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Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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6


Victim and Support Services

Victim and support services include a collection of services provided by an array of government agencies and nongovernmental organizations to individuals in need of assistance. Providers of these services to victims and survivors of commercial sexual exploitation and sex trafficking of minors include

•    individuals (e.g., case managers, social workers, child protection workers);

•    agencies and systems (e.g., child welfare, child protective services, the Department of Justice’s Office for Victims of Crime);

•    programs specifically designed to address commercial sexual exploitation and sex trafficking of minors (e.g., direct care/service providers, advocacy organizations);

•    programs that provide services to victims without recognizing their circumstances (e.g., runaway/homeless youth shelters);

•    programs that serve victims but lack a clear plan for responding (e.g., domestic violence shelters and runaway/homeless youth shelters); and

•    programs that are aware of commercial sexual exploitation and sex trafficking of minors but believe that serving these victims is beyond their scope of practice.

By the very definition of their work, all victim and support service professionals are working with vulnerable and victimized youth. As described in Chapter 3, victims/survivors of and minors at risk of commercial sexual

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

exploitation and sex trafficking may be vulnerable to or have experienced other forms of abuse. Further, these youth frequently are systems-involved and/or in need of or currently receiving some form of support services. As a result, these youth may come into contact with victim and support service professionals. Therefore, these professionals need to be prepared to recognize and address risk for or past or ongoing victimization by commercial sexual exploitation and sex trafficking among the children and adolescents in their care. Failure to do so increases the possibility that those at risk will become victims and that victims will remain vulnerable to further exploitation and abuse and miss opportunities for assistance.

This chapter begins with an overview of current practices in victim and support services designed to prevent, identify, and respond to the commercial sexual exploitation and sex trafficking of minors in the United States. The discussion highlights several noteworthy practices for assisting and supporting victims and survivors, including direct care and services, training and education of personnel, and protocols for assisting victims/survivors, among others. The chapter describes work at the federal, state, and local levels by both government agencies and nongovernmental organizations. The chapter then reviews the state of existing research on victim and support services. Next is a discussion of challenges and opportunities related to these services. The chapter concludes with the committee’s findings and conclusions on the role of victim and support service programs and professionals in addressing the commercial sexual exploitation and sex trafficking of minors in the United States.

CURRENT PRACTICES IN VICTIM AND SUPORT SERVICES

Nationally, a number of efforts are aimed at providing victim and support services to victims and survivors of commercial sexual exploitation and sex trafficking of minors. These include

•    curriculum development and education for at-risk children and adolescents, victims and survivors, and service providers;

•    training for victim and support service professionals;

•    direct care and support services for victims and survivors;

•    outreach and public awareness initiatives;

•    programs designed to prevent commercial sexual exploitation and sex trafficking of minors; and

•    hotlines (or help lines).

The specific goals, target populations, sources of funding, ideology, and designs of these efforts vary significantly. Examples of each are provided later in this section.

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

The committee learned about current practices in victim and support services from a variety of sources, including published research on commercial sexual exploitation and sex trafficking of minors, research in related fields of practice and study, and testimony during the committee’s workshops and site visits. The information thus gathered is summarized in this section. While some of the examples given are part of broader initiatives that involve other sectors (e.g., law enforcement, health care), this chapter focuses primarily on those aspects of this work related most directly to victim and support services. Multisector approaches are mentioned here, but are covered in greater detail in Chapter 10. This review is not meant to be an exhaustive accounting of such services, but to illustrate a range of current efforts and actors and to call attention to areas that require additional consideration. Finally, it should be noted that most of these activities have not been empirically evaluated; as a result, the committee does not intend to imply that it is endorsing any specific approach.

Child Welfare

Victims and survivors of commercial sexual exploitation and sex trafficking of minors may come to the attention of child welfare professionals. In addition, child welfare agencies may already be working with victims and survivors of these crimes but not recognize them as such (Adams, 2012; Walts et al., 2011). Because the ability of these professionals to identify victims and respond to their needs is essential to developing an overall response to commercial sexual exploitation and sex trafficking of minors, they need to be prepared to carry out these roles. Child welfare is well positioned to assume two important roles: (1) preventing commercial sexual exploitation and sex trafficking among populations already involved in child welfare, and (2) identifying and assisting victims and survivors of these crimes in their care.

Child welfare is a “group of services designed to promote the well-being of children by ensuring safety, achieving permanency, and strengthening families to care for their children successfully” (Child Welfare Information Gateway, 2013). Child welfare encompasses public and private child welfare agencies; out-of-home care, such as group homes, residential treatment facilities, and foster care; and in-home care, such as family preservation services (Child Welfare Information Gateway, 2013).

While one of the primary roles of child welfare is to prevent the abuse, neglect, and exploitation of children, this role traditionally has not been applied to extrafamilial victimization. According to the Department of Health and Human Services’ Administration for Children and Families, “in general, child welfare agencies do not intervene in cases of harm to children caused by acquaintances or strangers. These cases are the responsibility of

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

law enforcement” (Child Welfare Information Gateway, 2013, p. 2). As a result, child welfare historically has not been actively involved in addressing the commercial sexual exploitation and sex trafficking of minors. This lack of involvement presents a number of problems for victims and survivors of these crimes and the range of professionals who encounter them. First, as described in Chapter 1, commercial sexual exploitation and sex trafficking of minors, at their core, are forms of child abuse, and child welfare agencies therefore should have a responsibility to assist victims and survivors of these crimes as part of their overall charge. In addition, child welfare caseworkers may serve an important role as “gateway providers” to supportive services for victims/survivors of abuse (Dorsey et al., 2012). In this capacity, child welfare professionals can help ensure that victims of commercial sexual exploitation and sex trafficking of minors have access to needed services.

As noted in Chapter 3, involvement in the child welfare system, including out-of-home placement, such as in group homes and foster care, may be a risk factor for commercial sexual exploitation and sex trafficking of minors. Understanding the potential risks related to involvement in the child welfare system can help child welfare professionals recognize and address both risk and ongoing or past exploitation among the children and adolescents in the state’s care. Failure to do so increases the likelihood that these youth will remain vulnerable to further exploitation and abuse.

The committee learned about several noteworthy models for intervention by the child welfare system: creating a specific “allegation of harm” for commercial sexual exploitation and sex trafficking of minors to improve case management, requiring reporting to child protective services, raising awareness and building capacity in child welfare, and developing state guidelines and tools for child welfare professionals. Examples of each are described below.

Creating an “Allegation of Harm” for Commercial
Sexual Exploitation and Sex Trafficking of Minors

Several states, including Connecticut, Florida, and Illinois, have taken the step of designating human trafficking as a specific abuse allegation. For example, the Illinois Safe Children Act includes “human trafficking of children” as an allegation of harm in the Statewide Automated Child Welfare Information System (SACWIS), a state-based intake and case management tool for alleged child maltreatment (State of Illinois Department of Children and Family Services, 2011).1 This system serves as a central data collection point that helps maintain a complete case management history of child

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1Illinois Safe Children Act, August 20, 2010.

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

maltreatment (Children’s Bureau, 2012). The law stipulates that victims of commercial sexual exploitation and sex trafficking of minors should be considered “abused” under the Abused and Neglected Child Reporting Act and the Juvenile Court Act.2 As a result, when an individual under age 18 is taken into custody for a prostitution offense, law enforcement must notify the Illinois Department of Children and Family Services of the allegation of human trafficking. The Department of Children and Family Services, in turn, is required to open an investigation into the abuse within 24 hours of the initial report (State of Illinois Department of Children and Family Services, 2011). In fiscal year 2012, the Department of Children and Family Services conducted 103 investigations of reports of human trafficking of children, 14 of which revealed credible evidence that the abuse had occurred (State of Illinois Department of Children and Family Services, 2013). As discussed in Chapter 2, however, these reporting rates significantly underrepresent the actual number of underage victims of commercial sexual exploitation and sex trafficking.

This new allegation of harm also helps ensure that suspected cases of commercial sexual exploitation and sex trafficking of minors are categorized within the SACWIS system as “human trafficking,” as opposed to other reported types of child maltreatment (e.g., domestic violence, sexual abuse, incest, or other forms of physical abuse). In addition, the allegation can help officials collect and analyze state-level data and coordinate case management for victims (Children’s Bureau, 2012).

Requiring Reporting to Child Protective Services

In Massachusetts, all suspected cases of commercial sexual exploitation and sex trafficking of minors must be referred to child protective services.3 A report to child protective services prompts referral to a case coordinator, which in turn activates a comprehensive, coordinated response to the victim/survivor. (See Chapter 10 for a detailed discussion of the role of child protective services in a multisector response to commercial sexual exploitation and sex trafficking of minors in Suffolk County, Massachusetts.)

Raising Awareness and Building Capacity in Child Welfare

Although the committee learned about a handful of examples of antitrafficking work that involve child welfare, child welfare overwhelmingly is perceived as underrepresented or absent in such efforts (Brittle, 2008; Fong

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2Abused and Neglected Child Reporting Act.

3Massachusetts HB 3808, An Act Relative to the Commercial Exploitation of People, February 19, 2012.

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

and Berger Cardoso, 2010; Walts et al., 2011; Wilson and Dalton, 2008). Reasons for a lack of child welfare engagement include inadequate training, insufficient resources, high caseloads, and the perception that victims of commercial sexual exploitation and sex trafficking of minors should be handled in the juvenile justice system as opposed to child welfare (Walts et al., 2011; Wilson and Dalton, 2008). In an attempt to address the need to respond to victims and survivors of these crimes who are in the state’s care, the International Organization for Adolescents and the Center for the Human Rights of Children at Loyola University Chicago developed a handbook for child welfare agencies—Building Child Welfare Response to Child Trafficking Handbook (Walts et al., 2011). This handbook was developed in partnership with the Illinois Department of Children and Family Services to help child welfare agencies meet their responsibility of identifying and serving trafficking victims as required by the Illinois Safe Children Act.4

Developing State Guidelines and Tools for Child Welfare Professionals

Some states have taken additional steps to strengthen the capacity of child welfare and child protection professionals to respond to the commercial sexual exploitation and sex trafficking of minors. For example, the State of Florida’s Department of Children and Family Services has developed specific guidelines to assist child welfare and child protection professionals with reporting allegations of human trafficking of children (State of Florida Department of Children and Families, 2009b). In addition, the state developed a tool to assist child protection investigators in identifying victims of human trafficking (State of Florida Department of Children and Families, 2009a). Currently, guidance of this nature is lacking at the federal level and within most states.

Federal and State Government

Numerous federal agencies are charged with and engaged in responding to human trafficking. To help coordinate these various federal efforts to address the problem, the Trafficking Victims Protection Act (TVPA) of 2000 created the President’s Interagency Task Force to Monitor and Combat Trafficking. Members of the task force include the Department of State, Department of Defense, Department of Justice, Department of the Interior, Department of Agriculture, Department of Labor, Department of Health and Human Services, Department of Transportation, Department of Education, and Department of Homeland Security, among others. Each agency is responsible for responding to different (and sometimes complementary

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4Illinois HB 6462, Safe Children Act, August 20, 2010.

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

or overlapping) aspects of human trafficking within its jurisdiction. (See Chapter 10 for a more detailed discussion of this task force.)

The committee learned about several noteworthy models for intervention within federal and state government: at the federal level, making federal benefits and services available to victims of trafficking, funding service organizations, and providing employment and job training to trafficking victims; and at the state level, using a statewide coordinated care approach to the provision of victim and support services. Examples of each are described below. The primary focus of this section is on the efforts of federal and state agencies whose work on human trafficking relates directly to the provision of victim and support services to victims/survivors of commercial sexual exploitation and sex trafficking who are U.S. citizens or lawful permanent residents under age 18.

Making Federal Benefits and Services Available to Victims of Trafficking

According to its report to the President’s Interagency Task Force to Monitor and Combat Trafficking in Persons, the Department of Health and Human Services engages in a number of efforts focused on preventing, identifying, and responding to human trafficking. These efforts include regional training and meetings; outreach efforts to raise public awareness (e.g., the Rescue and Restore Victims of Human Trafficking campaign); technical assistance to program grantees who work with victims of human trafficking; and funding for the National Human Trafficking Resource Center, a national resource for victims of human trafficking and the public (U.S. Department of State, 2012).

In addition, the Department of Health and Human Services developed a guide to federal benefits and services available to victims of trafficking (HHS, 2012). This resource provides program-by-program information on benefits and services and includes eligibility requirements. Domestic victims/survivors of human trafficking (both U.S. citizens and legal permanent residents) may be eligible for, among others, Temporary Assistance for Needy Families; Medicaid; the Children’s Health Insurance Program; the Supplemental Nutrition Assistance Program; the Special Supplemental Nutrition Program for Women, Infants, and Children; and selected Substance Abuse and Mental Health Services Administration and Health Resources and Services Administration programs. However, the extent to which these services and benefits are accessed by domestic victims/survivors of human trafficking is unknown, as is the extent to which victim and support service providers are aware of services and benefits available to domestic victims/survivors of human trafficking.

In April 2013, the President’s Interagency Task Force to Monitor and Combat Trafficking in Persons released a federal strategic action plan on

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

services for victims of human trafficking in the United States (President’s Interagency Task Force to Monitor and Combat Trafficking in Persons, 2013).5 This 5-year plan envisions “that every victim of human trafficking is identified and provided access to the services they need to recover and rebuild their lives through the creation of a responsive, sustainable, comprehensive, and trauma-informed victim services network that leverages public and private partners and resources effectively” (President’s Interagency Task Force to Monitor and Combat Trafficking in Persons, 2013, p. 12). Among its goals, the plan calls for expanding access to services for victims of human trafficking throughout the United States. While the plan describes specific strategies for a range of agencies to increase access to victim and support services, it will be important to assess the extent to which this occurs in the plan’s implementation over time.

Funding Service Organizations

The Department of Justice provides funding to victim services organizations through grants made by the Office for Victims of Crimes. According to its report to the President’s Interagency Task Force to Monitor and Combat Trafficking in Persons, the Department of Justice, through its Office for Victims of Crime, provided funding to “eleven victim service organizations with a demonstrated history of providing trauma-informed, culturally competent services to male and female victims of sex trafficking and labor trafficking” (U.S. Department of State, 2012). This funding supports the provision of services at the local, regional, and national levels. The 2013 reauthorization of the TVPA has supplemented these programs by authorizing the Department of Health and Human Services (specifically the Assistant Secretary for Children and Families) to issue up to four grants to entities (i.e., states or units of local government) that “[have] developed a workable, multi-disciplinary plan to combat sex trafficking of minors,” with the requirement that two-thirds of the funding be used for residential care and services for minor victims and survivors of sex trafficking, to be provided by nongovernmental organizations.6 In addition, funds are used to develop interagency partnerships (described in Chapters 5 and 10) and public outreach and awareness campaigns (U.S. Department of State, 2012). This small number of grantees and programs may not be surprising given that work on commercial sexual exploitation and sex trafficking of minors in the United States is in the early stages, but it does suggest how

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5As of this writing, this plan was open to public comment. The final plan may be revised to reflect that input.

6Violence Against Women Reauthorization Act of 2013 (VAWA) img 1241 (2013) (the TVPA Reauthorization of 2013 was attached as an amendment to VAWA).

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

much additional work and funding would be required to bring these services to scale.

Providing Employment and Job Training to Trafficking Victims

The Department of Labor offers employment and training services to victims of severe forms of trafficking, as required by the TVPA. In addition, the TVPA stipulates that victims of convicted traffickers are entitled to full restitution for the labor they performed (U.S. Department of State, 2012). The extent to which these services and benefits are available to domestic victims/survivors of commercial sexual exploitation and sex trafficking of minors is unknown, as is the extent to which victim and support service providers are aware of job training and/or restitution available to domestic victims/survivors of human trafficking.

Using a Statewide Coordinated Care Approach to
the Provision of Victim and Support Services

Georgia Care Connection was established by Georgia’s Governor’s Office for Children and Families to serve as a central, statewide hub for victims and survivors of commercial sexual exploitation and sex trafficking of minors and for professionals (e.g., law enforcement personnel, school personnel, child welfare professionals, health care providers) seeking to help them (Georgia Care Connection Office, 2013). Through a broad network of state and local service providers and professionals, Georgia Care Connection coordinates a “comprehensive care plan” for victims and survivors (Georgia Care Connection Office, 2013). This comprehensive plan integrates and coordinates prevention, intervention, and treatment services (e.g., legal, mental and physical health, housing) that are guided by the specific the needs of each victim/survivor.

Nongovernmental Organizations

Nongovernmental organizations (NGOs) serving victims and survivors of commercial sexual exploitation and sex trafficking of minors include specialized direct service providers, faith-based organizations, service providers and community resources that serve other populations, advocacy organizations, and private foundations, among others. Some NGO efforts to address commercial sexual exploitation and sex trafficking of minors are integrated into broader service portfolios, while others focus exclusively on these crimes. Some NGO efforts are national or international in scope, while others focus their efforts regionally or locally. Finally, some NGOs focus on all forms of human trafficking (e.g., labor and sex) and the range

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

of populations affected (e.g., minors and adults), while others focus on specific subpopulations (e.g., lesbian, gay, bisexual, and transgender [LGBT] individuals; minors; U.S. citizens; legal permanent residents).

The committee learned about several noteworthy models for involvement by NGOs: curriculum development and education, training for victim and support service professionals, direct care and services, outreach and public awareness initiatives, prevention efforts, and hotlines. Examples of each are described below. While many of the organizations and efforts described in this section provide a range of services that fit within multiple categories, the discussion highlights specific program elements of note for each.

Curriculum Development and Education

A number of NGOs have developed and implemented curricula designed to reach individuals at risk for and/or victims/survivors of commercial sexual exploitation and sex trafficking of minors. One example is the My Life, My Choice (MLMC) curriculum, an educational curriculum developed by the Boston-based My Life, My Choice initiative, which works to identify and intervene with adolescent girls who are vulnerable to commercial sexual exploitation and sex trafficking (My Life, My Choice, 2012).

The MLMC curriculum consists of 10 sessions led and facilitated by trained staff, typically a licensed clinician and a survivor of commercial sexual exploitation or sex trafficking (Goldblatt Grace, 2012). The curriculum can be delivered in a variety of settings (e.g., group homes and residential facilities, child protective services offices, juvenile justice facilities, community-based organizations). The curriculum was developed for girls aged 12 to 18 who are at risk for or are victims/survivors of commercial sexual exploitation and sex trafficking. Thus, the goals of the curriculum include preventing commercial sexual exploitation and sex trafficking among at-risk adolescents and preventing revictimization among those previously exploited. The MLMC curriculum was designed to alter participants’ behavior by changing their attitudes, knowledge, and skills (i.e., improving attitudes regarding sexual health and self-esteem, increasing knowledge of the relationship between substance use and commercial sexual exploitation and sex trafficking, and developing skills to access resources and recognize potential exploiters) (Goldblatt Grace, 2012).

Facilitators of the MLMC curriculum administer pre- and posttest measures to evaluate participants’ progress across the 10-week curriculum. Participants are asked to report on their attitudes and knowledge regarding commercial sexual exploitation and sex trafficking and their skills to avoid future exploitation (Goldblatt Grace, 2012).

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

Training for Victim and Support Service Professionals

In addition to curricula designed to reach individuals at risk for or victims/survivors of commercial sexual exploitation and sex trafficking, a number of NGOs have developed and implemented training for victim and support service professionals, among others.

For example, Girls Educational and Mentoring Services (GEMS)—a New York City–based nonprofit organization that provides services to girls and young women (aged 12 to 24) who have experienced commercial sexual exploitation and sex trafficking—has developed and implemented two curricula for organizations working with victims/survivors of these crimes. The first, the Office of Juvenile Justice and Delinquency Prevention’s Commercial Sexual Exploitation of Children Community Intervention Project (CCIP) Train-the-Trainer curriculum, is designed to provide an overview of issues related to commercial sexual exploitation and sex trafficking of minors for victim and support service providers, law enforcement personnel, health care professionals, child welfare professionals, legal professionals (e.g., prosecutors, legal aid/public defenders, family court officials), school personnel, and first responders. Specific topics include prevention and identification strategies, assessment and counseling techniques, and investigation and interviewing strategies, among others. Second, the Victim, Survivor, Leader™ curriculum is designed to assist organizations interested in developing and providing “specialized services” for female victims and survivors of commercial sexual exploitation and sex trafficking. In addition to these two curricula, GEMS offers technical assistance to organizations seeking additional guidance on the design and delivery of services to victims/survivors of commercial sexual exploitation and sex trafficking (GEMS, 2013).

Other examples of organizations that conduct training for an array of victim and support service providers (among other sectors) include Motivating, Inspiring, Supporting, and Serving Sexually Exploited Youth; Polaris Project; Standing Against Global Exploitation; and Shared Hope International.

Direct Care and Services

A number of organizations provide direct care and services to victims and survivors of commercial sexual exploitation and sex trafficking of minors. Examples include temporary and longer-term shelter, intensive case management, victim outreach, support groups, counseling and therapeutic services, mentoring, and legal assistance.

For example, Courtney’s House is a survivor-run organization that provides services to victims and survivors of commercial sexual exploitation

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

and sex trafficking of minors in the Washington, DC, metropolitan area (Frundt, 2012). Courtney’s House provides case management; educational assistance; survivor-led support groups for boys, girls, and transgender victims/survivors; mentorship programs; counseling; group therapy; and academic tutoring (Frundt, 2012). In addition, it conducts an overnight street outreach program to identify victims, survivors, and minors who are at risk of commercial sexual exploitation or sex trafficking. Finally, Courtney’s House maintains a hotline staffed by victims and survivors of commercial sexual exploitation and sex trafficking (Frundt, 2012).

Another example is the Salvation Army’s STOP-IT Program, which provides services to victims of human trafficking in 11 counties in Illinois. The STOP-IT program works with both adults and minors and both men and women who are victims/survivors of sex and labor trafficking and are U.S. citizens, non-U.S. citizens, or lawful permanent residents. In 2011, the STOP-IT program served 70 victims/survivors of human trafficking, 43 of whom were U.S. citizens and 26 of whom were minors (Knowles-Wirsing, 2012). Referrals to the STOP-IT program are made by a range of individuals and organizations, including local and federal law enforcement, the Cook County Human Trafficking Task Force (described in detail in Chapter 10), hospitals, the Illinois Department of Child and Family Services, and the National Human Trafficking Resource Center, among others. The STOP-IT program creates individualized service plans for victims and survivors and provides referrals for shelter and housing, transportation, legal services, medical care, mental health services, education, and employment services (Knowles-Wirsing, 2012).

Several direct care service providers also focus on specific vulnerable populations, such as boys/adolescent males, LGBT youth, and homeless youth. As noted in Chapter 3, boys/adolescent males and LGBT youth often are overlooked as populations at risk for commercial sexual exploitation and sex trafficking. As a result, victim and support services for these populations are especially scarce. Their need for services is increasingly being recognized (Clawson et al., 2009b), and a handful of efforts are under way, with still more emerging, to meet this need. For example, Larkin Street Youth Services is a San Francisco–based nonprofit organization that provides a range of support services to homeless and runaway youth aged 13 to 24. Between July 2010 and June 2011, 66 percent of the youth served by Larkin Street were male or transgender, and 35 percent were LGBT or questioning (LGBTQ) (Larkin Street Youth Services, 2011). Many of the boys and LGBTQ youth served by Larkin Street report that they have been involved in some aspect of sex work or sexual exploitation and have a history of family violence, child sexual abuse, childhood abuse, or childhood neglect (Adams, 2012). Larkin Street provides underage emergency shelter, transitional living programs, primary medical care, case management, edu-

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

cation and employment services, HIV prevention information and testing, mental health services, and substance abuse intervention (Adams, 2012). In addition, Larkin Street collaborates with other area service providers that serve primarily girls and women to make services available to populations that they may be unable to assist. Other examples of organizations that serve boys and LGBTQ youth include the Center on Halsted, Courtney’s House (discussed above), and Boston Gay and Lesbian Adolescent Social Services (Boston GLASS, 2013).

Outreach and Public Awareness Initiatives

Some of the most visible efforts to address commercial sexual exploitation and sex trafficking of minors in the United States have been carried out by NGOs that have developed and implemented outreach and public awareness campaigns. Three national-level examples include the work of Shared Hope International, Polaris Project, and ECPAT-USA. Each of these organizations has employed multiple strategies to raise awareness of commercial sexual exploitation and sex trafficking of minors in the United States.

Shared Hope International, a nonprofit organization that works to eliminate sex trafficking, has conducted a number of campaigns to educate and inform service providers and the public about commercial sexual exploitation and sex trafficking that occur domestically. To that end, Shared Hope International has released a series of reports focused on demand (Shared Hope International, 2006), domestic sex trafficking of minors (Smith et al., 2009), and state-by-state legal responses to commercial sexual exploitation and sex trafficking of minors in the United States (Shared Hope International, 2012). In addition to disseminating its publications, Shared Hope International uses media (e.g., billboard campaigns and YouTube videos) and holds national conferences and public events to raise public awareness of commercial sexual exploitation and sex trafficking of minors in the United States.

Polaris Project is another national organization that engages in concerted public awareness and outreach activities. A nonprofit organization that operates the National Human Trafficking Resources Center, Polaris Project engages in activities designed to raise public awareness of human trafficking (including sex trafficking of minors) and the resources and services available to victims and survivors. Specifically, the Polaris Project website includes downloadable resources for the public, a range of service providers and professionals, victims and survivors, and individuals at risk for human trafficking. These resources include information on existing and pending federal- and state-level legislation on human trafficking, downloadable flyers that publicize the National Human Trafficking Resources

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

Center’s hotline number (translated in 20 languages), an online directory of selected state-by-state resources, and general information about commercial sexual exploitation and sex trafficking of minors.

Like Shared Hope International and Polaris Project, ECPAT-USA engages in a range of activities designed to raise public awareness of commercial sexual exploitation and sex trafficking of minors in the United States. In addition to providing resources on its website, ECPAT-USA organizes a youth-led educational outreach program, the Youth Committee, that engages high school students in efforts to address commercial sexual exploitation and sex trafficking of minors (ECPAT-USA, 2013b). Participants in the Youth Committee design their own projects and disseminate them in their communities (e.g., a video to teach other young people about risk factors associated with commercial sexual exploitation and sex trafficking of minors) (ECPAT-USA, 2013b). Another initiative to raise public awareness of commercial sexual exploitation and sex trafficking of minors is ECPATUSA’s Tourism Child-Protection Code of Conduct (The Code) (ECPATUSA, 2013a). The Code, described in greater detail in Chapter 9, is a set of principles that encourage domestic travel and tourism companies to adopt policies addressing commercial sexual exploitation and sex trafficking of minors within the United States (Smolenski, 2012).

Finally, other nonprofits and NGOs, state and local foundations, faith-based organizations, and student groups also engage in outreach and public awareness campaigns. These groups use a range of strategies to increase awareness, including testimony before Congress, print and media campaigns, and presentations to community-based groups. The committee did not conduct an exhaustive review of these activities and groups, as doing so was beyond the scope of this study. However, the committee believes it is important to call attention to these efforts and organizations, which represent natural partners in the prevention and identification of and response to commercial sexual exploitation and sex trafficking of minors in the United States.

Prevention Efforts

The majority of current prevention efforts focus on raising awareness of the problems of commercial sexual exploitation and sex trafficking of minors and improving capacity to identify children and adolescents at risk of victimization by these crimes and thereby prevent them from occurring. Additional prevention strategies include efforts to deter and eliminate demand by promoting victim- and survivor-centered law enforcement strategies and laws. For example, End Demand Illinois, a statewide campaign of the Chicago Alliance Against Sexual Exploitation (CAASE), supports the creation of new laws and resources for law enforcement to facilitate

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×

the arrest, filing of charges against, and prosecution of exploiters (e.g., traffickers and customers) who create the demand for commercial sexual exploitation and sex trafficking of minors (End Demand Illinois, 2013). (See Chapter 4 for further discussion of legislative strategies and Chapter 5 for discussion of law enforcement efforts.) Other organizations’ prevention work is focused primarily on assisting and supporting individuals who are at risk for commercial sexual exploitation and sex trafficking (GEMS and My Life, My Choice, discussed above, are examples). At least one other organization has focused on preventing commercial sexual exploitation and sex trafficking of minors by educating adolescent males about these issues. CAASE created Empowering Young Men to End Sexual Exploitation, a prevention program for adolescent males that is implemented in Chicago-area high schools (Dunn Burque, 2009). The program is designed to raise awareness about commercial sexual exploitation and sex trafficking of minors, underscore the role of men in driving demand for the commercial sex trade, and challenge misconceptions that perpetuate and normalize these crimes. (See Chapter 8 for a more detailed description of the CAASE curriculum for boys.)

The dearth of current efforts focused on preventing commercial sexual exploitation and sex trafficking of minors is the result of a field in its infancy, and underscores the need for additional work in this area. However, these early efforts focused on preventing commercial sexual exploitation and sex trafficking of minors can inform future approaches for victim and support services and can help move the field beyond raising awareness to additional prevention strategies.

Hotlines

A number of hotlines (or help lines) are operated to assist victims of human trafficking; provide referrals; and, to the extent possible, connect individuals with support services in their communities. As in other areas of crisis intervention (e.g., suicide and runaway prevention) and criminal activity (e.g., sexual assault, domestic violence, and missing/abducted children), human trafficking hotlines vary in staffing, size, locality, resources, and accessibility. Through site visits and workshop presentations, the committee learned about a number of human trafficking hotlines (Frundt, 2012; Knowles-Wirsing, 2012; Myles, 2012).

One example is the National Human Trafficking Resource Center (NHTRC), a 24-hour national hotline funded by the Department of Health and Human Services’ Office of Refugee Resettlement. This hotline, which is operated through a cooperative agreement with Polaris Project, answers crisis calls (e.g., from trafficking victims in need of immediate assistance), provides referrals to local victim and support services, receives tips related

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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to human trafficking, and responds to inquiries for general information and technical assistance (Polaris Project, 2013). The NHTRC hotline is answered by paid staff and uses tele-interpreter services to field calls in 170 languages. The NHTRC collects, analyzes, and summarizes call and caller characteristics and reports this information annually. The 2011 annual report notes that the hotline has experienced a steady increase in calls over time. Since 2008, the total number of calls received has increased 338 percent (from 5,748 to 19,427 unique calls) (Polaris Project, 2012a). According to the 2011 report, 4 percent of the calls to the NHTRC hotline were “crisis calls,” that is, calls from victims of human trafficking who required immediate assistance or emergency services, and more than half (54 percent) of the calls placed to the hotline were for general information on human trafficking or for information and requests beyond the scope of the NHTRC services (Polaris Project, 2012a).

Other examples include state and local human trafficking hotlines. For example, the Colorado Network to End Human Trafficking maintains a 24-hour, statewide human trafficking crisis and referral hotline. In Chicago, the Salvation Army’s STOP-IT program, discussed earlier, operates a 24-hour hotline. Both of these hotlines help connect callers with local service providers. Finally, there are hotlines that exist exclusively to assist commercially sexually exploited youth. One example is a hotline operated by Courtney’s House, also discussed earlier. This hotline, which connects victims with local resources, is answered by survivors of commercial sexual exploitation.

Neither the best model for human trafficking hotlines nor their overall effectiveness has been determined. While there is some evidence that crisis hotlines can result in positive short-term outcomes for potential victims of suicide (King et al., 2003) and victims of domestic violence (Bennett et al., 2004), no evidence currently exists on the benefits of human trafficking hotlines. In addition, research suggests that youth may not readily access this source of assistance (Gould et al., 2006). For example, a recent study of adolescents found that, even though they had high rates of awareness of hotlines, very few in this sample (2.1 percent) reported ever using them (Gould et al., 2006). The authors also found that those adolescents who appeared to have the greatest needs also found hotlines to be unacceptable (Gould et al., 2006). The two primary reasons given for nonuse of hotlines were shame and self-reliance. Additional barriers to hotline use may exist among commercially sexually exploited youth. As noted in Chapter 3, victims may not self-identify and therefore may not view a hotline as a needed resource. In addition, as noted in Chapter 5, commercially sexually exploited youth may be worried about personal safety and/or legal consequences of calling a crisis hotline or may not have the freedom to place such a call. Additional research is necessary to determine the overall effectiveness

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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of human trafficking hotlines, strategies that can improve their acceptability and relevance, and their appropriate attributes.

Foundations

Private foundations and philanthropic organizations can play an important role in raising awareness, advancing research, supporting prevention and intervention activities, and strengthening public policies related to a range of health problems, such as tobacco use, obesity, domestic violence, depression, and child abuse and neglect. A number of private foundations and philanthropic organizations have made sex trafficking and commercial sexual exploitation of minors a significant part of their work. The committee learned about several recently implemented foundation-led strategies: using big data to understand and disrupt human trafficking, providing direct support to state and local organizations, and using challenge grants to promote and scale innovative approaches. Examples of these strategies are described below. While many of the organizations and efforts described in this section support a range of activities that fit under multiple categories, the committee highlights specific strategies of note for each.

Using Big Data to Understand and Disrupt Human Trafficking

In 2012, Google awarded a $3 million grant through its foundation, Google Giving, to support the development of a Global Human Trafficking Hotline Network. This grant is designed to support collaboration and information sharing among three antitrafficking organizations: Polaris Project (in the United States), Liberty Asia (in Southeast Asia), and La Strada International (in Central and Eastern Europe). Each organization operates a human trafficking hotline, provides assistance to hotline callers, and collects data related to the calls received by the hotlines. Traditionally, this information has been “siloed from organization to organization, and region to region” (Google Giving, 2013). Therefore, the stated goal of the Global Human Trafficking Hotline Network is “to aggregate global data to help anti-trafficking organizations assist more victims of human trafficking and to identify larger, global trends that can inform broader strategic intervention” (Google Giving, 2013).

Providing Direct Support to State and Local Organizations

The Women’s Foundation of Minnesota is one example of statewide community foundations that support efforts to prevent and respond to commercial sexual exploitation and sex trafficking of minors, in this case girls, in their state (Women’s Foundation of Minnesota, 2011). In 2011,

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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the Women’s Foundation of Minnesota launched the “Minnesota Girls Are Not For Sale” campaign, a 5-year, $5 million campaign to support services, research, and public education on commercial sexual exploitation and sex trafficking of girls. Grantees have included local government (e.g., the St. Paul Police Department and the Ramsey County Attorney’s Office) and nonprofit organizations (e.g., the American Indian Community Housing Organization). Grants are designed to “[support] legislative action to change state laws to recognize girls under age 18 who have been trafficked for sex are victims of a crime, not criminals; pursue sustainable housing and comprehensive treatment for sex-trafficked girls; and decrease the demand through effective law enforcement and policies” (Women’s Foundation of Minnesota, 2011).

Using Challenge Grants to Promote and Scale Innovative Approaches

The Partnership for Freedom is an example of a public-private initiative that supports innovative solutions to prevent and respond to human trafficking, including sex trafficking and the commercial sexual exploitation of minors (Partnerships for Freedom, 2012). The Partnership, which includes two private foundations (Humanity United and the Goldman Sachs Foundation), the Department of Justice, and other federal agencies, will establish and distribute $6 million in Innovation Awards to Stop Human Trafficking. These awards are designed to support local communities to create “collaborative and comprehensive solutions to human trafficking survivor care that can be evaluated and expanded nationally and internationally through federal policies and programs” (Partnerships for Freedom, 2012). According to the Partnership for Freedom, grants will focus on “sustainable housing and shelter solutions for all types of trafficking survivors, comprehensive care and case management for survivors who are minors, and law enforcement engagement with survivors” (Partnerships for Freedom, 2012).

Private foundations and philanthropic organizations have the ability and resources to galvanize efforts to prevent and respond to pressing social problems. This role can be especially important in relation to emerging issues. Therefore, the committee believes that foundations are essential partners in a collaborative approach to preventing and responding to commercial sexual exploitation and sex trafficking of minors in the United States. (For suggested strategies for foundations, see Box 11-1 in Chapter 11.)

CURRENT RESEARCH ON VICTIM AND SUPORT SERVICES

As in many domains of victim and support services, providing direct services for victims and survivors of commercial sexual exploitation and

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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sex trafficking often takes priority over evaluating the effectiveness of services. Resources for evaluation are limited, and as noted in Chapter 1, numerous challenges arise in conducting research on services for victims and survivors of these crimes. These challenges include ethical issues (e.g., the assignment of subjects to experimental and control groups), legal issues (e.g., privacy, confidentiality, and autonomy), and practical issues (e.g., the safety and well-being of victims and survivors), among others. As a result, evaluation and other research on victim and support services for victims and survivors of commercial sexual exploitation and sex trafficking of minors is underdeveloped.

This section summarizes the current state of evaluation of victim and support services for victims/survivors of commercial sexual exploitation and sex trafficking of minors. It also summarizes what is known about the broad range of methods and approaches that have been incorporated into the provision of these services. Because this is an emerging area of research, the discussion includes evidence from related fields of practice and research (e.g., domestic and intimate partner violence, sexual assault). The examples in this section are not meant to be exhaustive. In fact, the committee’s examination of research on and evaluation of victim and support services was constrained by the extremely limited number of published reports on the subject. The examples provided are meant to be illustrative and to call attention to areas that require additional evaluation.

Evaluations of Victim and Support Services

While many victim and support service providers routinely collect data on the individuals they serve and the specific services they provide, very few evaluations of specific victim and support services have been conducted, and there are few published reports and even fewer peer-reviewed studies on these services. As a result, victim and support service professionals and programs lack a critically reviewed evidence base for practice. However, the committee learned about a handful of recent and forthcoming efforts to evaluate victim and support services for victims and survivors of commercial sexual exploitation and sex trafficking in the United States.

For example, the National Institute of Justice funded an independent evaluation of LIFESKILLS, an intervention program for victims/survivors of and individuals at risk of commercial sexual exploitation and sex trafficking (under age 18) in San Francisco. The authors found that participation in the program reduced contact with the criminal justice system (Cohen et al., 2010). In addition, participants reported increased self-efficacy, increased educational aspirations, and a more positive attitude toward employment from baseline to follow-up interviews (Cohen et al., 2010). However, the program was found to have no significant effect on other outcomes of

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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interest, including substance abuse, commitment to school, and social support for participants (Cohen et al., 2010). While informative, the findings from this evaluation should be viewed with some caution. First, the sample was very small at baseline (n = 32) and experienced considerable attrition at 3-month follow-up (n = 23). Further, the sample consisted of victims/survivors and high-risk individuals who were referred to the program (i.e., a sample of convenience), and parental consent to participate was required. Finally, because fidelity to the curriculum was uneven during implementation, it is difficult to pinpoint specific program effects (Cohen et al., 2010). Despite the limitations of this research, the evaluation offers some insights into the challenges of conducting research on the problems of commercial sexual exploitation and sex trafficking of minors in the United States.

Another effort to evaluate programs that serve victims and survivors of sex trafficking of minors in the United States is an independent evaluation of three victim and support service providers participating in the Office for Victims of Crime’s Domestic Minor Demonstration Project (see Chapter 10 for a more detailed description of this project). Although currently unavailable, findings from this research will document components of program implementation among three grantees serving domestic minor victims of human trafficking and identify promising practices (e.g., critical elements of the service delivery program, fidelity to program design, and approaches to making services acceptable to program participants) (National Institute of Justice, 2009). In addition, the four block grants authorized in the 2013 reauthorization of the TVPA for providing services to victims or survivors of sex trafficking of minors require an annual evaluation of these programs by an academic or nonprofit institution with experience in issues related to this crime (Violence Against Women Act sec. 1241).

Conducting research on victim and support services can help build a much-needed evidence base for understanding promising and best practices for providing such services to victims and survivors of commercial sexual exploitation and sex trafficking of minors in the United States to inform future work. Further, the committee supports broad dissemination of the findings of this research through publication in the peer-reviewed literature so that this evidence base will be critically reviewed.

Research on Approaches to the Provision of Services

Victim and support service providers employ a range of approaches to provide services to children and adolescents at risk of and to victims and survivors of commercial sexual exploitation and sex trafficking. These approaches include, among others, trauma-informed care, trauma-specific treatment, and trauma-focused services; case management; and survivor-led

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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and survivor-informed models. The following sections briefly describe what is known about each of these approaches.

Trauma-Informed Care, Trauma-Specific
Treatment, and Trauma-Focused Services

Advocates, victim and support services providers, governmental and nongovernmental entities, and other groups that deal with commercial sexual exploitation and sex trafficking of minors in the United States increasingly are calling for the use of trauma-informed care for victims and survivors of these crimes. For example, a recent Department of Justice report on children exposed to violence cites trauma-informed care, trauma-specific treatment, and trauma-focused services as central to the department’s strategies for assisting and supporting victims and survivors of violence and abuse (DOJ, 2012). Similarly, many of the providers and organizations that serve victims and survivors of commercial sexual exploitation and sex trafficking informed the committee that trauma-informed care is their standard practice (Goldblatt Grace, 2012; Holzman, 2012; Knowles-Wirsing, 2012; Piening and Cross, 2012; Ring, 2012; Westmacott, 2012a). Given the nature of abuse and violence experienced by victims of commercial sexual exploitation and sex trafficking (i.e., exposure to repeated physical, sexual, and in some cases psychological abuse or witnessing violence), it follows that services specifically designed to address trauma represent an appropriate approach.

Experiences with trauma can exceed a person’s ability to cope and often lead to adverse impacts on health and behavior that can persist long into the future (Hopper et al., 2009). Individuals who have experienced trauma may exhibit such symptoms as depression, anxiety, anger, disassociation, fearfulness, hopelessness, poor self-image, distrust of the environment, and difficulty maintaining healthy interpersonal relationships (Fortier et al., 2009). Recent developments in neuroscience research demonstrate that without treatment, traumatic experiences can lead to changes in the brain that may create an inherent sense of distrust toward all individuals, including those in a helping role, such as direct service providers and law enforcement personnel (DOJ, 2012). Further compounding a distrust of authority, youth who experience trauma may feel a sense of betrayal and resentment toward the society that did not protect them (DOJ, 2012). The literature provides evidence of trauma symptoms in response to multiple forms of trauma. For example, a study of 275 female college students found an association between sexual trauma and risky sexual behavior and substance use (Johnson and Johnson, 2013). In addition, a study measuring trauma symptoms in a sample of children exposed to domestic violence found that these children were more likely to experience a range of poor social outcomes, including

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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aggressive behavior, depression, and low self-worth, compared with children who had not undergone such exposure (Zerk et al., 2009).

Trauma-informed care is a systems-level approach that recognizes and responds appropriately to trauma symptoms. According to the Substance Abuse and Mental Health Services Administration (SAMHSA, 2012), the design of trauma-informed systems is “based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization.” Hopper and colleagues (2009, p. 133) define trauma-informed care as “a strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.” Elements of a trauma-informed system include ongoing training in trauma for staff and leadership, use of trauma assessment tools and provision of trauma-specific services, an environment that is physically and psychologically safe, and meaningful participation by both consumers of services and staff in the design and operation of the organization (Guarino et al., 2009). In addition, individuals at all levels of a trauma-informed organization realize the potential impact of trauma on consumers of services and staff; recognize the ways in which trauma symptoms can manifest, such as behavioral and substance abuse disorders; and respond to trauma symptoms in a way that facilitates healing (SAMHSA, 2012).

Evidence supports the effectiveness of trauma-specific services for victims and survivors of childhood sexual abuse and complex trauma and for women with criminal justice involvement. For example, evidence indicates the effectiveness of trauma-focused cognitive-behavioral therapy (TF-CBT) in reducing trauma symptoms among children who have experienced sexual abuse (Schneider et al., 2013) and youth who have experienced complex trauma (Cohen et al., 2012). Specific trauma symptoms effectively reduced by TF-CBT include depression, anxiety, low self-esteem, sexual risk behaviors, and unhealthy beliefs about sexuality (Olafson, 2011). In addition, a randomized controlled study of the impact of a trauma intervention program for adjudicated and at-risk youth found statistically significant reductions in trauma symptoms among adjudicated adolescents in residential treatment, including reductions in depression, anxiety, and rule-breaking behaviors and improvements in emotional regulation (Raider et al., 2008). Trauma-specific services also have been evaluated and found to be effective for women experiencing co-occurring disorders, including substance abuse and depression (Conradi and Wilson, 2010). For example, Helping Women Recover and Beyond Trauma are trauma-informed, gender-specific services that have been empirically evaluated and found to be effective

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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in reducing trauma symptoms in women with criminal justice system involvement. Outcomes include decreases in depression, substance use, and self-destructive behaviors, with increases in healthy coping mechanisms (Covington et al., 2008). The effectiveness of trauma-specific services for victims and survivors of commercial sexual exploitation and sex trafficking of minors, however, has yet to be evaluated. Given the growing support for and implementation of trauma-informed care, trauma-specific treatment, and trauma-focused services for victims and survivors of commercial sexual exploitation and sex trafficking, a more thorough evaluation of their effectiveness is warranted.

Case Management

Through case management, an individual in need of assistance receives support from a professional—often a case manager—who develops a service plan and serves as a central point of contact for a range of service providers and systems. This professional can assess an individual’s needs and identify and coordinate services on his or her behalf. Case management can be especially beneficial when an individual has complex needs (e.g., health care, mental health services, legal services) or must interact with multiple systems (e.g., criminal/juvenile justice, child protective services, foster care). As noted in Chapter 5, case management is a common component of a multidisciplinary team approach to assisting victims and survivors of domestic abuse, child abuse, and sexual assault.

Clawson and Dutch (2008) describe the benefits of case management for international victims of human trafficking based on their synthesis of key informant interviews. The authors found that case management helps victims/survivors of human trafficking navigate complex systems and achieve self-sufficiency. The authors suggest that, in addition to being beneficial to the victim/survivor, case management helps law enforcement and prosecutors. By connecting victims/survivors with needed assistance, case managers help stabilize them, making them better able to assist with investigation and prosecution of a trafficking case (Clawson and Dutch, 2008). Finally, the authors suggest that case management would likely be as beneficial to victims and survivors who are U.S. citizens and legal permanent residents as it is to international victims/survivors (Clawson and Dutch, 2008).

The committee learned from a variety of sources—most notably from testimony during its site visits and public workshops—that many victim and support services for victims/survivors of commercial sexual exploitation and sex trafficking use and/or support the use of case management (Adams, 2012; Baker, 2012; Knowles-Wirsing, 2012; Nelson, 2012; O’Malley, 2012; Ring, 2012). In addition, a handful of researchers have begun to exam-

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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img

FIGURE 6-1 Framework for a continuum of aftercare services to address international sex trafficking survivors’ changing needs.
SOURCE: Macy and Johns, 2011.

ine the benefits of case management for victims/survivors of these crimes (Macy and Johns, 2011). (See Figure 6-1 for an example of how “comprehensive and coordinated case management” can be used as part of an overall strategy for providing services to victims/survivors of international sex trafficking.) Understanding that this is a field of research in its early stages, the committee urges additional evaluation of the effectiveness of case management for victims/survivors of commercial sexual exploitation and sex trafficking.

Survivor-Led and Survivor-Informed Models

The committee likewise learned from a variety of sources—most notably from testimony during its site visits and public workshops—that many victim and support services for victims/survivors of commercial sexual

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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exploitation and sex trafficking use and/or support the use of survivor-led and survivor-informed approaches (Frundt, 2012; Goldblatt Grace, 2012; Holzman, 2012; Phillips, 2012). For example, survivor-led services and programs are central to GEMS (discussed earlier in this chapter and in Chapter 5). To document its participants’ perception of the importance of survivor-led services for victims and survivors of commercial sexual exploitation and sex trafficking, GEMS conducted interviews with 11 girls and young women (aged 18-24) who were GEMS participants. The participants reported that youth leadership by survivors of commercial sexual exploitation and sex trafficking was important to their personal growth and development (Lloyd, 2008). As one service provider stated at the committee’s public workshop in San Francisco, “It is also such a testament to the youth to be able to see people, and have tangible conversations, and interact with people who can say, ‘Yes I have been there. It is possible to get out. It doesn’t always have to be this way’” (Phillips, 2012).

While anecdotal evidence from participants and organizations that use a survivor-led or survivor-informed approach to services for victims and survivors of commercial sexual exploitation and sex trafficking of minors can offer insights into the approach’s effectiveness and acceptability, additional research is needed to establish evidence-based practice. Therefore, the committee urges the evaluation of this approach to providing services for victims and survivors of these crimes.

Lessons Learned from Related Fields of Practice and Research

As noted in Chapter 3, domestic violence, intimate partner violence, sexual assault, and commercial sexual exploitation and sex trafficking of minors are related and overlap in a number of ways (e.g., violence and victimization, trauma, and social isolation, among others). Thus, examining and understanding how victim and support services have addressed domestic violence, intimate partner violence, and sexual assault through prevention and intervention efforts can be informative. In addition, the committee recognizes the potential to expand existing related services to address commercial sexual exploitation and sex trafficking of minors.

The Mount Sinai Sexual Assault and Violence Intervention (SAVI) Program is one hospital-based violence prevention and intervention program that has expanded its scope of work to include services and support to victims and survivors of commercial sexual exploitation and sex trafficking (Lattimer, 2012). This expansion is based on SAVI’s recognition of the associations among sexual abuse, intimate partner violence, and commercial sexual exploitation/sex trafficking. SAVI offers individual trauma-informed counseling, group and family counseling, and case management to victims/survivors of commercial sexual exploitation and sex trafficking. It also con-

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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nects victims/survivors with community resources to provide support for education and job training, assistance in the process of applying for public benefits, legal advocacy and services, and health care services. SAVI clinicians coordinate services with partners in the Mount Sinai Medical Center, including the Mount Sinai Adolescent Health Center, and with community-based resources, such as GEMS (Lattimer, 2012).

CHALLENGES AND OPPORTUNITIES

Despite the number of efforts currently under way to provide victim and support services, broad consensus exists among professionals in each sector that serves victims/survivors of commercial sexual exploitation and sex trafficking that too few services are available to meet current needs. In addition, the services that do exist are unevenly distributed geographically, lack adequate resources, and vary in their ability to provide specialized care to victims/survivors of commercial sexual exploitation and sex trafficking. This section describes some of the overarching challenges to providing victim and support services to minors exploited through commercial sexual exploitation and sex trafficking and points to a number of opportunities to reach those in need of assistance.

Lack of Adequate Shelter and Housing

In a survey of law enforcement personnel familiar with sex trafficking cases, 65 percent identified shelter and housing as the most needed service for victims (Clawson et al., 2006). According to a number of reports, emergency, short-term, and long-term housing for victims of commercial sexual exploitation and sex trafficking is limited, and in many parts of the country is nonexistent (Aron et al., 2006; Clawson and Goldblatt Grace, 2007; Clawson et al., 2009a; Ferguson et al., 2009; Finklea et al., 2011; Giardino and Sanborn, 2011; Gragg et al., 2007; Shared Hope International, 2012). For example, a recent survey of 68 organizations providing shelter services to victims of human trafficking in the United States and U.S. territories found that 2,173 beds were available to human trafficking victims for at least one overnight stay (Polaris Project, 2012b). Of these, 678 were shelter beds exclusively designated for victims of human trafficking, and 525 were designated for victims of sex trafficking. Minors were eligible for shelter beds at 38 of the 68 organizations surveyed, representing a total of 1,196 shelter beds available to minor victims of human trafficking (Polaris Project, 2012b). Another survey, of 341 individuals from 117 programs funded by the Department of Health and Human Services, found that most female victims of commercial sexual exploitation and sex trafficking were placed in shelters that traditionally served victims of domestic violence and sexual

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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assault, that shelter stays were time limited, and that housing for male victims of commercial sexual exploitation and sex trafficking was lacking (Clawson et al., 2009b). This lack of housing for victims/survivors of commercial sexual exploitation and sex trafficking was echoed by participants in the committee’s workshops and site visits (Phillips, 2012). Participants in the New York City site visit noted that appropriate and acceptable shelter options are in particularly short supply for individuals who may face additional discrimination (Holzman, 2012; Westmacott, 2012b). For example, transgender youth may not be given the opportunity to designate the sex-specific housing with which they identify, potentially exposing them to violence and/or discrimination. Although the New York City Department of Homeless Services developed a policy to allow shelter placements to be determined by an individual’s stated identity (New York City Department of Homeless Services, 2006), it is unclear how well and how often this policy is implemented in practice (Westmacott, 2012b).

Few Victim and Support Services for Boys

As noted earlier in the chapter, few victim and support service providers work with male victims and survivors of commercial sexual exploitation and sex trafficking. This deficiency is noted in the literature (Clawson et al., 2009a) and also was cited in testimony to the committee during its site visits and public workshops (Frundt, 2012; Goldblatt Grace, 2012; Phillips, 2012; Westmacott, 2012b). Given the growing recognition among researchers and service providers that boys and young men are victims and survivors of commercial sexual exploitation and sex trafficking, greater attention is needed to preventing and identifying these crimes committed against these youth. In addition, more work is needed to ensure that gender-specific services are available to meet the needs of male victims of commercial sexual exploitation and sex trafficking.

Lack of Awareness Among Service Providers

Victim and support service providers working with vulnerable youth may lack an understanding of commercial sexual exploitation and sex trafficking, and therefore may not recognize youth in their care who are at risk of or are victims/survivors of these crimes. As a result, they fail to connect youth in need to appropriate and timely services. As described earlier in this chapter, a number of efforts are under way to train service providers in and raise public awareness of commercial sexual exploitation and sex trafficking of minors in the United States. Broadening the reach of these existing efforts is one strategy for increasing understanding and recognition of these crimes. Ideally, as individuals and entities work to enhance the availability

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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and accessibility of training for victim and support service professionals, they will engage in the evaluation of programs, practices, and policies and will explore innovative strategies for delivery and dissemination of this training (e.g., the use of technology).

Lack of Information Sharing and Communication
Among Victim and Support Service Providers

As noted earlier in this chapter, victims and survivors of commercial sexual exploitation and sex trafficking may require a range of victim and support services (e.g., mental health and substance abuse services, housing/shelter). As a result, victims and survivors are likely to interact with a number of agencies and professionals. Ensuring that victims and survivors receive all the services they need requires communication and coordination among victim and support service providers. Unfortunately, mechanisms that support information sharing and communication may not exist among service providers and systems of care that interact with victims and survivors of commercial sexual exploitation and sex trafficking. As noted earlier in this chapter, some of the challenges related to information sharing and communication among multiple service providers and systems of care can be addressed by case management. Multisector collaboration, described in Chapter 10, also can address challenges related to information sharing and communication.

Impact on Service Providers of Working with Victims and Survivors

A significant body of research suggests that professionals working with vulnerable and traumatized populations may experience negative effects from their support role, also known as vicarious victimization, secondary trauma, or vicarious trauma (Cornille and Meyers, 1999; Pearlman and Mac Ian, 1995; Salston and Figley, 2003). One recent qualitative study found that working with victims/survivors of sex trafficking has an impact on the physical and psychological health of health care and victim and support service providers (Kliner and Stroud, 2012). Study participants reported experiencing burnout (e.g., compassion fatigue) and secondary traumatic stress (e.g., sleep disturbance). Although the study sample was small (n = 12), these findings support the testimony of participants during the committee’s public workshops and site visits. Those involved in efforts to evaluate and provide victim and support services for victims and survivors of commercial sexual exploitation and sex trafficking need to examine the impact of this work on service providers. Findings from this research can inform strategies for supporting both victims/survivors and the professionals who work with them.

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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Lack of Consensus on Services and Service Delivery

A number of national and international efforts have been undertaken to define comprehensive services or a “continuum of care” for victims of human trafficking (Aron et al., 2006; Chicago Alliance Against Sexual Exploitation, 2012; Clawson et al., 2009b; Macy and Johns, 2011; Piening and Cross, 2012). For example, the Chicago Alliance Against Sexual Exploitation recently proposed a statewide system of specialized services for survivors of prostitution and sex trafficking, including services specifically for minors (Chicago Alliance Against Sexual Exploitation, 2012). Components of this proposed system include shelter, physical and mental health services, street outreach, transportation assistance, legal advocacy, employment and education resources, and referrals for other services (e.g., substance abuse treatment) (Chicago Alliance Against Sexual Exploitation, 2012). The proposal calls for all services to be provided by “both survivors and professional staff who are trained in the provision of trauma-specific services” (Chicago Alliance Against Sexual Exploitation, 2012, p. 12).

While there is some agreement on specific services needed, consensus currently is lacking on the range of services that should be available to assist and support victims and survivors of commercial sexual exploitation and sex trafficking effectively over time. Consensus also is lacking on the most effective or efficient model of service delivery for victims and survivors of these crimes. Additional research is needed to determine the range of services needed and to evaluate the delivery of services to populations in need. Finally, it should be noted that the delivery of comprehensive services cannot be accomplished through victim and support services alone. The need for a multisector response to commercial sexual exploitation and sex trafficking of minors is discussed in detail in Chapter 10.

FINDINGS AND CONCLUSIONS

Given their unique perspective, expertise, and resources and the likelihood that they are already working with youth vulnerable to and victimized by commercial sexual exploitation and sex trafficking, victim and support services have a responsibility to recognize these crimes and to address the needs of these youth in their care. The committee’s review of the literature and its careful consideration of expert testimony revealed several themes related to the provision of victim and support services to these youth. This chapter has highlighted a range of noteworthy and emerging efforts to provide these services. However, the committee emphasizes the urgent need to evaluate these and future efforts. The committee formulated the following findings and conclusions regarding the provision of victim and

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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support services to victims/survivors of commercial sexual exploitation and sex trafficking of minors:

6-1 Victims and survivors of commercial sexual exploitation and sex trafficking are frequently in need of services, often including out-of-home placement.

6-2 Advocates, victim and support service providers, governmental and nongovernmental entities, and other groups that deal with commercial sexual exploitation and sex trafficking of minors in the United States increasingly are calling for the use of trauma-informed care for victims and survivors of these crimes.

6-3 Given the growing support for and implementation of trauma-informed care, trauma-specific treatment, and trauma-focused services for victims and survivors of commercial sexual exploitation and sex trafficking, a more thorough evaluation of the effectiveness of these approaches is warranted.

6-4 Given the growing support for and implementation of case management and survivor-led and survivor-informed services for victims and survivors of commercial sexual exploitation and sex trafficking, a more thorough evaluation of the effectiveness of these strategies is warranted.

6-5 Broad consensus exists among professionals in each sector that serves victims/survivors of commercial sexual exploitation and sex trafficking that there are too few services available to meet current needs, and that services that do exist are unevenly distributed geographically, lack adequate resources, and vary in their ability to provide specialized care to victims/survivors of these crimes.

6-6 Emergency, short-term, and long-term housing for victims/survivors of commercial sexual exploitation and sex trafficking is limited, and in many parts of the country is nonexistent.

6-7 Few victim and support service providers work with male victims and survivors of commercial sexual exploitation and sex trafficking. More work is needed to ensure that gender-specific services are available to meet the needs of these youth.

Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
×
6-8 Professionals working with vulnerable and traumatized populations may experience negative effects of their support role, also known as vicarious victimization, secondary trauma, or vicarious trauma.

6-9 Research on victim and support services can help build a much-needed evidence base for promising and best practices for victims and survivors of commercial sexual exploitation and sex trafficking of minors in the United States to inform future work. Broad dissemination of the findings of this research through publication in the peer-reviewed literature is needed so that this evidence base will be critically reviewed.

6-10 With few exceptions, current victim and support services for victims and survivors of commercial sexual exploitation and sex trafficking of minors lack plans and mechanisms for evaluation and outcome measurement.

6-11 Additional research is needed to determine the range of services needed to assist and support victims and survivors of commercial sexual exploitation and sex trafficking of minors and to evaluate the delivery of services to populations in need.

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Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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Suggested Citation:"6 Victim and Support Services." Institute of Medicine and National Research Council. 2013. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press. doi: 10.17226/18358.
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Every day in the United States, children and adolescents are victims of commercial sexual exploitation and sex trafficking. Despite the serious and long-term consequences for victims as well as their families, communities, and society, efforts to prevent, identify, and respond to these crimes are largely under supported, inefficient, uncoordinated, and unevaluated.

Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States examines commercial sexual exploitation and sex trafficking of U.S. citizens and lawful permanent residents of the United States under age 18. According to this report, efforts to prevent, identify, and respond to these crimes require better collaborative approaches that build upon the capabilities of people and entities from a range of sectors. In addition, such efforts need to confront demand and the individuals who commit and benefit from these crimes. The report recommends increased awareness and understanding, strengthening of the law's response, strengthening of research to advance understanding and to support the development of prevention and intervention strategies, support for multi-sector and interagency collaboration, and creation of a digital information-sharing platform.

A nation that is unaware of these problems or disengaged from solutions unwittingly contributes to the ongoing abuse of minors. If acted upon in a coordinated and comprehensive manner, the recommendations of Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States can help advance and strengthen the nation's emerging efforts to prevent, identify, and respond to commercial sexual exploitation and sex trafficking of minors in the United States.

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