Gender, Psychology, and Justice: The Mental Health of Women and Girls in the Legal System - Linda Wolfe 2014
Women, Sex Trafficking, and the Justice System: From Victimization to Restoration
Women and Girls in Various Justice Settings
Thema Bryant-Davis, Tyonna Adams, and Anthea Gray
Maria is a client of the Coalition to Abolish Slavery and Trafficking—Los Angeles (CAST-LA). She is a survivor of sex slavery who was sold at the age of sixteen for two hundred dollars. She was raped, beaten, and tortured by her oppressor, who threatened to kill her and her family if she tried to escape.
Human sex trafficking takes many forms, including war-induced sexual slavery, ritual sexual slavery, forced marriage, and sexual servitude. Sex trafficking victims are persons who are compelled to trade sex by force, fraud, or coercion (see Trafficking Victims Protection Act. P.L. 106—386, codified at 22 U.S.C. § 7101, 2000). Trafficking survivors face multiple barriers that make accessing the judicial system difficult, including fear of violence, lack of awareness of resources, language barriers, fear of deportation, difficulty trusting, prior experience with corrupt government officials, constant monitoring from traffickers, fear of stigma, drug addiction, and pregnancy enforced by traffickers in attempts to control their movement (Rafferty 2008). To obtain services and legal protection, women and girls who have been trafficked often experience revictimization by being forced to disclose traumatic material multiple times in settings that are not emotionally supportive (Contreras and Farley 2011). They are harmed by being treated as criminals instead of victims, and may also be subjected to blaming statements and attitudes by agents of the justice system (Farley 2009).
This chapter will examine how social dynamics related to gender, class, and race shape the U.S. justice system’s response to victims of sex trafficking, and will present implications for the clinical care of trafficking survivors, based on a critical review of the literature and the first author’s clinical practice. It will focus on sex trafficking in the United States, although this is a global and national phenomenon. It will highlight issues of trust, oppression, and systemic and psychosocial barriers to safety and recovery. It will also propose guidelines for interprofessional collaboration and psycho-education for attorneys, evaluators, and judges concerning mental health issues of trafficking survivors.
An Overview of Sex Trafficking
The language used to identify commercial sex acts is varied and inconsistent. Commonly used terms such as “prostitution,” “pornography,” and “exotic dancing” refer to for-profit sex acts, while “sex trafficking” applies to sex acts that involve force, fraud, abduction, deception, control, and coercion (United Nations 2000). These are methods used to recruit, harbor, lure, transport, supply, or detain a person for the purpose of commercial sex (U.S. Department of State 2014). Debt bondage is yet another mechanism of subjugation whereby traffickers impose arbitrary fees on victims for things such as transport and housing, and do not permit them to leave the sex trade until they have paid off their “debt” (U.S. Department of State 2014). For these reasons, sex trafficking is a human rights violation (United Nations 2000). Regarding the use of language, it is also important to note that sex trafficking may or may not include transit across international or domestic borders, although the term “trafficking” implies movement (U.S. State Department 2014).
The United States government defines “commercial sex” as any sex act in which something of value is given or received (P.L. 106—386: § (3)). The question then arises as to how to determine whether a sex act is given willingly—consented to—or coerced. An adult might agree to participate in a commercial sex act, but there is truly no voluntary consent if that decision is motivated by any of the previously referenced external factors (e.g., force, fraud, coercion) (Contreras and Bryant-Davis 2011; U.S. Department of State 2014). With regard to children who may appear to willingly engage in commercial sex acts, “consent” is invalidated by the external variables listed above as well as the illegal status of sex acts with a minor (Hughes 2007). As for those who are inextricably born into the sex industry (e.g., individuals born into servitude), they are not in a position to provide consent (U.S. State Department 2014).
Prevalence Rates of Sex Trafficking
Statistics on sex trafficking vary greatly depending on the source (Clawson et al. 2009). This is due to limited pools of data and diverse methodological strategies for data collection. National reporting structures and barriers to disclosure are also factors that explain the dearth of demographic figures and variations in prevalence rates (Curtol et al. 2004; Hughes and Denisova 2001; U.S. Department of State 2014). Additionally, it is difficult to determine the incidence of sex trafficking because it is underreported. Underreporting is linked to (1) the fear of retribution from traffickers and law enforcement agencies (Curtol et al. 2004; Hughes and Denisova 2001), (2) the possible collusion and partnership of exploiters with authorities, who might return the victims to their traffickers (Hodge 2008), and (3) the social stigma commonly associated with commercial sex acts.
In 2013, the U.S. Department of State estimated that 44,758 individuals were trafficked across international borders, 9,460 were prosecuted, and 5,776 were convicted (U.S. Department of State 2014). Almost exclusively, these estimates represent the prevalence of international sex trafficking. National figures are less readily available (Laczko and Gozdziak 2005) and primarily account for the number of minors involved in the sex industry in the United States (U.S. Department of State 2009). According to the National Human Trafficking Resource Center (2014), in 2014 there were 3,598 reports of sexual trafficking—3,250 of which were women. Three of the most sexually trafficked cities were located in California: Los Angeles, San Francisco, and San Diego (U.S. Department of Justice 2009).
Hughes (2008) points out that economically strong, industrialized nations that either (1) permit prostitution or (2) have a preexisting, established sex industry, offer favorable conditions for commercialized sex activities. For example, the United States has the largest child pornography industry in the world (Flowers 2001), which makes the country highly attractive to traffickers. Estes and Weiner (2001) further explain that cities that are densely populated, particularly tourist and convention cities, are popular hubs for sex trafficking. As with any commercial market, the dominant driving force in keeping the commercial sex industry alive is demand for sex workers whom the traffickers supply to consumers (Hughes and Denisova 2001). Consumers of this profitable commerce include brothel owners, pornography producers, pimps, organized crime organizations (Hodge 2008), and everyday citizens.
Sex Trafficking Victims: Profile and Risk Factors
As a single mother in Mexico, Esperanza, a CAST-LA client, experienced the loss of a child due to starvation and decided she had to leave her children with her family and go to Los Angeles for a job as a seamstress. Following what she believed to be a legitimate job lead, Esperanza was sold into slavery, which separated her from her children and prevented her from sending home the money that she had gone to earn.
Each sex trafficking victim has a unique background; however, they share characteristics that place them at higher risk for sex trafficking. These characteristics include (1) poverty, (2) racial and ethnic marginalization, (3) being an undocumented immigrant, (4) identifying as lesbian, bisexual, transgender, and queer, (5) being disabled, (6) being a runaway and homeless, (7) being a survivor of childhood sexual abuse, (8) having little to no education, (9) having minimal vocational opportunities, and (10) coming from low-resource countries with little infrastructure to combat human trafficking (Contreras and Bryant-Davis 2011; Clawson et al. 2015). Trafficking recruiters are typically drawn to individuals who are impoverished and have very little access to social and economic opportunities (Clawson et al. 2015). Individuals who have limited access to opportunities such as education are often more susceptible to believing the empty promises of trafficking recruiters (Contreras and Bryant-Davis 2011). Another risk factor associated with domestic sex trafficking victims is age. Adolescents are particularly susceptible to recruitment (Flowers 2001; Clawson et al. 2015). The average age of entry into the commercial sex industry is twelve to fourteen for girls (Estes and Weiner 2001; Lloyd 2005), and eleven to thirteen for boys and transgendered youth (Estes and Weiner 2001). Being a runaway is also considered a risk factor for domestic sex trafficking. A significant portion of adult women with sexually exploitative prostitution histories reported being runaways during their youth (e.g., 72 percent in Boston) (Norton-Hawk 2002; Clawson et al. 2015). Identification as lesbian, gay, bisexual, transgendered, or questioning (LGBTQ) is an additional risk factor.
Victims of domestic trafficking are also likely to have a history of childhood sexual abuse (Clawson et al. 2015). In a meta-analysis of twenty studies, Raphael (2004) found that 33 to 84 percent of adult women who were exploited via prostitution were abused during their youth. Raphael (2004) also found increased rates of addiction and domestic violence within the homes of victims. Other thematic trends occurring among individuals involved in the commercial sex industry include low education rates (Aghatise 2004; Beyrer 2001), the presence of learning disabilities, and poor performance at school (Clawson et al. 2015), which correlate to low self-esteem (Harway and Liss 1999). The loss of a parent through abandonment, divorce, or death is also a risk factor (Clawson et al. 2015; Norton-Hawk 2002; Raphael and Shapiro 2002).
Recruitment into Sex Trafficking
There are four main pathways into the sex industry (Curtol et al. 2004): (1) false-front agencies, (2) local sex industries, (3) abduction, and (4) families living in poverty. Organizations known as false-front agencies offer employment, modeling, and even marriage to attract potential victims (Curtol et al. 2004). Recruiters will often lure prospects by offering promises of a better life. If the victim’s recruitment involves travel, the accrued expenses will be used as debt (Curtol et al. 2004). Those individuals who are already engaged in the sex industry (e.g., exotic dancing, entertainment, prostitution) are also likely candidates for trafficking because they are somewhat familiar with the demands of the sex industry (Curtol et al. 2004). Those who are new to the sex industry might be eased into the field through the use of pornography—a socially legitimate form of entertainment whose message of female objectification may be propagated, tolerated, and portrayed as innocuous via media (e.g., social, print, online, music) (APA Division 35 2011). Traffickers might also present pornography as a means of gaining fame or notoriety, a stepping stone to reaching one’s goals, or even an enjoyable, pleasurable experience (Lloyd 2005). Pornography may also be used as a means of psychological coercion, as these images are difficult to retract once posted on the Internet or printed (Estes and Weiner 2001; Raymond, Hughes, and Gomez 2001).
Individuals might also be abducted and forced into sexual exploitation (Curtol et al. 2004). Girls and women are most vulnerable to being abducted when they live in rural settings and urban areas with low levels of social cohesion. They may also be vulnerable when they are walking alone to and from work or school. Traffickers often send recruiters—a couple or a woman—to these low-resource communities to persuade impoverished families to let their young women and girls work for them (Curtol et al. 2004). The recruiters will promise the family members that they will secure employment for their young daughters, as a maid, nanny, or dancer, that they will take care of them, and that the young women and girls will earn enough money to provide for their relatives. Sometimes they also promise to assist the young women and girls in getting an education. These false promises are the mechanisms through which traffickers gain the trust of their victims’ family members.
The manipulation also starts with the facade of a normal relationship: Recruiters attract girls and women into the sex industry through courtship. However, gradually, the caring boyfriend becomes a demanding and abusive pimp (Kotrla 2010). Once victims have been recruited, they have little control over the hours they work (Clawson et al. 2015) and over the sexual acts they participate in (Hodge 2008). Their work is often subject to quotas enforced through the threat of punishment (Hodge 2008).
Impact of Sex Trafficking on Victims’ Functioning
Victims of the sex trade industry are impacted on a number of levels: physical, psychological, behavioral (Contreras and Bryant-Davis 2011), and social (APA Division 35 2011). Because sex trafficking victims are not able to advocate for safe-sex practices, their physical health is often compromised by sexually transmitted diseases (APA Division 35 2011). Other health problems include malnutrition (Rafferty 2008), physical injuries such as broken bones and head injuries (Rafferty 2008; Raymond, Hughes, and Gomez 2001), and gynecological complications like infertility and cervical cancer (APA Division 35 2011).
The psychological and behavioral sequelae of sex trafficking are pervasive. They may include guilt, depression, poor self-image, anxiety, social withdrawal, aggression, disorganized attachment, and isolation (Deb, Mukherjee, and Mathews 2011; Watts-English et al. 2006). Victims are also more likely to utilize dissociation to escape—figuratively—and to cope with their experience (Dworkin 2002). They may develop eating-disordered behaviors that provide them with a false sense of control over their body and lives (Contreras and Bryant-Davis 2011). Lastly, it is not uncommon for sex traffickers to introduce women and girls to substances as a means of establishing control over their victims (Courtois 2008).
Sex trafficking victims may feel shunned and shamed by their respective cultural communities when they try to get out of “the life.” Without treatment, even those individuals who are able to escape victimhood continue to experience the emotional and physical scars of domestic and international trafficking (Estes and Weiner 2001). The psychological and physical effects resulting from the mental and physical coercion of traffickers often leave women and girls at risk for continued victimization and exploitation.
Sex Trafficking and Entry into the Justice System
Lulu’s story is an example of how anyone can become a victim of trafficking. Lulu, a CAST-LA client, is an educated woman who believed she was coming to America for a legitimate job opportunity, only to discover that she had been sold into slavery.
Women and girls who are victims of sex trafficking are often brought into the justice system as criminals instead of victims (Farley 2008). They are arrested more frequently than traffickers and consumers (Farley 2008) and are viewed by criminal justice workers, including police officers, attorneys, and judges, as empowered and consenting persons who willfully commit the crime of exchanging sexual acts for money. This ignores the fact that most sexually trafficked women entered the sex industry when they were minors, and came of age as trafficking victims. Legally, minors cannot consent to sexual acts and therefore should not be held responsible (Hughes 2007). However, prostitution laws criminalize juveniles who are sex trafficked by defining them as individuals who offer themselves as prostitutes rather than as victims of child sexual abuse and statutory rape perpetrated by the buyers and sellers of the sex trade (Mir 2013). What explains women’s and girls’ differential treatment in the criminal justice system?
Traditional gender norms support the perception that sex trafficking victims are consenting individuals who are committing a crime, in particular, the belief that girls and women are sexual gatekeepers and that boys and men should not be expected to control their sexual behaviors. Research has produced evidence that gender shapes individuals’ attitudes towards sex trafficking. Menaker and Miller (2013) found that undergraduate college students who held sexist beliefs and who had little understanding of trauma were more likely to show lower empathy towards juvenile victims of sex trafficking, to place greater culpability on the youth, and to endorse punitive justice.
Socioeconomic status also has an influence on the differential treatment of sex trafficked individuals in the criminal justice system (Farley 2009): Female and male victims usually lack the information and resources necessary to defend themselves against police brutality or incarceration; they are without economic and political power and therefore are easier to police and prosecute than consumers and traffickers who have access to economic, social, and political resources.
Compared to white, middle-class women and girls, low-income, ethnic-minority women and girls are more likely to be criminalized and as a result incarcerated in a juvenile detention facility or placed on probation (Mauer 2013). Additionally, perpetrators of violence against ethnically and economically marginalized women are less likely to be prosecuted and convicted; when convicted, they often receive less time than those who violate white and economically advantaged women and girls (Kennedy 2006). Given their individual and collective experiences of discrimination, stigma, and stereotyping, women from marginalized communities may find it particularly difficult to report criminal acts against them (Bryant-Davis 2005). Mir (2013) notes that court professionals who endorse class and racial stereotypes are more likely to view impoverished, ethnic-minority sex trafficking victims as criminals, because racism and classism are built on the ideology that those who are racially and economically marginalized are immoral, untrustworthy, and thus less deserving of protection (Bryant-Davis 2005).
Victims of sex trafficking are exposed to diverse forms of violence. Kidnapping, robbery, sexual assault, battery, attempted homicide, and human trafficking are crimes that they are unlikely to report because they are afraid of coming into contact with the justice system and because they are not aware of their legal rights and of the community resources available to them (Deb, Mukherjee, and Mathews 2011; Watts-English et al. 2006). They suffer in silence for the many violations they have experienced, with psychological symptoms that include angry outbursts, self-harming behaviors, and self-medication with illicit substances.
Victims of sexual trafficking hesitate to report and participate in the criminal prosecution of their traffickers because they are worried the system will fail them. They fear social rejection, deportation, and retaliation against their loved ones and themselves. They are concerned about being charged with prostitution and deported (Mir 2013). Those who are mothers are also afraid they will lose their children. In addition, many victims have ambivalent feelings towards their pimps—attachment and fear of violent retaliation—that explain why they may not cooperate in criminal proceedings. Their concerns are legitimate, considering their exposure to numerous acts of violence, the barriers to safe employment and housing they experience after they become involved in the criminal justice system (Maxwell and Maxwell 2000), and the negative view many in society hold of sex trafficking victims as criminals who do not deserve public concern (Farley 2008; Farrell and Pfeffer 2014).
When women and girls come forward with their case and engage with the criminal justice system, they report their victimization directly or indirectly in their interactions with medical personnel, mental health professionals, advocates, or lawyers. This poses a number of challenges. First, the legal process requires that victims repeatedly tell their story, which is extremely difficult for women who experience trauma-related symptoms, such as shame, fear, self-blame, and lack of trust. In addition, the act of reporting is complicated by language barriers between the victims and the legal or health professionals, the victims’ dissociation at the time of the event(s) or during the telling, and memory and speech impairment caused by reduced hippocampal and amygdala processing, physical injury, or substance use (Hayes et al. 2011; Deb, Mukherjee, and Mathews 2011; Watts-English et al. 2006). Disclosing and recounting the traumatic events are particularly taxing when victims are confronted by justice professionals who have received little or no training on trauma victims in general and human trafficking victims in particular, who as a result conduct insensitive questioning (Mir 2013), and who are victim blaming, hostile, and threatening.
Exploitation at the hands of justice workers and members of various helping professions is yet another predicament (Mir 2013). Female victims of sex trafficking have been the target of physical assault, rape, molestation, and sexual harassment by police officers, lawyers, probation officers, prison guards, and mental health professionals (Shannon et al. 2009; Odinokova et al. 2014). Violations by persons who identify themselves as helpers, such as mental health service providers, lawyers, and police officers, can be particularly traumatizing and result in victims experiencing increased distrust of people in general and helping professionals more specifically (Gonsiorek 1995).
Sex Trafficking Myths
The literature indicates that sex trafficking does occur domestically and internationally. Women and girls who are economically, politically, and psychologically vulnerable are preyed upon and through force, fraud, or coercion are cornered into sex trafficking. Sex trafficking victims, including those engaged in prostitution, can be raped, and are raped multiple times by traffickers, pimps, and consumers. And it is often hard to leave traffickers who use economic and legal pressures, violence, and threats of violence, including threats to one’s family members (Contreras and Farley 2011). However, agents of the justice system and mental health professionals are often blind to this reality because they accept, or fail to question, the societal myths about sex trafficking victims that deny that violence and exploitation is an integral part of the trafficking process (NHTRC 2014). Among these myths are the beliefs that real human trafficking happens in other countries, not in the United States; that women and girls only become prostitutes because they want easy money; that prostitutes can’t be raped because they are giving sex away; and that if women don’t want to be sexually exploited they should just leave that life and start following the law.
These myths support the criminalization of trafficking victims and justify justice officials’ hesitation and refusal to prosecute traffickers and consumers (Mir 2013). They create conditions that deprive human trafficking victims of the hope that they may find safety in the legal system (Contreras and Farley 2011). They support victim blaming and the view that women’s and girls’ bodies are insignificant and unworthy of protection. Last, they can also be used to justify the victims’ further exploitation by justice workers. For all these reasons, myths about sex trafficking participate in the reproduction of an unjust justice system for victims of sex trafficking (Mir 2013).
Psychological and Justice Interventions for Sex Trafficking: Current Practices
Sex trafficking survivors and incarcerated women have often experienced pervasive and varied forms of trauma throughout their lives, conceptualized as complex trauma. Complex trauma is defined as reoccurring trauma, taking place over a period of time and within the context of specific relationships. It encompasses domestic violence, attachment trauma, witnessing death, experiencing rape, human trafficking, prostitution, and child abuse (Courtois 2008). Although experiences of complex trauma are prevalent, particularly for young urban women (Glass et al. 2007), there is little psychological research investigating what legal practices may minimize the harms experienced by victims of sex trafficking in the criminal justice system. At present, criminal proceedings do not take into consideration the developmental consequences of complex trauma for a person who transitions from childhood to adulthood (Deb, Mukherjee, and Mathews 2011; Watts-English et al. 2006). Without knowledge of complex trauma, court officials are not able to make decisions and create policies and procedures that are sensitive to survivors’ struggles with identity, affect recognition and regulation, trust, and meaning making (Lanktree and Briere 2013).
Safe Harbor policies are a promising development in the criminal justice system: These policies are intended to rectify the criminalization of minors who were sexually exploited. Rather than prosecute youth, they provide protection to those who have been exploited through sex trafficking, and prioritize the provision of wrap-around mental health and social services (e.g., housing, education, vocational training, and medical care) (Mir 2013). These policies have the potential to limit the harms that youth and adult victims experience in the legal system. There have been other notable, state-level legislative efforts in the fight against human trafficking, including the introduction of greater penalties for those convicted of human trafficking, the rejection of defense arguments stating that the trafficker did not know the age of the victim, and the removal of statutes of limitation on charges against traffickers (Hill 2013).
A review of the psychological literature also shows limited knowledge regarding which mental health interventions may promote resilience, growth, and healing following sex trafficking and/or incarceration. The current research indicates that cognitive behavioral therapy (CBT) is an effective approach to the treatment of trauma (Bomyea and Lang 2012; Iverson et al. 2011; Seidler and Wagner 2006). For survivors of complex trauma, CBT-oriented treatment involves identifying core beliefs, challenging maladaptive thinking, and developing adaptive coping strategies. Trauma Focused CBT (TF-CBT), primarily associated with the treatment of children and adolescents, is a psychosocial treatment model that has demonstrated decreases in severity and duration of acute psychological disorders as well as long-term psychological outcomes of child sexual abuse (CSA) (Cohen, Mannarino, and Deblinger 2006). Given that TF-CBT is child focused, it could function as an early intervention for child and adolescent sex trafficked survivors.
Prolonged Exposure (PE) is another treatment model that has produced positive outcomes for clients with chronic posttraumatic stress disorder (PTSD; Bradley et al. 2014). However, evidence of its effectiveness in community-based clinics is limited. Feske (2008) found that the implementation of PE in community settings was associated with decreased symptoms of PTSD, general anxiety, and depression among low-income, minority women receiving services at a community clinic. Feske (2001) also recommended that PE include interventions aimed at improving interpersonal problems experienced by female survivors of complex trauma.
Culturally Congruent Responses to Sex Trafficking
Justice professionals need to respond to human sex trafficking in a gender-sensitive and culturally congruent manner. However, the literature on effective responses to sex trafficking is minimal, and the role and dynamics of culture have largely been ignored, thus leaving a major gap in research-based knowledge and guidelines for psychological and legal practice with sex trafficking victims. Understanding human trafficking and violence against women in general necessitates a framework that makes central the intersection of gender, race, class, and sexuality and how it perpetuates the victimization of women (Merry 2009). Such a framework would facilitate the development of culturally and gender-sensitive training for judicial and mental health professionals. This training would be ongoing and bidirectional and would include psycho-educational components on human trafficking and its social and individual consequences, as well as components that describe the context of intersecting identity markers, such as race, ethnicity, gender, and socioeconomic status (Bryant-Davis et al. 2009). It should make judicial professionals aware of the need for cultural humility, which is counter to culture blindness (i.e., inability to understand viewpoints or experiences of individuals from other cultural backgrounds) and/or cultural arrogance and silencing. It should also help them develop awareness of their own assumptions and identity as well as provide a framework for cultural sensitivity that is based on empirical knowledge and skills for working with culturally diverse trafficking survivors (Sue and Sue 2013). It is important that this training also foster an understanding of such key terms as “power,” “privilege,” “racism,” “sexism,” “heterosexism,” “oppression,” and “stigma” (Sue and Sue 2013) and such psychological constructs as depression, anxiety, substance dependence, panic attacks, traumatic triggers, dissociation, and posttraumatic stress.
It is essential that clinicians and justice officials know there is more to culture than the experience of cultural oppression—that they recognize the cultural strengths of their clients, not just their pathologies or deficits (Bryant-Davis 2005). It is also critical that they develop culturally congruent responses to trafficking victims in order to enhance trust and respect in ways that will foster retention and rehabilitation. At the most basic level, the offices of judicial employees should represent diversity in staffing and leadership positions and should utilize art, magazines, books, and supplies for clients’ children that are culturally diverse and reflective of the various backgrounds of the survivors. Professionals should also be willing to speak directly about cultural issues and ask questions with respect and humility (Contreras and Farley 2011). These efforts will support the building of trust and the survivors’ sense that they are being valued, respected, and heard. They can also bring about greater disclosures that are less retraumatizing, and thus facilitate case preparation to address human trafficking as well as recovery and prevention efforts. Additionally, mental health and justice professionals should learn how to make use of cultural community leaders, religious leaders, experts, and trained interpreters to serve as consultants and assist with the provision of culturally congruent communication and support (Bryant-Davis 2005).
Project Rose provides a real-life example of the kind of partnerships that may develop to respond to sex trafficking. Created by an associate professor of social work and a police lieutenant, it is a community-based and interdisciplinary project that offers an alternative to arrest and detention (Roe-Sepowitz et al. 2014). Project Rose aims to alter victims’ relationships with law enforcement by providing opportunities to interact with trained officers who are sympathetic and supportive and who do not see or treat them as criminals. In addition, when victims complete the program, their criminal record is expunged. Project Rose is also designed to empower victims through the provision of wrap-around social services that assist the participants in creating new, healthy, and legal options for socioeconomic independence. Victims are given referrals for housing, substance abuse, and medical and mental health treatment; they are connected with a mentor who has successfully exited trafficking for at least a year, and with a police officer who orients them to the program. More than three hundred women, between the age of eighteen and fifty-eight, have participated in Project Rose since its inception in 2011. Only 9 percent were rearrested at twelve months’ follow-up, and participants in Project Rose were as likely as incarcerated women to show up to court. Critiques of Project Rose note that the program still threatens women with incarceration, which is disempowering (Roe-Sepowitz et al. 2014).
Recommendations for a Restorative Approach to Sex Trafficking
In order to adequately meet the unique needs of survivors of sex trafficking, it is critical that justice and mental health interventions be multifaceted, and that they target the multiple levels of this complex social issue. The following recommendations are derived from current knowledge of what works with trauma victims; they are intended to guide the development and implementation of effective strategies for women and girls who have been sex trafficked specifically. They are also grounded in the principles of the American Psychological Association’s Guidelines for Psychological Practice with Girls and Women. These guidelines highlight the importance of attending to clients’ context, including their cultural background, socioeconomic status, social support network, and the realities of oppression, stigma, and discrimination. They also recommend that those serving women and girls should engage in activities that are affirming and empowering, and that acknowledge and build on their strengths. Finally, it is critical for professionals serving women and girls to connect them with accessible, appropriate, effective community resources and for professionals to actively work to transform systems and not just individuals. Based on the APA guidelines described above, the following recommendations are made for providing services to women and girls who have been victims of sex trafficking in particular.
Recommendation #1: Adapt existing treatment approaches for use with sex-trafficking victims.
There is a dire need to develop therapeutic programs specifically designed for sex trafficking survivors. This may be accomplished by adapting already-existing models such as Prolonged Exposure (PE) in ways that are culturally syntonic. Developing and implementing culturally syntonic interventions would involve recognition of cultural variables such as language, socioeconomic status, and environmental factors.
Community studies have consistently shown that belonging to a minority group and having low socioeconomic status (SES) are associated with the use of fewer mental health services (Garcia and Weisz 2002). To address this issue, the underutilization of therapeutic services, it is essential to provide culturally informed treatment. Group modalities have been shown to be particularly effective for ethnically diverse populations, particularly when they integrate culturally syntonic values such as spirituality (Williams, Frame, and Green 1999). Engagement in group practices is based largely on the concept of establishing a community where reciprocal growth is plausible. Integration of group interventions is likely to be attractive to sex trafficked women who may feel a sense of isolation and loneliness. Through the sharing of stories, survivors can process their interpersonal traumas and receive compassion as well as validation from their peers. Creating a shared sense of community is particularly important when working in treatment settings where clients are vulnerable and/or suspicious of treatment.
It is equally important to tailor treatment to the needs of ethnically diverse survivors in ways that address gender-related concerns. Therapy approaches for female sex trafficking victims should aim to empower women and girls (Goodkind and Miller 2006); to accomplish this objective, attention must be given to improving body image and self-esteem and to developing adaptive coping strategies. It is also critical that clinicians build a strong therapeutic alliance and create a sense of safety for clients in order to promote recovery, rehabilitation, and, ultimately, reintegration.
Recommendation #2: Integrate adjunctive treatment approaches and advocacy.
Various adjunctive treatment approaches have been effective in fostering healing and resilience in survivors of complex trauma (Herman 1992; Kreuter and Reiter 2014). Herman (1992) suggests that healing occurs in three stages: safety, remembrance, and mourning. Culturally informed, adjunctive treatments such as expressive art therapy can support the healing process by helping survivors verbally express their trauma and make meaning of their experiences. For example, expressive writing, narrative journaling, poetry therapy, and art therapy are creative art interventions that aim to help victims transcend traumatization and thrive (Kreuter and Reiter 2014). Art therapy in particular has been found to promote biological as well as psychological change, to increase self-esteem, and to facilitate meaning making (Goodkind and Miller 2006), the integration of right- and left-brain functions, as well as the integration of traumatic memories and experiences (McNamee 2005; Talwar 2007). Implementation of expressive art therapies, if culturally syntonic, can provide survivors with a cathartic experience.
Like the creative arts, spirituality provides resources for healing. Helping women develop their own understanding of a higher power may stimulate the creation of meaning, a sense of wholeness, and self-transformation (Mattis 2000). Acknowledging the importance of spirituality and including spiritual ideals in treatment have proven to be culturally syntonic, particularly for ethnic minority populations (Covington 1998). Spiritual as well as religious beliefs are powerful agents of change for various ethnic minority groups, particularly African Americans, as they shape their understanding of justice, salvation, and coping with oppression (Mattis 2000). Religious beliefs can enhance an individual’s ability to cope with negative life events, and negative life events can lead to enhanced religious faith (McIntosh 1995; Pargament 1990). For these reasons, the integration of spiritual and religious ideals in treatment with sex trafficked women and/or incarcerated women should be considered.
In many respects, advocacy is an adjunctive treatment component. Yet psychologists have often failed to acknowledge that advocacy is integral to their role as change agents (Radius, Galer-Unti, and Tappe 2009), unlike other professionals, such as physicians and nurses, who view client advocacy as essential to delivering quality services (DeLeon et al. 2006). There are several reasons why psychologists are less involved in advocacy-related activities: lack of time, lack of related training, and the idea that advocacy is a time-consuming, lofty endeavor (J. Hill 2013). Advocacy within the field of psychology is a multifaceted process involving the use of collaboration with other helping professions and organizations to foster change (Fox 2008), as well as informing decision makers through the process of promoting the interests of clients, health care systems, public health, and welfare issues (Lating, Barnett, and Horowitz 2010). Advocacy as an intervention is tied to justice practices in the sense that psychologists are able to take an active role in promoting just actions and rallying for change on behalf of their clients. In order to enact change and promote social justice, psychologists need to redefine their roles and intervene at multiple levels of the sociopolitical sphere (micro-level, meso-level, and macro-level).
The American Counseling Association (ACA) has defined advocacy competencies and provided a framework for understanding the roles and responsibilities of mental health professionals who wish to engage in social justice work (Lewis et al. 2003). These competencies highlight the importance of intervening at multiple levels: the micro-level, which refers to counselors’ work with individual clients; the meso-level, which includes the client’s support system or immediate community; and the macro-level, which corresponds to the client’s social, cultural, or political context (Bradley, Werth, and Hastings 2011). Advocacy in support of sex trafficked women and girls in the judicial system should target all three levels of the client’s ecology (Bronfenbrenner 1977). Multisystemic approaches that address the micro-, meso-, and macro-levels are necessary to prevent the exploitation of potential victims and to protect those who have been exploited from reentering the world of sex trafficking. The scope of the problem is much greater than the psychology of the victims, and therefore the solution needs to target diverse contributing factors, such as poverty, oppression, and victim-blaming attitudes held by many in society (Bryant-Davis 2005).
There are several ways in which psychologists can expand their role to participate in advocacy practices specific to the needs of sex trafficked women in the judicial system. One of the critical steps of advocating on behalf of sex trafficked women is to investigate the interplay of trauma histories and contextual and historical factors (e.g., age, ethnicity, setting, racism, sexism), all of which have an impact on well-being. Research that examines these factors is critical to identifying the specific needs of the population. Once this information is collected, psychologists can disseminate information to leaders and partner with organizations that meet the needs of the specific interest areas. Specifically, psychologists should strive to provide and interpret data in a manner that demonstrates urgency for change, collaborate with meso-level stakeholders to develop a vision for implementing change, and develop a detailed plan for implementing the change process (Lewis et al. 2003). Lastly, psychologists and stakeholders should be mindful of macro-systemic barriers and anticipate resistance.
Advocacy initiatives for the micro-level rehabilitation of sex trafficked women and girls may need to be innovative in order to transcend systemic barriers. These initiatives may include wrap-around services that address victims’ needs for housing, education, employment, childcare, and legal advocacy. They may also involve collaboration with various meso-level helping professionals and psycho-education for members of the judicial system in order to increase attention to the mental health needs of sex trafficked survivors.
Recommendation #3: At the micro-level, identify and use self-care strategies to prevent burnout.
Psychologists, mental health practitioners, and justice personnel are particularly vulnerable to the negative consequences associated with working in helping professions, in particular compassion fatigue and burnout. While clinicians may exercise great care for others, they also may pay limited attention to their own well-being and experience greater levels of anxiety, depression, and emotional exhaustion than mental health researchers (Radeke and Mahoney 2000). Judicial system professionals may also develop symptoms of burnout, vicarious trauma, and occupational stress (Loo 1984; Chamberlain and Miller 2009). Hence the need for self-care strategies that protect against the development of adverse psychological conditions while serving victims of sex trafficking. Failure to engage in self-care practices could potentially lead to mental health impairment, which refers to an objective change in the professional’s functioning or improper behavior such as crossing professional boundaries (e.g., inappropriate sexual conduct) (Wise, Hersh, and Gibson 2012).
Researchers have asserted that long-term exposure to trauma can alter psychologists’ schemas about the world as well as result in intrusive thoughts and emotional reactions such as anxiety and anger (McCann and Pearlman 1990; Schauben and Frazier 1995; Jenkins and Baird 2002; Adams and Riggs 2008). It is imperative that mental health and justice providers of trauma-specific services adopt coping strategies aimed at helping them process work-related stress. Strategies that have been shown to be effective for psychologists include active coping (e.g., problem solving), seeking emotional support (e.g., from friends, family, or others), planning (i.e., making a plan of action), and seeking instrumental social support (i.e., getting advice from others) (Schauben and Frazier 1995).
Survivors of sex trafficking face psychological, social, medical, financial, and legal consequences (Farley 2008). The legal response to their victimization is usually one that criminalizes the trafficked person and minimizes consequences for the trafficker and consumer (Mir 2013). This chapter has made the case for a client-centered restorative process that addresses the multilayered needs of the survivors. It has also articulated recommendations for contextualized interventions that acknowledge the realities of oppression and the varied impact of long-term complex trauma. For justice to be served and to interrupt the cycle of human trafficking, there must be a shift in the guiding framework and procedures of the criminal justice system as relates to the treatment of victims of human trafficking. This shift would entail involving survivors of sex trafficking in the creation of policies and procedures that would assist and empower victims rather than criminalize them, and that would penalize traffickers and educate and train legal and helping professionals in order to promote justice models that focus on the restoration of victims psychologically, socially, and economically.
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