According to the U.S. Department of Justice, “Human trafficking, also known as trafficking in persons, is a crime that involves compelling or coercing a person to provide labor or services, or to engage in commercial sex acts…Exploitation of a minor for commercial sex is human trafficking, regardless of whether any form of force, fraud, or coercion was used.” Human trafficking can happen to men, women, or children, and it may occur within or across country/state borders. The coercion involved in human trafficking can be physical or psychological or both, as well as covert or overt.
While the majority of the coverage in the media refers to sex trafficking, there are actually two types of human trafficking: sex trafficking and labor trafficking.
While it is more likely that mental health professionals will encounter human trafficking survivors after they have escaped, it is also possible that we may encounter people who are currently being trafficked through our work in schools, hospitals, clinics, or community settings. Therefore, mental health professionals need to be aware of the potential indicators of human trafficking:
- Living situation is with employer or at the workplace
- Minors who are homeless and/or minors who are not living with relatives or foster parents (such as those living in motel or living with older non-relatives)
- Poor living conditions; multiple people living in an overcrowded or cramped space
- Cannot speak to the person alone (the person is often in the company of someone who speaks for them and/or seems to be in control of their actions and interactions)
- Answers appear to be coached and rehearsed
- Employer is holding identity documents
- Signs of physical abuse (bruises, burns, scars, etc.) and/or neglect (dental issues, malnutrition, exhaustion, inadequate clothing, hygiene concerns, etc.)
- Signs of emotional abuse and psychological trauma (submissiveness, fearfulness, depression, anxiety, shame, nervousness, withdrawal, reluctance to interact with professionals, substance misuse, PTSD, etc.)
- Unpaid or underpaid; may be forced to perform work due to debt bondage
- Isolated/disconnected from family, friends, community
- A child or adolescent who has stopped going to school
- Sexual acting out in a child or adolescent
- Confusion; disorientation; difficulty focusing/concentrating; unaware of basic information such as location, age, or date/time
- Signs of being deprived of basic needs, like housing, food, water, sleep, clothing, and/or medical care
- Gives conflicting or confusing stories about basic information
- Lacks personal belongings
- Excessive security measures in place
Please note that the above list is not comprehensive and that meeting some of the red flags above does not mean that the person is being trafficked; rather, think of the above list as a basic screening for the warning signs of trafficking. (As always, when abuse or neglect of any sort is suspected, mandatory reporting laws and ethical guidelines apply).
Regarding the role of mental health professionals when human trafficking is suspected, there are some key points noted in recent research (Altun et al., 2017):
- Whenever possible, see the person without their companion(s) present
- Use an independent interpreter if the person does not speak the local language
- Try to schedule a follow-up appointment, while understanding that the person may not wish to follow up and/or may not be able to follow up
- Provide crisis care even with little background information (because the person may be reluctant to provide details due to fear for the safety of themselves and loved ones, due to embarrassment/shame, due to fears about being deported, and/or due to difficulties remembering details due to trauma)
- Be prepared to provide information about referral options; be familiar with available resources
- Ask about current and historical experiences of abuse
- Provide risk assessment and safety planning, including addressing the risk of re-trafficking
- Whenever possible, offer a choice regarding the gender of the mental health professional and the interpreter, if needed
- The Vera Institute of Justice’s Screening for Human Trafficking is a useful screening measure which is available in English and Spanish: https://www.ncjrs.gov/pdffiles1/nij/grants/246713.pdf
- During assessment, explore common reactions, such as fearfulness, sadness, guilt, shame, anger, memory loss, confusion, hopelessness, emotional numbing, feelings of isolation, hyper-alertness, and risk of suicidal ideation and self-harm
- Include assessment of substance misuse; trafficked people may be forced to use drugs or alcohol and/or may use them as coping mechanisms
- Ensure informed consent and encourage client participation in treatment planning
- Be aware of cultural differences, which may impact the person’s perception of psychological symptoms/needs and treatment preferences
- Provide trauma-informed care; however, note that stabilization of physical health, psychological health, and safety are likely to be necessary before starting therapy
- “Evidence-based interventions for PTSD such as narrative exposure therapy (NET), trauma-focused cognitive–behavioral therapy (TF-CBT), and eye movement desensitization and re-processing (EMDR) may be suitable for survivors who are ready to talk about their trauma.” (Altun et al., 2017). (Also, see below for recommendations for specific types of trafficking).
- Consult with colleagues who are familiar with human trafficking and trauma-informed care; participate in training opportunities to increase knowledge of human trafficking and recommendations for working with trafficking survivors
- Be aware of the Core Competencies for providers working with survivors of human trafficking:
- Use a trauma-informed and culturally responsive approach
- Understand human trafficking, including definitions, facts, warning signs for identification, and treatment approaches
- Identify and assess the risk of trafficking
- Evaluate the needs of those who have experienced trafficking and those who are at-risk of trafficking
- Provide patient-centered practices/care
- Understand and use legal and ethical standards
- Integrate trafficking prevention strategies into practice
- Utilize the Self-Assessment Tool For Healthcare and Behavioral Health Providers: https://www.acf.hhs.gov/blog/2021/10/mental-health-resources-human-trafficking-survivors-and-allies
- Be aware of the National Human Trafficking Hotline, which is funded by the U.S. Department of Health and Human Services (HHS). The Hotline is operated by Polaris, a nongovernmental organization. Since 2007, the Hotline has identified more than 47,000 cases of human trafficking across the United States. The hotline provides information, crisis assistance, safety planning, support, and/or connections to emergency services.
While the warning signs and recommendations that are listed above are for both types of human trafficking (labor trafficking and sex trafficking) due to considerable overlap, it is important to note that the specific emotional/mental impacts to survivors will differ based on a variety of factors, including, but not limited to, the following: type of trafficking, length of time in trafficking, circumstances/specifics of trafficking, and survivor characteristics, such as background, age, sex, sexual orientation, gender identity, health status, disability/disabilities, specific life experiences, temperament, culture/ethnicity, global overall functioning, exposure to previous adverse childhood experiences (ACEs), current support system, current employment and housing opportunities, etc.
Therefore, in addition to the above combined information and recommendations regarding both types of trafficking, the specific potential effects of each specific type of trafficking are discussed below, along with recommendations about how mental health professionals can best support survivors:
Sex trafficking: Potential specific effects in regard to sex trafficking include, but are not limited to, the following: fearfulness, nervousness, dissociation and dissociative disorders, depression, anxiety, anxiety and mood disorders, obsessive-compulsive disorder (OCD), panic attacks, irritability, anger, sleep disturbances, numbness, post-traumatic stress disorder (PTSD)/complex PTSD (C-PTSD), feeling “on guard,” avoiding activities that may remind them of events, sudden emotional and/or physical responses when reminded of events, recurrent thoughts of events, feelings of isolation and alienation, memory loss, attention/concentration difficulties, emotional dysregulation, attempted avoidance of thoughts regarding events, substance misuse/disorders, sexually transmitted diseases, traumatic brain injuries (TBIs), exposure to coercion, exposure to threats, exposure to physical and sexual violence, and feelings of helplessness/hopelessness. According to the U.S. Department of Health and Human Services, Evidence-Based Mental Health Treatment for Victims of Human Trafficking, the following evidence-based therapies are recommended for PTSD associated with sex trafficking: Cognitive Therapy, Cognitive-Behavioral Therapy (CBT), Exposure Therapy, Eye Movement Desensitization and Reprocessing (EMDR), and Stress Inoculation Training. Motivational Interviewing (MI)/Motivational Enhancement Therapy (MET) is mentioned in regard to treatment of substance misuse/disorders. Additionally, Edmund (2018) discusses EMDR, Cognitive Processing Therapy (CPT), and Skills Training in Affective and Interpersonal Regulation/Narrative Story Telling (STAIR/NST) as trauma treatments for sex trafficking survivors.
Labor trafficking: Potential specific effects in regard to labor trafficking include, but are not limited to, the following: physical injuries, scars, headaches, hearing loss, cardiovascular problems, limb amputation, chronic pain, visual problems, respiratory problems, gastrointestinal problems, helplessness, shame, humiliation, shock, denial and disbelief, disorientation and confusion, anxiety disorders, post-traumatic stress disorder (PTSD)/complex PTSD (C-PTSD), phobias, panic attacks, depression, effects of malnutrition, bone density issues, dental problems, problems with attention/concentration, and emotional dysregulation. While most of the literature in regard to evidence-based treatments seems to focus more on sex trafficking survivors versus labor trafficking survivors, the therapies listed above from the U.S. Department of Health and Human Services, Evidence-Based Mental Health Treatment for Victims of Human Trafficking, the following evidence-based therapies are also recommended for PTSD associated with labor trafficking: Cognitive Therapy, Cognitive-Behavioral Therapy (CBT), Exposure Therapy, Eye Movement Desensitization and Reprocessing (EMDR), and Stress Inoculation Training.
For both sex trafficking and labor trafficking survivors, an individually-tailored, client-centered, trauma-informed, culturally-responsive, wrap-around approach is recommended to address the specific needs of each client.
In summary, the crime of human trafficking affects numerous individuals in the United States and around the world, with lasting, significant impact to survivors. There are numerous resources and training opportunities available to mental health professionals to raise awareness, to help identify potential victims as well as those at-risk for being victimized, and to provide valuable tools to help with evaluation and treatment planning; see resource list, below.
References/Resources:
Altun, S., Abas, M., Zimmerman, C., Howard, L. M., & Oram, S. (2017). Mental health and human trafficking: responding to survivors' needs. BJPsych international, 14(1), 21–23. https://doi.org/10.1192/s205647400000163x
Edmond, T. (2018). Evidence-based trauma treatments for survivors of sex trafficking and commercial sexual exploitation. In A. J. Nichols, T. Edmond, & E. C. Heil (Eds.), Social work practice with survivors of sex trafficking and commercial sexual exploitation (pp. 70–96). Columbia University Press. https://doi.org/10.7312/nich18092-006
Hopper, E. K., & Gonzalez, L. D. (2018). A Comparison of Psychological Symptoms in Survivors of Sex and Labor Trafficking. Behavioral Medicine, 44(3), 177–188. https://doi.org/10.1080/08964289.2018.1432551
Hossain, M., Zimmerman, C., Abas, M., Light, M., & Watts, C. (2010). The relationship of trauma to mental disorders among trafficked and sexually exploited girls and women. American journal of public health, 100(12), 2442–2449. https://doi.org/10.2105/AJPH.2009.173229
National Human Trafficking Hotline: https://humantraffickinghotline.org/en; 1-888-373-7888; text HELP to BEFREE (233733); email [email protected]
Novotney, A. (2017, August 18). 7 in 10 human trafficking victims are women and girls. What are the psychological effects? https://www.apa.org/topics/women-girls/trafficking-women-girls
Police Chief Magazine, Labor Trafficking Vulnerabilities and Victimization: https://www.policechiefmagazine.org/labor-trafficking-vulnerabilities-victimization/
U.S. Department of Health and Human Services, Core Competencies For Human Trafficking Response in Health Care and Behavioral Health Settings: https://nhttac.acf.hhs.gov/resource/report-core-competencies-human-trafficking-response-health-care-and-behavioral-health
U.S. Department of Health and Human Services, Evidence-Based Mental Health Treatment for Victims of Human Trafficking: https://aspe.hhs.gov/reports/evidence-based-mental-health-treatment-victims-human-trafficking
U.S. Department of Health and Human Services, Fact Sheet: Labor Trafficking: https://www.acf.hhs.gov/archive/otip/fact-sheet/fact-sheet-labor-trafficking-english#
U.S. Department of Health and Human Services, Mental Health Resources for Human Trafficking Survivors and Allies: https://www.acf.hhs.gov/blog/2021/10/mental-health-resources-human-trafficking-survivors-and-allies
U.S. Department of Health and Human Services, Myths And Facts About Human Trafficking: https://www.acf.hhs.gov/otip/about/myths-facts-human-trafficking
U.S. Department of Health and Human Services, SOAR Training: https://nhttac.acf.hhs.gov/soar
U.S. Department of Homeland Security, Blue Campaign: https://www.dhs.gov/blue-campaign
U.S. Department of Justice, Human Trafficking: https://www.justice.gov/humantrafficking/ (Includes contact information for the National Human Trafficking Hotline)
U.S. Department of State, Identify and Assist a Trafficking Victim: https://www.state.gov/identify-and-assist-a-trafficking-victim/
