furthermore left at a disadvantage if limited in English language proficiency and/or by their immigration status. Living in fear, isolation and amidst violence, restricts one’s normal ability to be able to connect in community, engage with the public or feel a sense of trust or belief that there may be community out there that would value you or stand up with you against injustice, or even value you as a human being deserving of rights and protections.

The impact of trafficking on survivors is far reaching, encompassing physical, psychological and social consequences.  In considering the nature of victimization through trafficking, involving largely secretive cycles of violence and exploitation, psychological sequelae are highly complex.  An ecological perspective (Bronfenbrenner, 1996; Harvey, 2007) is particularly helpful in conceptualizing both the severity of impact of trafficking on women and girls and the challenges of accessing adequate mental health services and intervention.  From this perspective, the interaction of the individual and social environment is paramount to understanding the ways in which survivors of trafficking or commercial sexual exploitation (CSE) are affected by trauma and how they may negotiate traumatic experiences by mobilizing strengths and resources.

With respect to physical health, many women and girls suffer a wide range of problems, such as sexually transmitted diseases, physical injuries, and malnutrition (Rafferty, 2008). Sexual and physical violence and lack of power to negotiate safe sex with traffickers and ‘johns’ makes women and children more vulnerable to many sexually transmitted diseases. Much of the HIV literature until recent times focused on the high prevalence of HIV among sex workers, ignoring the fact that rape by customers and increased physical violence in response to requests for condom use were primary factors that caused HIV infection in women (Karim, Karim, Soldan, & Zondi, 1995; Farley, 2003).  The IOM report commissioned by Congress in 1998 alluded to barriers to prevention and treatment for women in the AIDS epidemic. The report, however, began with the HIV-infected woman, missing an opportunity to discuss how she came to be infected in the first place. Public health attention to the issue focused instead on concern for the customers and their exposure to the disease. In addition to sexually transmitted diseases, research has also shown that women and girls in CSE are at increased risk for a range of diseases such as cervical cancer, chronic hepatitis B and C, uterine infections, ovarian pain, infertility, and complications in pregnancy. Women and girls also reported suffering from malaria, asthma and other lung diseases, anemia, cancer, arthritis, gastrointestinal infections and diabetes (Farley, 2003; Loring & Smith, 1999). Women in prostitution suffer serious physical injuries from beatings and rapes by pimps, tricks, and partners.  Broken bones, teeth knocked out, dislocations, and traumatic head injuries often lead the women directly to emergency rooms (Farley; Loring & Smith; Stark & Hodgson, 2003).

Healing from physical injuries can sometimes take many years, especially for women and children who have been severely wounded by their traffickers or customers.  Lloyd (2011) found in her work in New York City that some young women and girls carry scars, including tattoos and brands, inflicted by their pimps and suffer the physical pain for years. Even with a supportive network of medical workers, social workers and some in law enforcement, those who have become infected with sexually transmitted diseases like HIV/AIDS live in constant fear of their mortality. As they see some of their peers die from the disease, it becomes an overwhelming and constant reminder of traumatic experiences (Lloyd, 2011).

Physical health problems are interwoven with psychological consequences of trafficking. Victims often experience multiple layers of trauma including physical and sexual violence and psychological damage from captivity (Stark & Hodgson, 2003; Ugarte, Zarate, & Farley, 2003). In fact, mental health providers have reported higher levels of fear, more severe trauma, and greater mental health needs among survivors of trafficking as compared with other victims of crime (Dovydaitis, 2010).  Clinical case studies with survivors of trafficking have noted experiences of depression, anxiety, somatic symptoms, hopelessness, guilt, shame, flashbacks, nightmares, and loss of self-esteem, all of which are consistent with post-traumatic stress (Rafferty, 2008).  For many survivors, these traumatic experiences contribute to the development of various disorders such as post traumatic stress disorder (most common), panic disorder, major depression, substance abuse and eating disorders (Zimmerman, 2006).

While research on the psychological impact of trafficking on women and girls is still in its infancy, evidence from research on abuse and neglect of children and rape and domestic violence directed against women offers important knowledge in understanding the psychological experiences of survivors of trafficking.  For girls, severe forms of abuse and neglect have been associated with isolation, negative self-concept, anxious and disorganized attachment, social and emotional withdrawal, behavioral problems, and aggressive behavior (Deb, Mukherjee, & Mathews, 2011; Watts-English, Forston, Gibler, Hooper, & DeBellis, 2006).  Multiple, repeated forms of trauma further contribute to risk of substance abuse and suicide (Courtois, 2008).

Both cognitive and affective changes accompany trauma incurred in commercial sexual exploitation. Survivors’ thought processes may become narrowed such that the survivor is focused almost exclusively on survival.  They often feel helpless, and as though there are little or no options in the present and the future.  Survivors may also cope with traumatic experience by rationalizing the violence directed against them, or by distracting themselves through fantasy (Logan et al., 2009).  Research highlights the role of dissociation in coping with traumatic experiences related to trafficking or CSE.  For example, many women who engage in prostitution have been found to suffer from a range of dissociative disorders.  Dissociation is a coping mechanism and permits psychological survival in the face of repeated trauma, such as in combat or in CSE. Ross, Farley and Schwartz (2003) analyzed four studies on dissociation among women in prostitution and found that dissociative disorders are accompanied by post-traumatic stress, depression and substance abuse.

Dissociation is an escape and avoidance strategy in which overwhelming human cruelty results in fragmentation of the mind into different parts of the self that observe, experience and react, as well as parts that remain ignorant of the harm (Dworkin, 2002). While dissociation may insulate a person from short-term emotional trauma, it can also increase the risk of further victimization (Herman, 1997). The survivor may not be able to mobilize other, healthier defensive strategies when in real danger.  Many survivors of sexual exploitation use the psychological device of splitting the self into parts which are variously present, absent or co- conscious, each with varying combinations of amnesia and depersonalization (Kluft, 1987). Dissociation helps them cope with overwhelming fear and pain and reduce internal conflict and cognitive dissonance (Schwartz, 2000), but often at the expense of any ability to make decisions that could improve their safety.

Additionally, while an initial reason for why a woman or girl is in an exploitative situation is the lack of safety in the home and/or economic hardship, the issue of safety is even more complicated in the context of physical, sexual, and emotional abuse by the trafficker(s). The survivor is placed in a position where safety is negotiated in any number of ways, and coping with traumatic stress is uniquely determined by an interaction of personal and environmental factors.  The ways in which women and girls are trafficked (born into slavery, kidnapped, sold, physically forced, or tricked) (Logan et al., 2009), and their specific sociocultural contexts contribute to coping with the traumatic circumstances.  For example, sexually exploited women and girls who were kidnapped may decide to return to the trafficker after attempting to escape, because they fear that the trafficker would find and kill them or a loved one (Hodge & Lietz, 2007). In some cases, women and girls are encouraged to make sacrifices for the sake of their families and to help improve the family’s economic situation through commercial sex work.  In such cases, women and girls who are exploited may fear deportation and choose not to return home either because they have not been able to send enough money to their families, meet expectations of filial piety which may be an important cultural value, or feel shame or embarrassment about being sexually violated (Chung, 2010).

Female migrants coming to the U.S. may feel culturally and linguistically isolated, and as such, more susceptible to coercion and initiation by traffickers. Those who face debt bondage agreements and ambiguous immigration status may fear local authorities and therefore are placed into situations where they are literally trapped. Under these circumstances, women and girls are easily subjected to horrendous forms of physical and psychological abuse by traffickers. Traffickers, concurrently, take advantage of immigration policies by withholding forms of identification to restrict the movement of their victims. Yet, as Raymond and colleagues (2001) point out, trafficking needs to be framed as a “human rights violation, rather than an immigration crime” to avoid furthering “a xenophobic climate” in U.S. society.

Logan, Walker, and Hunt (2009) identified seven main themes describing trafficking as a unique type of trauma: 1) more difficult to identify, due to covert nature of trafficking, language and cultural barriers, lack of victim’s knowledge of rights, isolation, and fear; 2) prejudice toward victims; 3) greater physical and psychological needs; 4) fewer available resources and services; 5) greater fear and concerns of safety; 6) more limited access to justice; and 7) complex criminal cases.  Culturally appropriate interventions must consider the unique complexity of survivor’s circumstances and traumatic histories. The following sections address some important considerations in conceptualizing interventions with survivors of trafficking, and approaches to crisis intervention, advocacy, and psychotherapy.

Conceptualizing language of trafficking

The term “trafficking” often conjures large scale operations such as organized crime gangs and women in sexual slavery, as portrayed by media.  Although these situations do occur in some circumstances, the typical case of worker exploitation and sexual exploitation is not often as clear cut, but rather hidden in plain sight in ordinary life interactions. The assumptions brought about by the term can often obscure the actual context of the human experience, the circumstances that result in people’s vulnerability to being abused or exploited, choices that people may have made that resulted in harmful outcomes, the effects of poverty and the complexity of the familial, social and political environment that shape a person’s life trajectory. It is also important to keep in mind that a woman or a girl who enters counseling may not regard the instance of being “trafficked” or working in terrible conditions or prostitution as the primary stressor in her life.  Many people who have been in prostitution or in exploited labor, may not identify as “victimized” with no agency in the situation, but had exercised a choice to engage in the life or sacrificed their life to be an overseas migrant worker in order to provide a better life for family in the home country. What most never consented to, or anticipated however is the inflicted violence, control and abuse and subsequent trauma that they may have experienced.

It would be helpful for practitioners to name the violence that people face using language that clearly identifies the abuse or violence, for example, “the sexual exploitation” or the “prostitution” of a person or the labor exploitation of a domestic worker, or exploitation of immigrant farm workers. Within the populations of survivors we encounter, we can further break down the populations by U.S. born individuals and those who are immigrants with varying documentation states; adult survivors vs minors; by gender. The human rights violations and trauma that people who have been “trafficked” typically face can be broken down into any number of traumatic situations (not all may be experienced by each person) such as: sexual assaults, physical assaults, threats, verbal and psychological abuse, malnutrition, medical neglect, kidnapping, wage withholding or non-payment of wages, working in slave-like conditions, being housed in squalid, overcrowded, workers quarters, fraud, with holding of immigration papers, being prostituted, being filmed in pornography/child pornography, child sexual assault, child labor, being threatened with deportation and arrest if they left the employ, the trauma of being arrested, caught in a raid and detained in prison, and witnessing violence against others.

Approach to Healing

Many mental health professionals lack knowledge and expertise in working with women and girls who have experienced CSE.  Moreover, survivors are often unable to articulate what they need, and they sometimes report that male mental health professionals treat them with contempt like the ‘johns’ did (Ross et al. 2003). Effective services for women of color require an understanding of the intersection between slavery and prostitution, racism in current day institutions, the complex influences of poverty and homelessness and the cultural and social barriers that define the unique experiences of black women in CSE (Carter, 2003). Preventing relapse into substance abuse as well as into prostitution, for example, requires a thorough understanding of the structural and economic systems that recruit and keep women and girls trapped in the trade.  Feelings of shame and guilt, insecurity, and the desperate desire for strong and affirming relationships with men many times drive women back into the control of other pimps or traffickers. Sexual exploitation, emotional rejection and parents’ relationship problems can also have a negative effect on self-confidence and the ability to form healthy attachments (Hedin & Mansson, 2003).

The most difficult period for survivors tends to be when survivors find themselves between two life patterns, living in a state of uncertainty and ambivalence, and encountering challenges in the healing process (Hedin & Mansson, 2003). This is the period when survivors need the most support. Everyday mundane existence, the difficulties and frustrations in developing new skills, the challenges of creating positive relationships with men who can be trusted, and setbacks in the quest for work and housing – all of this may create a yearning for the familiar, even though it was violent and humiliating (Farley, 2003).

Simply giving survivors a non-judgmental audience to tell their personal stories can serve as a powerful healing tool.  Receiving acceptance, kindness and sympathy from others in public forums can be very empowering to survivors.  But it can also generate reactions ranging from morbid curiosity to condescending pity to poorly disguised contempt. There is also a danger that the grotesque stories will become one’s primary identity, eclipsing other facets of personality and life experience.  Many survivors who work as advocates in the field emphasize the need to humanize former CSE victims and challenge people’s preconceived notions about them (Lloyd, 2011).

Those leaving prostitution need not only supportive personal relationships but also the ability to mobilize both informal and formal professional support.  Locating the resources and points of support needed for a renewed life can be an arduous process. Building new networks of friends and advocates who do not judge them are important and critical to their healing and personal empowerment.  Lloyd (2011) reported that many young people in CSE talk about those who made a difference in their lives – ‘the judge who was nice, the counselor who was a good friend, the person who listened to what I had to say.’  When their strongest connection to another person, often the trafficker, is removed, they need to feel connected to someone else.  Ultimately, feeling loved genuinely and unconditionally can alleviate some of the pain and the fear of the recovery process

One potentially beneficial approach to the healing process is for survivors themselves to become fighters and advocates for change.  This can not only help survivors overcome their own prejudices based on race, gender, socioeconomic status but also help them overcome their guilt, shame, and people’s perceptions of their abilities, and intelligence.  Lloyd (2011) created a program called GEMS in New York City helping girls escape the life of CSE. As a survivor of CSE herself, Lloyd (2011) also began youth leadership groups to help move the girls and young women into activism. Discussions about CSE in the global context, public speaking, peer counseling, community organizing and advocacy – are all tools that GEMS staff use to help survivors become advocates for change. GEMS has been successful in advocating for legislative changes in NY state by seeking and securing the passage of the Safe Harbor Act that decriminalizes children and prevents incarceration of children who are commercially sexually exploited.  Lloyd (2011) reports that after a four and half year battle the fact that people in power actually listened to commercially sexually exploited children was a significant factor in their healing. She says, ‘for girls and young women who have experienced such immense trauma and pain, for whom a happy and healthy future seemed an impossibility, the need to be able to envision themselves moving forward, creating a new life, accomplishing and achieving, loving and being loved, being an important part of the world and making an impact on that world, is the true indication of real healing and recovery’ (Lloyd, 2011).

Crisis Intervention

The nature of trafficking as a system of abuse places its victims in crisis. Crisis intervention attends to the immediate needs of the victims with resources such as food, shelter, medical services, security, legal representation, and brief counseling.  The Transnational Referra Mechanism for the Victims of Trafficking document by USAID and the International Center for Migration Policy Development (2007 ) outlines four measures that can be taken during crisis intervention care for victims of trafficking. Measure 1 (Information Provision of Assistance Options and Conditions) encourages providers to give victims of trafficking clear and detailed information about the services their program provides and any conditions and/or stipulations for receiving such services. In addition, victims should be informed of the procedures and why they might be asked certain questions. Information should also be conveyed in a manner that is supportive, encourages victims to ask questions and express concerns, and uses simple terms (non-technical) in a language the victim comprehends. Measure 2 consists of an intake and assessment of basic needs (e.g. accommodation, diet, sleep, prescription medications and communication with family), risk (e.g. current & past safety concerns, potentially harmful individuals, concerns for family/friends, and unsafe locations for the victim), health needs (e.g. serious medical problems, current/past injuries, mental illness, and learning disabilities) and legal/administrative needs (e.g. legal representation). In Measure 3 there is the Development of an Assistance and Security Plan which is a clear and detailed description of the next steps for the care of the victim. This plan details the victim’s current needs and wishes for the future, information on how the case will be taken forward by providers, location of accommodations or resources the victim has been referred to,  time of next meeting, safety plan outlining what to do when the victim has security concerns, and psycho-social needs and availabilities. Measure 4 (Consent Procedures to Implement Assistance Plan) involves thoroughly informing the victim of the assistance being offered and terms and conditions of continuance of service or termination. Victim is also given the opportunity to ask questions and misunderstandings clarified. Last, the victim is asked if she agrees to the conditions of the assistance and if she does then she is asked to sign a consent form.

Beyond immediate crisis intervention, many organizations also continue to maintain assistance to victims of trafficking to promote stabilization and reintegration into the community of the host country or their native home. An example of an organization that provides noteworthy crisis and long-term intervention for victims of trafficking is the POPPY Project in the United Kingdom. Established in 2003 the POPPY Project provides intervention to women who have been trafficked into prostitution or domestic servitude (Stephen-Smith, 2007).  POPPY provides assistance in three stages, the first of which is crisis intervention that lasts up to four weeks. During these weeks victims spend time reflecting on their experiences and psychologists work to provide a sense of safety and help build a supportive relationship with the victim (Stephen- Smith, 2007).

Advocacy

Given the complexity of challenges that trafficked women and children face in the host countries, they may benefit from providers advocating on their behalf. Such advocacy may be directly geared towards assisting one victim, a group of victims or fighting against the entire system of trafficking. In addition, trafficking impacts nations globally therefore victims of trafficking are women and children of various linguistic and cultural backgrounds. As such providers need to use linguistic and culturally appropriate ways to effectively engage and serve victims. In Europe some organizations use “cultural mediators” or “cultural advocates” in an attempt to accomplish this goal (Davies, 2003). Cultural mediators are employed by providers and are usually members of the migrant community with strong bicultural and bilingual skills that can bridge communication between the victims of trafficking and the host country organization (Vargas, 2000). However, as employees of the host organizations some cultural mediators may be loyal to the aims of the organization; and limit advocacy for victims that may be desired by the victims but conflict with the goals of the organization (Davies, 2003). For example some organizations might encourage trafficking victims to returns to their native countries despite their wishes to extend stay in the host country. An alternative to the cultural mediator is a cultural advocate who would work to promote the interests of the trafficked women and children (Davies, 2003). For instance a cultural advocate may promote empowerment by assisting the women in a) forming their own organizations, b) challenging immigration policies that adversely affect them and/or c) networking with others who may be able to help with obtaining residency in the host country.

While having a cultural advocate would be beneficial in delivering culturally appropriate advocacy there are general steps that can be taken with or without the presence of a cultural advocate. First, providers can ensure the availability of employers or translators to facilitate communication with victims in a language they are able to speak. Second, conduct a thorough intake assessment or interview with victims in which information is also gathered about the salience of their cultural background to their identity and how it may influence their decisions such as reintegration in their native community. Third, culture is not a concept that is static and universal for all individuals of a particular background, and therefore advocates should be careful not to apply broad stroke assumptions and instead get to know the individual victim they are serving. Fourth, as discussed in section two, gender is an important factor in the lives of trafficked women and children and as such female gender norms, expectations and practices within their culture should be taken into consideration. Lastly, although women and children of trafficking are often disempowered by trafficking and various targeted identities (e.g. female, migrant, low SES) they are not without resilience and the capacity to self-advocate if given the right tools and assistance. Therefore advocates should aim to empower victims and assist them in reaching their goals instead of instructing victims on what choices to make which may recreate the power imbalance that exists between victims and traffickers.

Psychotherapy

While the psychological consequences of trafficking are complex and challenging to address, there is an absence of literature examining effective therapeutic interventions and coping strategies that are culturally appropriate specifically for victims of trafficking (Clawson, Salomon, & Grace, 2008).  In the absence of such literature, insights for therapeutic intervention for many victims of trafficking may be drawn from literature on effective treatments for disorders such as PTSD (Williamson, Dutch, & Clawson, 2010), and for complex post-traumatic stress (Herman, 1997).

Effective therapeutic treatments for individuals who suffer from PTSD include cognitive behavioral approaches such as Prolonged Exposure (Foa, Keane, Friedman, & Cohen, 2010) and Cognitive Processing Therapy (Resick, Monson, & Rizvi, 2008).  Cognitive Processing Therapy treats PTSD via psychoeducation about PTSD, exploration of the individual’s cognitions regarding the traumatic event, cognitive restructuring of maladaptive cognitions, and addressing themes such as trust, esteem and power. The individual is asked to write about the most traumatic event (include emotions felt and how the event impacted her) and read the narrative to the therapist and at home. Prolonged Exposure Therapy involves psychoeducation about PTSD, clients listening to and retelling the trauma story repeatedly at home and in therapy, and conducting in vivo exposures to stimuli that are reminiscent of the event. Unlike CPT, PET does not involve extensive discussion of cognitions regarding the event. Both CPT and PET have shown efficacy with trauma populations such as rape victims and combat veterans. More recently work by Resick, Nishith, and Griffin (2003) has also shown that CPT is effective with individuals with complex trauma who have had numerous traumatic experiences.  In addition, protocols such as Cognitive Therapy for Depression (Young, Rygh, Weinberger, & Beck, 2008), Interpersonal Psychotherapy for Depression (Bleiberg & Markowitz, 2008), Seeking Safety – combined treatment for PTSD and substance abuse (Najavits, 2001) and the Transdiagnostic Cognitive Behavioral Therapy for eating disorders (Fairburn,Cooper, Shafran, & Wilson, 2008) might be beneficial in treating some victims of trafficking.  However, most of these protocols were developed in the United States using majority Caucasian samples and therefore the effectiveness of these approaches with various cultural groups has just began to be established. For instance, researcher Guillerma Bernal studies the cultural adaption of evidence based treatment for Latino adolescents with depression (Rosselló & Bernal, 1999).

Beyond evidence based protocols there are alternative therapeutic approaches that might be beneficial to victims of trafficking and may coincide with some culturally congruent coping strategies they have utilized. Among some cultural groups coping strategies include engaging in spiritual/religious activities (e.g. church, prayer, meditation); emotional expression (e.g. sadness, anger); seeking/giving support from/to friends, family, or community members; seeking assistance from traditional healers; talking to fortune tellers; engaging in cultural physical activities (e.g. Chi-Gong); using herbal remedies; and social activism such as taking on roles to help other victims (Dale and Henderson-Daniel, in press). Alternative forms of therapy for victims of trafficking with trauma exposure may include art therapy, journaling, poetry and song writing, yoga, body work, drama, outdoor physical activities and organized spiritual/religious activities such as regular meditation or prayer.

Treatment models specifically to address complex post-traumatic stress (Courtois, 2008; Herman, 1997; Mathews & Chu, 1997) can be particularly helpful in psychotherapy with survivors of trafficking, due to the multilayered impact of trafficking on the whole person. The treatment of complex trauma has been conceptualized as involving a series of stages in a way that secures physical and emotional safety within and outside the therapeutic relationship.  The initial stages of therapy involve the establishment of safety and self-care, through a safe and consistent relationship with a therapist (Herman, 1997).  In this initial stage, the focus is on addressing potentially harmful behaviors and circumstances, such as substance abuse, self-injury, and high risk or dangerous situations where a survivor could be revictimized.  This stage often involves an active therapeutic approach in which psychoeducation concerning the impact of trauma may play a beneficial role.  As safety is more adequately established, therapeutic work in the second stage can involve more detailed discussion about the traumatic experience, the mourning of trauma and loss, and the reconstruction of a coherent narrative (Herman, 1997; Mathews & Chu, 1997).   The last stage of trauma recovery involves reconnection with positive supports or the establishment of new forms of support, and redefining one’s identity. This final stage may involve an active seeking of positive relationships, or engagement in social action as a form of empowerment.  Survivors of complex trauma, such as those who have been trafficked, may revisit each stage of recovery, particularly as new challenges and opportunities may arise across the lifespan (Herman, 1997).

In any of the therapeutic approaches mentioned so far, mental health practitioners should consider the interaction between the individual and her environment in the assessment of pathology and resilience, as both are interconnected and relevant to the experience of trafficking (Harvey, 2007; Tummala-Narra, 2007).  Expressions of pathology and resilience should be considered in light of the survivor’s sociocultural context.  There are several suggestions for mental health providers to incorporate cultural considerations and enhance the appropriateness of therapy for victims of trafficking. First, providers should provide environments (waiting room, office, etc.) that are welcoming to victims of diverse cultural and linguistic backgrounds by integrating diverse paintings/pictures, written material, sounds, etc. In addition, during the initial sessions it is worthwhile for providers to inform the survivors that it is safe and open for them to discuss how aspects of their trafficking experience intersects with their cultural identity. Willingness to engage in such dialogues around culture may be difficult if providers are uncomfortable with the subjects or hold values/beliefs counter to the victim’s values. That said, providers should explore their cultural values and challenges for working with women from diverse cultural groups as well as receive ongoing supervision around these issues as they arise in treatment. Second, mental health providers will need to be patient in developing a trusting relationship with victims of trafficking. Similar to victims of childhood sexual abuse and domestic violence, women and children who are trafficked are subject to terrifying power and control tactics used by perpetrators and as a result may deny the abuse, conceal physical injury, blames themselves, and stay with the perpetrator to avoid further harm (Yoshihama, 2005). Victims of trafficking may be untrusting of others and hesitant to share information because of the fear of potential retaliation by the abusers. In addition, some victims may belong to cultural groups in which mental health issues are expected to be addressed within the family unit and close community circle and not by professionals outside of these circles. In many cultures mental health issues are highly stigmatized (Cauce et al., 2002; Neighbors, 1985) therefore individuals might minimize their symptoms or struggles in order to avoid stigma or avoid entering a facility in their community that clearly targets such issues as indicated by the facility’s name or legacy in the community.  Providers therefore need to be very mindful of these factors and avoid any stance that might be perceived as judgmental. Techniques such as motivational interviewing might be helpful in this regard. Third, providers should consider the daily obstacles in the lives of trafficked victims that may require flexibility in how, when and where therapy is delivered. For instance, some victims may not be able to attend weekly sessions and/or do homework outside of session. In addition, for some victims of trafficking, therapy that is delivered in locked treatment facilities may feel threatening and reminiscent of trafficking experiences. Fourth, many victims of trafficking may have limited proficiency in the language spoken in the host country and therefore services will need to be provided in their native language. As noted in the section on advocacy, to accomplish this goal organizations can hire mental health providers that speak the language of the victims, utilize translators, and have all printed material available in the languages spoken by the victims. Culturally appropriate therapy can also be delivered by incorporating women who belong to the same cultural backgrounds as the victims, have survived experiences of being trafficked and established stable lives. These women can be trained to be peer supporters and/or co-facilitate groups for victims of trafficking.

Clinical care should adopt a flexible and multifaceted approach which may be necessary to help create a trusted relationship with the survivor, as well as to co-create a safety net of support for the survivor on multiple levels.  Providing crisis intervention, emotional support, parenting support to caretakers, family members and loved ones who are feeling helpless, frustrated and at a loss as to how to prevent their child from running away or walking the streets, may be a critical part of the therapeutic work to address the safety, health and well being of the entire family system. A mutli- systemic treatment model or coordinating a community response and convening a network of concerned loved ones and service providers (sometimes even including law enforcement agents and immigration or civil attorneys (not prosecutors, District Attorneys or U.S. Attorneys as they are not allowed to engage with too many players for evidentiary protection) may be essential as a safety net that can support the survivor through the complexities of her circumstances. This is particularly necessary when dealing with survivors who have been sexually exploited and/or labor exploited and undocumented with few trusted social connections, family, or resources.

Practitioners can consider the following principles when providing advocacy for survivors of trafficking:

1. Adopt a flexible model of care and intervention: Be prepared to engage in a variety of roles (e.g. clinician, advocate) when working with survivors if providing support.  Your assistance in bridging social support systems and resources for the survivor will be critical to her healing and independence in the long term.

2. Become knowledgeable about the systems that survivors may interface with:  An understanding of the strengths and barriers of systems of care can help you assist survivors deal with the stresses, anxiety and confusion she may experience from having to testify against her exploiters. Preparing your client to anticipate potential barriers, shortcomings and risks within the systems can be useful to reduce secondary trauma and help her make more informed choices about steps she can take to keep safe and prepared for possibly disappointments.

3. Seek an immigration legal consult for survivors to establish available protections under the law: There are certain immigration protections that are available to undocumented victims of crime, including those who are trafficked under the Violence Against Women Act 2010 for the U visa, T visa, VAWA or political asylum or Temporary Protective Status (TPS) if the immigrants country conditions and migration history may indicate eligibility for asylum as an option. It is imperative that every immigrant survivor you encounter be referred to an immigration attorney or your local legal services agency to assess for immigration relief that may be available to them.

4. Assess for civil legal remedies: Especially in cases of labor exploitation, survivors may be able to access civil restitution for lost wages or pain and suffering. Class action lawsuits if possible to organize is solidarity among workers, may be an effective remedy as well to effect systemic change in an exploitive place of work (eg: in a healthcare setting, factory or farm).

Trafficking of women and girls is a global and domestic problem rooted in economic and social and structural inequities including issues of labor conditions, poverty, race, gender, globalization, ethnicity, migrant rights, immigration policies among others.  Attending to the causes for the economic inequalities and social and structural issues and the impact of these issues on individual survivors of trafficking including commercial domestic, agricultural and other physical labor as well as sexual exploitation is critical to ensuring the basic rights of individuals, families, and communities.  Given the higher percentage of women and girls being trafficked and the intersectionality of poverty, gender with race, ethnicity and immigration related issues, a feminist and international perspective should be adopted in understanding and policymaking. Most importantly, a perspective dedicated to human rights instead of being driven by national security, border control and concerns about the moral order focus should be emphasized. Survivors of trafficking have complex needs in light of repeated violations to their basic human rights.

• Co-Chairs:  Rakhshanda Saleem & Usha Tummala-Narra

• Committee Members:  Sannisha Dale, Milena Doerfer Claudius, Carol Gomez & Nalina Narain

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