Overview

Today, some label human trafficking as a form of "modern day slavery," and frequently, human trafficking has been linked to sex work and prostitution, although there are other forms of trafficking, such as forced labor and domestic work. Human trafficking can involve women, men, and children. Its victims experience a host of psychological problems, including post-traumatic stress, helplessness, and depression, due to the physical, sexual, and psychological abuse they have experienced. This course encompasses a basic overview of human trafficking. The course will attempt to provide practitioners with a glimpse of the realities of human trafficking victims' lives and the physical, psychological, social, and sexual abuse they experience. Specific interventions and responses are covered, including mental health, social services, educational, prevention, and legal efforts. Finally, for practitioners who do work with human trafficking victims, the emotional toll that it takes upon practitioners will be discussed. The course ends with an array of resources, including organizations/agencies, books, and films/documentaries focusing on the issue of human trafficking.

Education Category: Psychiatric / Mental Health
Release Date: 10/01/2014
Review Date: 10/01/2016
Expiration Date: 09/30/2018

Audience

This course is designed for physicians, nurses, social workers, psychologists, therapists, mental health counselors, and other members of the interdisciplinary team who may intervene in suspected cases of human trafficking and/or exploitation.

Accreditations & Approvals

NetCE is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. NetCE is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. NetCE, #1092, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org through the Approved Continuing Education (ACE) Program. NetCE maintains responsibility for the program. ASWB Approval Period: 03/13/2016 to 03/13/2019. Social workers should contact their regulatory board to determine course approval for continuing education credits. This program is approved by the National Association of Social Workers (Approval #886531582-9661) for Social Work continuing education contact hours. NetCE is accredited by the International Association for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE SW CPE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #0033. This course is considered self-study, as defined by the New York State Board for Social Work. This course is approved by the Association of Social Work Boards - ASWB NJ CE Course Approval Program Provider #14 Course #299. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules. Social workers will receive the following type and number of credit(s): General Social Work Practice 5 for the approval period starting 04/23/2015 and ending 04/23/2017.

Designations of Credit

NetCE designates this enduring material for a maximum of 5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NetCE designates this continuing education activity for 5 ANCC contact hour(s). NetCE designates this continuing education activity for 6 hours for Alabama nurses. NetCE designates this continuing education activity for 2 NBCC clock hour(s). Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 5 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. Social workers participating in this intermediate to advanced course will receive 5 Clinical continuing education clock hours, in accordance with the Association of Social Work Boards. AACN Synergy CERP Category B. NetCE is authorized by IACET to offer 0.5 CEU(s) for this program.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353, (valid through December 12, 2017); California, BRN Provider #CEP9784; California, LVN Provider #V10662; Florida, Provider #50-2405; Iowa, Provider #295; Kentucky, Provider #7-0054 through 12/31/2017.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190; Texas State Board of Social Worker Examiners, Approval #3011; Texas State Board of Examiners of Professional Counselors, Approval #1121; Texas State Board of Examiners of Marriage and Family Therapists, Approval #425.

Special Approvals

This activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Competency.

Course Objective

As human trafficking becomes an increasingly more common problem in the United States, healthcare and mental health professionals will require knowledge of human trafficking patterns, the health and mental health needs of human trafficking victims, and successful interventions for victims. The purpose of this course is to increase the level of awareness and knowledge about human trafficking and exploitation so health and mental health professionals can identify and intervene in cases of exploitation.

Learning Objectives

Upon completion of this course, you should be able to:

  1. Define human trafficking.
  2. Identify the forms of human trafficking.
  3. Identify economic, political, social, and cultural factors that contribute to human trafficking.
  4. Describe methodological and research barriers to the study of human trafficking.
  5. Compare the different perspectives that have been used to frame the problem of human trafficking.
  6. Analyze the trafficking experience, including how traffickers recruit and the financial implications of trafficking.
  7. Explain the psychological, health, and social consequences of human trafficking.
  8. Utilize interviewing strategies to assess and identify victims and promote the ethical treatment of trafficking victims.
  9. Describe various educational, prevention, mental health, legal, and social services interventions and responses targeted to human trafficking victims.
  10. Discuss the countertransference and secondary traumatization practitioners experience when working with victims of human trafficking and the importance of self-care.

Faculty

Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correctional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families.

Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon University, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online curriculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities.

Faculty Disclosure

Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

John M. Leonard, MD

Jane C. Norman, RN, MSN, CNE, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Table of Contents

Technical Requirements

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#96311: Human Trafficking and Exploitation

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  • Participation Instructions

INTRODUCTION

Human trafficking is not a new social problem; it has always existed. In the United States, it has historically been referred to as "white slavery," although it involves people of all races and ethnicities [1]. Even in the last three decades, human trafficking has continued to be an issue. In the 1970s, there was an increased number of foreign-born sex workers in Europe, with a large percentage originating from Southeast Asia. By the 1980s, more women from Africa and South America were entering into the sex work trade in Europe [1]. However, it was not until the 1990s that human trafficking gained global media attention, particularly as it related to women from Eastern Europe and the former Soviet Union. One reason it is believed the public embraced this social problem at that time was because the victims were depicted as white and innocent, women whose lack of education and socioeconomic advantages made them prey to human traffickers. Portrayed in this manner, there was public sympathy and outcry to provide assistance [1]. Fears of "white slavery" in the 19th century stemmed from anxieties about outside intrusion. Today, human trafficking, a modern-day slavery, evokes fear stemming from multiculturalism. For those in developing countries, it symbolizes the encroachment of Western values [2].

Although human trafficking has always existed, it has begun to garner increased attention as a result of awareness and outreach efforts. All social problems compete for attention, and various groups will make compelling claims about social problems using persuasive rhetoric and dramatic statistics [3]. More than just a human rights issue, it has garnered attention from feminists, religious conservatives, labor activists, immigration specialists, and the mental health professions [22]. Furthermore, attention will be drawn from the media, politicians, organizations, and public, all of whom will respond to the gravity of the condition. It is through this process of claims-making and counter claims-making that "conditions" that may not necessarily have initially attracted attention can develop into a recognized social problem [3]. How the problem is described or constructed will influence public opinion, which will then ultimately facilitate action from governmental agencies, social service organizations, and international agencies [4,5].

This course will provide a basic overview of human trafficking (e.g., the scope, definitions and frameworks, contributing factors, different forms). The course will attempt to provide practitioners a glimpse of the lives of human trafficking victims, including physical, psychological, social, and sexual abuse that human trafficking victims experience and the types of control tactics perpetrators use. Specific interventions and responses will be covered, including mental health, social services, educational, prevention, and legal efforts. Finally, for practitioners who do work with human trafficking victims, the emotional toil that it takes upon practitioners as well as the importance of self care will be discussed. The course will end by offering an array of resources. Practitioners will be encouraged to view films and documentaries about human trafficking, as this is one way to "enter the lives" of human trafficking victims and better understand the dynamics of the complex world of human trafficking.

SCOPE OF HUMAN TRAFFICKING

As the issue of human trafficking is so complex, it is difficult to determine the scope of the problem. Many scholars and researchers believe that published estimates are just educated guesses. On a global level, the United Nations has estimated that [4]million people are trafficked every year, but has since stated that this estimate may not be methodologically sound [31,108]. In 2015, nearly 6,000 cases of human trafficking were reported in the United States, though the actual number of victims is believed to be much greater [107]. Overall, it is estimated that [27]million men, women, and children are being trafficked globally at any given time [27].

The estimates for the United States are equally unclear, but some approximate that 14,500 to 17,000 individuals are illegally transported to the United States every year for the purpose of exploitation [31]. Weitzer's content analysis of websites and publications about human trafficking found that human trafficking is portrayed as an epidemic, growing at alarming rates, with some government reports estimating 40,000 to 50,000 individuals trafficked in the United States each year [33]. Weitzer argues that many of the reports have overestimated the scope of the problem and points out that the estimates fluctuate drastically year to year [29]. The U.S. Department of Justice reported 161 convictions for human trafficking-related crimes in 2013, including forced labor and sex trafficking of adults and minors. This was an increase of more than 13% over the number reported in 2010 [32].

DEFINITIONS OF HUMAN TRAFFICKING

The United Nations defines human trafficking as [6]:

The recruitment, transportation, transfer, harbouring or receipt of persons, by means of 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. Exploitation shall include, at a minimum, the exploitation or the prostitution or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs.

In essence, this definition involves three elements: the transport of the person, the force or coercion of the victim, and the abuse and exploitation [47]. The United Nations Office on Drugs and Crime divides the definition of human trafficking into three sections: the act, means, and purpose [7]. The act, or what is done, generally refers to activities such as recruitment, transportation, transfer, harboring, or receipt of persons. The means of trafficking consists of threats or use of force, coercion, abduction, fraud, deception, abuse of power or vulnerability, or giving payments or benefits to a person in control of the victim. Finally, these acts are carried out for the purpose of exploitation, which includes prostitution, sexual exploitation, forced labor, slavery or forced servitude, and the removal of organs [7]. It is important to remember that human trafficking is not human smuggling. Human smuggling involves an individual being brought into a country through illegal means and is voluntary. The individual has provided some remuneration to another individual or party to accomplish this goal [8].

In many cases, women and children are considered the typical victims of human trafficking. Hart posits that women are more vulnerable to trafficking due to the lack of social safety nets in many developing countries [9]. Coupled with women's subordinate social statuses in many cultures, this leads to the "feminization of poverty." Although the social conditions may make women and children more vulnerable to human trafficking, the reality is that men are also victims of human trafficking.

FORMS OF TRAFFICKING

SEX TRAFFICKING

The Victims of Trafficking and Violence Protection Act (VTVPA) of 2000 (PL 106-386) is a United States federal statute passed by Congress to address the issue of human trafficking and offers protection for human trafficking victims. This statute defines sex trafficking as, "the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act" [10]. A commercial sex act is, "any sex act on account of which anything of value is given to or received by any person" [10]. In other words, it involves the illegal transport of humans into another country to be exploited in a sexual manner for financial gains [11]. Victims of sex trafficking could be forced into prostitution, stripping, pornography, escort services, and other sexual services [12]. Victims may be adult women or men or children, although there is a higher prevalence of women and girls. The term "domestic minor sex trafficking" has become a popular term used to connote the buying, selling, and/or trading of children for sexual services within the country, not internationally [12]. In the United States, the children most vulnerable to domestic minor sex trafficking are those who are homeless, abused, runaways, and/or in child protective services [12].

Although highly controversial, it is said that sex trafficking victims differ from prostitutes in that sex trafficking victims are forced to involuntarily perform sexual services and are often not paid for their "work." On the other hand, individuals involved in prostitution make a decision to provide sex services for a fee. The decision to enter prostitution does not eliminate the possibility of being a victim of trafficking if one is held against his/her will through physical and/or psychological abuse [27]. It is also important to remember that this does not necessarily mean prostitution is a choice these individuals would have made if other options were available or that they have a choice in selecting their sexual partners and/or sexual activities [13].

BONDED LABOR/FORCED LABOR

The United Nations has defined debt bondage as [14]:

The status or condition arising from a pledge by a debtor of his personal services or of those of a person under his control as security for a debt, if the value of those services as reasonably assessed is not applied towards the liquidation of the debt or the length and nature of those services are not respectively limited and defined.

Essentially, because the individual does not have money as collateral for the debt owed, the individual pledges his/her labor or, in some cases, the labor of a child or another individual for an unspecified amount of time [15]. These individuals may be transported or trafficked into another country for the purpose of forced labor.

In many cases of bonded labor, the initial loan may be welcomed by the individual. However, the victims do not realize that with the low wages, unspoken high interest rates and other continually accruing fees, and the owner's manipulation of the "accounts," laborers can never repay the loans. Some families find themselves in a cycle of poverty as the debt cannot be paid off and is passed down from generation to generation [15]. Bonded labor can involve laborers in brick kilns, mines, stone quarries, looming factories, agricultural farms, and other manufacturing factories [15]. In the United States, individuals may be trafficked to work long hours in garment factories, restaurants, and other manufacturing sectors. Frequently, the employer/captor will take away victims' identifications, monitor their movements, socially isolate them, and/or threaten deportation if they do not comply [16]. Migrant workers are at high risk of forced labor [27].

In the United States, forced labor is predominantly found in five sectors [16]:

  • Prostitution and sex industry (46%)

  • Domestic servitude (27%)

  • Agriculture (10%)

  • Sweatshops and factories (5%)

  • Restaurant and hotel work (4%)

It is speculated that most of the forced labor occurs in California, Florida, New York, and Texas, all major routes for international travel [16].

Domestic servitude refers to a category of domestic workers (usually female) who work as servants, housekeepers, maids, and/or caregivers, often in private homes. In some cases, young women are lured with the promise of a good education and work, and when they arrive in the United States, they are exploited economically, physically, and/or sexually. Their passports or identification papers are taken away, and they are told they have to pay off the debt incurred for their travel, processing fees, and any other bogus expenses. Because they do not speak English, they find they have no other recourse but to endure exploitive working conditions [17]. Unfortunately, as in many sectors of forced labor, there are no regulations to monitor the conditions under which domestic servants operate [16].

CHILD LABOR

Child labor can be viewed as a specific form of bonded labor or forced labor. However, not all child laborers have been trafficked. Child labor is defined by International Labour Organization (ILO) as economic labor performed by a child younger than 15 years of age. Child labor is deeply rooted in poverty and the infrastructure and political stability of the country as well as market forces [18]. The ILO estimates that there are 168 million child laborers in the world [48]. Between 2000 and 2012 there was a nearly 33% decrease in the number of children in child labor. The reduction was greater for girls (40%) than for boys (25%). The largest numbers of child laborers are found in Asia and the Pacific region [48].

The definition of child labor is controversial because the definitions for "work" and "childhood" are ambiguous and often culturally defined [20]. On a conceptual level, work may be beneficial for the socialization and educational processes of children [20,56]. So, it is important to differentiate between child work and child labor. Child work has been defined as activities that are supervised by an adult and that promote the development and growth of the child, while child labor does not benefit the child [18]. Many definitions of child labor create a dichotomy whereby child work is considered not harmful while child labor has negative emotional, intellectual, and social consequences [21]. Work that is exploitive for children has been defined as working long hours at a young age, work that is poorly compensated, and work that produces physical, social, and psychological stress that will hamper development, access to education, and self-esteem [23]. The ILO adds that child labor is work that interferes, deprives, and interrupts schooling and places children in the position of trying to balance school and long work hours [56].

CHILD CONSCRIPTION

In some cases of trafficking, children are kidnapped and trafficked to serve as soldiers. It is estimated that at any one time 250,000 to 300,000 children younger than 18 years of age are currently serving as child soldiers [24,72]. Traffickers prefer to recruit children to serve as soldiers because they are inexpensive and more easily molded and shaped to comply and obey without question [25]. They are also more likely to kill fearlessly and recklessly. Child soldiers are treated as adults, without any regard to how the physical and psychological rigors of war will affect them psychologically and developmentally. In Uganda, where children are kidnapped or recruited as child soldiers relatively often, the Lord's Resistance Army has been known to initiate new child soldiers in brutal ritualized killings of others so as to terrorize them into submission and annihilate any moral conscience they may have about killing [25].

It can be difficult to comprehend the atrocities that these children witness and experience. Bayer, Klasen, and Adam conducted a study involving 169 former Ugandan and Congolese child soldiers who were an average of 15.3 years of age [26]. Almost all (92.9%) reported having witnessed a shooting, 89% witnessed someone wounded, and 84% witnessed someone seriously beaten. A total of 54.4% reported having killed someone, and 27.8% reported that they were forced to engage in sexual activity [26]. In another study, the researchers found that the experience of conscription among children produced significant emotional and psychological traumas and a host of cognitive and behavioral problems [27]. In this study of 19 child soldiers, 18 had volunteered to join the army and one had been abducted. Although most of the children volunteered into the army, their participation became involuntary. Some tried to run away or disobey, which resulted in beatings and imprisonment. If captured, they were told to commit suicide [27]. The reintegration of child soldiers is not easy. Many are stigmatized when they return to their home villages, as their families and friends fear that these former child soldiers may be violent [72].

Girls as young as 9 years of age may be abducted or given to serve as soldiers, sex slaves, cooks, and/or wives for soldiers; an estimated 40% of child soldiers are girls [19]. These children are also stigmatized, perhaps even more so given the cultural value placed on female virginity before marriage. These young girls may have committed acts of violence, experienced sexual abuse, and/or been pregnant [74]. As a result, they are often rejected by their families if they return home [72].

FACTORS THAT CONTRIBUTE TO HUMAN TRAFFICKING

GLOBALIZATION

Human trafficking has been called one of the "darkest sides of globalization" [35]. Globalization is the term used to describe the interconnectedness of countries and nations, which facilitates easy communication, exchange of ideas, and flow of goods, capital, and services [35]. Crimes such as human trafficking are affected by globalization just as legitimate businesses are [45]. Furthermore, the ideals of Western capitalism may reinforce human trafficking as a business or industry, with its emphasis on the free market and the flow of goods and services across international borders [45].

POVERTY

Poverty and incessant economic stressors caused by civil wars, natural disasters, and collapses of government systems all contribute to human trafficking [9]. Families entrenched in deep poverty may feel they have no other recourse but to sell a child or may be more easily lured with promises of money and better future [78,79].

CORRUPTION

Human trafficking cannot occur without the existence of corruption within existing infrastructures. Public officials, police officers, and local leaders in many developing countries have been known to take bribes to provide protection to parties involved in various aspects of human trafficking [35].

DIGITAL TECHNOLOGY

The rampant use of digital technology, such as the Internet, greatly facilitates sex trafficking. The relative anonymity of online contact can empower traffickers to recruit or sell victims. Graphic images of women and children engaged in sexual acts can be easily disseminated over the Internet [46]. Traffickers may employ the Internet for advertising, marketing to those interested in making pornography [46]. In addition, social media sites such as Facebook, Craigslist, and Instagram have been used as a means of facilitating trafficking [80]. Newsgroups offer opportunities for those interested in locating women and children for sexual exploitation.

In a 2013 qualitative study, smartphones were found to be integral in the business of trafficking [80]. Researchers indicated the phones were used "to maintain contact with each other, in order to facilitate the business 'transactions' and stay in touch with transnational 'partners' and other traffickers who remained in the country of origin" [80].

RACIALIZED SEXUAL STEREOTYPES

Race and ethnicity have been inextricably linked to sexual violence and victimization. Myths regarding sexuality in certain cultures or racial fetishization may affect trafficking patterns. For example, there is an over-representation of Asian women on American Internet pornography sites in part due to popular myths sexualizing, eroticizing, and exoticizing Asian women. This has translated into trafficking, as traffickers respond to the demand for young Asian women and girls in part fueled by these stereotypes of exotic, docile, submissive, and eager-to-please Asian women [17].

These racial stereotypes go beyond simply framing the victims in a particular manner [81]. They raise implicit questions regarding how the powers of state are depicted. In other words, the patriarchal attitudes of certain countries lead to "bad" or "backward" cultural practices or ways of being that then cause trafficking—setting up is a dichotomy of the "West" and "others" [81].

CULTURE

Although many are careful in linking cultural factors to the etiology of human trafficking for fear of imposing judgment on a particular culture, many maintain that cultural ideologies that tolerate sexual trafficking, bonded labor, and child labor may be a stronger factor than poverty in predicting trafficking rates [17,23]. For example, some cultures emphasize collectivism and prioritizing the needs of the family and group first before the needs of the individual. Some children may feel they have to sacrifice themselves for their family when traffickers promise money [17]. Traffickers also know that they can threaten to hurt victims' families to keep them from escaping [17].

Furthermore, in many cultures, boys are more highly valued than girls, and as a result, girls are considered more dispensable [17]. Sons are considered the family's social security, staying with the family while daughters marry into other families. Therefore, girls may be more likely to be sold into slavery than boys.

Child labor is also inextricably tied to cultural factors. In India, for example, child labor is common because it is believed that children in the lower levels of caste system (i.e., the "untouchables") should be socialized early to understand their positions in society [23]. It has been observed that when traditional cultural and societal norms about women's roles were relaxed in some European countries and more women entered the labor force, child labor decreased [23]. Ultimately, it is difficult to unravel the effects of poverty and culture because the pressures of poverty can lead families to use tradition as a justification to sacrifice young men, women, and children [23].

Ultimately, the conversation about human trafficking is complex, and to attempt to isolate the causes is beyond challenging. Multiple factors have been suggested as possibly predicting human trafficking, including macroeconomic factors (e.g., gross domestic product per capita), unemployment rates, female inequality, and lack of protection of women's rights [82]. In one study, ease of land access to the destination country appeared to be a powerful predictor in terms of the number of individuals trafficked [82].

BARRIERS IN STUDYING HUMAN TRAFFICKING

Although the United Nations definitions are used in this course, scholars, practitioners, researchers, and policy makers have not come to a consensus definition of human trafficking. Consequently, terms such as sexual slavery, human smuggling, and modern-day slavery have all been used [28]. When the term human trafficking is utilized, it often has connotations of sexual exploitation affecting mainly women and girls, the most visible victims, but this is not accurate [28]. This perspective is partially attributable to the large number of religious and feminist organizations who have worked to eradicate prostitution [29]. This lack of consensus definition also raises questions about the study population in the research. The involved parties (i.e., the trafficker, those who are trafficked, and the networks) are continually changing in time and space [83].

Defining these terms is essential because it will ultimately influence responses to human trafficking. As stated, all social problems are competing for attention and resources, and the response is influenced by how the social problem is defined and portrayed [3]. Ultimately, the lack of a consensus definition is one of the reasons studying human trafficking has been a challenge and that research yields unreliable prevalence estimates.

Another reason human trafficking has been a difficult topic to research is the hidden and invisible nature of its victims and perpetrators. This makes it difficult for researchers to use traditional sampling methods. Even if trafficked victims are identified, perpetrators can move them to new locations [30]. If and when researchers access this hidden population, victims are often reluctant to talk due to fear, shame, and the stigma associated with their experiences. Consequently, much of what has been studied has relied on interviews with professionals (e.g., lawyers, advocates, police/law enforcement, and other service providers), which has led to recommendations that are not based on firsthand accounts [84].

A host of ethical issues also arise for those conducting research in this area. Protecting study participants' identities is paramount, and consequently, study participants signing informed consent forms, which are often required by institutional review boards, becomes complicated. Understandably, victims and perpetrators often will not want to sign forms using their real names for fear of deportation, arrest, and/or reprisals [30].

PERSPECTIVES OF HUMAN TRAFFICKING

Several perspectives have been employed to understand human trafficking and exploitation, including feminist, criminal justice/criminology, migration and labor, human rights, and labor rights perspectives. Each offers insight into how the problem is viewed and presented.

FEMINIST PERSPECTIVE

The feminist perspective frequently equates human trafficking with prostitution or sexual slavery [34]. Feminist scholars argue that human trafficking is an extreme form of violence against women or a form of commodification of women's bodies [1]. Female victims are often coerced and threatened physically and psychologically by a third party. The women's economic situations and their families' poverty reinforce their powerlessness [30]. When viewed from the feminist perspective, human trafficking, particularly sexual trafficking, entails coercion and exploitation perpetuated by patriarchal norms and institutions [1]. Feminists would maintain that social and economic circumstances that lead to gender inequality ultimately result in women and children being vulnerable to human trafficking schemes.

CRIMINAL JUSTICE/CRIMINOLOGY PERSPECTIVE

A second lens used to frame human trafficking is a criminal justice or criminology perspective, which focuses on assigning blame and guilt, potentially charging the victim for criminal activities such as illegal migration or prostitution [36]. For example, entering the United States illegally is a crime, and law enforcement could view the trafficked person as a criminal co-conspirator [37]. This is important because the United States government is struggling to address the illegal immigration issue; those adhering to this perspective would view all "irregular" migrants in the United States as criminals first. When individuals are shown to have been abused and exploited, they are then recast as victims [28]. Similarly, human sexual trafficking is often equated with prostitution and is viewed as morally sinful and evil [36]. This perspective conceptualizes trafficking as an elaborate system of organized crime networks that sponsors a hugely profitable industry [38].

MIGRATION AND LABOR PERSPECTIVE

The migration and labor perspective focuses on the illegal movement of people across national or international borders [1]. The labor dimension is concerned with workers who are exported from economically weak to affluent countries who may end up being exploited and abused [39]. This perspective classifies countries as either sending or receiving [35]. Some countries, such as Ukraine, are considered sending countries, as they tend to experience the recruitment and transit of citizens to other countries. Other countries, such as the United States, are predominately receiving countries, the destinations of trafficked individuals [35]. This perspective highlights the "push-and-pull factors" that lure the poor to more affluent countries [35]. Push factors are those environmental conditions that "push" or motivate individuals to leave their country [82]. A key push factor for many countries is poverty and the incessant economic stresses of civil wars, natural disasters, collapses of governmental systems (as in the Soviet Union), and lack of economic growth [9]. On the other hand, the pull factors generally involve the needs of businesses to find laborers to fill low-wage jobs [9]. These types of conditions create an excess pool of potential victims from which traffickers select [82].

To further complicate matters, the issue of transit countries should also be considered. Transit countries are found in the middle of a trafficking route [85]. For example, traffickers in Asia, and specifically South Korea, commonly send victims through Canada with the ultimate destination of the United States. In this chain, Canada would be considered a transit country. Transit countries shared several common characteristics [85]:

  • They are convenient or easily accessible to the receiving countries by land, air, or sea.

  • They have poor systems in place to deal with traffickers.

  • Immigration laws are liberal.

  • A strong underground criminal infrastructure is in place to support trafficking.

HUMAN RIGHTS PERSPECTIVE

The human rights perspective focuses on the link of human trafficking to historical forms of slavery and the denial of human rights and dignity. Human rights are often considered the natural and universal rights or laws for human beings [81]. However, the issue is not this simple—it is important to consider what these universal conditions are and to what extent Eurocentrism is instilled in the work of human rights activists [81].

As with slavery in the 18th and 19th centuries, trafficking victims today have no choice over their abusive and exploitive conditions. Unlike the "older" forms of slavery, this modern form is an outcome of globalization [28]. The human rights perspective also argues that, to some extent, the general public indirectly contributes to the problem of human trafficking as consumers in the global market [28]. In a study of how human trafficking is socially constructed, the videos being examined portrayed general consumers and corporations as perpetrators of human trafficking in addition to pimps, crime organizations, and middlemen recruiters [40].

LABOR RIGHTS PERSPECTIVE

The labor rights perspective is concerned with the rights of illegal migrant workers in the United States. This perspective incorporates elements of the human rights, feminist, and migration/labor perspectives; however, the difference is that this perspective encompasses all forms of labor and frames sex work as an economic activity [34]. For example, some women engage in sex work intermittently to supplement their income while others rely on sex work for their main or sole income [86]. Advocates in this camp fight for laws and policies that create rights to protect migrant workers and lift the legal restrictions on illegal immigration [34].

These wide-ranging perspectives help to frame the problem and influence public response. When human trafficking is framed as an illegal immigration activity, the public response is generally unsympathetic [1]. When human trafficking is viewed as a cultural remnant of patriarchy and inherent to the institutional landscape and when victims are portrayed as young women and girls, the public may be more sympathetic to their plight. It is important to remember that each perspective will also highlight the different victims involved. For the most part, the media does not portray trafficked victims to include agricultural workers, domestic workers, or factory workers [47].

THE TRAFFICKING EXPERIENCE

Five stages of the trafficking experience have been identified [41,87]:

  • Pre-departure stage: The period before the victim becomes involved in the trafficking situation. This may include recruitment and preparing for travel.

  • Travel and transit stage: The time after recruitment during which the victim "agrees" or is coerced into the trafficked situation. This phase also includes the journey whereby the trafficker(s) brings the victim(s) to their work destination. It is important to remember that this stage can be very dangerous and can involve numerous transit points.

  • Destination stage: This is the period during which the victim arrives at the intended destination. This stage is marked by exploitation, abuse, victimization, and coercion. One way to control the victims is to continually inflate their debt so they have to constantly work to pay it off.

  • Detention, deportation, and criminal evidence stage: If a victim is arrested by the police or immigration authorities, victims are held in legal proceedings and they often fear deportation, and/or retaliation from the trafficker(s).

  • Integration and re-integration stage: During this stage, government and nongovernment agencies provide services to victims that involve a long process of attempting to reintegrate the victim back into his/her community.

TRAFFICKERS: AN OVERVIEW

Much attention has been focusing on victims of trafficking; however, it is important to also understand the perpetrators.

Methods of Recruitment

It has been suggested human traffickers employ five general strategies to recruit and traffic victims [42,88]:

  • Kidnapping: Traffickers may kidnap their victims. They may lure them with food or treats or take them by force. Victims with few if any social ties are highly vulnerable, as no one will miss them or report their disappearance.

  • Targeting poor families: Traffickers may convince families to sell their children (often daughters). Because many families in developing countries live in abject poverty, traffickers will stress to victims' families how the money will help them to survive. Other traffickers may tell families that selling their daughter will provide her with more promising opportunities.

  • Fake storefronts: Some employment, modeling, or marriage agencies are fronts for illegal trafficking operations. A potential victim might be lured with the promise of employment, a lucrative modeling contract, or an arranged marriage in the United States. After victims have been lured in, traffickers come to assess their "product."

  • Legal storefronts: Some legal businesses in the tourism, entertainment, and leisure industries integrate trafficking activities into their business structure.

  • Recruiting local prostitutes: Traffickers might purchase prostitutes working in local night clubs from brothel owners or simply lure prostitutes by promising them a more affluent future.

In some cases, the perpetrators are family members, friends, or acquaintances of the victims and families. In a study focused on child trafficking in Albania, interview participants indicated that some trafficking recruiters were individuals known to the families [43]. They would tell stories of better opportunities, such as jobs and/or education for the child and the ability of the child to send money back to their family, in order to recruit new victims. Recruiters or pimps are often women who had been lured into the sex industry themselves. One study found that 60% of the perpetrators were female who reported that they felt the only way to survive and even possibly escape was to lure other young women [89]. This is a particularly common practice in Thailand [87].

The Financial Profits

Unfortunately, human trafficking can be a lucrative business. According to the ILO, profits from forced labor, trafficking, and modern slavery are estimated to be $150 billion annually [90]. The majority of this total is attributable to commercial sexual exploitation ($99 billion) followed by construction/manufacturing/mining ($34 billion), agriculture ($9 billion), and domestic work ($8 billion) [90].

The receiving country and location of trafficking will affect the profits. For example, if a girl is kidnapped from a village in Nepal and taken to India, she can be sold in India for $1,000 [42]. If she is then trafficked to the United States, she could be sold for $20,000.

Interestingly, the "cost" of a slave has not risen over time. According to Bales, the cost of obtaining a slave to work in the agriculture sector in 2007 was about $100; in 1850, this same slave would cost the equivalent of $40,000 in 2007 currency [44].

CONSEQUENCES OF HUMAN TRAFFICKING: IMPACT ON VICTIMS

The social realities of victims of human trafficking are difficult to comprehend, and some may wonder why victims remained silent and complied with their traffickers. The Silence Compliance Model was created to explore the factors that promote victims' seeming willingness to comply to their traffickers' demands [91]. This model has three categories: coercion, collusion, and contrition. Victims are coerced, brutalized, and threatened, and basic necessities of life are withheld from them. This serves to silence victims and create a sense of helplessness. Victims are then forced to collude with the traffickers as a result of their relative isolation, fear, false sense of belonging, and complete dependence on the trafficker. Finally, victims feel contrite, ashamed, stigmatized, and remorseful of the things they have been made to do [91].

PSYCHOLOGICAL AND MENTAL HEALTH CONSEQUENCES

Victims of trafficking experience a host of psychological, mental health, and emotional distress. Post-traumatic stress disorder (PTSD) is common given the trauma many victims experience, including physical and/or sexual violence and abuse; victims forced into prostitution experience continual, daily sexual assault [49]. In a study of 192 European women who were trafficked but who managed to escape, the overwhelming majority (95%) disclosed that they experienced physical and sexual violence during the time of their trafficked experience [50]. More than 90% reported sexual abuse, and 76% reported physical abuse.

Trafficked victims experience fear from the start of their capture through the transit phase and after they arrive at their destination. During the transit stage, many victims experience dangerous border crossings, risky types of transports, injury, beatings, and sexual assault [41]. Upon arrival to their destination, many trafficking victims have been socially isolated, held in confinement, and deprived of food. All sense of security is stripped from them—their personal possessions, identity papers, passports, visas, and other documents [41]. The continual fear for their personal safety and their families' safety and the perpetual threats of deportation ultimately breed a sense of loss of control and learned helplessness. It is not surprising that depression, anxiety, and PTSD are common symptoms experienced by trafficked victims.

In a study of 164 survivors of human trafficking who returned to Nepal, the authors examined the extent to which they experienced PTSD, depression, and anxiety [51]. All of the survivors experienced some level of these disorders, but the survivors who were trafficked for sex experienced higher levels of depression and PTSD compared to those who were not trafficked for sex. In a study with Moldovan survivors of human trafficking, researchers found that six months after their return, 54% had diagnosable mental health issue. Specifically, 35.8% met the diagnostic criteria for PTSD, 12.5% met the criteria for major depression, and 5.8% were diagnosed with an anxiety disorder [92].

There is also some evidence that trafficked victims may experience complex PTSD, a type of PTSD that involves an acute change of the victims' sense of self, their relationship with others, and their relationship with God or higher being [93]. These persons direct anger inwardly (toward themselves) in addition to toward their perpetrators, which results in a loss of faith in themselves and the world [93].

Substance abuse is also common among victims. In interviews, trafficked women discussed how traffickers forced them to use substances like drugs and/or alcohol so they could work longer hours, take on more clients, and/or perform sexual acts that they could not normally [41]. Other victims used substances as a means to cope with their situations.

Children forced into labor experience grueling hours and are frequently beaten by their owners. According to Clawson and Goldblatt, underage victims of domestic sex trafficking fluctuate through a range of emotions from despair, shame, guilt, hopelessness, anxiety, and fear [52]. Depending upon the level of trauma, some engage in self-destructive behaviors like self-mutilation or suicide attempts. For some, their ambivalence toward the perpetrators may be confusing. On the one hand, they want to escape the abuse, yet simultaneously, they may have a sort of traumatic bond with the perpetrators [52].

Children forced into conscription will also experience a host of psychological symptoms. In a study comparing former Nepalese child soldiers and children who were never conscripted, former child soldiers experienced higher levels of depression, anxiety, PTSD, psychological difficulties, and functional impairments [53]. In another study of former children soldiers from the Congo and Uganda, one-third met the criteria for PTSD [26]. The researchers found there was a relationship between greater levels of PTSD symptoms and higher levels of feelings of revenge and lower levels of openness to reconciliation [26]. In-depth narrative interviews of former child soldiers from northern Uganda found that the children spoke of the violence and atrocities they witnessed without any emotion, as if they had removed themselves from their experiences [94]. This speaks to how the victims have to numb themselves psychologically in order to cope. The researchers also found that the children who lost their mothers were more traumatized by this experience than the violence they witnessed as soldiers.

Some have argued that the diagnostic criteria of PTSD may not be easily applied to those from different cultures. As a result, it is important to assess for other psychiatric disorders, such as depression. Japan, for example, never used the PTSD diagnosis prior to 1995, despite the fact that they have a large and intricate mental health system [54]. Ultimately, PTSD cannot be universally applied to every culture and for every humanitarian crisis; therefore, if a human trafficking victim does not necessarily fall within the Diagnostic and Statistical Manual of Mental Disorders criteria for PTSD, one cannot necessarily conclude that they have not experienced trauma or are not traumatized [54].

SOCIAL CONSEQUENCES

When rescued and attempting to reintegrate into their communities, victims of human trafficking often experience stigma, ostracism, and marginalization [53]. For example, in Nepal, community members perceived returning child soldiers who had performed acts such as carrying dead bodies or coed sleeping as in violation of Hindu cultural norms [53]. One documentary following former child soldiers living in a refugee camp in northern Uganda found that preconceived notions and myths about children soldiers often led to ridicule and ostracism after they were liberated from the army and returned home.

However, girls who were recruited as soldiers, who were forced to have sex, or who return with children appear to be the most marginalized group [55]. In a qualitative study of former girl soldiers in Sierra Leone, researchers found that, compared to returning boy soldiers, girls were perceived to have violated gender norms and values about sexuality. Although psychologically and developmentally they were still children, the community perceived and treated them as "damaged" or "unclean" women. Their communities were not able to integrate them back in despite the victimization they experienced. These girls lacked voice and experienced shame, marginalization, poverty, and powerlessness upon their return [55].

HEALTH CONSEQUENCES

In one study of trafficked women, headaches, fatigue, dizziness, back pain, pelvic pain, stomach pain, and gynecological infections were common, generally the result of continual physical, psychological, and sexual abuse [50]. It is important to remember that some of these somatic complaints, such as headaches, fatigue, and gastrointestinal problems, may be underlying symptoms of anxiety, depression, and stress [50]. Some cultural groups might not use the terms "depression," "sad," or "anxious," but may use metaphors and somatic symptoms to describe their pain, all of which are embedded within cultural ideologies. The most common culture-based idioms of distress are somatic symptoms. Some groups tend not to psychologize emotional problems; instead, they experience psychological conflicts as bodily sensations (e.g., headaches, bodily aches, gastrointestinal problems, and dizziness).

Using an in-depth, direct interview survey designed to explore each stage of the trafficking experience, a multi-country European study identified a range of aversive health, sexual, and reproductive consequences common among women and adolescent victims of human trafficking [41]:

  • Pre-departure stage: All victims reported having had limited knowledge of the health implications of having sex with strangers, and only 1 in 25 felt well-informed regarding the risks of acquiring HIV or other sexually transmitted infections (STIs).

  • Travel and transit stage: Half of those interviewed reported having been confined, beaten, and/or raped during the journey.

  • Destination stage: A large majority reported having been "intentionally hurt" (as evidenced by contusions, lacerations, loss of consciousness, and signs of head trauma); subjected to solitary confinement and deprived of human contact and adequate food and nutrition; subject to a variety of physical ailments, including headache, fever, undiagnosed pelvic pain, urinary tract infection, STIs, rash/scabies, and oral/dental health issues. All had experienced repeated sexual abuse or coercion, and 1 in 4 reported at least one unintended pregnancy (often involving negative outcomes of abortions performed in unsafe and unhealthy conditions).

In the context of forced prostitution among trafficked victims, safeguards against infection (e.g., regular condom use), early diagnosis, and adequate antimicrobial treatment are inconsistently employed or absent entirely [41]. Consequently, in addition to unwanted pregnancy, the risk for pelvic inflammatory disease and subsequent infertility is relatively high. Moreover, the relationship between forced prostitution and HIV infection is stronger when sexual violence is involved. Women who are forced into prostitution are 11 times more likely to become HIV-infected than women who entered prostitution voluntarily [95]. Sexual violence may increase the transmission risk as a result of open abrasions and injuries to the vagina. Furthermore, sexual violence can negatively impact self-esteem, which could then deter victims from advocating more strongly for condom use [95].

Among child victims of human trafficking, healthy growth and development is especially problematic. Malnourishment and poor hygiene often lead to delayed bone growth, poorly formed teeth, and early dental caries [59]. The intense nature of child labor also has severe negative physical and health consequences. Children working in unsafe conditions without protection, such as in mines or mills, can lead to respiratory problems such as asthma and bronchitis [57]. A study of adult and child laborers on tobacco farms in Kazakhstan found that the workers were unaware that exposure to tobacco and pesticides could affect their health. Protective garments were also rare, which many children not even having gloves [96].

Under normal circumstances, young children are still developing physically; however, such adverse conditions can halt their development. The lungs of adolescent boys typically experience the most rapid growth around 13 to 17 years of age; working in conditions characterized by excessive toxic dust or unclean air makes them more vulnerable to developing silicosis and fibrosis [57]. In the United States, young children participating in agricultural work are at risk of the major traumas associated with farm work, such as injuries caused by tractors or falling from heights, in addition to those injuries associated with repetitive stress and exposure to toxins. Children have thinner layers of epidermis, which make them more vulnerable to the toxicity of pesticides, and this can ultimately increase their risks for certain cancers [57]. Children working in gold mines do intensive digging, lifting, and transporting and mix mercury with the crushed ore, often with their bare hands. Mercury toxicity can lead to neurological symptoms such as loss of vision, tremors, and memory loss [96].

IDENTIFICATION AND ASSESSMENT

Healthcare providers are often the most likely to encounter a victim of human trafficking under circumstances that provide an opportunity to intervene. Because human trafficking and exploitation are, by nature, covert processes, the identification and rescue of the victim can be difficult. Traffickers move victims from one area to another to reduce the risk of identification, and one of the main problems with the assessment of such individuals is that practitioners may only have a one-time encounter with the victim [98]. Bruises, scars, and other signs of physical abuse may be missed on examination, as victims are often beaten in areas hidden by clothing (e.g., the lower back) so as not to affect the victim's outer appearance. In a survey of 110 emergency department physicians, nurses, and physician assistants, the majority (76%) reported having a knowledge of human trafficking, but only 13% felt equipped to identify a trafficking victim and only 22% were confident in their ability to provide satisfactory care for such patients [106]. Less than 3% had ever received any training on this topic. In a separate survey of healthcare and social service providers, only 37% had ever received training on identification of trafficking victims [109].

With regard to episodic clinical encounters, recommendations for providing safe assessments in a culturally sensitive manner are lacking. The Department of Health and Human Services Administration for Children and Families maintains a useful website that addresses practical issues of human trafficking for allied professional groups, known as the Rescue and Restore Campaign [59]. Included are diagnostic and interviewing tips to help healthcare providers recognize, intervene, and refer trafficking victims. Emergency and primary care providers should be cognizant of clues that a patient may be the victim of trafficking and prepared to engage in greater depth of inquiry with special attention to the following indicators [59,65,97]:

  • Does someone, other than family, who behaves in a controlling manner, accompany the patient? Traffickers attempt to guard and control most every aspect of the victim's life, while maintaining isolation from family, friends, and other common forms of human interaction.

  • Does the patient speak English? If not, has he or she recently been brought to this country, and from where? Many victims of human trafficking have recently been trafficked from other countries. As discussed, common sending countries/regions include Eastern Europe, Asia, Latin America, Africa, India, and Russia.

  • If the patient is accompanied by someone other than a family member, who does the talking, and why? Attempt to interview and examine the patient separately and alone, using an interpreter if necessary. Probe in a sensitive manner for detailed information on the situation and relationship.

  • Does the patient show signs of psychosocial stress (e.g., appears withdrawn, submissive, fearful, anxious, depressed)? Can the individual account for this?

  • Are there visible signs of physical abuse (e.g., bruises, lacerations, scars)? How does the individual explain these?

  • Does the patient lack a passport or other immigration and identification documentation (e.g., driver's license, social security number, visa)? If so, what explanation is given?  To control victims' movements, traffickers often take away passports and any legal identification documents.

  • What is the patient's home and work situation? Basic questions about what they eat, where they live and sleep, who else lives with them, and what work they do can be revealing. For example, "Can you leave your work or job situation if you wish?" or "When you are not working, can you come and go as you please?"

  • Is the explanation given for the clinical visit consistent with the patient's presentation and clinical findings?

If answers to these questions indicate that an individual may be a victim of human trafficking, one should contact the National Human Trafficking Resource Center at 1-888-373-7888. Under the child abuse laws, practitioners who are mandated reporters and who are suspicious that a minor is being abused should immediately report the abuse. For more information regarding specific states' reporting requirements, please visit https://www.childwelfare.gov/topics/systemwide/laws-policies/state.

INTERVIEWING TRAFFICKED VICTIMS: BEST PRACTICE GUIDELINES

Service providers should repeatedly weigh the risks and benefits of various actions when interviewing human trafficking victims [88,99,100]. The following interviewing recommendations were published by the World Health Organization to encourage service providers to continually and ethically promote human trafficking victims' safety during every phase of the interviewing process [66]:

  • Each victim and trafficking situation should be treated as unique; there are no standard templates of experiences. Listen carefully to the victim's story. Each story told is unique, and each patient will voice distinctive concerns. Believe each story, no matter how incredible it may seem. As rapport and trust build (perhaps very slowly), accounts may become more extensive.

  • Always be safe and assume the victim is at risk of physical, psychological, social, and legal harm.

  • Evaluate the risks and benefits of interviewing before starting the interviewing process. The interviewing process should not invoke more distress. In other words, the interviewing process should not end up re-traumatizing the victim.

  • Provide referrals for services where necessary; however, it is necessary to be realistic and not make promises that cannot be kept. Trust is vital because it has been severed on so many levels for trafficking victims.

  • Victims' readiness to change will not be based on what societal defines as "ready" or social expectations. Some victims will eagerly grasp new opportunities, while others may be fearful of potential traffickers' threat and be less receptive to help.

  • Determine the need for interpreters and if other service providers should be present during the interviewing phase. Ensure that everyone involved is adequately prepared in their knowledge about human trafficking, how perpetrators control their victims, and how to ask questions in a culturally sensitive manner. Keep in mind that often times, traffickers will offer to help with the interpreting.

  • All involved should be prepared for an emergency plan. For example, is there a set plan for a victim who indicates he/she is suicidal or in danger of being hurt?

  • Always be sure to obtain informed consent. Remember the informed consent process is going to be unfamiliar to many victims. In addition, self-determination and autonomy have been compromised by continual threatens and being forced to commit dehumanizing acts. Avoid using legal and technical jargon.

INTERVENTIONS

EDUCATION AND PREVENTION

Education is believed to be a key ingredient in the prevention of human trafficking. Raising awareness through advertisements, campaigns, and other creative vehicles regarding recruitment threats, the various deception techniques employed, the different forms of human trafficking, and the consequences of human trafficking can decrease the incidence [42,58]. Because the general public often believes human trafficking is a problem that only occurs in developing countries, there is a clear need for public education about trafficking and safety for young children and women in and outside the United States [12]. The Campaign to Rescue and Restore Victims of Human Trafficking provides brochures and posters about human trafficking, which are available to be ordered (at no cost) from http://www.acf.hhs.gov/orr/rescue-campaign [59]. Posting these brochures or posters increases the possibility that a trafficked victim will self-report [100].

Education about human trafficking has become a higher international priority. Innovative and creative approaches are being implemented to disseminate information about human trafficking. For example, groups have used street plays to educate communities about child labor dangers in India [61].

Although the topic of human trafficking has become more common in public discourse, service providers and law enforcement authorities remain under-educated about human trafficking. They are not sure what to look for, what to ask, and what to do if they do identify individuals who are victims of human trafficking [58]. Law enforcement officials require training to identify and assess potential victims at various borders and ports of entry. If a minor is accompanied by an adult who is not the child's parent or legal guardian, this should raise a red flag [58]. Furthermore, to work effectively to identify human trafficking victims, there is a need for service providers to navigate and collaborate with a complex host of government, social service, mental health, and nongovernment legal entities [58].

MENTAL HEALTH AND SOCIAL SERVICES

When trafficking victims are rescued, a great deal of counseling services and practical, day-to-day assistance will be required. Housing, transportation, food, clothing, medical care, dental care, financial assistance, educational training, reunification (for those who wish to return to their homeland), and legal aid are some of the concrete services needed [91]. Practitioners should connect, coordinate, and case manage these services as much as possible.

As discussed, human trafficking victims experience an array of mental health and psychological issues. Mental health counseling is vital, but it is important to remember that the concept of counseling or talk therapy may be foreign to victims from non-Western cultures [88]. The expression of emotions may be in opposition to cultural values of emotional restraint, which can be intensified by feelings of shame and guilt resulting from experiences with sexual and physical assault. Beyond the paramount importance of the practitioner gaining the patient's trust, practitioners may educate patients about the counseling process and explore their patients' expectations about counseling, healing, and recovery [60].

Given differing cultural beliefs about healing, it is crucial that practitioners be open to alternative treatment and explore with patients the use of traditional healing methods [88]. There are many indigenous healing interventions victims may be using, including cultural rituals, faith healing, therapeutic touch, herbal remedies, and spiritual practices [62]. These interventions are multi-layered, taking into account the physical, psychological, communal, and spiritual [62]. These healing methods are historically rooted in specific cultures, and therefore, practitioners should become familiar with traditional healing methods and how they can be integrated with Western counseling techniques [60]. For example, given many cultural groups' beliefs that unmarried girls are defiled if raped, a cultural cleansing ritual may be needed as a first step to help a community accept a returning victim who was sexually assaulted during her trafficking experience [17]. After this ritual is performed, it is possible that both the patient and her family may be more open to counseling and other services.

Physicians, social workers, nurses, therapists, and counselors must be familiar with legal, educational, case management, educational, job and life skills training, and housing services in the community. Human trafficking victims are not only unfamiliar with navigating the social service system, but many are also not proficient in English. Therefore, practitioners will serve as coordinators and advocates, linking necessary services. In one study, the majority of agencies had to rely on collaboration in order to refer clients [101]. Social workers and practitioners relied on word-of-mouth and community meetings to learn about services in order to better meet the needs of human trafficking victims. Furthermore, because many community organizations and agencies are not familiar with human trafficking, practitioners must take a primary role in educating colleagues about the complex dynamics of human trafficking.

ADVOCACY

Physicians, social workers, nurses, allied health professionals, counselors, and psychologists will find themselves in multiple roles when working with victims of human trafficking. Advocacy is one of these roles and involves the practitioner being an agent for change. This consists of engaging in activities that alter the social conditions at the individual, family, community, and institutional levels [63]. One way to advocate on behalf of human trafficking victims is by signing petitions or joining credible organizations concerned with changing the circumstances that lead to human trafficking. Many organizations have petitions established on their websites for individuals to persuade policymakers, legislators, and government officials to advocate for the protection of human trafficking victims, create greater awareness of the problem, and prosecute traffickers, including:

LAWS AND POLICIES

Justice for Victims of Trafficking Act

In May 2015, the Justice for Victims of Trafficking Act (JVTA) became law, allowing survivors formal input in federal anti-trafficking policy and providing incentives for states to enact laws to prevent the prosecution of child victims for crimes committed as a direct result of being subjected to trafficking. The JVTA provides additional bases of criminal liability for those who patronize or solicit trafficking victims for commercial sex and creates a new offense prohibiting the advertising of sex trafficking activity. It also clarifies that traffickers in child sex trafficking cases who had a reasonable opportunity to observe the victim can no longer claim ignorance about a victim's age as a defense [27].

Victims of Trafficking and Violence Protection Act

A wide range of laws have been established to protect human trafficking victims and to prosecute perpetrators. A general knowledge of these laws is helpful when caring for victims and seeking appropriate social services. The VTVPA was enacted in 2000 and reauthorized in 2003, 2005, 2008, and 2013 by the Trafficking Victims Protection Reauthorization Acts [27]. It emphasizes the three Ps: prevention, protection, and prosecution [102]. The prevention component consists of training and awareness; the protection dimension gives trafficked victims the ability to receive services using federal funds like other refugees; and the prosecution component focuses on laws and policies for the prosecution of traffickers.

Because victims of trafficking are often viewed as criminals, this law states that victims of severe trafficking should not be penalized for any illegal behaviors or acts they engaged in as a result of being trafficked, including entering the United States with false documents or no documentation or working without appropriate paperwork [42]. This law also allows T Nonimmigrant Status (T visas) to be granted to victims of trafficking so they may remain in the United States with the purpose of collaborating with the federal authorities to prosecute the perpetrators. During this time, victims are offered a range of benefits and services, including access to the Witness Protection Program [42]. After three years, victims can apply for permanent resident status [8].

One of the criticisms of the Act is that it places the burden of demonstrating innocence and coercion on the victim [34]. The Act also fails to recognize the complex dynamics of human trafficking. Many victims have been abused and terrorized by the perpetrators, who they must now provide information and evidence against to stay in the country. Victims are continually fearful that they will be deported [34].

Victims who are of minor age are eligible for Unaccompanied Refugee Minors programs, the Children's Health Insurance program, and Temporary Assistance to Needy Families [58]. Furthermore, victims between 16 and 24 years of age are eligible for work permits and can apply for the Job Corps program [58]. However, it is important to remember that the key to this law is that the victim must have experienced a "severe form" of trafficking and the victim must be willing to assist in the apprehension and prosecution of the perpetrator to receive services [31].

Trafficking Victims Protection Reauthorization Act

The Trafficking Victims Protection Reauthorization Act was introduced and signed into law in 2013. It allocated $5 million in 2009, $7 million in 2010, $7 million in 2011, and $8 million annually through 2017 to provide services to victims and to prevent human trafficking [12,64,110]. It amends the VTVPA and assists foreign governments to implement programs to prevent human trafficking. Victims of human trafficking in other countries are also eligible for assistance through organizations that have grants from the U.S. government [64]. Greater monitoring of trafficking trends through databases will also be implemented. The Act also declares that it is not a defense that a defendant is not criminally liable or is subject to reduced criminal liability due to acceptance of the illicit conduct in the foreign jurisdiction.

The Prosecutorial Remedies and Other Tools to End the Exploitation of Children Today Act

The Prosecutorial Remedies and Other Tools to End the Exploitation of Children Today Act was enacted in 2003. This law maintains that all sexual activity with minors, within or outside the United States, is illegal. American citizens who engage in sex with minors in any country and who are caught will be prosecuted in the United States [42].

As of 2012, all 50 states have enacted criminal anti-trafficking laws. In addition, very state has a law on labor trafficking, and all but two states have passed criminal statutes for sex trafficking [103].

COUNTERTRANSFERENCE, SECONDARY TRAUMATIZATION, AND SELF CARE

INTERNATIONAL AND POLITICAL COUNTERTRANSFERENCE

International and political countertransference can occur when practitioners work with patients from other countries and cultural groups [67]. This is manifested on several levels. First, practitioners may assume that what works in the United States can be applied to immigrants and refugees. This enthnocentric view presupposes that Western paradigms about healing and well-being are universal to all cultures. Second, the Western construct of the healthcare or social service provider as an expert may promote unequal power relationships [67]. These attitudes can be quickly picked up by victims of human trafficking, which can negatively impact the rapport and trust building phases of the therapeutic relationship.

The most prevalent assumption is that because the victim has been abused and has undergone dehumanizing treatment, he or she will want to leave. Yet, trafficked victims have been known to miss their traffickers, have ambivalent feelings about leaving their situation, or feel that sex work is the only viable option for them [99]. This can be difficult for practitioners to accept.

Practitioners may be, consciously or unconsciously, affected by media depictions of particular cultural groups and the social problem of human trafficking [67]. Media portrayals can mold social norms and beliefs, which can then translate into ethnocentric, imperialist, or negative reactions and responses toward the victim. For example, human sex trafficking and prostitution are often linked by the media, and the practitioner's beliefs about prostitution can affect his or her relationship with the victim. A common instinctive reaction to prostitution is to remove the individual from the situation, with force if necessary [67]. Similarly, the media often shows young female human trafficking victims being collected by police officers. This may cause practitioners to believe on some level that victims of human trafficking are criminals. In many cases, the media perpetuates racialized and colonizing views of women of color who are victims of sex trafficking [34]. The colonizing depictions reinforce the myth that women from developing countries are helpless and powerless, deserving of our protection and worthy of being saved [34]. To what extent have these messages been internalized and how might these messages ultimately affect practitioners' attitudes and beliefs systems about human trafficking victims?

SECONDARY TRAUMATIZATION

The terms "secondary traumatization," "secondary traumatic stress," "secondary victimization," "vicarious traumatization," and "compassion fatigue" refer to the psychological impact of being in close contact with those who are directly affected by trauma and helping or wanting to help the victim. Figley has defined secondary traumatic stress as, "the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other" [68]. Vicarious traumatization consists of a "transformation of the inner experience of the therapist that comes about as a result of empathic engagement with patients' trauma material" [69]. Vicarious traumatization can include emotional and cognitive arousal symptoms such as increased emotional sensitivity, lack of well-being, intrusive thoughts, and difficulty concentrating [70].

Secondary trauma can affect practitioners' beliefs about the world, others, and self [71]. For example, humans have beliefs about safety, trust, sense of control, intimacy, and sense of esteem and competence [71]. But trauma, even indirect trauma, can disturb these beliefs. Trauma that is caused by another human (e.g., abuse) may be more difficult for practitioners to cope with because it is related to the issue of human evilness. Human trafficking certainly raises questions about how one human can inflict such terror upon another. Ultimately, this profoundly affects existing beliefs, more so than trauma caused by natural events (e.g., natural disasters) [71].

PRACTITIONER SELF CARE

In a study of clinicians who work with sexual abuse survivors, clinicians were asked what parts of their work were enjoyable. They indicated that they enjoyed being part of the journey and process of patients' growing, healing, and changing. Witnessing patients' resilience and strength also spurs clinicians' own personal growth. However, one cannot ignore that when practitioners who work with victims of trauma, including human trafficking, they enter the world of victimization, horror, and abuse through their patients' detailed and graphic stories. As a result of building a rapport and relationship with their patients, practitioners share their emotional burden. This can affect clinicians socially, psychologically, spiritually, and/or interpersonally. Self care is integral to the prevention of negative symptoms such as burnout, secondary traumatization, and compassion fatigue. Practitioners' education, training, and licenses do not necessarily provide effective shields to these types of stressors [73]. To some extent, practitioners might be more vulnerable to neglecting self care because rigorous academic studies and early professional training may have overlooked this aspect of professional life [73].

Self care can consist of an array activities that touch on the following domains: physical (e.g., exercise, nutrition, sleep), recreational (e.g., play activities, vacation time, hobbies), social support (e.g., interaction with friends, family members), and spiritual/religious (e.g., prayer, meditation) [70]. Self-care activities exist along a continuum, with proactive planning and reactive intervention on either end [70]. Practitioners should determine where along this continuum they will implement self-care activities. To be most effective, self care should be viewed as proactive rather than reactive when a specific stressor occurs. Practitioners should spend some time asking themselves about the specific behaviors they are currently engaging [70]. For example, what type of exercise regimen is the practitioner currently engaged in? How frequently? How often does the practitioner interact with friends (with whom specifically) [70]? A self-care plan might also include cognitive and stress management techniques, such as biofeedback, hypnosis, and other cognitive strategies. A self-care plan could also actively incorporate rest into day-to-day practice. Committing time daily to a meditation or deep breathing practice can be beneficial [104].

Practitioners are often told to "leave their work at work," but this is often not as simple as it sounds. A ritual may be needed to make a concrete transition from work to home, such as walking in silence around the block for 5 minutes before getting into the car to drive home [104].

The monitoring of self care is as important as establishing a plan. Self-care check-ins can be established, whereby practitioners are assigned to peers so they can hold each other accountable to their self-care plans [75]. Or if a practitioner is comfortable, a supervisor can incorporate this monitoring into his/her regular supervision.

When providing education and interventions to practitioners about self care and secondary traumatization, a message of "blaming the victim (practitioner)" can inadvertently be conveyed [76]. Practitioners may feel that they are perceived as weak because they are encouraged to take care of themselves. Along the same lines, organizations should determine if their culture and climate may implicitly convey a message that hinders practitioners from engaging in self-care activities. For example, is taking vacation time implicitly associated with a lack of commitment or dedication? If practitioners do not work overtime, do they feel they will be perceived as less motivated than their colleagues who are working overtime [77]? Is there space in the work environment for practitioners to relax? Ensuring that there is a designated space for practitioners to take breaks after emotionally difficult meetings with patients and their families can encourage self-care behaviors [77].

POST-TRAUMATIC GROWTH

Victims of tremendous trauma may experience PTSD and a range of negative consequences socially, emotionally, and relationally. However, post-traumatic growth can also occur. Post-traumatic growth refers to a set of positive changes that develop in response to trauma [105]. Some will grow relationally, with enhanced relationships with others and a greater sense of compassion for others. Some will grow in terms of seeing themselves in a new way and developing a stronger sense of identity. Others will acquire a new personal life philosophy of life and greater appreciation for life [105]. Practitioners witnessing post-traumatic growth may also experience a positive impact in their professional and personal lives.

CONCLUSION

Human trafficking is a severe human rights violation. Because the roots of human trafficking are multifaceted, no one solution exists to eliminate this problem. Unfortunately, as the problem grows, practitioners will be confronted with the issue in their patient populations. Practitioners should be committed to the collaboration amongst disciplines to address poverty, racism, discrimination, and oppression in order to reduce the vulnerable positions of human trafficking victims and their families. Because of the social justice component in the codes of ethics of professionals such as physicians, nurses, social workers, psychologists, and counselors, all practitioners can play a key role in the individual, community, and systemic levels to help address this gross abuse of power. One way to begin is to educate oneself and one's respective disciplines about the global nature of human trafficking and the complex dynamics of the problem.

RESOURCES

For more information and to become involved in advocacy movements, please utilize the following resources. In some cases, the tools provided may be valuable for patient and/or peer training.

ORGANIZATIONS

Coalition to Abolish Slavery & Trafficking
http://www.castla.org
Coalition Against Trafficking in Women--International
http://www.catwinternational.org
Human Rights Watch
http://www.hrw.org
Initiative Against Sexual Trafficking
http://www.iast.net
International Justice Mission
http://www.ijm.org
International Labour Organization
http://www.ilo.org
Office of Refugee Resettlement
http://www.acf.hhs.gov/programs/orr/programs/anti-trafficking
National Human Trafficking Resource Center (Polaris Project)
https://polarisproject.org
Salvation Army
http://www.salvationarmyusa.org
Sex Workers Project
http://www.sexworkersproject.org
U.S. Department of Health and Human Services
Administration for Children and Families
http://www.acf.hhs.gov
Services Available to Victims of Human Trafficking: A Resource Guide for Social Service Providers
http://www.acf.hhs.gov/programs/orr/resource/services-available-to-victims-of-human-trafficking
U.S. Department of Justice
Bureau of Justice Assistance
https://www.bja.gov
U.S. Department of Justice
Office for Victims of Crime
http://www.ojp.usdoj.gov/ovc
U.S. Department of Labor
Reducing Child Labor and Forced Labor
http://www.dol.gov/ilab/child-forced-labor
U.S. Department of State, Office to Monitor and Combat Trafficking in Persons
http://www.state.gov/g/tip

BOOKS

Bales K. Disposable People. Berkeley, CA: University of California Press; 2004.

Bales K. Ending Slavery: How We Free Today's Slaves. Berkeley, CA: University of California Press; 2007.

Bales K, Soodalter R. The Slave Next Door: Human Trafficking and Slavery in America Today. Berkeley, CA: University of California Press; 2009.

Bales K, Trodd Z, Kent A. Modern Slavery: The Secret World of 27 Million People. Oxford: Oneworld Publications; 2009.

Bales K. Blood and Earth: Modern Slavery, Ecocide, and the Secret of Saving the World. New York, NY: Spiegel and Graw; 2016.

Batstone DB. Not for Sale: The Return of Global Slave Trade – How We Can Fight It. San Francisco, CA: Harper Collins; 2007.

Hepburn S, Simon RJ. Human Trafficking Around the World: Hidden in Plain Sight. New York, NY: Columbia University Press; 2013.

Kara S. Sex Trafficking: Inside the Business of Modern Slavery. New York, NY: Columbia University Press; 2008.

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Evidence-Based Practice Recommendations Citations

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