U.S. Department of Health and Human Services, 

Office of the Assistant Secretary for Planning and Evaluation 

1

HUMAN TRAFFICKING INTO AND WITHIN THE UNITED STATES: 

A REVIEW OF THE LITERATURE 

1. INTRODUCTION 

This paper presents a comprehensive review of current literature on human trafficking into and within the 

United States. This review of the literature is part of a larger study funded by the U.S. Department of 

Health and Human Services (HHS), Office of the Assistant Secretary for Planning and Evaluation, to 

examine how HHS programs are currently addressing the needs of victims of human trafficking, 

including domestic victims, with a priority focus on domestic youth. This study is also structured to 

identify barriers and promising practices for addressing the needs of victims of human trafficking, with a 

goal of informing current and future program design and improving services to this extremely vulnerable 

population. 

 

While historically there have been inconsistencies and disagreements regarding the definition of human 

trafficking among politicians, practitioners, and scholars (Laczko & Gramegna, 2003; Richard, 1999), for 

the purpose of this literature review, the legal definition of human trafficking set forth in the Trafficking 

Victims Protection Act of 2000 (TVPA) will be used. In the TVPA, Congress defines severe forms of 

trafficking in persons as: 

a) Sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in 

which the person induced to perform such act has not attained 18 years of age; or 

b) The recruitment, harboring, transportation, provision or obtaining of a person for labor or 

services, through the use of force, fraud, or coercion for the purpose of subjection to 

involuntary servitude, peonage, debt bondage, or slavery (8 U.S.C. § 1101). 

To conduct a comprehensive review of the literature associated with the trafficking of foreign nationals 

into the United States and of U.S. citizens and legal permanent residents within the country,1

 we 

performed multiple searches of the literature using GoogleTM and EBSCOhost® search engines. In 

particular, within the EBSCOhost search engine, we searched the following databases: Academic Search 

Elite, PsycINFO, PsycARTICLES, ERIC, and PsycEXTRA.2

 Our initial searches featured a wide array of 

 

1

 For the purposes of this literature review, the foreign nationals who are trafficked into the United States are referred to as international victims 

and the United States citizens and permanent residents trafficked within the United States are referred to as domestic victims.

2 Academic Search Elite offers full text for more than 2,000 serials, including more than 1,500 peer-reviewed titles. This multidisciplinary 

database covers virtually every area of academic study. More than 100 journals have PDF images back to 1985. This database is updated daily via 

EBSCOhost. 

PsycINFO, from the American Psychological Association (APA), contains nearly 2.3 million citations and summaries of scholarly journal 

articles, book chapters, books, and dissertations, all in psychology and related disciplines, dating as far back as the 1800s. Ninety-seven percent 

of the covered material is peer-reviewed. Journal coverage, which spans 1887 to the present, includes international material selected from more 

than 2,100 periodicals in more than 25 languages. 

PsycARTICLES, from the APA, is a definitive source of full-text, peer-reviewed scholarly and scientific articles in psychology. The database

contains more than 45,000 articles from 57 journals, 46 published by the APA and 11 from allied organizations. It includes all journal articles, 

letters to the editor, and errata from each journal. Coverage spans 1985 to the present. 

ERIC, the Educational Resource Information Center, contains more than 2,200 digests along with references for additional information and 

citations and abstracts from more than 1,000 education and education-related journals. 

PsycEXTRA, produced by the APA, is a bibliographic and full-text companion to the scholarly PsycINFO database. The document types include 

technical, annual, and government reports; conference papers; newsletters; magazines; newspapers; consumer brochures; and more. It contains 

more than 85,000 records with nearly a quarter million full-text pages.
U.S. Department of Health and Human Services, 

Office of the Assistant Secretary for Planning and Evaluation 

2

directly related terms, including: trafficking in persons, human trafficking, trafficking/youth/adult, 

international trafficking, domestic trafficking, sex trafficking, sexual exploitation, child prostitution, 

commercial sexual exploitation of children, forced labor, labor trafficking, labor exploitation, minor 

(persons younger than age 18) trafficking victims, debt bondage, domestic servitude, involuntary 

servitude, and modern day slavery. Most of the research, particularly research published in peer-reviewed 

journals, was limited to qualitative and quantitative studies of the scope of the problem (i.e., who is 

vulnerable to trafficking and the characteristics of those who are trafficked). Information on the needs of 

trafficking victims and the services provided to this population was limited to information contained in 

Federal reports, non-peer reviewed journals, manuals and fact sheets, Web sites for advocacy 

organizations and nongovernmental organizations (NGOs) working with trafficking victims, recently 

published books on trafficking, and personal communications with direct service providers and trafficking 

survivors. Given the state of the field, with the limited research that is available on this issue, personal 

communication was relied on for many portions of this review to supplement the available literature. Only 

first names are used in the citations, to protect the identity of the survivors interviewed for this study. 

To collect more rigorous information on promising or effective practices or strategies for serving victims 

of human trafficking, we expanded our search to related disciplines and victim populations, including: 

prostitution,3

 torture victims, refugees, asylum seekers, homeless/runaway/throwaway youth, juvenile 

justice system, adolescent substance abuse, child and adolescent mental health, trauma, co-occurring 

disorders, domestic violence and sexual assault, and child protective services. The search criteria were 

refined further by specifically seeking literature related exclusively to adults (women and men) and 

minors (girls and boys). This search revealed significantly more research-focused articles evaluating 

substance abuse, domestic violence, mental health, and trauma-related services for adults and youth in 

general. While not specific to human trafficking, information obtained from these latter searches provides 

important context about key service delivery systems needed by victims of human trafficking. It should be 

noted, however, that even with a broader search, very little information was available regarding the 

specific needs of and service response for victims of labor trafficking. This is a significant gap in the 

literature that is only recently being addressed through calls for research by Federal agencies focused on 

labor trafficking and, in particular, male victims of labor trafficking. 

The results of this comprehensive review are organized by the following key questions: 

 What is human trafficking? 

 How prevalent is human trafficking into and within the United States? 

 Who are the victims of human trafficking? 

 What are the needs of victims of human trafficking? 

 How are victims identified? 

 What services are victims of human trafficking eligible to receive? 

 What are the barriers to and challenges in accessing and providing services? 

 What are promising practices for serving victims of human trafficking? 

 

3

 The term human trafficking is not used in many studies about the prostitution of minors. However, the prostitution 

of minors is, by statutory definition, a form of sex trafficking and prostituted minors are victims of trafficking. Thus 

the literature related to this problem is included in this review. 
U.S. Department of Health and Human Services, 

Office of the Assistant Secretary for Planning and Evaluation 

3

This review of the literature provides one of the first comprehensive syntheses of information available on 

human trafficking into and within the United States. 

2. WHAT IS HUMAN TRAFFICKING? 

The crime of human trafficking affects virtually every country in the world (Europol, 2005; Miko, 2000) 

and has been associated with transnational criminal organizations, small criminal networks and local 

gangs, violations of labor and immigration codes, and government corruption (Richard, 1999; U.S. 

Government Accountability Office, 2006). Historically, trafficking has been defined most often as the 

trade in women and children for prostitution or other immoral purposes (Europol, 2005). More recently 

trafficking has been defined to include other types of force, fraud, or coercion beyond sexual exploitation. 

It has been further clarified that victims do not need to be transported across international or other 

boundaries in order for trafficking to exist. In 2000, the international community developed and agreed to 

a definition for trafficking in persons that can be found in Article 3 of the United Nations Protocol to 

Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children: 

Trafficking in persons shall mean the recruitment, transportation, transfer, harboring or receipt of 

persons, by means of the threat or 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 of the 

prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or 

practices similar to slavery, servitude or the removal of organs (Europol, 2005, p. 10). 

At the same time, the U.S. Congress defined and classified human trafficking into two categories—sex 

trafficking and labor trafficking—in the TVPA. As stated previously, sex trafficking involves 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 force, fraud, or coercion, or in which the person 

forced to perform such an act is younger than age 18. A commercial sex act means any sex act on account 

of which anything of value is given to or received by any person. Types of sex trafficking include 

prostitution, pornography, stripping, live-sex shows, mail-order brides, military prostitution, and sex 

tourism. Labor trafficking is defined in the TVPA as the recruitment, harboring, transportation, provision, 

or obtaining of a person for labor services, through the use of force, fraud, or coercion for the purpose of 

subjection to involuntary servitude, peonage, debt bondage, or slavery. Labor trafficking situations may 

arise in domestic servitude, restaurant work, janitorial work, sweatshop factory work, migrant agricultural 

work, construction, and peddling (8 U.S.C. § 1101). 

Human trafficking is synonymous with trafficking in persons and has commonly been referred to as 

modern day slavery. Under the U.S. definition, transportation or physical movement of the victim does 

not necessarily need to be present in order for the crime to occur; instead, it is the presence of exploitation 

(force, fraud, or coercion) that indicates whether a trafficking crime has occurred. The TVPA and 

subsequent reauthorizations not only provide a standard legal definition of the crime of human trafficking 

but also offer a framework for current and future U.S. anti-trafficking efforts. It addresses the prevention 

of trafficking, protection and assistance for victims of trafficking, and prosecution and punishment of 

traffickers (U.S. Government Accountability Office, 2006). While most of the anti-trafficking efforts 

within the United States have historically focused on trafficking of foreign nationals into the country, the 

2005 reauthorization of the TVPA highlighted the need to address the trafficking of U.S. citizens and 

permanent residents, in particular minor victims of sex trafficking or the prostitution of minors, within 

U.S. borders (22 U.S.C §7103). 
U.S. Department of Health and Human Services, 

Office of the Assistant Secretary for Planning and Evaluation 

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3. HOW PREVALENT IS HUMAN TRAFFICKING INTO AND WITHIN 

THE UNITED STATES? 

3.1 Trafficking into the United States 

The data and methodologies for estimating the prevalence of human trafficking globally and nationally 

are not well developed, and therefore estimates have varied widely and changed significantly over time. 

The U.S. State Department has estimated that approximately 600,000 to 800,000 victims are trafficked 

annually across international borders worldwide and approximately half of these victims are younger than 

age 18 (U.S. Department of State, 2005, 2006, 2007). Additionally, the U.S. State Department has 

estimated that 80 percent of internationally trafficked victims are female and 70 percent are trafficked into 

the sex industry (U.S. Department of State, 2005). In comparison, the International Labor Organization 

has estimated that at any given time, 12.3 million people are in forced labor, bonded labor, forced child 

labor, sexual servitude, and involuntary servitude (International Labor Organization, 2005). Other 

estimates of global labor exploitation range from 4 million to 27 million (U.S. Department of State, 2006, 

2007). 

Initial estimates cited in the TVPA suggested that approximately 50,000 individuals were trafficked into 

the United States each year. This estimate was subsequently reduced to 18,000–20,000 in the U.S. 

Department of State’s June 2003 Trafficking in Persons Report, and in its 2005 and 2006 reports, altered 

again to an estimate of 14,500–17,500 individuals trafficked annually into the United States. 

According to official administrative data, since 2001, the U.S. Department of Justice has prosecuted 360 

defendants in human trafficking cases, and secured 238 convictions (U.S. Department of Justice, 2007). 

Additionally, as of June 2007, 1,264 foreign nationals (adults and children) have been certified by the 

U.S. Department of Health and Human Services as victims of human trafficking, eligible to receive public 

benefits. Of these, 1,153 are adults, with 69 percent female victims. Of the 111 minor victims certified, 

82 percent were female. For some victim service providers and NGOs, these figures are not considered 

representative of the actual number of human trafficking victims in the country. They believe that many 

victims go unreported (and uncounted) because they do not want to cooperate with law enforcement and, 

therefore, are never reported to authorities or receive Federal assistance (Caliber Associates, 2007). 

3.2 Trafficking within the United States 

To date, estimates of human trafficking have focused almost exclusively on international trafficking 

victims (Laczko & Gozdziak, 2005), and this holds true for the United States as well. Only a recent 

estimate of minors at risk for sexual exploitation comes close to estimating U.S. domestic trafficking. 

Between 244,000 and 325,000 American youth are considered at risk for sexual exploitation, and an 

estimated 199,000 incidents of sexual exploitation of minors occur each year in the United States (Estes 

& Weiner, 2001). These figures, however, are limited estimates of youth at risk for human trafficking 

and do not address adult U.S. citizens trafficked into the sex industry or American children and adults 

trafficked for labor. We can, however, turn to estimates of other at-risk populations, such as 

runaway/throwaway youth, youth exploited through prostitution, and child labor, to gain a better sense of 

the potential prevalence of domestic trafficking, or at least the numbers of people at high risk of 

trafficking. 

Given the correlations between runaway/throwaway youth and minors exploited through prostitution 

(Estes & Weiner, 2001), findings from the Second National Incidence Studies of Missing, Abducted, 
U.S. Department of Health and Human Services, 

Office of the Assistant Secretary for Planning and Evaluation 

5

Runaway, and Thrownaway Children can offer additional information about the possible prevalence of 

minors trafficked or at risk of being trafficked domestically into the commercial sex industry (Hammer, 

Finkelhor, & Sedlak, 2002). For example, in 1999, 1,682,900 youth had a period of time in which they 

could be characterized as a runaway or throwaway youth; 71 percent of these youth were considered at 

risk for prostitution (Estes & Weiner, 2001). 

Data reported by the runaway and homeless youth programs supported by funding from the Family and 

Youth Services Bureau (FYSB) within HHS provide additional information about this at-risk youth 

population. In 2007, 50,718 youth received services from FYSB-funded runaway and homeless programs 

(U.S. Department of Health and Human Services, n.d.). Of these youth, 54 percent were female. 

Additionally, 770,223contacts (distribution of written materials, health and hygiene products, and/or food 

and drinks) were made with youth through street outreach programs. It is unclear, however, whether 

these numbers include duplicate counts (e.g., youth receiving services multiple times from one or more 

service providers), which is a problem often inherent in administrative data (Gozdziak & Collett, 2005). 

In addition, it is not known how many street youth do not come into contact with service providers. 

National juvenile arrest data provide another glimpse of the potential magnitude of the domestic 

trafficking of youth. Nationwide in 2003, 2,220,300 juveniles were arrested, 11 percent fewer than in 

1999 (U.S. Department of Justice, 2004). During 2003, 1,400 youth were arrested for prostitution and 

commercialized vice. Of these youth, 69 percent were female and 14 percent were younger than age 15. 

Unlike overall juvenile arrest rates, these numbers increased 31 percent between 1994 and 2003. 

Notwithstanding these general data, there is no clear consensus on the numbers of girls versus boys 

exploited through prostitution nationwide. The differential treatment of boys and girls, coupled with the 

differences in the circumstances under which they prostitute (including location), make these statistics 

extremely difficult to interpret. 

As with most other data related to human trafficking, there are huge gaps between estimates of 

“prevalence” or populations “at risk” and individuals actually identified as trafficking victims or enrolled 

in government programs. Better data and research are needed to begin distinguishing among possible 

reasons for the gaps between prevalence estimates and administrative data. 

In addition to domestic sex trafficking, American minors and adults are likely trafficked for forced labor; 

however, children are generally preferred to adults in the labor world as they are more easily controlled, 

cheaper, and less likely to demand better working conditions (Herzfeld, 2002). Unfortunately, we know 

even less about labor trafficking, both into and within the United States, than we do about sex trafficking. 

There is evidence that forced child labor exists in the African and Latin American regions and also in 

more developed countries such as the United States (International Labor Organization, 2002). An 

International Labor Organization study indicated that girls are more likely to be trafficked for commercial 

sexual exploitation and domestic services, and boys tend to be trafficked for forced labor in commercial 

farming, petty crimes, and the drug trade. 

A review of the data on child labor, however, provides some insight into the potential for labor trafficking 

within the United States. Data from the National Longitudinal Survey of Youth 1997 (NLSY97) show 

substantial work activity among 14- and 15-year-old children (Bureau of Labor Statistics, 2001).

Employment among 14- and 15-year olds was concentrated in a small number of industries, with 

restaurants and supermarkets the most common industries in which youth were employed. 

 Babysitting and yard work were by far the most common freelance jobs youth reported having 

worked. NLSY97 figures and those of the Child Labor Coalition (CLC) indicate that youth employment 
U.S. Department of Health and Human Services, 

Office of the Assistant Secretary for Planning and Evaluation 

6

is growing in the United States. The CLC estimated there are 5.5 million youth between the ages of 12 

and 17 employed across the United States. This estimate was derived from the NLSY97 data. The CLC 

(2007) also estimates there are 500,000 U.S. children working in various agricultural settings, with most 

being members of minority groups. In addition to agricultural work, the CLC estimates 50,000 children 

are involved in street peddling, including peddling magazines, candy, and other consumer goods. Many 

teens become involved, believing peddling is a good way to make money, and do not realize the dangers 

associated with these activities. The CLC indicates that youth peddlers work long hours with little pay, in 

extreme temperatures, and with no access to bathrooms, water, or food; work for activities or prizes they 

never receive; and work alone in strange neighborhoods or cities. Youth peddlers also may be abandoned 

or deserted if they do not meet their quota for the day, or may be forced to walk home for angering the 

crew leader. Many parents are also unaware of these dangers and believe they are allowing their children 

to work for respected and legitimate companies. 

In FY 2004, the U.S. Department of Labor found 1,087 minors employed in violation of Hazardous 

Occupation Standards. During the same period, the Wage and Hours Division reported 5,840 children 

were employed in violation of child labor laws. Both sets of figures represent reductions from prior 

years; however, advocates contend that the reductions are the result of reduced Federal enforcement, not 

declining use of child labor. This assumption is partly due to the fact that there are only 34 Department of 

Labor employees assigned to monitor this area, or one per every 95,000 child laborers. The advocates’ 

contention is supported by the U.S. Government Accountability Office (2002). These child labor 

estimates represent a proportion of the population that may be at risk for labor trafficking within the 

United States, and should be explored further from the perspective of domestic labor trafficking. 

Despite these various estimates, we are still uncertain about the actual prevalence of human trafficking 

into and within the United States for several reasons. First, given the covert character of the crime, 

accurate statistics on the nature, prevalence, and geography of human trafficking are difficult to calculate 

(Clawson, Layne, & Small, 2006). Trafficking victims are guarded closely by their captors, many victims 

lack accurate immigration documentation, trafficked domestic servants remain “invisible” in private 

homes, and private businesses often act as a front for a back-end trafficking operation. These factors 

make human trafficking a particularly difficult crime to identify and count. Additionally, available data 

are often non-comparable and contain duplicate counts, are limited to information on women and children 

trafficked for sexual exploitation and not other forms of human trafficking, and are often inconsistently or 

inaccurately recorded due to differing definitions and beliefs among service providers and law 

enforcement about who is a victim of human trafficking (Clawson, Layne, & Small, 2006). 

Despite these challenges, steps are being taken to improve the methods used to estimate human 

trafficking (Clawson, Layne, & Small, 2006) and improve the reliability and validity of the data. For 

example, Massachusetts created the Child Sexual Exploitation Database through the SEEN Coalition 

(formerly the Teen Prostitution Prevention Project) in Suffolk County. Through increased awareness and 

a new reporting system, better data are available on the number of prostituted teens in the area. In 2003, 

for example, only five prostituted teens were recorded by Suffolk County, but by September 2005, the 

number jumped to 59. Of those 59, 58 were female, one was male, and none identified as transgender. 

Providers in Boston believe this jump may be attributed to increased awareness by those coming in 

contact with youth (including law enforcement, health care, and child protective services) as well as a 

more effective identification and referral mechanism, particularly of female minors exploited through 

prostitution. However, to date, there has been no analysis that documents whether these increasing 

numbers reflect improved awareness and identification, or an actual increase in the incidence of minor 

prostitution (Teen Prostitution Prevention Project, 2006). 
U.S. Department of Health and Human Services, 

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7

Obtaining more stable and reliable estimates is key to helping Federal, State, and local governments 

appropriately allocate resources and develop programs and strategies to prevent human trafficking, 

prosecute traffickers, and protect and serve victims of this crime. 

4. WHO ARE THE VICTIMS OF HUMAN TRAFFICKING? 

4.1 Commonalities Among Victims 

While current stereotypes often depict the victims of human 

trafficking as innocent young girls who are seduced or 

kidnapped from their home countries and forced into the sex 

industry (Bruckert & Parent, 2002), it is not just young girls 

who are trafficked. Men, women, and children of all ages 

can fall prey to traffickers for purposes of sex and/or labor. 

Victims may be trafficked into the United States from other 

countries or may be foreign citizens already in the United 

States (legally or illegally) who are desperate to make a 

living to support themselves and their families in the United 

States or in their home countries (Florida University Center 

for Advancement of Human Rights, 2003). 

Regardless of sex, age, immigration status, or citizenship, 

certain commonalities exist among victims of trafficking (for both sex and labor), such as their 

vulnerability to force, fraud, or coercion (Protection Project, 2002). Traffickers prey on those with few 

economic opportunities and those struggling to meet basic needs. Traffickers take advantage of the 

unequal status of women and girls in disadvantaged countries and communities, and capitalize on the 

demand for cheap, unprotected labor and the promotion of sex tourism in some countries (Aronowitz, 

2001; Miller & Stewart, 1998). Victims of human trafficking, both international and domestic, share 

other characteristics that place them at risk for being trafficked. These include poverty, young age, 

limited education, lack of work opportunities, lack of family support (e.g., orphaned, 

runaway/throwaway, homeless, family members collaborating with traffickers), history of previous sexual 

abuse, health or mental health challenges, and living in vulnerable areas (e.g., areas with police corruption 

and high crime) (Salvation Army, 2006). 

 Age 

 Poverty 

 Gender inequality 

 Unemployment

 Sexual abuse 

 Health/mental health problems 

 Police/political corruption

 High crime 

Risk Factors for Trafficking

Victims 

Victims of international trafficking may be trying to escape from internal strife such as civil war and 

economic crises (Aiko, 2002). Many international trafficking victims originate from poor countries 

where human trafficking has become a significant source of income (Newman, 2006). Traffickers exploit 

conditions in impoverished countries in Asia, Eastern Europe, Africa, and Latin America that offer few 

employment opportunities and are characterized by high rates of organized crime and violence against 

women and children, discrimination against women, government corruption, political instability, and 

armed conflict (Bell, 2001; U.S. Department of State, 2005). Many trafficking victims are merely trying

to remove themselves from unstable or unsatisfactory living conditions. According to the latest figures 

from HHS (as reported in the DoJ Annual Report to Congress), of those certified as victims of human 

trafficking in 2006, the countries of origin with the highest populations of victims were El Salvador 

(28%) and Mexico (20%) (U.S. Department of Justice, 2007). 
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Traffickers often deceive their victims through false promises of economic opportunities that await them 

in more affluent destination countries, such as the United States. Thus routes of trafficking often flow 

from less developed countries to neighboring 

countries or industrialized nations with 

higher standards of living (Miko, 2000). 

Many of those who accept offers from 

traffickers find themselves in situations 

where their documents are destroyed, their 

families are threatened with harm, or they are 

bonded by a debt they will not be able to 

repay (Human Trafficking Organization, 

2006). Traffickers use threats, intimidation, 

and violence, as well as deception and 

trickery, to force or lure victims to engage in 

sex or labor in slavery-like conditions. 

Victims of labor trafficking may be promised 

well-paying jobs, yet once in the destination 

country they find themselves trapped in 

substandard living and working conditions. 

In these situations, abuse can range from the 

imposition of excessive working hours to verbal and physical abuse to sexual harassment and sexual 

attacks, and may extend to forcing the worker into the sex trade (International Organization on Migration, 

2005). Migrants residing illegally in destination countries, such as the United States, are more exposed to 

this kind of abuse (Tuller, 2005). However legal citizens also can be subjected to such exploitation 

(International Organization on Migration, 2005). 

A Federal Case of Domestic Labor Trafficking 

Labor camp owners recruit homeless African-American 

addicts from shelters throughout the Southeast, including 

Tampa, Miami, Orlando, and New Orleans, to work at 

labor camps, promising food and shelter for only $50 a

week. The camp owners picked up the prospective 

workers in vans and transported them to isolated labor

camps in North Florida and North Carolina. Once on site, 

the workers were supplied with crack cocaine. The cost of 

the drug was deducted from their pay checks. Every

evening camp owners gave workers the opportunity to buy 

crack, untaxed generic beer and cigarettes from the 

company store. Most workers spiraled into debt. On

average, workers were paid about 30 cents on the dollar

after deductions. The case broke in 2005 after a Federal 

raid on the North Florida camp. Advocates were stunned 

that the camps could so easily exploit American citizens. 

(Naples Daily News, September 23, 2006) 

In the United States, vulnerable workers have been recruited from homeless shelters and elsewhere, 

transported to isolated labor camps, and ultimately exploited and abused. According to some experts in 

the labor movement, the power differential between a farm worker and an employer can create a situation 

that may escalate into exploitation, regardless of the 

immigration status of the worker (Bales, 2004; Zeitlin, 2006). Risk Factors for Minor Domestic 

Sex Trafficking Victims 

 Age 

 Poverty 

 Sexual abuse 

 Family substance/physical abuse 

 Individual substance abuse 

 Learning disabilities 

 Loss of parent/caregiver

 Runaway/throwaway

 Sexual identity issues 

 Lack of support systems 

4.2 Minor Victims of Domestic Sex Trafficking 

Minors, including American children, are among the most 

vulnerable populations. A look at the characteristics of minors 

exploited through prostitution and prostituted adults who were 

recruited as minors (Raphael, 2004) provides useful 

information to help answer the question, “Who are the victims 

of domestic sex trafficking?” Minors are deceived, 

manipulated, forced, or coerced into prostitution every day. 

Nationally, the average age at which girls first become 

exploited through prostitution is 12–14 years old, but direct 

service providers around the country report they have been 

encountering increasingly younger victims over the past 

decade (Estes & Weiner, 2001; Lloyd, 2005; Spangenberg, 

2001). For example, service providers in New York City report 

that the average age that girls enter prostitution has dropped 
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from 14 to 13 or 12 years of age in recent years (Spangenberg, 2001). The average age that boys and 

transgender youth begin prostitution is even younger: 11–13 years old (Estes & Weiner, 2001). 

In terms of race and ethnicity, all subgroups of adolescents are at risk for prostitution. The vast majority 

of male and female adolescents arrested for prostitution are White or Black (Flowers, 2001). The only 

specific research conducted on a subpopulation of exploited minors shows that African-American girls 

and women are arrested in prostitution at a far higher rate than girls and women of other races involved in 

the same activity (Flowers, 2001; MacKinnon & Dworkin, 1997). Although it appears that no 

socioeconomic class is immune to domestic trafficking, Estes and Weiner (2001) acknowledge that 

poverty (as noted previously for victims of trafficking in general) places adolescents at increased risk of 

exploitation. Though their sample was small (10 boys), Lankenau, Clatts, Welle, Goldsamt, and Gwadz 

(2005) found that 100 percent of a study’s subjects were born into homes characterized as poor or 

working class. The correlation between poverty and trafficking has been corroborated by qualitative 

reports from law enforcement, social service providers, and others working in the anti-trafficking 

movements (Clawson & Dutch, 2008). Further, Lloyd (2005) states that low-income girls are at greater 

risk of recruitment and may find it harder to exit. 

One common characteristic or risk factor for prostituted girls is a history of childhood sexual abuse. In 20 

recent studies of adult women who were sexually exploited through prostitution, the percentage of those 

who had been abused as children ranged from 33 percent to 84 percent (Raphael, 2004). For example, a 

study of 106 adult women in Boston who were incarcerated for prostitution-related offenses or had ever 

been arrested for prostitution-related offenses found that 68 percent of the women reported having been 

sexually abused before the age of 10 and almost half reported being raped before the age of 10 (NortonHawk, 2002). Other smaller studies of prostituted girls affirm these figures. For example, the 

Huckleberry House Project in San Francisco reported that 90 percent of the girls involved in prostitution 

had been sexually molested (Harlan, Rodgers, & Slattery, 1981). Two other studies of juveniles estimated 

the percentage of girls engaged in prostitution who had a history of sexual abuse to be between 70 percent 

and 80 percent (Bagley & Young, 1987; Silbert & Pines, 1982).

Research has demonstrated that the younger a girl is when she first becomes involved in prostitution, the 

greater the likelihood that she has a history of childhood sexual abuse and the greater the extent of the 

abuse (Council for Prostitution Alternatives, 1991). Further, the history of childhood trauma experienced 

by most girls involved in prostitution includes abuse that is chronic in nature and takes the form of 

physical abuse, emotional abuse, and/or sexual abuse by multiple perpetrators (Farley & Kelly, 2000). A 

1994 National Institute of Justice report (as cited in Spangenberg, 2001) states that minors who were 

sexually abused were 28 times more likely to be arrested for prostitution at some point in their lives than 

minors who were not sexually abused. 

In addition to a history of childhood abuse, prostituted girls are likely to experience other forms of family 

disruption. Multiple studies suggest that girls involved in prostitution are more likely to come from homes 

where addiction was present (Raphael, 2004). For example, one study of 222 women in Chicago 

involved in prostitution found 83 percent had grown up in a home where one or both parents were 

involved in substance abuse (Center for Impact Research, 2001). Further, prostituted girls are more likely 

to have witnessed domestic violence in their home; specifically, girls are likely to have seen their mother 

beaten by an intimate partner (Raphael, 2004). 

Some literature has begun to recognize a correlation between school-related problems, most notably 

learning disabilities, and sexual exploitation. Current research does not allow us to distinguish whether 

the learning disability was present before or is a consequence of the exploitation. However, the later the 

disability is diagnosed and an appropriate educational plan put in place, the greater the likelihood of the 
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girl experiencing failure in school and/or low self-esteem, making her vulnerable to exploitation (Harway 

& Liss, 1999). 

Another risk factor that emerges for youth at risk for exploitation through prostitution is the loss of a 

parent through death, divorce, or abandonment. For example, in two separate studies of adolescent girls 

involved in prostitution, a third of the sample had a deceased mother (Norton-Hawk, 2002; Raphael & 

Shapiro, 2002). This familial disruption often results in the child’s involvement in the child welfare 

system, involving placement in foster care or group homes. One study in Canada of 47 women in 

prostitution found that 64 percent had been involved in the child welfare system, and of these, 78 percent 

had entered foster care or group homes (Nixon, Tutty, Downe, Gorkoff, & Ursel, 2002). The themes of 

trauma, abandonment, and disruption, begun in childhood, are central to the narratives of adolescent girls 

trafficked into commercial sexual exploitation. Girls describe having had a profound sense of being alone 

without resources: “They [the women and girls] described their isolation, lack of connectedness, and 

feelings of separation as the single most important factor in making them vulnerable to prostitution to 

begin with...” (Rabinovitch, 2003). 

The prostitution of boys is not as visible as that of young girls (McKnight, 2006). According to Flowers 

(1998), boys primarily sell their bodies to “survive financially, explore their sexuality, and/or make 

contact with gay men,” with money a major motivator to continue prostituting. Young prostituted males 

are also more likely to be involved in criminal or delinquent behaviors in addition to prostitution 

(Flowers, 1998); however, they are arrested much less frequently (McKnight, 2006). McKnight also 

states that boys are more likely than girls to leave home due to a feeling of being unwanted or 

misunderstood regarding their sexual orientation. Similar to girls, however, most boys exploited through 

prostitution come from dysfunctional homes and a large percentage have been the victim of some kind of 

abuse in the past (Flowers, 1998). 

4.3 Other Populations at Risk for Trafficking: Runaway and Homeless Youth 

According to the Federal Bureau of Investigation (FBI) Uniform Crime Reports (2006), across the United 

States 36,402 boys and 47,472 girls younger than age 18 were picked up by law enforcement and 

identified as runaways. Girls who run from their homes, group homes, foster homes, or treatment centers, 

are at great risk of being targeted by a pimp (or trafficker) and becoming exploited. Research consistently 

confirms the correlation between running away and becoming exploited through prostitution. Researchers 

have found that the majority of prostituted women had been runaways; for example, 96 percent in San 

Francisco (Silbert & Pines, 1982), 72 percent in Boston (Norton-Hawk, 2002) and 56 percent in Chicago 

(Raphael & Shapiro, 2002). Among prostituted youth (both boys and girls), up to 77 percent report 

having run away at least once (Seng, 1989). Experts have reported that within 48 hours of running away, 

an adolescent is likely to be approached to participate in prostitution or another form of commercial 

sexual exploitation (Spangenberg, 2001); however, no definitive published research substantiates this 

claim. 

Like girls, boys exploited through prostitution are most often runaways or throwaways (Flowers, 2001; 

Lankenau et al., 2005; Moxley-Goldsmith, 2005). For example, one study found that two-thirds of males 

exploited through prostitution had run away from home prior to becoming involved (Allen, 1980). While 

many of the factors leading to a young person leaving home are similar for boys and girls, it is estimated 

that between 40 and 50 percent of boys exploited through prostitution had been thrown out of their homes 

because of sexual identity issues (Earls & David, 1989; Seattle Commission on Children and Youth, 

1986). Approximately 25–35 percent of prostituted boys self-identify as gay, bisexual, or 

transgender/transsexual (Estes & Weiner, 2001). Further, regardless of the boy’s self-identification, at 

least 95 percent of all prostitution engaged in by boys is provided to adult men (Estes & Weiner, 2001). 
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Regardless of their sex, when minors leave their homes, it is to protect themselves, often because they 

view living on the streets as either less dangerous or no more dangerous than staying at home (Hyde, 

2005; Martinez, 2006). 

Once on the street, homeless youth are at risk for being victimized because they lack the funds, 

interpersonal and job skills, and support systems necessary to survive on their own (Martinez, 2006). 

Having often come from chaotic families, runaways tend to lack strategies for problem solving, conflict 

resolution, and meeting basic needs such as food, clothing, and shelter (Martinez, 2006; Robertson & 

Toro, 1999; Whitbeck, Hoyt, & Yoder, 1999). Some minors turn to substance abuse, crime, and “survival 

sex” to meet their basic needs (Greene, Ennett, & Ringwald, 1999; Riley, Greif, Caplan, & MacAulay, 

2004; Robertson & Toro, 1999). Furthermore, exposure to the dangers of the street makes them more 

visible and vulnerable to traffickers, and their risky lifestyles and routines put them at greater risk of 

being victimized (Kipke, Simon, Montgomery, Unger, & Iversen, 1997; MacLean, Embry, & Cauce, 

1999; Tyler, Cauce, & Whitbeck, 2004). 

Most runaway/throwaway youth are likely to run to and congregate in urban areas, so it is not surprising 

that there is general consensus that a greater percentage of minors are exploited in the U.S. sex industry 

in urban areas, though they may be brought from suburban and rural areas (Flowers, 2001). However, an 

increase in minor arrests in suburban counties/areas and rural areas has experts speculating that the 

increase is indicative of an expansion of prostitution beyond city limits (Flowers, 2001). While these data 

are somewhat outdated, anecdotal evidence from service providers indicates that this trend continues (A. 

Adams, personal communication, March 2006; N. Hotaling, personal communication, June 2006). 

However, further research is needed to determine whether the increase in suburban arrests is due to better 

identification or an actual increase in incidence. 

5. WHAT ARE THE NEEDS OF VICTIMS OF HUMAN TRAFFICKING? 

5.1 Needs of International Victims 

An examination of the services provided to international 

victims of human trafficking (adults and children) reveals 

emergency, short-term, and long-term needs (Caliber 

Associates, 2007; Clawson, Small, Go, & Myles, 2004). Some 

victims initially may present to a service provider with basic 

needs for safety, housing, food, and clothing. In fact, the need 

for safe and secure housing and overall support and advocacy 

are primary needs for virtually all victims of trafficking. 

Needs of International Victims 

 Emergency

o Safety, housing, 

food/clothing

 Short-term/Long-term

o Legal assistance

o Advocacy (emotional/moral 

support) 

o Housing 

o Medical care (including 

dental) 

o Mental health 

services/trauma recovery

o Transportation 

o Education 

o Job training/employment

o Reunification/repatriation 

These basic needs often are accompanied by an immediate 

need for legal assistance/representation to handle issues related 

to immigration status, provide legal representation that may be 

required in an ongoing investigation and prosecution of the 

trafficking case, or provide counsel in a civil lawsuit against 

the trafficker or in a potential custody case (Caliber 

Associates, 2007; Florida University Center for Advancement 

of Human Rights, 2003). Interviews with service providers 

and NGOs reveal that beyond these common immediate needs, 

the needs of victims are as diverse as the countries from which 
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the victims originate. Additionally, during the course of working with victims, their needs are likely to 

change (Caliber Associates, 2007). 

A needs assessment conducted with service providers working with victims of human trafficking 

identified a broad range of victims’ needs, including emergency, transitional, and permanent housing; 

food/clothing; medical services (including dental care); advocacy (moral/emotional support), legal 

services; transportation; and information/referral services (e.g., rights as a victim of human trafficking, 

available services) (Clawson et al., 2004). For international victims, more often than not, there is a need 

for language assistance, often requiring an interpreter/translator to help the victim communicate with first 

responders and those trying to provide assistance. Only after these immediate needs have been met can a 

victim benefit from treatment for depression, trauma, re-traumatization, and other issues (Misra, 

Connolly, Klynman, & Majeed, 2006). 

Addressing the symptoms exhibited by victims of human trafficking is critical to their long-term 

recovery. Victims of human trafficking have been described as exhibiting symptoms and needs for 

service similar to torture victims, victims of domestic violence/sexual assault, battered immigrant women, 

migrant workers, refugees, and asylum seekers (Clawson et al., 2004). Like torture victims, victims of 

human trafficking (both sex and labor trafficking) often experience post-traumatic stress disorder (PTSD), 

depressive disorder, other anxiety disorders, and substance abuse (De Jong, et al, 2001; Shrestha, Sharma, 

Van Ommeren, Regmi, Makaju, et al., 1998). Specific symptoms exhibited by victims can include 

nightmares, difficulty concentrating, becoming easily upset, and having difficulty relaxing. Victims can 

frequently feel sad or angry, have difficulty thinking, experience feelings of hopelessness, and 

demonstrate sleep disorders. The trauma itself also may manifest as physical symptoms, such as 

headaches, chest pain, shaking, sweating, and dizziness (Center for Victims of Torture). 

Beyond trauma-recovery services, long-term service needs include permanent housing, legal assistance, 

job training, job placement, education, family reunification (within the United States), and repatriation (in 

some cases). For some victims, in particular victims of labor trafficking, the victim may have a need for 

long-term medical care to address physical disabilities resulting from the abuse and/or harsh labor 

conditions under which the person was forced to work (Bales, 2004; Caliber Associates, 2007). Based on 

research on the needs of unaccompanied refugee minors, minor international trafficking victims may 

experience depression and feelings of isolation, but given their culture, they may not know how to express 

or describe what they are feeling. They may display psychosomatic symptoms; experience high levels of 

anxiety (especially if language obstacles and cultural differences exist between the minor and the 

caregiver); experience survivor guilt (victims feel they do not deserve to be alive and in a safe place when 

friends, siblings, or other family members are suffering); exhibit behavioral problems, including 

aggression; and question their ethnic identity (Ryan, 1997). 

Intensive case management and medical, mental health, and social services are important for responding 

to the needs of these children. Additionally, educating and training foster care families about the 

dynamics of human trafficking, the needs of victims, and the symptoms of trauma are also needed to 

ensure appropriate placement for children in need of homes. Given the complex needs of international 

victims of human trafficking, it is not surprising that providers report working with clients for more than a 

year and often for several years, frequently on an intermittent basis. This makes sustained progress 

challenging (Caliber Associates, 2007; Clawson et al., 2004). 
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5.2 Needs of Domestic Victims 

Information specifically documenting the needs of victims of 

human trafficking is limited and has focused primarily on 

international victims. However, research on prostitution and 

on homeless and runaway youth can provide some insights 

about the needs of domestic trafficking victims and can help 

increase understanding about the similarities and differences 

across the victim types. 

Girls and women escaping prostitution report housing (both 

transitional and long-term) as an urgent need (Commercial 

Sexual Exploitation Resource Institute, 1998). Substance 

abuse treatment and mental health counseling are also 

common needs among this population. The use of substances 

and subsequent drug addiction is well documented among 

homeless youth exploited through prostitution. One study 

found that more than 75 percent of these youth abuse alcohol 

or drugs, while virtually all admit to some level of use 

(Yates, Mackenzie, Pennbridge, & Swofford, 1991). These rates were notably higher than among 

homeless youth not exploited through prostitution (R. Lloyd, personal communication, May 2007). 

While it is important to note that a significant percentage of girls enter prostitution with no history of drug 

or alcohol abuse (Farley & Kelly, 2000), some studies suggest that girls who become exploited through 

prostitution are likely to have begun using substances at an earlier age than their at-risk peers who do not 

become exploited in this way (Inciardi, Pottieger, Forney, Chitwood, & McBride. 1991; Nadon, 

Koverola, & Schludermann, 1998). Substance abuse is also a rampant problem among the male 

population. For example, one study found that 77 percent of the boys exploited through prostitution were 

regular users of marijuana (Harlan et al., 1981). Another study found that 42 percent of the prostituted 

boys could be classified as heavy drinkers or alcoholics and 29 percent were regular users of hard drugs 

(Allen, 1980). In 1989, the County of Los Angeles found that of all the runaway youth, both boys and 

girls, seeking medical assistance, 75 percent of those exploited through prostitution had a substance abuse 

problem compared with 36 percent of those youth not being prostituted (Klain, 1999). Both girls and boys 

also present with medical needs. Females trafficked in the sex trade have increased risk of cervical cancer 

and chronic hepatitis as well as HIV (Farley et al., 2003), thus requiring immediate and potentially longterm medical care. Boys are at particularly high risk of contracting HIV due to high rates of unprotected 

anal sex with adult men as well as frequent intravenous drug use (Flowers, 2001). 

Needs of Minor Domestic Victims 

 Emergency

o Safety, housing, 

food/clothing

 Short-term/Long-term

o Legal assistance

o Intensive case management

o Medical care 

o Alcohol and substance abuse 

counseling/treatment 

o Mental health counseling 

o Life skills training

o Education 

o Job training/employment

o Family reunification 

Rates of mental health problems are similar between girls and boys, though girls have been studied far 

more extensively (Flowers, 2001; Klain, 1999; Lankenau et al., 2005; Moxley-Goldsmith, 2005). 

Adolescent girls suffer severe emotional and physical consequences as a result of domestic trafficking. 

Survivors of prostitution demonstrate a high rate of dissociative disorders, self-destructive behaviors 

(including cutting), suicide attempts, and clinical depression (Farley, 2003; Farley & Kelly, 2000; 

Giobbe, 1993; Lloyd, 2005; Nixon et al., 2002). Additionally, as a result of the chronic trauma, 

prostituted girls often develop symptoms congruent with PTSD. One international study of prostituted 

children and adults, including male prostitutes, in five countries found that almost three-fourths met the 

diagnostic criteria for PTSD (Farley, Barel, Kiremire, & Sezquin, 1998; Silbert & Pines, 1981). The 

clinical manifestations of PTSD “can limit an individual’s ability to function effectively, decreasing the 

likelihood that he or she can take advantage of available resources and possibly minimizing any

likelihood of leaving prostitution” (Valera, Sawyer, & Schiraldi, 2001). 
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As with all victims of human trafficking, adolescent girls may display symptoms of Stockholm syndrome, 

otherwise most frequently seen among prisoners of war and torture victims (Graham & Wish, 1994). As a 

means of emotional and physical survival, the captive (the girl) identifies with her captor. She expresses 

extreme gratitude over the smallest acts of kindness or mercy (e.g., he does not beat her today), denial 

over the extent of violence and injury, rooting for her pimp, hypervigilence regarding his needs, and the 

perception that anyone trying to persecute him or help her escape is the enemy. She may lash out at law 

enforcement or anyone else attempting to help her exit, and insist that she is fine and happy in her current 

situation. Further, the manifestations of her trauma may make her reticent to trust those outside “the Life” 

who state they are trying to help her (Friedman, 2005; Raphael, 2004). 

While presented here as separate needs or conditions, recognition of co-occurring disorders among 

adolescent victims of trafficking and the need for integrated treatment approaches, specifically for trauma, 

substance abuse, and mental health disorders, has gained momentum over the past 5–10 years (Austin, 

Macgowan, & Wagner, 2005; Battjes et al., 2004; Dasinger, Shane, & Martinovich, 2004; Dennis et al., 

2002, 2004; Godley, Jones, Funk, Ives, & Passetti, 2004; Robbins, Bachrach, & Scapocznik, 2002). A 

number of studies indicate high rates of co-occurring disorders among adolescents. In one clinical study 

of youth in the mental health system, for example, about half had a co-occurring substance abuse disorder 

(Greenbaum, Foster-Johnson, & Petrilla, 1996). In the substance abuse system, estimates are even higher 

that as many as 75–90 percent of drug abusing adolescents having a co-morbid mental health disorder 

(Eisen, Youngman, Grob, & Dill, 1992; Grella, Hser, Joshia, & Rounds-Bryant, 2001). Mood disorders 

(especially depression and anxiety), conduct disorders, and attention deficit hyperactivity disorder are 

most often cited as co-occurring with substance abuse disorders in adolescents (Crowley & Riggs, 1995; 

Wise, Cuffe, & Fischer, 2001). Given the high documented rates of co-morbidity in substance abusing 

clinical populations, Grella et al. (2001, p. 391) concluded that adolescent drug treatment programs 

should assume that “co-morbidity among their patients is the norm, rather than the exception.” 

The needs of homeless and runaway youth parallel the needs of victims of human trafficking 

(international and domestic). These include the need for food, clothing, and housing; medical care; 

alcohol and substance abuse counseling and treatment; mental health services; education and employment 

assistance; and legal assistance (Robertson & Toro, 1999). In two studies, homeless youth reported 

wanting assistance with life skills training (Aviles & Helfrich, 2004; DeRosa et al., 1999). Other 

important service needs are assessment and treatment for exposure to trauma (Dalton & Pakenham, 2002; 

Steele & O’Keefe, 2001) and risk of suicide (Martinez, 2006). 

Overall, the needs of victims of human trafficking, whether international or domestic, sex or labor 

trafficking, can be characterized as complex, requiring multiple and comprehensive services and 

treatment representing a continuum of care (emergency, short-term, and long-term assistance) that can 

last for several years. 

6. HOW ARE VICTIMS IDENTIFIED? 

Although victims of human trafficking are difficult to identify because of the hidden nature of the crime, 

many sectors of U.S. communities have the potential to come in contact with them. For example, victims 

of trafficking are at risk for the same types of injuries as victims of domestic violence and rape. They 

frequently contract sexually transmitted infections or become pregnant. Therefore, health clinic workers 

or emergency room personnel are often first responders and should be trained to assess whether someone 

is a victim of human trafficking (Hughes, 2003). In addition, female trafficking victims may be able to 

gain admission to, and potentially could be identified through, battered women and homeless shelters. For 

this reason, several domestic violence and sexual assault coalitions have issued guidelines for battered 
U.S. Department of Health and Human Services, 

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15

women service providers on identifying and serving victims of trafficking (Dabby, 2004; Salvation Army, 

2006). Social workers, mental health professionals, and school personnel are also at times on the front 

line of encountering and identifying potential victims. Community-based organizations, faith leaders, and 

citizens can also be in a position to identify victims of trafficking. As public awareness of the problem 

has grown, victim referrals from these groups to NGOs and service providers have increased significantly 

(Caliber Associates, 2007). 

Perhaps the greatest chance of identifying victims lies with law enforcement. Most victims of human 

trafficking who have been referred to NGOs and other service providers have been initially identified by 

Federal and local law enforcement (Caliber Associates, 2007). Additionally, many of the documented 

cases of domestic trafficking have been the result of law enforcement task force investigations. For 

example, the U.S. Department of Justice has attempted to address identification and outreach to victims of 

domestic sex trafficking through the FBI’s Innocence Lost program, which was launched in 2003. The 

FBI established 14 task forces in cities with the most reports of prostituted youth; currently, task forces 

are in 27 cities. In more than two and one half years, 300 child victims have been rescued. The program 

also has resulted in 241 investigations and reported more than 662 arrests, 151 informations/indictments, 

and 100 convictions (Federal Bureau of Investigation, 2005). Similar multidisciplinary anti-trafficking 

task forces have been funded in 42 communities across the country with the goal of identifying, 

investigating, and prosecuting cases and providing the protection and services needed by victims (U.S. 

Department of Justice, 2006). According to a Department of Justice press release in 2005, indictments 

were made against 31 individuals in four U.S. Districts (the Middle District of Pennsylvania, the District 

of New Jersey, the Eastern District of Michigan, and the District of Hawaii) that included charges of 

transportation of minors to engage in prostitution and sex trafficking of children. A challenge for these 

task forces is the inconsistency in the definition of human trafficking. There does not seem to be a 

consensus within law enforcement as to whether a minor involved in prostitution is a victim or an 

offender (Finkelhor & Ormrod, 2004). 

Law enforcement personnel report often coming in contact with victims of human trafficking through the 

investigation of other crimes (Clawson, Dutch, & Cummings, 2006; Venkatraman, 2003). Victims of sex 

trafficking have the greatest chance of being identified through arrests made by law enforcement pursuant 

to State prostitution and commercial vice statutes. Uniform Crime Reports estimate that in 2005, there 

were 84,891 arrests for adult prostitution or commercialized vice. National Incident-Based Reporting 

System (NIBRS) data from 13 States found slightly more arrests of males for prostitution than females. 

The arrest rate (a standard measure of the percent of reported cases where an arrest was made) was high 

for these crimes (85% for males and 82% for females), although it is not known what percent of 

individuals involved in prostitution actually come to the attention of police. 

A significant challenge to identifying victims of human trafficking is that many have historically been, 

and in some instances continue to be, viewed as criminals (e.g., undocumented immigrants, prostitutes) 

and subject to arrest, detention, and/or deportation. But under the TVPA, these individuals previously 

identified as criminals should be identified and treated as trafficking victims. This change is important 

and challenging for Federal, State, county, and local law enforcement and prompts the need for adequate 

and ongoing education, training, and commitment at all levels of these agencies. This shift in focus has 

not been achieved consistently, due in part to the decentralized structure of our law enforcement system 

with more than 13,000 local police departments alone in the United States (Bureau of Justice Statistics, 

2003). Further complicating this systemic and conceptual shift is the fact that some individuals, such as 

adults engaged in commercial sex activity without the elements of force, fraud, or coercion, may not be 

considered victims of trafficking. Ideally, every law enforcement officer would have the proper training 

and tools (e.g., common screening questions and protocols) to be able to correctly apply the trafficking 

law, make the proper distinctions, and refer trafficking victims for health and human services. 
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7. WHAT SERVICES ARE VICTIMS OF HUMAN TRAFFICKING ELIGIBLE TO 

RECEIVE? 

7.1 Services for Adult Victims 

Prior to the passage of the TVPA in 2000, NGOs and other service providers with scarce resources 

struggled to piece together the comprehensive services needed by victims of human trafficking (Clawson, 

Small, Go, & Myles, 2004). Under the TVPA, the U.S. government designated HHS, along with the 

Office for Victims of Crime (OVC) at the Department of Justice, as the primary Federal agency 

responsible for helping international victims of human trafficking become eligible for benefits and 

services, and allocated some resources for service delivery. One responsibility of HHS is to certify 

international victims of trafficking once they have been identified. This certification provides a victim of 

trafficking who is not a U.S. citizen or lawful permanent resident with the appropriate documentation 

allowing eligibility for a special visa, refugee benefits, and other refugee services that are not available to 

citizens and lawful permanent residents. U.S. citizens who find themselves victims of trafficking do not 

need to be certified in order to be eligible for mainstream benefits, such as Temporary Assistance for 

Needy Families (TANF), Medicaid, and the Supplemental Nutrition Assistance Program (formerly known 

as the Food Stamp Program). As U.S. citizens, they already are eligible for such services. However, 

anyone applying for mainstream benefits such as these must do so through the State in which they reside 

and must meet the eligibility requirements for each program (e.g., be single mothers with children, 

disabled, or meet other criteria, and have low income). Variations in State application processes, 

documentation requirements (e.g., birth certificate, driver’s license), and the movement of victims once 

they are rescued may make it difficult for victims to access these services (Holcomb, Tumlin, Koralek, 

Capps, & Zuberi, 2003). 

 

To receive certification, an international adult must first be determined to be a victim of a severe form of 

trafficking, as defined by the TVPA, and be willing to assist in the investigation of the traffickers. 

Following this determination by law enforcement, victims must complete a bona fide application for a Tvisa or be awarded “continued presence” by a U.S. Immigration and Customs Enforcement official (8 

U.S.C. 1101 a15T 2000), which allows them to legally, albeit temporarily, reside in the United States. Tvisas were established under the TVPA and allow international victims of trafficking to become 

temporary residents of the United States. Once a T-visa is obtained, a victim may remain in the United 

States for up to 3 years. At the end of this time period, the victim may be eligible for permanent resident 

status (Protection Project, 2002). Continued presence is a discretionary status provided by the U.S. 

Department of Homeland Security, generally for a period of 1 or 2 years and can be renewed. 

Certified adult victims are eligible to receive federally funded services and benefits similar to refugees. 

Some of the refugee-specific services that victims of trafficking are eligible to receive through HHS and 

NGOs are Refugee Cash and Medical Assistance, housing or shelter assistance, food assistance, income 

assistance, employment assistance, English language training, health care assistance, mental health 

services, and assistance for victims of torture. Other non-refugee specific benefit programs that certified 

victims may apply for are TANF, which provides a cash benefit and work opportunities for needy 

families with children younger than age 18, and Medicaid, which provides public health insurance for 

needy people with low income and limited resources (22.U.S.C. §7105(b)(1)). 

Victims also are eligible for the Department of Labor’s One-Stop Career Center System, which offers free 

job search and employment centers that provide information and assistance for people who are looking 

for a job or who need education and training to obtain a job. It also provides support services such as 

transportation, child care, and housing. Other programs available to victims who meet standard income 
U.S. Department of Health and Human Services, 

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and eligibility requirements of each program include the Supplemental Nutrition Assistance Program, 

Supplemental Security Income, State Children’s Health Insurance Program, Job Corps, public housing, 

and State-specific programs (U.S. Department of Justice, 2006). 

The process for obtaining certification and thus access to services can be lengthy, since it often takes law 

enforcement agencies a while to formally determine that a person meets the statutory criteria to be 

considered a victim of a severe form of trafficking (Caliber Associates, 2007). During this waiting 

period, international victims, in most cases, are not eligible for either refugee-specific or mainstream 

services. For this reason, OVC began administering comprehensive service grants to communities to 

provide pre-certification services to international victims of human trafficking who were pursuing 

certification and cooperating with law enforcement. Additionally, HHS extended the parameters of its 

direct services (now per capita services) funding to cover the period of pre-certification. The Per-Capita 

Victim Services contract is designed to centralize services while maintaining a high level of care for 

victims of human trafficking through “anytime, anywhere” case management. Working with the HHS 

ongoing Rescue and Restore public awareness campaign, subcontractors are reimbursed for the services 

actually provided to each human trafficking victim. The contract also streamlines support services to help 

victims gain timely access to shelter, job training, and health care. Pre-certification services parallel most 

of the certification services, including housing, food/clothing, advocacy, legal assistance, medical/dental 

care, language services (e.g., interpreters/translators), mental health counseling, education, and job 

training (U.S. Department of Justice, 2006). Most of these services are provided in response to 

emergency or immediate needs, which can be several. Most international victims become certified before 

their long-term needs, such as permanent housing and employment, develop (Caliber Associates, 2007). 

For some international victims, including those who decide not to cooperate with law enforcement, NGOs 

and service providers seek alternative remedies to meet their needs. This has included filing for U-visas4

and accessing services under the Violence Against Women Act, seeking asylum for the victim, and for 

some agencies, tapping non-federal or unrestricted funding streams to provide ad hoc services (Caliber 

Associates, 2007). 

7.2 Services for Minor Victims 

Unlike adults, minor victims of human trafficking do not need to be certified in order to receive services 

and benefits, as they are eligible for benefits through the Office of Refugee Resettlement within the HHS 

Administration for Children and Families (22.U.S.C. §7105(b)(1)). Similar to international adult victims, 

international minor victims of trafficking (younger than age 18) do not need to be certified, but instead 

receive a letter of eligibility from HHS and are then eligible to apply for a similar range of services as 

refuges, including the Unaccompanied Refugee Minor Program. The Unaccompanied Refugee Minor 

Program originally was designed to provide resettlement services to those refugee minors located both in 

the United States and abroad without a parent or guardian, and to provide a linguistically and culturally 

appropriate alternative to the mainstream Federal/State foster care and adoption system. This program 

assists with the development of skills minors need to enter adulthood and achieve economic and social 

self-sufficiency. According to each State’s law, victims receive the full range of assistance, care, and 

 

4 A U visa is available to victims of crimes, such as domestic violence, rape, assault, abduction, and other 

violent crimes, who have suffered mental or physical abuse because of the crime and not only have information 

regarding the activity, but also are willing to assist government officials in the investigation of the criminal 

activity. U.S. Citizenship and Immigration Services can grant up to 10,000 U visas each year, authorizing the 

holder to remain and work legally in the United States for up to 3 years, at which time the victim can apply for 

a green card.
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services to which all children in the State are entitled. In addition, a legal authority is designated to act on 

behalf of the minor in the absence of the minor‘s parents. This includes English language training, career 

planning, health/mental health needs, socialization skills/adjustment training, residential care, 

education/training, and ethnic/religious preservation. Reunification with parents or other family also is 

encouraged when available and appropriate, and attempts to trace family are conducted in coordination 

with local refugee resettlement agencies. Most children in the Unaccompanied Refugee Minor program 

are placed in licensed foster homes, although other settings, including therapeutic foster care, group 

homes, residential treatment centers, and independent living programs, may be utilized depending on the 

needs of the minor (U.S. Department of Health and Human Services, 2007). 

Although some research suggests services available for minor victims are meeting some of their needs 

(Bales & Lize, 2004; Caliber Associates, 2007), larger, long-term studies are needed to confirm early 

findings. 

8. WHAT ARE THE BARRIERS TO AND CHALLENGES IN ACCESSING AND 

PROVIDING SERVICES? 

There are many barriers to and challenges in responding to the needs of victims of human trafficking. 

Some of these barriers result from an overall lack of knowledge about human trafficking and lack of 

public awareness of the issue, and differing definitions and perceptions regarding who is a victim 

(Clawson et al., 2004). To compound the problem, research has suggested that trafficking victims are 

often reluctant to identify themselves as victims; therefore, self-referrals are less common than with other 

types of crime (Richard, 1999). Victims of human trafficking are also a hard-to-find, hard-to-reach 

population. Many victims have been taught to fear law enforcement authorities and NGOs, often because 

of their experiences with corrupt law enforcement personnel or authorities in their countries of origin 

(Bales, 2004). Additionally, victims are often reluctant to come forward because they fear retribution 

from their traffickers and fear arrest and deportation. 

Despite the definition offered by the TVPA, inconsistencies still exist in how law enforcement and service 

providers define victims and handle cases, presenting a primary barrier to identification. For example, 

there is no nationwide consensus regarding the treatment of juveniles engaged in prostitution (whether 

they should be considered victims or offenders). Data from the FBI’s NIBRS 1997–2000 (prior to the 

TVPA) were analyzed, looking at a sub-sample of 241 prostitution arrests involving juveniles nationwide 

(Finkelhor & Ormrod, 2004). Of these incidents, 229 juveniles were counted as offenders and 61 as 

victims. Further, boys were more likely than girls to be considered offenders. As boys most often do not 

have the formal coercion of a pimp, this may account for them being more frequently labeled as offenders 

rather than victims. In addition, law enforcement may fail to record a prostitution offense at all, believing 

it is in the adolescent’s best interest to be released or charged with another offense (e.g., disorderly 

conduct, trespassing). Law enforcement also may be affected by other issues, such as the demeanor of the 

adolescent, the officer’s sympathy for a particular teenager, or specific law enforcement policies in a 

jurisdiction (Finkelhor & Ormrod, 2004). 

The stigma associated with sexual exploitation in general, and prostitution in particular, also increases the 

difficulty in identifying victims. Both international and domestic victims of sex trafficking are not likely 

to disclose their involvement in prostitution to providers, especially law enforcement, due to their own 

sense of shame and fear of the response (Lloyd, 2005; Raphael, 2004; U.S. Department of Justice, 2002). 

Further, the power of the trafficker’s or pimp’s seduction and manipulation, as well as the manifestations 

of Stockholm syndrome, render some victims less likely to see themselves as victims and more likely to 

protect their perpetrator at all costs (Caliber Associates, 2007; Lloyd, 2005; Raphael, 2004). 
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For international victims, and perhaps some domestic victims, 

other significant challenges to accessing services include 

cultural and language barriers. Victims may not learn about 

available services if information about these services is not 

provided in their native language. Additionally, some victims 

may be illiterate in their native language. While most service 

providers engage an interpreter/translator to assist with 

communication, the presence of a third party can make it more 

difficult for the provider (often the case manager) to develop a 

relationship of trust with the victim. Cultural differences also 

can interfere with the ability to provide or receive services and 

lead to culturally inappropriate services, insensitive responses, 

and/or misinterpretation of behavior or actions. For example, 

victims’ unwillingness to look directly at the person speaking 

to them may be misinterpreted by providers as a sign that 

someone is hiding something or not telling the truth rather 

than understood as a sign of respect, as is the case in some 

cultures. Basic logistical barriers, including lack of familiarity 

with the community, transportation, or child care, can prevent 

victims from accessing available services (Clawson et al., 

2004). 

Studies of runaways provide useful insights about why these 

youth do not use available services and programs or 

discontinue using them (De Rosa et al., 1999; Martinez, 

2006). Reported barriers included restrictive rules at shelters; 

concerns regarding confidentiality, including concerns about 

being reported to child protective services; lack of ageappropriate therapeutic groups; lack of culturally appropriate 

services; inability to establish trust with staff members due to 

high staff turnover; and the need for emotional, financial, and 

other support that will help empower these victims to leave 

the streets and exploitation (Aviles & Helfrich, 2004; Dalton 

& Pakenham, 2002). With the exception of the last barrier, 

the barriers described here are similar to concerns expressed 

by international trafficking victims during individual interviews conducted as part of a larger evaluation 

of comprehensive services for victims of human trafficking (Caliber Associates, 2007). 

 Fear of law 

enforcement/arrest/deportation

 Lack of trust

 Shame/stigma

 Learned helplessness/PTSD 

 Cultural/language barriers

 Lack of transportation

For Providers: 

 Difficult to identify/reach victims 

(hidden crime)

 Lack of awareness/training 

 Lack of adequate 

resources/services 

 Cultural/language barriers 

 Ineffective coordination of

services 

 Safety concerns 

Barriers and Challenges to 

Accessing and Providing Services 

For Victims:

 Unable to self-identify 

 Lack of knowledge of services 

 Fear of retaliation

Seeking some services may have potential legal ramifications for victims. As is the case with adult 

victims of domestic violence, the legal consequences of being identified with a substance abuse or mental 

health disorder can be profound for an immigrant illegally in this country. An international trafficking 

victim may fear that the problem will be documented and negatively affect a future immigration hearing 

or a possible custody case (Caliber Associates, 2007). 

With minors (but also with many adults), one of the greatest barriers is persuading a victim to commit to 

substance abuse and/or mental health treatment. Research indicates that most adolescents do not present 

themselves for substance abuse treatment voluntarily and therefore have low motivation for treatment; 

they are either mandated to services or enter as a result of family pressure (Melnik, DeLeon, Hawke, 

Jainhill, & Kressel, 1997; Noel, 2006). Studies also document higher rates of attrition in adolescent 

programs compared to adult programs (Dobkin, Chabot, Maliantovitch, & Craig, 1998; Noel, 2006; 
U.S. Department of Health and Human Services, 

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Siegal, Rapp, Fisher, Cole, & Wagner, 1993; Spooner, Mattick, & Noffs, 2001). Both research and 

program administrators identify demographics (younger age, ethnic minority status, female gender, and 

being pregnant and parenting), substance use severity, mental health symptoms, and motivation/treatment 

readiness as the leading predictors of dropping out of treatment (Gainey, Wells, Hawkins, & Catalano, 

1993; Grella et al., 2001; Haller, Miles, & Dawson, 2002; McCaul, Svikis, & Moore, 2001; McComish, 

Greenberg, Ager, Chruscial, & Laken, 2000). 

Additionally, the complex needs of victims of human trafficking can create tremendous challenges for 

providers trying to deliver integrated services (Caliber Associates, 2007; Van Leeuwen, 2004). Common 

difficulties cited include lack of adequate resources to provide intensive case management and followon/aftercare services for extended periods of time (Dennis, 2006); lack of training about how to gain 

victims’ trust, effective outreach methods, cultural competency, and/or confidentiality (Bird, 1999; 

Clawson et al., 2004); and staff inability to identify and respond to the co-occurrence of emotional and 

behavioral problems (especially among adolescents) (Mark et al., 2006). Other agency problems include 

ineffective coordination of services across agencies (Clawson, Dutch, & Cummings, 2006), safety 

concerns for victims and staff (Clawson et al., 2004), insufficient monitoring of service quality (Lyons & 

Rogers, 2004), and a general lack of services in the surrounding community. Services that are 

particularly lacking include appropriate interpreters/translators, secure housing, and affordable 

medical/dental care (Clawson et al., 2004). 

9. WHAT ARE PROMISING PRACTICES FOR SERVING VICTIMS OF 

HUMAN TRAFFICKING? 

There is little literature on effective programs and services specifically for victims of human trafficking. 

In fact, what is known is limited to a couple of recent studies that examined services for international 

victims of human trafficking (Bales & Lize, 2004; Caliber Associates, 2007) and anecdotal information 

from providers and victims. Information from more than a decade of work with victims of domestic 

violence, prostitution, homeless and runaway youth, and victims experiencing trauma in general provide 

most of the groundwork that requires further exploration, application, and assessment with victims of 

human trafficking. 

Despite the lack of rigorous evaluations of effective practices and programs, providers nationwide have 

begun to agree on some promising practices in the field of human trafficking and, in particular, in 

working with prostituted minors (A. Adams, personal communication, March 2006; Caliber Associates, 

2007; N. Hotaling, personal communication, June 2006; National Center for Missing and Exploited 

Children, 2002; K. Seitz, personal communication, October 2006; R. Lloyd, personal communication, 

May 2007). These ideas can be organized into two categories: components of promising 

services/strategies and continuum of care. 

9.1 Components of Promising Services/Strategies 

While little evidence exists to support the effectiveness of specific interventions or services for victims of 

human trafficking, it is possible to identify certain components of promising services and strategies based 

on the observations and experiences of service providers working with trafficking victims and similar 

populations. 
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Safety Planning 

Physical and emotional safety is a theme throughout the 

various programs serving victims of human trafficking 

(international or domestic, adult or child). Similar to 

battered women, victims are often at greatest risk for harm 

by their trafficker (or pimp) when they leave their situation. 

Because traffickers may be involved in organized crime, 

local gangs, or trafficking networks, the risk may be even 

greater for a victim of human trafficking (Salvation Army, 

2006). Agencies must ensure that they are maximizing the 

safety of victims and that providing or referring to services 

does not further jeopardize victims’ physical well-being. 

Protecting the safety of staff working with victims also is 

important and safety plans should be developed for both 

victims and staff.5

 As a safety measure, many providers 

working with victims of trafficking do not publish their 

physical location or address, similar to domestic violence 

shelters (Clawson, Small, Go & Myles, 2004). Frequently, 

case managers and other providers are involved in outreach 

activities, which potentially place them at greater risk for 

visibility and harm. When in the field, outreach workers 

should not appear as a threat to a pimp or trafficker (e.g., by trying to ostentatiously convince a girl to 

exit), and therefore must be creative about how and when they reach out to victims or potential victims 

(O. Briceno, personal communication, June 2006). For example, street outreach teams at The Paul & Lisa 

Program are specifically trained to carefully observe and assess a girl’s situation on the street prior to 

taking any precipitous actions (National Center for Missing and Exploited Children, 2002; The Paul & 

Lisa Program, 2006). 

Components of Promising 

Services/Strategies 

 Incorporate safety planning (for 

staff and client) 

 Require collaboration across 

multiple agencies 

 Foster trust and relationship

building consistently 

 Ensure culturally appropriate 

approaches 

 Establish trauma-informed

programming 

 Involve survivors 

Security also becomes a concern when providing housing for victims. Similar to battered women’s 

shelters, safety must be a priority not only for the victim and staff but also for the other residents (A. 

Adams, personal communication, March 2006; Children of the Night, 2006). Clear communication of 

shelter rules (e.g., use of telephone, disclosure of location, precautionary measures for entering and 

leaving facility) and strict enforcement of those rules are necessary for the safety of everyone. 

Another safety consideration is whether the victim has been exposed to infectious diseases such as 

tuberculosis, HIV, and typhus (Salvation Army, 2006) and the risk of exposure to others. This should be 

determined as part of an initial assessment or screening of the victim. 

Collaboration 

Because trafficking victims’ needs are complex and extensive, it is impossible for a single agency to 

respond effectively to this population. Some NGOs and providers are able to offer core services in-house 

(e.g., case management, social services, legal assistance). However, many other services needed by

victims can only be obtained through collaboration with other providers. These providers include 

domestic violence/sexual assault shelters, health/dental clinics, counseling services (including mental 

health and substance abuse treatment), legal advocates/immigration attorneys, language translation 

 

5 Visit www.safehorizon.org for a sample safety planning guide. 
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services, and food banks. (A. Adams, personal communication, March 2006; Caliber Associates, 2007; N. 

Hotaling, personal communication, June 2006; MacInness, 1998; National Center for Missing and 

Exploited Children, 2002; K. Seitz, personal communication, October 2006). 

The value of a collaborative approach to meeting the needs of victims of human trafficking is supported 

by the development of HHS anti-trafficking community coalitions, OVC’s comprehensive service 

initiatives, and multidisciplinary anti-trafficking task forces across the country that require collaboration 

among Federal, State, and local law enforcement, attorneys, other government agencies (e.g., Department 

of Labor, social service agencies), NGOs, and victim service providers (Caliber Associates, 2007; U.S. 

Department of Justice, 2006). The Florida Coalition Against Domestic Violence carries out a 

multidisciplinary response to human trafficking, adapted from its coordinated community response model 

to assist victims of domestic violence and sexual assault. According to members of the coalition, 

“Multidisciplinary coordinated community response is one of the best ways for communities to respond 

to victims of trafficking. Just as with domestic violence survivors, trafficked persons have a variety of 

needs. Developing a community response to human trafficking requires the collaboration of many 

persons, agencies and organizations” (Florida Coalition Against Domestic Violence, 2004, p.14). 

Other collaborations exist throughout the United States and Canada, including the SEEN Coalition of the 

Suffolk County (MA) Children’s Advocacy Center. With a collective goal of increasing awareness and 

identification of services to adolescents exploited through prostitution, project partners launched 

Multidisciplinary Team Guidelines in October 2006. These guidelines ensure that within 48 hours of any 

agency identifying a girl or boy being exploited through prostitution, representatives from all relevant 

agencies (including law enforcement, child protective services, medical providers, and district attorneys) 

convene to jointly ensure the victim’s immediate safety needs are met and to plan for longer term needs 

and recovery. Although the model is predicated on a victim’s choice about exit and planning, the team 

convenes to exchange information and provide support, whether or not the victim is ready to receive these 

services. If the victim is not ready to receive services, the collaboration ensures that follow-up takes place 

(Teen Prostitution Prevention Project, 2006). 

The Southern California Regional Sexual Assault and Exploitation Felony Enforcement (SAFE) team is a 

task force of Federal, State, and local investigators and prosecutors who are physically located together 

for the purpose of investigating cases of child sexual exploitation. Each agency contributes important 

resources such as investigative expertise. Members are deputized as U.S. marshals and operate under a 

formal memorandum of understanding. The SAFE team meets biweekly and compiles monthly 

summaries of cases and activities, including any training received by members. Based on these 

summaries, statistics on the number of investigations and their outcomes are tracked. Street work and 

reverse stings are the primary means used to investigate the prostitution of children. Community policing 

techniques also are used to build rapport with runaway, homeless, or street youth, enabling law 

enforcement to work with them to identify and apprehend pimps, customers, and others who exploit the 

youth. The task force works closely with victim service providers, child protective services, children’s 

advocacy centers, and youth shelters (National Center for Missing and Exploited Children, 1999). 

One review found that to be most effective, collaborations and relationships among agencies must be 

clear and established before a victim is in need of assistance (Braun, 2003). While task forces and 

collaborations continue to emerge as promising practices in addressing trafficking and meeting the needs 

of victims, no rigorous assessment of their success has been conducted to date. 
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Relationship Development/Consistency 

As is commonly recognized among providers serving adult women, “Making connections and building 

relationships have proven to be crucial first steps in moving out of prostitution” (Rabinovitch, 2003). 

Girls and women in “the Life” have been systematically isolated from the “straight world.” Girls and 

women report going months or even years without talking with anyone outside the sex trade (Audrey M., 

personal communication, December 2006; N. Hotaling, personal communication, June 2006; Michelle S., 

personal communication, December 2006). Research, predominantly focused on adult women, has shown 

that supportive relationships are a key factor in exiting the Life (Hedin & Mansson, 2003; MacInness, 

1998; Raphael, 2004). This relationship building requires consistency over time, coupled with a 

nonjudgmental approach and significant perseverance on the part of providers. Considerable time and 

repeated contacts may be necessary before a relationship has been built sufficiently for a girl to accept 

services designed to empower her to leave the Life (Audrey M., personal communication, December 

2006; Hotaling, Burris, Johnson, Yoshi, & Melbye, 2003; Massachusetts Department of Social Services, 

2006; Michelle S., personal communication, December 2006; National Center for Missing and Exploited 

Children, 2002; Rabinovitch, 2003; R. Lloyd, personal communication, May 2007). 

Significant hurdles must also be overcome in establishing a relationship with victims of international 

trafficking. In addition to language and cultural differences, many victims may not trust the provider and 

may not understand or believe the provider is willing to help. According to one victim of international 

labor trafficking, she had been taught not to trust people and therefore was suspicious of offers to help, 

expecting she would have to give something in return (Caliber Associates, 2007). 

NGOs and other providers have found that working with international victims requires significant 

patience and consistency. Turnover, especially among case managers or other key providers, can cause 

setbacks in a victim’s recovery. Through adequate education, training (including cultural sensitivity 

training), support (including emotional and psychological support), and caseload management, many 

agencies have experienced success in retaining case managers (Caliber Associates, 2007). 

Culturally Appropriate Service Provision 

Racial and/or cultural issues are important when dealing with all victim populations (Carter, 2003; 

Rabinovitch, 2003). For example, according to Breaking Free, a program focused on African-Americans 

in Minnesota and serving prostituted women, “The services that black women need may seem to be the 

same as those required by white women. However, because of the repeated and sustained harms of 

racism, the needs of African-American women are significantly different” (Carter, 2003). Similarly, just 

because a group of women or men were involved in the same trafficking case does not mean they will 

have the same experience. Service providers working with victims of international human trafficking 

have encountered cultural issues that can affect service delivery (e.g., dietary needs, religious practices, 

and behavior). A recent evaluation of a comprehensive initiative in Los Angeles explored some of the 

challenges encountered by international victims from different cultures living in the same house (a shelter 

designed specifically for victims of trafficking). The women experienced problems and conflict, but 

through cultural sensitivity workshops, cultural events (e.g., hosting cultural dinners, celebrating 

holidays), and efforts to foster open dialogue and communication, the women were able to form 

relationships and overcome some of the cultural barriers even though they often did not speak the same 

language (Caliber Associates, 2007). 

To deliver culturally appropriate services and support, providers must be aware of cultural differences and 

develop an understanding of culture. The Center for Victims of Torture (2006) provides the following 
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24

guidelines for developing cultural understanding for victims of torture. These are largely applicable for 

providing services to international trafficking victims: 

 Learn to identify and articulate one’s own cultural beliefs, practices, and assumptions. 

 Investigate ways to address cultural differences or similarities among provider, survivor, and 

interpreter (if used). 

 Learn from multiple sources and perspectives about the countries, cultures, and subcultures of 

survivors the provider is serving. 

 Assess and address culturally relevant variables such as spirituality and religious practices, family and 

social roles, stages of resettlement and/or acculturation. 

 Use tools designed for cross-cultural dialogue. 

 Ask survivors what their culture means to them. 

 Find out who the survivor was before the torture. 

Similar guidelines emerged from an evaluation of programs for unaccompanied refugee minors (Ryan, 

1997). These guidelines can help promote culturally appropriate services and better respond to the needs 

of victims of human trafficking. 

Trauma-Informed Programming 

All victims of human trafficking share the experience of trauma. While each victim may respond 

differently, trauma is a constant among all victims and therefore should be considered in any 

comprehensive service plan. For example, the literature on prostitution indicates that focused support 

related to recovery from trauma is fundamental to a successful exit from prostitution. Adult women’s 

programs, such as the Standing Against Global Exploitation Project, Inc. (SAGE) STAR program, specify 

that trauma recovery is a lifelong process and imperative for every survivor of prostitution. This includes 

being able to acknowledge and share the harsh realities of their lives in prostitution without fear of 

shaming, confrontation, or minimization: “Like Vietnam veterans, women in prostitution must overcome 

public denial about the truth of their experiences” (Hotaling et al., 2003). Well-established adolescent 

programs serving exploited girls also make trauma recovery a key component of treatment. This may 

include individual therapy, group therapy, or art therapy in an atmosphere of love, support, and 

unconditional acceptance. Further, providers use a variety of grounding techniques to assist girls who 

experience flashbacks and other symptoms of trauma (B. Everts, personal communication, November 

2006; Girls Educational & Mentoring Services, 2006; Nixon et al., 2002). 

Given that girls may heal and develop through connections to others, and that trauma from prostitution is 

relational in nature, a gender-specific trauma recovery program should focus on the need for healing 

connections in the face of the complex relationships that girls bring into treatment. As explained in 

relation to traumatized girls in the juvenile justice system, “[Gender-specific trauma recovery programs] 

should help girls negotiate gender and family roles, determine appropriate boundaries in relationships, 

and avoid conflict and violence in [intimate] relationships” (Hennessey, Ford, Mahoney, Ko, & Siegfried, 

2004). These considerations also apply to victims of international trafficking. 

According to Harris and Fallot (2001), providers often need to make fundamental changes in their 

attitudes, beliefs, and practices related to understanding trauma and its impact in order to be more 
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successful in meeting the needs of their clients. The following concepts are key to making services 

trauma-informed and more effective: 

 Understanding trauma is a defining and core life event with a complex course that can shape a 

survivor’s sense of self and others, rather than a discrete event with predictable and immediate 

impact. 

 Understanding the consumer/survivor’s complaints and symptoms are coping mechanisms and 

original sources of strength within a relational approach to solutions that may no longer be effective, 

rather than viewing them as problems within an individualized view of the solutions. 

 Understanding the primary goals of services are empowerment and recovery (growth, mastery, and 

efficacy) which are prevention-driven, limited by survivor self-assessment and recovery needs, and 

requiring both the consumer and provider to assume shared risks, rather than the primary goals being 

stability and absence of symptoms, a crisis orientation, time-limited by economic and administrative 

needs, and oriented to minimizing provider liability. 

 Understanding the service relationship is collaborative, with the survivor and provider having 

equally valuable knowledge, rather than viewing it as hierarchical with the provider having superior 

knowledge. This equal relationship ensures survivors are active planners and participants in ensuring 

their safety and developing services. This approach places a priority on choice and control and trust 

developed over time, rather than treating the survivor as a passive recipient where safety and trust are 

assumed from the outset. 

Characteristics of trauma-informed services also include universal screening and assessment for trauma; 

training all staff about trauma and its impact (especially the multiple and complex interactions of trauma 

and drug/alcohol use); hiring staff members who are knowledgeable about trauma dynamics; reviewing 

agency policies and procedures to identify any that are potentially harmful to trauma survivors (Carmen et 

al., 1996); and recognizing that ancillary services, including safe housing, parenting and other life skills, 

health care, legal services, and vocational supports, are critical to comprehensively meeting the needs of 

individuals who have experienced trauma (Finkelstein, VandeMark, Fallot, Brown, Cadiz, & Heckman, 

2004). 

Providing a context for bonding and a sense of safety through group processes is essential in a traumainformed approach. Other trauma-specific elements include helping clients develop new coping skills, 

find meaning in their lives, and see the correlation between their traumatic experiences and other 

symptoms they may have (Gatz et al., 2007). Integrating these elements into comprehensive services, 

along with the changes in beliefs, attitudes, and practices outlined above, is necessary for a traumainformed approach to services. 

Research conducted by Elliott, Bjelajac, Fallot, Markoff, and Reed (2005) suggests that service systems 

that do not follow a trauma-informed approach or do not have an understanding of the impact of trauma, 

can unintentionally create a destructive or negative environment. Many common practices in service 

settings can trigger trauma reactions, creating an unsafe place for survivors (Harris & Fallot, 2001). For 

example, a group home may send youth to their rooms as a punishment for misbehavior; imposing this 

punishment on victims of trafficking can result in the youth feeling a sense of confinement and trigger a 

traumatic reaction. Systems and providers that are unaware of these trauma-related issues may not serve 

their clients effectively (Elliott et al., 2005). Continuing research is needed to evaluate the traumainformed approach in order to better understand its effects on work with survivors of trauma, particularly 

victims of human trafficking. 
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Involving Survivors of Trafficking in Developing and Providing Services 

Helping traumatized minor or adult females who have been trafficked develop trust with a provider is 

always challenging. In particular, the shame associated with the Life, manifestations and symptoms of 

PTSD, and allegiance to the perpetrator often can make trust building an enormous hurdle (A. Adams, 

personal communication, March 2006; B. Everts, personal communication, November 2006; N. Hotaling, 

personal communication, June 2006; National Center for Missing and Exploited Children, 2002; K. Seitz, 

personal communication, December 2006). Therefore, some advocates and service providers believe that 

the most successful programs serving young women exiting prostitution need to incorporate a peer-topeer counseling model and often hire survivors to provide either some or all of the services to clients (N. 

Hotaling, personal communication, June 2006). As stated in a report of the Massachusetts Department of 

Social Services (2006), “Often children identify others who have been in ’the Life’ as the easiest and most 

comfortable adults with whom to talk about and to understand their own situations, and they need the 

non-judgmental support, understanding and help of adult survivors in order to successfully transition to a 

new life beyond sexual exploitation.” Rabinovitch and Strega (2004) add, “Peer-led services reduce or 

remove the cultural and language barriers that most sex trade workers experience when trying to 

communicate with those whose education about the trade has been academic and professional. Talking 

with peers, or even talking to a non-peer in a predominantly peer-led setting, lessens sex trade workers’ 

fears of confessing to a stigmatized identity and producing in service providers a range of reactions from 

horror to titillation.” 

One example of youth survivors engaged in helping other youth is the Young Women’s Empowerment 

Project (YWEP) in Chicago. YWEP employs adolescent girls who have exited prostitution or are still 

engaged in prostitution and are willing to attend a 16-session training to conduct outreach and education 

to peers. The girls receive a stipend for their time. They operate under a harm reduction model and are 

offered a range of supports at a drop-in center (e.g., hygiene products, a place to rest) (Young Women’s 

Empowerment Project). The Young Women’s Leadership Project in Detroit similarly employs girls with 

a history of some type of high-risk activity to provide street outreach to their at-risk peers (Alternatives 

for Girls, 2006). 

SAGE is another organization that employs a peer-to-peer treatment model. In an address to the United 

Nations, Hotaling (2000) remarked, “The personal knowledge and experience possessed by many of the 

staff enables [sic] us to effectively provide support and engender trust without re-traumatizing even the 

most fragile of clients.” By using a peer empowerment model, Hotaling indicates that SAGE has seen 

dramatic decreases in PTSD, depression, suicide, re-victimization, and recidivism in the clients they 

serve. In addition, SAGE has seen increases in client self-esteem, confidence, and overall health. Clients 

have benefited from this model by being able to take charge of their lives, obtain and keep legal jobs, 

advance in education, and recover from substance abuse. 

More service providers who work with victims of international human trafficking are starting to engage 

survivors in programming. The Coalition to Abolish Slavery and Trafficking (CAST) has developed a 

survivors of trafficking council that assists in program decision-making and provides peer-to-peer and 

group mentoring and support to current clients. The survivors are individuals who graduated from the 

social services program offered by CAST. Interviews with survivors suggest that involving survivors, 

when they are ready, in the care of others can be beneficial to both the survivor and the victim (Caliber 

Associates, 2007). Some programs have formed communities of survivors to serve as peer groups, 

assisting other victims in rebuilding their sense of personal efficacy. Part of the success of these groups 

involves allowing victims to set the agenda for meetings and focus on what is most important to them. 

Activities have included computer training, language classes, ethnic celebrations, and even writing plays 

about their personal experiences. Other programs assign survivors of labor trafficking as peer counselors 
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to work one-on-one with victims to help stabilize their life and offer opportunities for survivors to become 

involved in education and outreach activities (Bales & Lize, 2004). 

An important element of including survivors in program development and implementation is that they can 

speak about their own experiences, sharing strengths while acting as role models to reduce instances of 

relapse. Elliott et al. (2005) state that, “Like the concept of sponsorship in AA, a trauma survivor can 

help another one through this transition.” Allowing survivors to work with others gives them the chance 

to return the help they received, with the added result of boosting self-esteem. 

That survivors are ideally suited to reach their peers has been demonstrated over time with other 

populations of traumatized individuals, including addicted individuals, individuals with HIV, and 

Vietnam veterans (as cited in Hotaling et al., 2003). This non-traditional approach to service provision (in 

contrast to following a traditional clinical model) has gained increasing support across the United States: 

“When working with traumatized, politically disenfranchised, and stigmatized individuals, service 

providers must avoid traditional therapeutic neutrality and clearly support those they work with.” 

(Hotaling et al., 2003). Many agree (though do not universally practice) that survivors may be in the best 

position to assist peers, working in collaboration with clinicians and other necessary supports. However, 

there is limited research on the impact of peer models on recovery. 

9.2 Continuum of Care 

While objective measurement of successful reintegration of a trafficking victim is difficult to achieve, 

service providers nevertheless have moved ahead and adapted their services to meet the needs of victims. 

It is difficult for trafficking victims to successfully reintegrate into society, and it is also difficult for 

providers and researchers to develop standards of measurement that would indicate such reintegration. 

As already discussed, both international and domestic victims have diverse needs and can require 

assistance and support over a significant period of time, thereby requiring a continuum of care. Providers 

have conceptualized this continuum of care as having three phases: crisis intervention and assessment, 

comprehensive assessment and case management, and social reintegration (Bales & Lize, 2004). The 

goal is to help the victim progress along the continuum that begins at crisis or the need for emergency 

assistance and moves to a position of safety (all within phase 1). With ongoing assessment and 

intervention to address existing and emerging needs, the victim can move to stability in phase 2. Finally, 

victims (now often referred to as survivors) can integrate into their environment and begin to thrive. 

Among the best evidence of the success of offering a continuum of care and becoming reintegrated is in a 

survivor’s report, “I work like a normal person, and they treat me like a normal person...When you’re in 

the kind of situation we were in, you feel like the world has ended. And once you’re back here on the 

outside...Everything is different now. Just imagine if you were reborn. That’s what it’s like” (Bales & 

Lize, 2004). A continuum of services appears to be central to successfully engaging and supporting all 

victims of human trafficking. This continuum echoes the Exit Counseling Model developed by 

MacInness (1998), which illustrates the importance of beginning trust building and engagement with 

prostituted youth and moving toward stabilization and support. 

Given the complex needs of victims of human trafficking and the challenges and barriers to providing 

them services, several key components seem to be required in a continuum of care for this population. 

Identification 

Successful identification of victims of human trafficking can be facilitated by increased education and 

training on the crime of human trafficking, the rights of victims, how to respond to victims, the needs of 
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victims, and available resources (Clawson et al., 2004). Additionally, the use of standard protocols to 

screen for victims of human trafficking (including questions to ask and techniques for interviewing 

victims) is essential to successful identification and ultimately cooperation from victims (Clawson, Dutch, 

& Cummings, 2006). Since passage of the TVPA and increased funding to NGOs, law enforcement, and 

other service providers, the availability of protocols for identifying and responding to human trafficking 

victims has grown substantially. Commonly referenced resources include the HHS Rescue & Restore 

Campaign Outreach Kits (www.acf.hhs.gov/trafficking/), Hiding in Plain Sight: A Practical Guide to 

Identifying Victims of Trafficking in the U.S. (www.uri.edu/artsci/wms/hughes/hiding_in_plain_sight.pdf), 

WHO Ethical and Safety Recommendations for Interviewing Trafficked Women (Zimmerman & Watts, 

2003), and the Domestic and Sexual Violence Advocate Handbook on Human Trafficking (Florida 

Coalition Against Domestic Violence, 2004). 

While protocols have been developed to determine if a foreign national is a potential victim of human 

trafficking, there are few published assessment protocols with questions to determine potential victims of 

domestic trafficking. While some agencies that conduct outreach to this population (e.g., prostituted 

children/adults) have developed their own assessment tools, there are no published protocols for use by 

medical providers, child protection workers, and others as there are for international trafficking and 

domestic violence victims. For example, SAGE uses an assessment tool within the juvenile justice 

system which remains unpublished and unavailable for review (N. Hotaling, personal communication, 

June 2006). 

To assist with identification, the HHS Office of Refugee Resettlement has established the Campaign to 

Rescue and Restore Victims of Human Trafficking. This public awareness campaign has established 

Rescue and Restore coalitions composed of social service providers, law enforcement, academics, 

students, and other key stakeholders in 24 cities, regions, and States. The goal of these community action 

groups is to raise awareness of human trafficking and build local anti-trafficking networks. The Office of 

Refugee Resettlement’s street outreach grants facilitate identification of victims through direct outreach to 

individuals involved in or at-risk for trafficking. Additionally, the agency funds the National Human 

Trafficking Resource Center a toll-free hotline (888-373-7888) where community members, law 

enforcement, social service providers, victims of human trafficking, and others can report incidents of 

human trafficking, receive technical assistance, and obtain referrals for a variety of services (U.S. 

Department of Health and Human Services, 2009) 

Like coalitions, multidisciplinary teams and task forces are promising approaches to effective 

identification. Through ongoing communication and sharing of information, coordinated outreach, and 

service follow-through, these entities are better positioned to identify and respond to all victims of human 

trafficking than single agencies operating in isolation (Clawson, Dutch, & Cummings, 2006). 

Coordinating the identification process also helps protect victims by not requiring them to tell their story 

repeatedly to different providers. Anti-trafficking task forces funded by the Bureau of Justice Assistance 

and OVC, other State anti-trafficking task forces and community coalitions, and the Innocence Lost task 

forces are making inroads in addressing the challenges of identifying victims and coordinating 

communications and services (Clawson, Dutch, & Cummings, 2006; U.S. Department of Justice, 2006). 

The number of Department of Justice anti-trafficking task forces increased from 22 at the end of FY 2004 

to 32 at the end of FY 2005. In Houston Texas, the task force helped rescue and provide assistance to 

almost 100 victims of trafficking, and 10 defendants have been convicted on trafficking charges in cases 

involving forced prostitution and forced labor (U.S. Department of Justice, 2006). Additionally, 

Northeastern University, in conjunction with the National Institute of Justice, conducted a study to 

address how law enforcement defines human trafficking, the number of investigations conducted, the 

extent of reporting, the nature of coordination with other agencies, and what are considered best practices 

in responding to human trafficking (Northeastern University, Institute on Race and Justice, 2006). 
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Various States are using other mechanisms to ensure providers respond quickly and victims have access 

to services. In Suffolk County, Massachusetts, all providers (including law enforcement, medical 

providers, and school-based personnel) are instructed to file a 51A report of child sexual abuse to the 

Massachusetts Department of Social Services if they have sufficient reason to believe that an adolescent 

is being exploited through prostitution. The provider files on behalf of the youth against an unknown 

perpetrator (i.e., pimp) when more information on the pimp is not available. This report is screened out by 

the Department of Social Services if the perpetrator is not a family member and is sent to the district 

attorney’s office as a discretionary referral. An assistant district attorney and a victim/witness advocate 

are assigned immediately and the Multidisciplinary Team Guidelines take effect (Teen Prostitution 

Prevention Project, 2006). While a multidisciplinary approach to identification has been shown to be 

promising, more research on effective models of identification (including assessment tools) should be 

conducted. 

Another promising strategy for identification and tracking is the use of a centralized database with 

information from diverse sources. While little progress has been made in this area with regard to tracking 

victims of international trafficking (Clawson, Layne, & Small, 2006), some success has been experienced 

in addressing child sexual exploitation. For example, in both Suffolk County and Fulton County, 

Georgia, the Children’s Advocacy Center has spearheaded a child sexual exploitation database (Priebe & 

Suhr, 2005; Teen Prostitution Prevention Project, 2006). In Georgia, 14 different agencies make referrals 

to this database, named Child Abuse Case Tracking Information System, which tracks both the victims 

and their exploiters (Priebe & Suhr, 2005). 

Outreach and Education 

Outreach and education to communities about the crime of human trafficking and the needs of victims are 

important when it comes to identifying victims. The most significant outreach campaign associated with 

human trafficking is the Rescue and Restore Victims of Human Trafficking public awareness campaign 

supported by HHS. As a result of this nationwide campaign, local coalitions are being established, local 

and national media coverage of human trafficking is taking place, and national partnerships are being 

formed. Campaign materials have been distributed, particularly to intermediaries or first responders most 

likely to come into contact with victims. These include law enforcement agencies, social service 

providers, health care professionals, faith-based organizations, domestic violence prevention groups, 

homeless assistance professionals, and child protective services (U.S. Department of Health and Human 

Services, 2009). However, the impact of this nationwide campaign has not been formally assessed. 

Other examples exist of promising outreach activities being conducted by NGOs and local programs. 

These strategies include conducting global television campaigns to combat human trafficking (Vital 

Voices, 2003); developing public service announcements for ethnic radio, television, and newspapers; 

posting billboards in ethnic communities and garment districts; and distributing flyers (in multiple 

languages) and other items (e.g., Band Aids®, matchbooks) at laundromats, ethnic supermarkets, beauty 

parlors, and other establishments that victims may be allowed to visit (Clawson et al., 2004; Raymond & 

Hughes, 2001). Victim service providers report increases in calls to crisis hotlines and referrals from 

community-based organizations and good samaritans following such outreach efforts (Caliber Associates, 

2007). 

Countries around the world also are conducting outreach to increase public awareness of human 

trafficking. Colombia and Ecuador are relying on the entertainment industry for delivering antitrafficking messages. In Colombia, the United Nations Office of Drugs and Crime worked with the 

producer of the popular soap opera “Everybody Loves Marilyn” to incorporate a storyline that dramatized 
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the plight of a trafficking victim. The widely viewed Spanish language television series, broadcast 

throughout Colombia and exported to Venezuela, Ecuador, and the United States, is being used to educate 

a large segment of the population. It is also intended to attract the attention of potential victims and 

educate them about the methods used to deceive victims and the abuse they could face from a trafficker. 

In Ecuador, volunteers from the National Institute for Children and Family worked with visiting 

international musician Ricky Martin, his charitable foundation, and Colombian entertainer Carlos Vives 

to disseminate anti-trafficking messages and information that reached approximately 24,000 people 

attending their concerts in Quito and Guayaquil (U.S. Department of State, 2006). These represent 

innovative ideas for outreach to a wide audience.

Other “street outreach” efforts are also underway. Outreach workers should be well-trained and 

understand the inherent safety concerns (see Safety Planning section). Further, they must be willing to 

build a relationship with a victim repeatedly, for as long as necessary (MacInness, 1998). Relevant to 

domestic sex trafficking, many agencies provide drop-in centers, as part of their continuum of care 

efforts, to meet the short-term needs of exploited youth (e.g., food, hygiene products) and to build 

relationships aimed at long-term change (O. Briceno, personal communication, June 2006; Girls 

Educational & Mentoring Services, 2006; N. Hotaling, personal communication, June 2006; Priebe & 

Suhr, 2005). Outreach services must be offered in a non-judgmental, careful way so trust can begin to be 

built. As previously stated, developing a trusting relationship with a victim of human trafficking can be 

extremely difficult for a variety of reasons, including the victim’s trauma history, threats to safety from 

the trafficker (pimp), distrust, and possibly prior negative experiences with authorities or “the system.” 

These same recommendations for effective and appropriate outreach are highlighted in the literature 

related to runaway and homeless youth. The Substance Abuse and Mental Health Services 

Administration’s Treatment Improvement Protocol 32: Adolescent Substance Abuse Treatment suggests 

that outreach is a primary intervention strategy for engaging homeless youth (U.S. Department of Health 

and Human Services, 1999a). Youth workers should meet young people on the street, developing trusting 

relationships over time and encouraging and facilitating youth access to treatment. In a 1998 survey of 

health providers for homeless Australian youth, outreach workers highlighted the importance of a nonjudgmental approach as well as the importance of maintaining client confidentiality and anonymity, 

noting that youth would go without treatment if they suspected that outreach workers were connected to 

police or protective services (Harrison & Dempsey, 1998). 

In addition, Slesnick, Meyers, Meade, and Segelken (2000) describe an engagement process specifically 

for substance abusing runaways that draws upon the success of the Szapocznik et al. (1988) and 

Szapocznik, Kurtines, Santisteban, and Rio (1990) Strategic Structural Systems Engagement (SSSE) 

approach and the Meyers and Smith (1997) Community Reinforcement and Family Therapy (CRAFT) 

intervention. Both models engage a client in treatment through a family member or significant other. 

Using the SSSE model, Szapocznik et al. found that 93 percent of substance abusers and their families 

became engaged in treatment, compared to 42 percent of those entering treatment without 

families. Primary components of the combined SSSE and CRAFT intervention include approaching the 

runaway youth and engaging him or her in a non-threatening manner, identifying and addressing his or 

her treatment motivators and barriers, and negotiating with the counselor about treatment. Additionally, 

the intervention involves contacting parents to gain their approval, informing them about the treatment, 

engaging them in treatment, addressing their treatment motivators and concerns, and negotiating with 

them about treatment. Each stage in the engagement process includes developmentally appropriate and 

motivational techniques specific to the population. Components of these approaches may be more 

applicable for victims of domestic trafficking than international trafficking given the need to involve a 

family member or significant other. 
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Prevention 

To date, there is no documented best practices research related to the prevention of human trafficking. 

However, the incorporation of a prevention component into the TVPA suggests the importance of this 

element of service. Additionally, the literature on treatment of domestic sex trafficking victims 

consistently points to the importance of prevention education (Girls Educational & Mentoring Services, 

2006; National Center for Missing and Exploited Children, 2002; Priebe & Suhr, 2005). The Paul & Lisa 

Program, The Center to End Adolescent Sexual Exploitation (CEASE), and Girls Educational & 

Mentoring Services (GEMS) use a well-constructed prevention program for middle school and/or high 

school youth. The Alternative for Girls, an agency in Detroit, has several components, including a 

prevention program that involves weekly meetings and activities for at-risk girls. Nationwide, most 

agencies such as schools and child welfare agencies are not engaging in such primary prevention, and 

those engaged in secondary and tertiary prevention lack an evidence-based curriculum to meet their goals. 

The My Life, My Choice Project in Massachusetts is an example of a program designed to offer primary, 

secondary, and tertiary prevention to a population of particularly vulnerable girls—those in group care 

settings. Co-written by a clinician and a survivor, the group work component of the My Life, My Choice 

Project of the Home for Little Wanders uses a 10-session curriculum presented in weekly 1.25 hour 

modules. The sessions include material on dispelling myths and stereotypes about prostitution, awareness 

of recruitment tactics by pimps, information on sexual health, understanding the link between substance 

use and prostitution, resource lists, strategies for increasing safety in the Life, and an overarching 

emphasis on improving self-esteem. In addition, throughout the 10 weeks, participants hear both written 

and live testimony by women who have been in the Life. The sessions include interactive activities (e.g., 

games, role plays), art, music, reading, and journaling. Initial participant feedback on the My Life, My 

Choice group work component has shown a positive impact on the young women involved (GoldblattGrace, personal communication, December 2006). 

Intensive Case Management 

Given their complex needs, victims of human trafficking can be expected to encounter a range of law 

enforcement, social service providers, medical professionals, counselors, legal advocates, and shelter 

personnel, which can be a daunting experience, especially for international and minor victims. In 

response, service providers have adopted intensive case management approaches to working with these 

victims. The case manager’s broad range of responsibilities can include assessing service needs; 

providing victims with information about their rights to services, establishing a comprehensive service 

plan with victims, identifying and making referrals for services, coordinating services, sometimes 

accompanying victims to appointments, advocating on behalf of victims to other providers and agencies, 

providing emotional and moral support to victims, and often keeping victims informed of progress on 

their legal case, T-visa, and other applications (e.g., Social Security card, and work permit). The role of 

the case managers is critical. Not only are they responsible for supporting the victim but also, by the 

nature of their work, they support other providers and agencies by enabling law enforcement officials, 

attorneys, counselors, and others to focus on their services for the victim (Caliber Associates, 2007; 

Salvation Army, 2006). 

As part of service coordination, the case manager also is responsible for ensuring regular communication 

and information sharing (without violating confidentiality) among providers working with victims. 

Intensive case management often requires expansion of the traditional service delivery role of a case 

manager and widening the network of providers. For example, evaluation of services provided to torture 

victims confirms that coordinated care that takes a holistic approach to treatment, while often challenging, 
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is essential to meeting the medical, psychological, and social needs of victims (Center for Victims of 

Torture, 2006; Program for Torture Victims, 2006). 

In fact, the case management approach demonstrated by nurses working with torture victims appears to 

mirror the intensive case management model being used with victims of trafficking. Nursing case 

management is a process of ensuring that individual survivors receive appropriate health care services 

both within the torture treatment center or primary care facility and in the larger community. The case 

manager coordinates and monitors the clinical services the survivor receives to ensure the individual’s 

unique health care needs are met. Responsibilities of the nursing case manager include: 

 Health care service planning and resource identification. 

 Linking clients to needed services and coordinating individual client care in the community health 

care system. 

 Client advocacy and problem solving with the health care system. 

 Monitoring service delivery. 

 Evaluating services. 

Nurses also educate survivors about accessing and navigating the U.S. health care system, including 

gaining information about patient rights (Center for Victims of Torture, 2006). 

An examination of well-established programs for girls who have been exploited through prostitution also 

highlights the importance of comprehensive case management (A. Adams, personal communication, 

March 2006; Girls Educational & Mentoring Services, 2006; N. Hotaling, personal communication, June 

2006; National Center for Missing and Exploited Children, 2002). Some of these case management teams 

(e.g., SAGE, CEASE) collaborate with the juvenile justice system, combining outreach, advocacy, and 

case management. Others offer case management services through a drop-in center (e.g., A Way Back). 

Still others (e.g., GEMS) offer both. The most important aspect of case management appears to be the 

quality of the relationship between the case manager and the victim, and the case manager’s ability to 

access a wide range of resources on behalf of the victim. A case manager’s first priorities must be helping 

the client achieve physical safety and meet basic needs (such as food, clothing, and housing) (A. Adams, 

personal communication, March 2006; O. Briceno, personal communication, June 2006; Girls 

Educational & Mentoring Services, 2006; N. Hotaling, personal communication, June 2006; National 

Center for Missing and Exploited Children, 2002). The Unaccompanied Refugee Minor Program requires 

this type of intensive case management and is a primary reason that international minor victims of 

trafficking are served under this system. 

According to Healey (1999), the criminal justice system also follows a case management approach in 

working with released offenders. Several programs working with the criminal justice population employ 

a holistic service approach that addresses multiple issues, including unemployment, homelessness, and 

substance abuse, that could contribute to an offender relapsing. As with the models already described, the 

activities of the case manager in the criminal justice field include engaging the client in the treatment 

process, assessing client needs, developing a service plan, linking the client with appropriate services, 

monitoring client progress, intervening with sanctions when necessary, and advocating for the client when 

needed. 

Many experts, program directors, and case managers support intensive case management as a tool for the 

criminal justice field; however, some obstacles exist. Poorly designed programs can be less effective and 
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make it difficult for case managers to establish relationships with other service providers. Overburdened 

case managers can affect program outcomes as well; managing too many cases with too few resources 

makes it difficult for case managers to spend the time needed with each client. Another obstacle cited by 

Healey (1999) is the transfer of offender treatment information. Case managers must pass along basic 

offender information and treatment plans to another agency or case manager providing care. Ensuring the 

documentation arrives at the receiving agency before the offender can be challenging. 

While the effectiveness of intensive case management has not been documented fully, the work of Cauce 

et al. (1994) lends evidence to the success of intensive mental health case management for homeless 

adolescents. Preliminary data from 115 adolescents indicated that after 3 months of treatment, youth 

randomly assigned to intensive case management did somewhat better in treatment than those in basic or 

regular case management in terms of self-reported aggression, general externalizing behaviors, and 

satisfaction with quality of life. However, young people in both groups reported improvements while 

receiving services. Case management continues to be used by the trafficking, medical, criminal justice, 

mental health, and domestic violence fields, as well as by those working with victims of torture (Bennett, 

Stoops, Call, & Flett, 2007; Center for Victims of Torture, 2006; Healey, 1999; Lattimore, Broner, 

Sherman, Frisman, & Shafer, 2003; Salvation Army, 2006). 

Comprehensive Services 

The complex needs of victims of human trafficking appear to require a comprehensive approach to 

service delivery that includes the provision of core services such as housing, legal assistance, medical 

assistance, social services, trauma therapy, and substance abuse treatment. 

Housing/Shelter Services 

Since there are so few shelters across the country that serve only victims of trafficking, most victims are 

placed in shelter or housing programs that traditionally serve victims of domestic violence and sexual 

assault. Shelters that have been successful in serving both domestic and international victims of human 

trafficking have adjusted their programs for this population. These adjustments have included: 

 Extending the length of stay for victims in emergency and transitional housing. Compared to victims 

of domestic violence, victims of human trafficking may take longer to secure a job and obtain 

affordable housing due to their certification and/or documentation status, which can affect their 

ability to work legally in the country, as well as other barriers to work (e.g., physical disabilities, lack 

of English language skills, lack of employable skills). Additionally, when victims can work, many 

feel the need to send money to their families and are therefore unable to save money for housing as 

other victims might. 

 Relaxing rules about mandatory participation in group activities and counseling. Language barriers, 

lack of social support, and other factors may make it difficult for trafficking victims to engage in 

traditional requirements of communal living, such as communal meals, participation in support 

groups, and sharing living space with women of different ethnic, cultural, and religious backgrounds. 

 Providing more intensive case management. Most victims of human trafficking require more 

intensive and specialized case management given the complexity of their needs, including their legal 

status. 

 Interacting with Federal (and local) law enforcement. While many domestic violence shelters work 

closely with law enforcement, the circumstances of a trafficking case may require more frequent 
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visits by law enforcement to the shelter. The implications of these visits to other shelter occupants 

can be disruptive and need to be carefully considered. 

In emergencies, domestic violence shelters may be called upon to provide shelter for minor victims. In 

some cases, this is not possible because shelters are not equipped to serve children. In most cases, housing 

for minor victims of international human trafficking is provided through the Unaccompanied Refugee 

Minor Program. These children often are placed in foster care or group homes. Domestic violence and 

sexual assault shelters are not used to house male victims of trafficking. Instead, these victims often are 

referred to homeless shelters, shelters run by NGOs and faith-based organizations, or are put in hotels or 

temporary housing paid for by the service provider (Salvation Army, 2006). 

Literature regarding adult women exiting prostitution emphasizes the importance of a therapeutic housing 

community to prevent relapse and build stability (Carter, 2003; Hotaling et al., 2003; Rabinovitch, 2003; 

Raphael, 2004). Any housing program designed to support this population must take into account the 

myriad ways in which the self-esteem of the women and girls has been diminished. Edwina Gately of 

Chicago’s Genesis House described the importance of the physical space in this way: “If you offer space, 

you are using the space to give every version of the message that you can give; that is, these people who 

are coming to this space are worth something” (Raphael, 2004). Housing or shelter programs for 

adolescents who are leaving prostitution are traditionally small (6–10 beds) and provide a comprehensive 

array of services, including mental health services, family support services, education support, career 

planning, life skills education, and recreational programming. Children of the Night in Los Angeles 

accepts both boys and girls while others (including SAGE House in San Francisco and Angela’s House in 

Atlanta) serve only girls. The Paul and Lisa Program does not offer a group home setting but rather 

facilitates appropriate housing using existing resources (including specialized foster homes) (National 

Center for Missing and Exploited Children, 2002). While some variations in housing programs exist, all 

tend to be grounded in an understanding of the trauma history of residents and the survival and coping 

skills learned in the Life (such as manipulation and dissociation), which must be unlearned and replaced 

in order for the adolescents to heal (A. Adams, personal communication, March 2006; Children of the 

Night, 2006; N. Hotaling, personal communication, June 2006). 

Legal Services 

The legal needs of most international and domestic victims can be extensive. Attorneys are needed to 

explain to victims their legal options and rights; educate victims about the U.S. legal system; represent 

victims in legal hearings (e.g., detention/deportation hearings); complete applications for certification, Tvisas, U-visas, or derivative visas for family members; and assist with gaining permanent resident status, 

as well as assist with the repatriation process (Florida Immigrant Advocacy Center, 2006; Salvation 

Army, 2006). The most pressing concern for victims is often their immigration status, followed by their 

ability to reunite with their families and children. Many victims of domestic trafficking have had multiple 

contacts with the juvenile and/or criminal justice systems and may have been identified as the result of an 

arrest for prostitution, panhandling, or other crimes. Thus, they also usually need legal representation in 

juvenile or criminal proceedings and, in many cases, family hearings. 

Attorneys who work with victims of human trafficking who do not have the support of a case manager 

must be prepared to assist them with a wide range of needs, including lack of adequate housing, 

unemployment, isolation, medical problems, or lack of transportation. Working in collaboration and close 

communication with a case manager can be beneficial to both the attorney and the victim. The attorney 

should recognize that until their legal cases are resolved, some victims cannot move forward with their 

lives (Caliber Associates, 2007; Center for Victims of Torture, 2006). 
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Attorneys also should recognize that the trauma suffered by victims may influence their ability to 

participate in legal proceedings. For example, fear of authority figures (including the victim’s own 

attorney), immigration officials, law enforcement, and judges may interfere with the attorney-victim 

relationship or the victim’s ability to go forward with the legal case. Establishing a trusting relationship 

will take time and require patience on the part of the attorney (Caliber Associates, 2007). 

There are a few comprehensive documents available to assist attorneys working with victims of human 

trafficking: Identification and Legal Advocacy for Trafficking Victims (2nd Edition) (NYC Antitrafficking Network Legal Committee, 2005) and the Guide for Legal Advocates Providing Services to

Victims of Human Trafficking (United States Conference of Catholic Bishops, 2004). 

Medical Services 

Victims of human trafficking present with a range of medical needs. Service providers have reported the 

following needs for medical services: basic physical exams; gynecological exams; tests for infectious 

diseases; treatment for stomach problems and headaches (often symptomatic of an emotional problem); 

chronic back, hearing, cardiovascular, or respiratory problems; and eye and dental care (Caliber 

Associates, 2007). 

Work with torture victims indicates that medical treatment is essential to their physical and psychological 

healing. Lingering body pains and physical symptoms often create daily reminders of past torture. 

Medical providers play an important role in clarifying the nature of physical symptoms in torture 

survivors and alleviating their complaints. A similar need appears to present in victims of human 

trafficking and requires educating victims about the association between stress and symptom exacerbation 

so they do not perceive their treatment as ineffective and understand that their increased symptoms will 

diminish gradually (for example, if they are receiving treatment for the trauma) (Center for Victims of 

Torture, 2006). Of those seeking treatment, some will require one treatment, some will require 

intermittent treatment at various periods in their life, and others will require ongoing services, particularly 

those who suffer from a physical disability resulting from the trafficking experience. 

Through their research, Willis and Levy (2002) found that prostituted minors are at high risk for many 

infectious diseases, including HIV. The risk of prostituted minors contracting HIV depends on the local 

prevalence of HIV infection in sex workers, access to condoms, and attitudes of clients toward the use of 

protection. Minors involved in prostitution are also at high risk of contracting STDs other than HIV, as 

well as transmitting these diseases to others (e.g., their children and clients). They are also more likely to 

develop drug-resistant forms of the STDs. Willis and Levy found that minors are at higher risk than their 

adult counterparts because they have less power to ensure their clients use condoms. 

Most other research on the prevalence of HIV and STDs in trafficking victims has focused on 

international victims and those trafficked outside of the United States. For example, a study conducted on 

the prevalence of HIV in sex-trafficked Nepalese girls and women found that among 287 victims, 109, or 

38 percent, tested positive for HIV (Silverman et al., 2007). Silverman et al. also found that girls 

trafficked prior to age 15 were at higher risk of being infected with HIV, with 20 of 33, or 60.6 percent, 

infected among this age group in the study sample. 

Another study conducted by the United Nations Development Programme (2006-2007) focused on 

trafficking in India and the links between HIV and trafficking. This study explored four categories of 

trafficking victims: sex workers, domestic workers, forced labor, and street-based workers. The study 

found that many of those involved in the study were unaware they should always use a condom to prevent 

the spread of HIV. Additionally, only 19 to 28 percent of the study’s respondents in the sex worker 
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category were aware of sexually transmitted diseases; percents were even lower for respondents in the 

other categories. Awareness of HIV was highest among those in the forced labor category, ranging from 

47 to 71 percent for the various age groups compared to 28 to 38 percent among those in the sex worker 

category. 

Given the limited research done in this area, there is more to study about the health implications of human 

trafficking and the medical needs of all types of victims. 

 

Social Services 

Providing social services is essential to meeting the needs of victims. These services help stabilize 

victims by offering opportunities for educational, personal, and economic advancement. Obtaining an 

education, developing life and social skills, learning a new language, gaining job skills, and obtaining 

employment are essential for a victim to be able to reintegrate into society. Through social services, 

victims can become personally and economically independent. For international victims, they can also 

learn about the new culture in which they are living (Caliber Associates, 2007). Despite the importance of 

social services for victims of human trafficking, there are currently no published studies that identify 

promising or best practices in this area. 

A report (Thompstone, n.d.) was developed that discusses the need for a Quality of Care Standard (QCS) 

across all services, specifically one that recognizes the need for homes that provide recovery services for 

minor victims of commercial sexual exploitation and trafficking. However, the report does not indicate 

what might be the best or promising practices for social services. Since there is no universal or commonly 

agreed to QCS, some countries, such as Cambodia, have created their own QCS to regulate services to 

minors. Standards that can be adopted by other countries include: (1) all children trafficked for sexual 

purposes shall have equal access to education programs, regardless of citizenship; (2) care plans shall be 

developed and case records shall be maintained in care homes for all children; and (3) repatriation 

schemes will include child protection mechanisms to ensure that child victims of trafficking are returned 

to a place of safety. According to this report, within direct service programs, the role of QCS is to 

facilitate the full recovery and social integration of the survivors. 

Trauma Therapy 

While the availability of a wide range of mental health services is important, the focus of this review is on 

trauma therapy because all victims of human trafficking have experienced some form of trauma. 

Although some victims are hesitant at first to access trauma therapy or mental health services, making 

them accessible throughout the continuum of care is important. It may take months or even years for a 

victim to accept counseling (Caliber Associates, 2007). 

According to the literature, trauma recovery models begin with pretreatment assessment and a critical 

understanding of a victim’s current safety risk. Once the victim’s immediate safety is established, a 

trained clinician can begin to address the trauma issues and their related symptoms, begin any appropriate 

family work, and treat any co-occurring disorders (Mahoney, Ford, Ko, & Siegfried, 2004). Trauma 

treatment research and studies of manualized treatment options, especially for working at the intersection 

of trauma and co-occurring disorders in adolescents, are quite limited. While the literature is extensive on 

PTSD in children and youth, no published literature is available on controlled adolescent intervention 

studies with sufficient sample size to be generalizable. Furthermore, especially for minors with multiple 

and intersecting challenges (like those of young victims of human trafficking), there has been criticism 

that the current treatment literature is too narrowly focused on symptom reduction rather than on 
U.S. Department of Health and Human Services, 

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37

measures of functioning (including health, academic performance, peer networks, and family 

relationships) (Feeny, Foa, Treadwell, & March, 2004). 

The evaluation literature on trauma treatment is more advanced in the adult arena than for adolescents, 

especially since the publication of a number of articles based on the Women, Co-Occurring Disorders and 

Violence (WCDV) study funded by the Substance Abuse and Mental Health Services Administration 

(Elliot et al., 2005; Finkelstein et al., 2004; Giard et al., 2005; Huntington, Moses, & Vaysey, 2005; 

Morrissey et al., 2005; Noether et al., 2005). This was the first large-scale, multi-site study investigating 

promising treatment models for women with histories of traumatic violence and substance use and mental 

health disorders. The study framework and some of its trauma interventions are particularly relevant to 

victims of human trafficking. 

 

Research has provided strong support for several trauma-specific interventions (such as cognitive 

behavioral therapies, eye movement desensitization and reprocessing, and trauma-focused educational 

groups). The strongest evidence for adults supports the efficacy of cognitive behavioral therapies in 

reducing PTSD symptoms (Feeny et al., 2004; Foa & Rothbaum, 1998). Cognitive behavioral therapy 

(along with exposure therapy) also shows promise in child and adolescent populations in reducing PTSD 

symptoms (National Institute of Mental Health, 2001). Also promising are early findings on the 

effectiveness of integrated models of adult trauma treatment in substance abuse settings, particularly in 

reducing substance abuse, general mental health problems, and PTSD symptoms (Brady et al., 2001; 

Fallot & Harris, 2004; Najavits, Weiss, Shaw, & Muenz, 1998; Rosenberg et al., 2001; Zlotnick, 

Najarvits, Rhsenow, & Johnson, 2003). 

 

At least two of the group trauma-specific integrated models of treatment examined in the WCDV study 

have been modified for adolescents (Seeking Safety and the Trauma Recovery and Empowerment 

Model), while a number of others are under development (Mahoney et al., 2004; Rivard et al., 2004). 

Seeking Safety is the first of the modified adolescent versions to undergo a randomized, controlled trial 

exploring the impact of this 25-session, manualized intervention for mental health, trauma symptoms, and 

substance use in youth6

 (Najavits, Gallop, & Weiss, 2006). The sample size for this study was quite 

small (N=33) and included outpatient adolescent girls with PTSD (the most frequent trauma category

sexual abuse) and substance use disorders (with cannabis and alcohol the most frequently used 

substances). Despite the small sample, participants showed significantly better outcomes post-treatment 

than the treatment-as-usual group, including decreased substance use, trauma-related symptoms, and 

improvement on cognitive measures related to substance use disorders and PTSD. While quite 

preliminary, the authors believe these early results are especially hopeful because they suggest that the 

highly prevalent co-occurrence of PTSD and substance use disorders may be amenable to early change—

an important finding because the usual trajectory of these disorders persists into adulthood (Ouimette & 

Brown, 2002). 

 was 

 

While it has not been part of a rigorous evaluation of services, a comprehensive initiative for victims of 

human trafficking in Miami has observed significant recovery (including a decrease in recovery time) 

among victims, especially minors, who receive trauma therapy. In one case, after participating in therapy, 

not only had the individual’s mental state improved but her physical state also improved (Caliber 

Associates, 2007). The therapy incorporated many non-Western techniques into the treatment, such as 

breathing exercises and physical therapy and massage. These services were well received by international 

victims. This is consistent with treatment programs and results observed among victims of torture 

(Center for Victims of Torture, 2006). 

6 For details on the treatment, see www.seekingsafety.org.
U.S. Department of Health and Human Services, 

Office of the Assistant Secretary for Planning and Evaluation 

38

Not only is trauma therapy important for victims’ overall well-being, but addressing the trauma also may 

help their legal case. Information on torture victims has demonstrated that the symptoms of trauma may 

interfere with clients’ ability to participate in their case. For example, victims may have difficulty 

remembering details of events. Their emotional reactions when recounting traumatic events may seem 

inappropriate. They may avoid discussing the torture or other traumatic events or begin missing 

appointments with their attorney (or other services) when they anticipate the discussion will be too 

painful. Additionally, victims may not recount the torture events in a linear fashion; they may jump from 

one event to the next or omit details. This may be particularly true for individuals for whom torture 

started at an early age. Therefore, helping a victim recover from trauma, although a lengthy process, may 

also prove beneficial to the prosecution of these cases (Center for Victims of Torture, 2006). 

Substance Abuse Treatment 

Limited information is available regarding substance abuse treatment for adult victims of human 

trafficking. One explanation given by a service provider for this absence is the belief that victims are 

reluctant to divulge this problem for cultural reasons as well as concern that by acknowledging they have 

a problem, they may be jeopardizing their credibility as a witness in their trafficking case, their 

immigration case, or a future custody case (Caliber Associates, 2007). Likewise, research specific to 

substance abuse in minor trafficking victims is also extremely limited. However, there is some general 

research on adolescent treatment programs that might provide some guidance about effective substance 

abuse services for minor trafficking victims. 

Adolescent treatment for substance abuse must be tailored to the unique challenges and developmental 

needs of that population (Hser et al., 2001; Physician Leadership on National Drug Policy, 2002). 

Additionally, the earlier treatment is received, the shorter the course of substance abuse. While 

encouraging, the problem is that fewer than 1 in 10 adolescents with substance abuse or dependence 

problems receives treatment (Dennis, 2006). 

Research also has found that gender differences in the use of substances have implications for effective 

treatment design (Amaro, Blake, Schwartz, & Flinchbaugh, 2001). For example, a factor to be considered 

when designing effective treatment programs specifically for girls includes the need to improve a girl’s 

self-image, including body image and self esteem/efficacy. There are, however, other factors that are 

important to consider when designing treatment programs for adolescents in general. These include 

developing life skills in areas such as intrapersonal competencies, problem-solving, and self-assertion; 

promoting healthy life styles; improving family functioning, including families with adolescent parents; 

treating the long-lasting effects of sexual abuse; and addressing racial and ethnic differences in risk 

factors through culturally tailored approaches. 

The number of studies evaluating adolescent substance abuse treatment programs has increased 

significantly in recent years, with major methodological advances, especially exploring new manualized 

therapies (Dennis, 2002; Dennis et al., 2002). While there is no evidence that one particular treatment 

format or modality is appropriate for all adolescents, key elements of effective interventions have been 

described in a number of articles and reports (Brannigan et al., 2004; Dennis, 2006; Mark et al., 2006; 

Physician Leadership on National Drug Policy, 2002). These elements reflect the components of effective 

services and strategies reviewed previously: 
U.S. Department of Health and Human Services, 

Office of the Assistant Secretary for Planning and Evaluation 

39

 Comprehensive assessment and treatment matching, including mental health and medical problems, 

learning disabilities, family functioning, and other key aspects of adolescents’ lives. 

 Comprehensive and integrated treatment approach, 

addressing the broad range of needs rather than 

concentrating only on curtailing substance abuse. These 

may include individual or group targeted sessions to 

address victimization, anger management, depression, 

medication management, educational deficits, and health 

care. 

 Language to which young people 

can relate 

 Videos or other visual material 

(Harrison & Dempsey, 1998) 

Components of Effective 

Programming for At-Risk Youth 

 Small group setting

 Relaxed and casual environment

 Interactive and experiential 

 Driven/informed by participants 

rather than the group leader 

 Family involvement in treatment, maintaining close links 

with family, school, and where necessary the juvenile 

justice system.

 Wraparound services, including transportation, case 

management, and care coordination. 

 Recreational activities and exposure to non-using

activities. 

 Developmentally appropriate programs designed specifically for adolescents.

 Engagement and retention based on developing trust between the teen and therapist or counselor. 

 Qualified staff trained in adolescent development, co-occurring disorders, substance abuse, and 

addiction. 

 Gender and cultural competence, addressing the unique needs of girls and boys, as well as cultural 

differences. 

 Continuing care, including relapse prevention, aftercare, referral to community resources, and followup. 

Given the percentage of minors in prostitution who develop substance abuse issues, any programming, at 

least for minor victims of domestic sex trafficking, should include access to substance abuse treatment (A. 

Adams, personal communication, March 2006; B. Everts, personal communication, November 2006; N. 

Hotaling, personal communication, June 2006; National Center for Missing and Exploited Children, 

2002; K. Seitz, personal communication, December 2006). 

10. CONCLUSION

Despite increased attention to the problem of human trafficking into, and most recently within, the United 

States, knowledge and understanding of the issue remains fairly limited (Albanese, Donnelly, & Kelegian,

2004; Derks, Henke, & Vanna, 2006). Research on trafficking has focused primarily on estimating the 

scale of the problem, mapping routes, and reviewing policies and legal frameworks (Gozdziak & Collett, 

2005). 
U.S. Department of Health and Human Services, 

Office of the Assistant Secretary for Planning and Evaluation 

40

Very little is known about the prevalence of trafficking and the number of victims; characteristics of the 

victims and perpetrators; the long-term impacts of human trafficking on victims, their families, and 

communities; the effectiveness of anti-trafficking programs; and best practices in meeting the complex 

needs of victims. More specifically: 

 There is little literature on effective programs and services designed specifically for victims of human 

trafficking. Information from more than a decade of work with victims of domestic violence, 

prostitution, homeless and runaway youth, and victims experiencing trauma in general provide most 

of the general groundwork summarized here, and there is a need for research that explores the 

applicability and effectiveness of these approaches with victims of human trafficking. 

 While there is little hard evidence to support the effectiveness of specific interventions or services for 

victims of human trafficking, it is possible to identify components or characteristics that seem 

promising in services and strategies for trafficking victims and similar populations based upon the 

limited information available. 

 In looking at promising models to assist victims in their recovery, indications are that survivors may 

be in the best position to assist peers, working in collaboration with clinicians. However, there is 

limited research evidence about the impact of peer models on recovery. 

 With limited research, more needs to be learned about the health implications of human trafficking 

and the medical needs of all types of victims—males, females, adults, and children. 

 Trauma treatment research and studies of manualized treatment options, especially those programs 

working at the intersection of trauma and co-occurring disorders in adolescents, are quite limited. 

While the literature is extensive on PTSD in children and youth, no published literature is available 

on controlled studies of adolescent interventions. 

 Limited information is available regarding substance abuse treatment for adult victims of human 

trafficking. 

 Research specific to substance abuse in minor trafficking victims is also extremely limited. 

What is known about victims of human trafficking is focused primarily on the trafficking of international 

women into the United States for sexual exploitation, with little attention to domestic trafficking, minor 

victims, and in particular, male victims of sex and labor trafficking. 

 

However, a richer source of information based on more rigorous research studies can be found in related 

fields, as demonstrated in the current literature review. Inferences can reasonably be made from what is 

known about victims of domestic violence, torture victims, child sexual exploitation and prostitution, and 

runaway and homeless youth, and what we expect to find from similar studies of international and 

domestic victims of human trafficking. In the absence of existing studies, conclusions can be drawn only 

from overviews, commentaries, and anecdotal observations and experiences of providers and others in the 

field (Gozdziak & Collet, 2005). 

The challenges associated with combating human trafficking and protecting victims are overwhelming but 

manageable. Many NGOs feel that a multi-dimensional approach to addressing trafficking should include 

not only legislative initiatives and crime prevention, but also social welfare, job training, rights protection, 
U.S. Department of Health and Human Services, 

Office of the Assistant Secretary for Planning and Evaluation 

41

and development initiatives in the source, transit, and destination countries and locales (Caliber 

Associates, 2007; Richard, 1999). Effective strategies should be comprehensive and provide for 

collaboration among governments, governmental agencies, NGOs, advocacy groups, service providers, 

survivors, and affected communities (Miller & Stewart, 1998). Intensive case management, 

comprehensive services provided through partnerships, and ongoing outreach and education most likely 

will produce an effective response to the needs of victims. Ongoing communication with existing 

programs and documentation and assessment of their activities will offer valuable lessons for the field. 

NGOs working with different groups of trafficking victims (e.g., sex trafficking or labor trafficking, 

males or females, adults or minors) and populations with similar needs (e.g., torture victims, refugees, 

minor prostitutes, runaway and homeless youth, victims of domestic violence) represent an untapped 

wealth of practical knowledge and expertise on how to develop appropriate assistance and treatment 

programs for trafficking victims and survivors. More research is needed to document these evolving 

approaches and strategies, provide results that will inform and strengthen the response by sectors already 

involved in combating trafficking, and serve as best practices for those communities wanting to replicate 

this work. 

Federal and State laws addressing specifically the crime of human trafficking are less than a decade old, 

and while some of the literature for this review was drawn from prostitution research or other related 

fields, much remains to be learned about persons who are trafficked into and within the United States. 

This review of the literature, along with a series of issue briefs and the final study report, can be 

downloaded from the following Web sites: 

http://aspe.hhs.gov/hsp/07/HumanTrafficking/

http://www.icfi.com/markets/social-programs/
U.S. Department of Health and Human Services, 

Office of the Assistant Secretary for Planning and Evaluation 

42

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