International Society for Traumatic Stress Studies

Treatment Considerations When Working with Survivors of Human Sex Trafficking

09/01/2019
by Bita Ghafoori, PhD
Human sex trafficking is a significant global public health issue and a violation of human rights. Sex trafficking is defined as “the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act… in which a commercial sex act is induced by forced, fraud, or coercion” (Trafficking violence Protection Act, 2000). Research suggests victims of human sex trafficking span all cultures, races, ages, genders and socioeconomic brackets (Shandro, Chisolm-Straker, & Duber, 2016). The exact prevalence of human sex trafficking in countries across the globe is unknown due to the varying definitions of sex trafficking, the various research methodologies used to capture prevalence rates, and the hidden nature of the crime (Stransky & Finkelhor, 2012). Existing research suggests high exposure to traumatic events among victims of human trafficking (Ghafoori & Taylor, 2017; Kerr, 2016). Common psychological difficulties associated with sex trafficking include depression, posttraumatic stress disorder (PTSD) and substance abuse disorders, as well as impairment in functioning (Ghafoori & Taylor, 2017; Williamson, Dutch, & Clawson, 2010).
 

Trauma Treatment in Victims of Human Trafficking

 
Victims of sex trafficking often have chronic and/or complex trauma histories that would benefit from professional psychological and/or psychiatric treatment. However, currently there is a lack of empirical evidence on mental health treatment for victims of sex trafficking. Although many efficacious treatments for PTSD have been developed, to the best of our knowledge no study to date has investigated the use of an evidence-based PTSD treatment, such as prolonged exposure (PE) therapy, cognitive processing therapy (CPT), or eye movement desensitization and reprocessing (EMDR), in a population of individuals who have experienced sex trafficking. A recent review suggests that given the paucity of research, specific treatment protocols and best treatment practices for human trafficking victims have not been developed and/or studied (Salami, Gordon, Coverdale, & Nguyen, 2018).
 
It is important to note that sex trafficking victims are a heterogenous population and may enter treatment with diverse experiences and needs. Some researchers suggest human trafficking victims are often reluctant to seek and engage in mental health care due to issues of fear, safety and mistrust (Salami et al., 2018). It may be helpful for mental health professionals to normalize and validate the client’s experiences and take time to engage in rapport-building, explaining confidentiality, and psychoeducation (Zimmerman et al., 2008). Other important considerations in treatment include language and cultural background (Salami et al., 2018). It remains unclear if interpreters or cultural mediators may be helpful in working in a therapeutic context with sex trafficking victims. Use of interpreters may aid with respect to cultural connectedness (Salami et al., 2018). However, depending on the level of training interpreters or mediators may receive, these individuals may also serve as a barrier to engaging with treatment (Hemmings et al., 2016). Sex trafficking victims may feel reluctant to disclose in a therapeutic context due to legal issues, stigma or judgement (Hemmings et al., 2016). Psychological treatment is occasionally offered in the context of the victim’s involvement with legal investigation (Salami et al., 2018). Victims who have been trafficked internationally may be able to obtain specific visas for identified victims of human trafficking as well as health care and mental health services when they cooperate with an investigation and prosecution. Thus, the victim’s immigration status may affect their access to post-trafficking services, including mental health care for the traumas experienced during trafficking (Salami et al., 2018).
 
A continuing challenge for clinicians is accurate assessment and treatment planning for victims of sex trafficking as well as engaging victims in mental health treatment. Components of assessment may include a clinical interview, self-report measures and information gathered from collaboration with other entities who are assisting the victim. During the clinical interview, the clinician may obtain information about the types of traumas experienced as well as severity of trauma exposure. There are many self-report instruments measuring trauma exposure and mental health outcomes associated with trauma exposure that may be helpful in the assessment of sex trafficking victims. For example, frequently used to assess exposure to potentially traumatic events is the Life Events Checklist for DSM-5 (LEC-5; Weathers et al., 2013), a 17-item measure of potential traumatic events individuals may have experienced that yields the type of trauma(s) experienced as well as the quantity and severity of trauma exposure. The PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (PCL- 5; Weathers, et al., 2013), a 20-item self-report PTSD symptom measure with good psychometric properties, may be a good instrument to aid in assessment of PTSD. Once a comprehensive assessment has been completed, it is essential to identify socially and culturally appropriate methods to address trauma-related distress and other mental health concerns.
 
Experts in the field of human trafficking advocate for mental health treatment that embraces a trauma-informed care (TIC) model (Kerr, 2016; Salami, 2018). TIC refers to a treatment approach that includes the incorporation of knowledge about trauma in the provision of mental health services (SAMHSA, 2014). TIC includes specialized training of staff to understand the effects of trauma on interpersonal interactions, the impact that a client’s cultural values may have, and an understanding of client behaviors within the framework of traumatic stress (Kerr, 2016). In addition to TIC, there is empirical support for the utilization of comprehensive case management in the treatment of the trauma of sex trafficking (Clawson & Dutch, 2008; Kerr, 2016). Comprehensive case management focuses on identifying and addressing the psychosocial needs of the victim to optimize probability of successful post-trafficking adjustment and self-sufficiency and prevent re-entry into sex trafficking (Clawson & Dutch, 2008; Kerr, 2016).
 
Available research suggests the first stage of mental health treatment, which often occurs in emergency shelters or hospitals, should focus on crisis intervention (Clawson, Dutch, Solomon, & Grace, 2009). The model recommended is similar to the model utilized for domestic violence victims: Ensure that the person exiting human trafficking has the basic resources to live, including safety, food, shelter and clothing. In the second stage of mental health treatment, clinical work with the individual who has experienced sex trafficking may begin, and this stage usually occurs in a social service setting, such as a long-term shelter or residential treatment program (Kerr, 2016). Mental health treatment in this stage may include interventions for PTSD, anxiety disorders, depressive disorders), or other psychiatric conditions (Kerr, 2016). It may be appropriate to start a trauma-focused, evidence-based therapy with a victim of sex trafficking at this stage, however no empirical studies have been done to support this. The third stage of mental health treatment may include a continuation of treatment with a survivor who has exited their trafficking situation, has met basic survival/safety needs and is attempting to overcome the long-term emotional, physical and social consequences of trafficking (Kerr, 2016). A primary goal during this stage is to develop the skill set and confidence for sustaining life outside of sex trafficking and developing self-sufficiency (Kerr, 2016).
 
Additional information regarding treatment for victims of human trafficking may be found by accessing a comprehensive chapter written by Kerr (2016). In addition, some online materials are available to guide clinicians in the understanding and treatment of common traumas experienced by victims of human trafficking (Clawson & Dutch, 2008; Williamson, Dutch, & Clawson, 2010).
 

About the Author:

 
Dr. Bita Ghafoori is a clinical psychologist who specializes in the assessment and treatment of traumatic distress in diverse victims of crime and violence.  She is a Professor at California State University Long Beach and the Director of the Long Beach Trauma Recovery Center.
 

References

 
Clawson, H. J., & Dutch, N. (2008). Addressing the needs of victims of human trafficking:
 
Challenges, barriers, and promising practices. Office of the Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services, Retrieved from http://aspe.hhs.gov/sites/default/files/pdf/75471/ib.pdf
 
Clawson, H. J., Dutch, N., Solomon, A., & Grace, L. G. (2009). Human trafficking into and
within the United States: A review of the literature. US Department of Human and Health Services. Retrieved from http://aspe.hhs.gov/basic-report/human-trafficking-and-within-united-states-review-literature 
 
Ghafoori, B., Taylor, R. (2017).  Age related differences in trauma experiences, mental
health needs and mental health service use in victims of human trafficking: a pilot investigation of transition aged youth compared to older adults. Journal of Human Trafficking. DOI: 10.1080/23322705.2016.1219840
 
Hemmings, S., Jakobowitz, S., Abas, M., et al. (2016).  Responding to the health needs of
victims of human trafficking: a systematic review.  BMC Health Services Research, 16,
 
Kerr, P. (2016).  Treating trauma in the context of human trafficking: Intersections of psychological, social, and cultural factors. In International perspectives on traumatic stress: theory, access, and mental health services.  B. Ghafoori, Y.Caspi, S. Smith (Eds), (pages).  New York: Nova Press.
 
Salami, T., Gordon, M., Coverdale, J., & Nguyen, P. T. (2018). What therapies are favored in the
treatment of the psychological sequelae of trauma in human trafficking victims? Journal of Psychiatric Practice24(2), 87–96.
 
Shandro, J., Chisolm-Straker, M., Duber, H.C., et al. (2016). Human trafficking: A guide to
identification and approach for the emergency physician.  Annals of Emergency Medicine, 68, 501-508.
Substance Abuse and Mental Health Services Administration. (2014). Trauma-informed care in
behavioral health services. Treatment improvement protocol (TIP) series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Author.
 
Stranksy, M., & Finkelhor, D. (2012). Sex trafficking of minors: How many juveniles are being prostituted in the U.S? Durhan, NH: Crimes against Children Research Center, University of New Hampshire. Retrieved from http://www.unh.edu/ccrc/pdf/CV279 Revised Sex Trafficking Bulletin.pdf
 
Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. P., & Keane, T.
M. (2013). The Life Events Checklist for DSM-5 (LEC-5) – Standard. [Measurement instrument]. Available from https://www.ptsd.va.gov/
 
Weathers, F.W., Litz, B.T., Keane, T.M., Palmieri, P.A., Marx, B.P., & Schnurr, P.P. (2013).
The PTSD Checklist for DSM-5 (PCL-5). Scale available from the National Center for
PTSD at www.ptsd.va.gov.
 
Williamson, E., Dutch, N., & Clawson, H. (2010).  Evidence-based mental health treatment for victims of human trafficking.  Washington, DC: US Department of Health and Human Services.  Available at: https://aspe.hhs.gov/report/evidence-based-mental-health-treatment-victims-huan-trafficking
 
Zimmerman, C., Hossain, M., & Watts, C. (2011). Human trafficking and health: A conceptual model to inform policy, intervention and research. Social Science & Medicine73(2), 327-335. doi: 10.1016/j.socscimed.2011.05.02
 

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