Keywords

Introduction

On August 28, 2020 the national televisions and social media shared news of an amazing development in the fight against human trafficking; a group of 39 children believed to be victims of sex trafficking were recovered in Georgia [1]. This accomplishment was the result of a collaborative effort among multiple agencies (both federal and state) in a raid that was called “Operation Not Forgotten.” Only 4 days prior to that, in a separate event, 36 individuals were convicted as part of an international sex trafficking organization that victimized women from Thailand [2]. Every day, a new development in the fight against human trafficking or trafficking in persons is achieved, and yet so little is known about the clinical management of the victims and the role of the mental health practitioners in preventing, attending to the needs, and assisting in the recovery process of individuals affected by these crimes.

Sex trafficking, an organized crime endeavor, is a global enterprise with local ramifications. The activities at a local scale tend to concentrate in urban locations affected by social disorganization [3] frequently targeting socially disadvantaged populations especially the homeless. In general, trafficking tends to flow from poor countries to affluent ones, or countries that are perceived as relatively affluent; however, traveling is not necessary for the activity to be defined as trafficking [4].

According to Raymond and colleagues, sex trafficking activities are likely to be found near military bases and urban and suburban areas of large cities. The infrastructure consists of local business of all sorts with slight variations according to the culture of the region. Some of them have legitimate fronts like health clubs, massage parlors, hotels, or rented homes, while other businesses are clearly known as dwellings for prostitution [5].

Homelessness is an important risk factor for trafficking victimization. A study by Estes in 2001 [6] shows that of the 900,000 missing persons per year reported by the Federal Bureau of Investigation, 80% are under 18 years of age. The study estimated that a third of runway or throwaway youth are recruited into prostitution within 2 days of leaving their homes.

It is important to note that commercial sexual exploitation (CSEC) of children includes prostitution, sex tourism, mail-order-bride trade, early marriage, pornography, stripping, and performing in sexual venues [4]. When these actions occur in US territory and the victims are children who are US citizens or legal residents, it is called domestic minor sex trafficking (DMST). Survival sex (engaging in sex acts in exchange for money, shelter, or other basic necessities) although considered a form of CSEC is not sex trafficking per se but in many instances serves as a gateway to the encounter with handlers involved in what some call modern-day slavery.

This chapter contains an overview of the current understanding of these problematic and recent developments in legislature and advocacy efforts as well as some recommendations for the mental health professionals who serve at-risk individuals.

The Problem

Statistics

Human trafficking is a global security and health problem that affects all countries in varying degrees of severity. The number of human trafficking cases reported globally and in the United States may include different forms of trafficking (sex, labor, organ, debt bondage), and the number of sex trafficking cases may vary from one source to the other due to difficulties gathering the information that are intrinsic to this population.

The Global Report on Trafficking in Persons published by the United Nations Office on Drugs and Crime (UNODC) in 2009 [7] utilized data from 111 countries reporting victims identified in 2006. Only 65 of those countries reported the age and gender of the victims. Among those victims, they estimated that 66% of the victims were women, 16% girls, 12% men, and 9% boys. They also point out that sexual exploitation is by far the most commonly identified form of human trafficking (79%), followed by forced labor (18%).

In 2015, the National Human Trafficking Resource Center (NHTRC) responded to over 5500 cases of human trafficking. Of those cases, 75 percent involved sex trafficking. In 2019, the National Human Trafficking Hotline calculate that they had reported 63,380 cases since the year 2007 [8]. According to the US State Department [9], trafficked US citizens are more likely to be involved in sex trafficking than in labor trafficking, and foreign victims are found in labor trafficking more than in sex trafficking.

The Department of Justice (DOJ), the Department of Homeland Security (DHS), and the Department of State (DOS) are the primary investigating agencies for federal trafficking offenses. During the fiscal year 2018, the DOJ secured convictions against 526 traffickers, an increase from 499 convictions in 2017. During 2018, the DOJ provided $31.2 million for victim service providers offering comprehensive and specialized services across the United States [10].

Calculating the prevalence of sex trafficking has proven to be a difficult task. The difficulties range from collecting the data (i.e., failure to report cases, victims avoiding self-identification, and other gaps in identification, inaccuracies, duplications of data), comparing it across the system (i.e., lack of standardization regarding what needs to be measured, mixed population, differences in technology), and understanding the implications of the data collected [4].

The state of Texas has confronted great challenges related to the number of human trafficking cases reported in the state. Almost 1731 phone contacts of the 5500 contacts reported by the National Human Trafficking Resource Center (NHTRC) in 2015 were from Texas. Of those calls, 433 were identified as potential cases, and the vast majority of those cases were sex trafficking cases (77.8%). The estimated number of human trafficking victims in Texas in 2016 was 313,000, and approximately 79,000 of them were minor and youth victims [11].

A study published in 2019 by Anderson et al. [12] found 484 known victims in a sample from state and local agencies who collected data in Ohio from 2014 to 2016. The study found that counting potential victims and at-risk individuals is a crucial first step for an accurate prevalence estimate and advocates for the creation of a database that utilizes validated assessment tools to identify individuals according to the risk factors, one that can support integration across agencies.

Advances in Legislation

At a global scale, the United Nations initiated the “Palermo Convention” on November 15, 2000 during the 55th session of the General Assembly of the United Nations at the Palazzi di Giustizia in Palermo, Italy [13], and 2 years later, the “Brussels Declaration” took place during the European Conference on Preventing and Combating Trafficking in Human Beings [14]. The Palermo Protocol and the Brussels Declaration increased the international awareness, and as of 2016, over 150 countries had developed criminal laws for human trafficking [15].

Drawing from increased global awareness, many immigration, trading, terrorism, and victim protection laws converge in the provision of safeguards to prevent human trafficking. For example, although not specific to sex trafficking, the Civil Asset Forfeiture Reform Act (CAFRA) promulgated in the year 2000 provides notice to property owners whose properties have been identified as being used to facilitate smuggling or harboring of aliens. Similarly, the Intelligence Reform and Terrorism Prevention Act of 2004 enhances the responsiveness to issues related to alien smuggling and trafficking. Another example is the Customs Facilitation and Trade Enforcement Reauthorization Act of 2009 that “prohibits the importation of goods to the United States made by benefit of human trafficking or forced labor” [16].

In 2016, President Barack Obama proclaimed January 2017 as the National Slavery and Human Trafficking Prevention Month [17]. This proclamation is sustained by numerous laws and regulations that have been developing in the United States since the early 1900s.

The Mann Act of 1910 is the first law targeting human trafficking, and it is still in effect with the addition of multiple amendments over the years. According to this law, it is a felony to knowingly persuade, induce, entice, or coerce an individual to travel across state lines to engage in prostitution or attempt to do so. It was welcomed as a tool to deter from trafficking; however, some believe that it was largely misused to target people who were not involved in trafficking Schemes [18].

Modern legislature specific to the issue of human trafficking utilizes a definition similar to the one used in the Palermo Convention [see Table 1]. In the United States, the first comprehensive federal law to address trafficking in persons was the “Victims of Trafficking and Violence Protection Act” also known as the “Trafficking Victims Protection Act” (TVPA). It was enacted on October 28, 2000 by the US Congress (22 USC 7101) requiring victims to cooperate with the prosecution of traffickers [19], strengthening the prosecutions and punishment of trafficker, and authorizing appropriations. The law also provides authority to permit the “continued presence of the victim in the US soil to assist with the investigation and prosecution of the traffickers” [20]. It acknowledges that victims of severe forms of trafficking should benefit from governmental custody with specific protections including (A) not to be detained in facilities inappropriate to their status as crime victims; (B) to receive necessary medical care and other assistance; and (C) to be provided protection if the victim’s safety is at risk or if there is danger of additional harm by recapture of the victim by a trafficker. The law has been ratified several times (2003, 2006, 2008, 2018, 2019) [21, 22].

After the TVPA, the Senate enacted the Prosecutorial Remedies and Other Tools to End the Exploitation of Children Today Act of 2003 also known as the PROTECT Act. It encompasses seven titles (titles I–VII) with prosecutorial remedies and other tools. The PROTECT Act strengthens the penalties against kidnapping and sex tourism [23] with a clear delineation between the sanctions and the different types of sexual offenses, ranging from parental kidnapping to sex tourism, pornography, sexual abuse, sexual torture, and murder, among other related crimes. It also defines sources for public outreach including the national AMBER alert system that was created in 1996 [24] and the creation of a cyber tip line.

In 2015, the enactment of the Survivors of Human Trafficking Empowerment Act (Section 115 of the Justice for Victims of Trafficking Act of 2015 [25] created the domestic trafficking victim’s fund and increased of the compensation and restitution of the victims with the use of both forfeited and non-forfeited assets.

In parallel to these developments, many laws were enacted with the purpose to identify, monitor, and sanction sex offenders [see graph 2]. Some worth mentioning include the Jacob Wetterling Act (1994), Megan’s Law (1996), Jacob Wetterling Improvement Act (1997), Protection of Children Act (1998), Campus Sex Crimes Prevention (2000), Adam Walsh Act and Sex Offender Registration and Notification Act or SORNA (2006), and Keeping the Internet Devoid of Sexual Predators Act or KIDS Act (2008). The description of these laws is beyond the scope of this chapter.

The US Department of State (DOS) has created the Trafficking in Persons Report or the “TIP Report”. The first edition was released in the year 2000. This report is a compilation of facts and developments in the fight against human trafficking. The Department of State uses the report to publish the placement of each country onto one of four categories or tiers based on the extent of their government’s efforts to meet the standards of the TVPA [9, 10]. The United States is currently ranked in the Tier 1 category which is the highest ranking. The US Department of State makes it clear that being ranked Tier 1 does not mean that a country has no human trafficking problem or that it is doing enough to address the problem. Rather, a Tier 1 ranking indicates that a government has made efforts to address the problem that meets the TVPA’s minimum standards [10]. Countries ranked in Tier 2 and Tier 3 “watch list” are considered to be noncompliant with the standards but showing efforts to change. On the other hand, countries on Tier 3 are considered to lack both in meeting the minimum standards and the efforts to improve. Tier 3 countries may face certain restrictions on assistance from the international community [9, 10].

At a national level, all US states and US territories (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the Virgin Islands) have laws prohibiting trafficking of persons for the purpose of commercial sexual activity, but specific local efforts in the fight against sex trafficking vary from state to state. A list of state-specific statutes can be found at https://www.childwelfare.gov [26]. For example, Massachusetts enacted a law, effective February 2012, establishing that any youth charged with prostitution is a victim of sex trafficking, which is defined as a form of child abuse [27]. In Texas, the criminal code of procedures Chapter 57D section 01 and section 02 provides safeguards for victims’ confidentiality allowing the use of a pseudonym (initials or fictitious name) and the confidentiality of the records [28].

In the United States, there are several potential immigration protections and remedies available for victims of crimes and trafficking, including special types of visas and asylum claims: the U visa for victims of domestic violence and the T visa for persons who have suffered severe forms of human trafficking and who “have assisted in the investigation or prosecution of traffickers, and who would suffer extreme hardship upon being forced to leave the United States” [29]. Asylum claims based on LGBT status may be successful if they are based on a well-founded fear of persecution in the country of origin on account of sexual orientation or gender identity (real or perceived) [30].

Advocacy

Organizational advocacy has a ripple effect that can yield significant gains for individuals, communities, and entire organizations [31]. The advocacy against sex trafficking at the organizational level promotes accountability with a focus on the victim’s best interest. However, a google search for advocacy groups against human trafficking produced 30,300,000 results in 1.03 seconds. Finding the right organization to join or volunteer in these advocacy efforts can be a daunting task.

Some well-known international advocacy groups listed by Saad [32] in a social media article include:

  1. 1.

    “The Global Alliance Against Traffic in Women” (GAATW) that includes 80 non-governmental organizations from around the world including Africa, Asia, Europe, Latin American and the Caribbean, and North America.

  2. 2.

    “Stop the Traffik,” an organization that advocates through education and technological initiatives like the creations of an app to report human trafficking.

  3. 3.

    “The Sex Workers Project,” a group that concentrates in legal advocacy and therapeutic support.

  4. 4.

    “The Freedom Network USA,” a group created by survivors, also provides legal services.

  5. 5.

    “FAIR Girls,” a group dedicated to providing housing, trauma-informed services, and education for female victims.

  6. 6.

    “Love146” is an international anti-child trafficking group based in the United States that coordinates preventive education modules in many countries around the world.

Two international resources specifically for LGBT victims of sex trafficking are the United Nations Global Initiative to Fight Human Trafficking (UN GIFT) and the Global Forum on MSM and HIV (MSMGF) [29].

At a national level, the US government launched the “Blue Campaign.” This is a national public awareness campaign, designed to educate the public, law enforcement, and other industry partners to recognize the indicators of human trafficking and how to appropriately respond to possible cases. Blue Campaign works closely with the Department of Health Services (DHS) to create training and materials to increase detection of human trafficking and to identify victims [33]. Their resources can be found at: https://www.dhs.gov/blue-campaign.

Locally, in the state of Texas, Children at Risk (C@R) is a nonprofit, non-partisan research and advocacy organization created in 1989 in response to the absence of strong public policy in Texas at that time. At this point, the organization has grown to have statewide impact in many causes related to vulnerable children including trafficking. Many of the educational activities take place in Houston, Dallas, and Fort Worth. The group also coordinates a program called “Cities Empowered Against Sexual Exploitation” (CEASE) in charge of developing strategies to reduce the demand for commercial sex. In Houston, with the collaborations of the Harris County Attorney’s Office and private law firms, CHILDREN AT RISK established Project AWESOME (Attorneys Working to End Sexually Oriented Massage Establishments) which allows civil attorneys to file suits against these establishments on behalf of the county [34].

Another Texas initiative for preventive advocacy is the Texas Court Appointed Special Advocate (CASA) [35]. It works by providing a judge-appointed volunteer to advocate for the best interest of children moving from abusive homes and into the welfare system. The volunteer is called a “Court Appointed Special Advocate” or “CASA” (home in Spanish). These advocates also participate in the State’s legislative sessions to support and promote policy changes.

Victimization Risk Factors

Many characteristics have been identified as potential risk factors for victimization in sex trafficking schemes. Some of these characteristics pertain to the individual and others to the society. The socially based risk factors include factors that promote the organized crime activities; those related to the society at large – poverty, social disadvantage/inequality, and social disorganization (the inability of a community structure to realize the common values of its residents and maintain effective social controls) [3]; and those related to the community the individual belongs to: levels of violence, corruption, natural disasters, and other social determinants of health. On the other hand, the factors intrinsic to the individual are believed to increase the person’s vulnerability to exploitation. Among them, the most commonly cited is homelessness, followed by a history of abuse or neglect, deficits in education, and substance use [36] (see Table 2).

A recent example of the impact of natural disaster occurred during Hurricane Harvey. According to data posted during the weeks of May 29, 2017 and September 11, 2017, there was a surge of trafficking cases to level even higher than the ones estimated during the weeks prior to the storm. The factors potentially implicated in this surge are the loss of housing/income or other means to survive, the trafficker’s attempts to recuperate revenue lost during the storm, and/or the traffickers anticipation of an influx of male workers during the recuperation phase [11].

Identifying the Victim

Victims’ Characteristics

Typically, female victims are easier to identify because the majority of information published regarding sex trafficking cases involves girls and women; however, commercial sexual exploitation can also involve males [4] and LGBT individuals [29, 36]. Males have been identified (with the known limitations to gather accurate numbers) as a smaller proportion compared to females. However, statistics on LGBT victims are more difficult to find. The lower report rate and issues with self-identification may stem from the stigma that surrounds same-sex prostitution [29].

The analysis of a small sample of female victims done by Muftic et al. utilizing a semi-structured qualitative interview found that American female domestic victims were significantly older, more likely to be non-white, and better educated than international victims and non-trafficked sex workers. These domestic cases came from urban areas and were more likely to have experienced physical and/or sexual trauma in their childhood [37].

Although first responders are in the best position for identifying the victims of sex trafficking, this task can be difficult. Law enforcement, for example, has opportunities to identify victims by means of their daily interactions with persons who are homeless, runaway youth, and policing gang-active areas or responding to domestic violence calls [3], but oftentimes the victims hide important clues for many different reasons. The training of the officers is paramount in allowing them to see those interactions and to recognize the actors for whom they truly are.

Some screening tools have been created to assist in the identification of victims and people at risk. The “WestCoast’s Commercial Sexual Exploitation-Identification Tool” (CSE-IT, pronounced “see it”) was designed for early identification of children who are commercially sexually exploited [38]. According to the developer, the CSE-IT is appropriate for use by any provider serving youth, including child welfare workers, probation officers, mental health clinicians, and first responders. CSE-IT has been validated with data from a 15-month pilot to ensure that it accurately identifies youth who have clear indicators of exploitation. It is a copyrighted open domain tool for use in service delivery systems.

Other tools designed to identify trauma-related symptoms, although not specific to sex trafficking, can be useful in this population. Some of these tools include [39]:

  1. 1.

    The Screen for Child Anxiety Related Emotional Disorders (SCARED) consists of 41 items for adolescents up to the age of 18. It assesses symptoms associated with general anxiety, panic disorder, separation anxiety, social phobia, and school avoidance.

  2. 2.

    The therapist-Administered PTSD Scale for Children and Adolescents (CAPS-CA) is a 33-item scale for youth 8–18 that can effectively assess symptoms associated with the experience of trauma.

  3. 3.

    The Achenbach System of Empirically Based Assessment (ASEBA) that identifies anxiety, depression, social problems, somatic complaints, attention difficulties, and behavioral problems (including rules breaking and aggressive behavior).

Perpetrators’ Characteristics

The identification of potential perpetrators (e.g., pimps, recruiters, traffickers, buyers) is also important. They are key part of the equation and may be the clue to identifying a victim who doesn’t want to be identified. The buyers of commercial sex appear to be a heterogeneous group, coming from a wide range of ages and socioeconomic classes. The study by Raymond and Hughes [5] showed that the majority of men were married. They also gathered that 20 percent of the international female victims and 28 percent of the domestic female victims had intimate relationships with the men who pimped them.

In some instances, victimized youth become offenders themselves. They have a history of sexual, physical, and emotional abuse and more exposure to pornographic material. In this group of young people that are sexually offended, the levels of criminal history and antisocial association appear to be lower than for those offenders who have other forms of criminal behavior [40].

Some of the tools developed to assess juvenile sex offenders listed by O’Reilly [40] include:

  1. 1.

    Juvenile Sex Offender Assessment Protocol-II

  2. 2.

    Juvenile Sexual Offence Recidivism Risk Tool-II

  3. 3.

    Juvenile Risk Assessment Scale (J-RAS)

  4. 4.

    Structured Assessment of Violence Risk in Youth (SAVRY)

  5. 5.

    Psychopathy Checklist: Youth Version

In a study that included 117 offenders and 179 victims in cases involving the sex trafficking of juveniles that were adjudicated from 1990 to 2011, the researchers found that individuals who engage in sex trafficking of juveniles (STJ) have a motivation that is in alignment with the increased prevalence of psychopathy in such offenders, making their incentive more instrumental or predatory in nature [41]. In this study, STJ offenders were initially classified into four types:

  1. 1.

    Charismatic/Manipulative Type #1A (Non-violent Type)

  2. 2.

    Charismatic/Manipulative Type #1B (Violent Type)

  3. 3.

    Aggressive/Antisocial Type with Minor Charismatic/Manipulative Traits Type #2A (Violent Type)

  4. 4.

    Aggressive/Antisocial Type with No Charismatic/Manipulative Traits Type #2B (Violent Type)

Their results suggest that the Type 1B (Charismatic/Manipulative-Violent) STJ offenders poses the greatest danger to society [41].

Challenges in Engaging the Victim

After recognizing a victim, the next step in the road to protect them is to engage them where they are. According to Zimmerman [42], there are five stages of trafficking: pre-departure, travel and transit, destination stage, detention/deportation/criminal evidence, and integration/reintegration. Each one of them presents different challenges for the engagement of the victims.

Understanding the victim’s initial motivation to engage in activities that led, directly or indirectly, to becoming a victim of commercial sexual exploitation can open the door to the engagement. For example, in international cases, the pre-departure phase may align with cultural traditions that incentivize migration, promoting it as a solution for reducing the national deficit and/or family survival, by means of remittances. In other cases, like countries with high levels of violence, the conditions are set forth to accept an association with the predator in order to run away from violence. At a local level, pre-departure is incentivized by romanticized stories of achieving prosperity and wealth, or romantic relationships with the lure of a charming boyfriend. Yet, others are seduced into the world of exploitation through promises of drugs and excitement [4].

The victims’ state of mind can range from hopeful and future oriented during the pre-departure to anxious, ashamed, and with an increased sense of dependence on the trafficker during the travel, destination, and detention phase. During the integration phase, shame will still be present along with emotional distancing and other trauma-related states of mind. Therefore, a trauma-informed approach must be at the forefront of dialogue.

Resources to equip the community agencies with trauma-informed programs depend largely on governmental support. The design and implementation of such program requires the collaboration community stakeholders (law enforcement, social services, legal, medical) and the administrative support within the specific agency or institution.

Health Effects and Healthcare

To help victims recover from this experience and to assist in a steady healing process, it is important to understand the health implications of sex trafficking.

In the study aimed to identify the relationship between the risk factor and the health outcomes of women victims of sex exploitation [37], Muftic and Finn compared domestic sex-trafficked women, international sex-trafficked women, and female sex worker. In general, the study showed that domestic trafficking victims displayed poorer health outcomes compared to international trafficking victims. In terms of physical health, half of the women reported at least one physical problem.

Another study [5] found similar results, showing that 80% of domestic sex trafficking victims sustained bruises, 53% oral/dental injuries, 47% head injuries, and 35% a broken bone. Other reports on physical health show that back pain, memory difficulty, stomach pain, pelvic pain, gynecological infection, and headaches and fatigue were also very common [42].

Looking at a different aspect of their general health, a study in 2018 [43] recruited a small group of women (18–25 years old) and asked the participants to complete a questionnaire and to get testing for HIV and other STIs (syphilis, gonorrhea, and chlamydia) at baseline. They found that one fourth of the participants were sex trafficked when they were younger than 18 years. Among those who experienced child sex trafficking, the majority had their first pregnancy (54.3%), marriage (60.2%), and sexual violence experience (55.2%) before they were aged 16 years.

Muftic and Finn [37] found that 42.1 percent of the women with history of sexual exploitation in their sample contemplated suicide. They point out that suicidal ideation was greatest among women who were sexually exploited by an abusive pimp or trafficked for sex domestically.

In terms of substance use disorder, the same study found that there were significantly fewer international trafficking victims (33.3%) who were addicted to drugs and/or alcohol compared to 94.4% of domestic trafficking victims and 75% of non-trafficked sex workers.

Community Reintegration

Victims of sexual trafficking often lack familial support, adequate housing, and socioeconomic stability. In many cases, the difficulties to attain basic needs is what put them at risk in the first place. When the community finds a way to overcome the logistical and financial constraints of delivering interventions within the healthcare system, the reintegration is feasible.

At an individual level, informational posters, videos, and social media resources can be utilized to guide the victims and reduce the anticipatory anxiety. Many examples of autobiographical success stories of reintegration can be found in social media.

Knowing that more time in trafficking was associated with higher levels of depression and anxiety [44], the system should be prepared to offer different levels of care according to the victim’s needs. A group from the Netherlands conducted an interview of 14 sex trafficking victims who were staying in a system of 3 shelters. They noted that the participants exhibited signs of working towards a better future. During the interviews, the participants identified that learning the language was seen as a prerequisite for many important aspects of integration (finding a job, getting an education, and establishing a family and a social network). The participants also pointed out that other important tools are important for integration to the community, including skills training (self-defense, vocational skills) and opportunities to volunteer [45].

Many victims are identified after being charged with a sexual offense (i.e., prostitution), and in those cases, integration may be accompanied with court stipulations. Schmidt [46] recommends that initial outpatient contact with parents or caregivers of “Adolescents with Illegal Sexual Behavior” (AISB) should emphasize the establishment and reinforcement of supervision standards within the home, community, and school. He explains that evolving models of AISB treatment include greater treatment participation by parents, alternate caregivers, and siblings; less focus on the sexual offense; and increased focus on general behavior and decision-making and on developing specific social, behavioral, and interpersonal competencies.

Other general recommendations include avoiding the propensity to withhold support in exchange for specific behavior, avoiding actions that reinforce shame or trigger trauma-related response, understanding that there will be a tendency to repeat destructive patterns, avoiding the tendency to blaming the victim, and avoiding power struggles. Above all, promoting a sense of belonging is the most important target in the process of reintegration.

Barriers and Proposed Solutions

A fragmented healthcare system and a criminal justice system plagued with bias against minorities are huge barriers in the advancement of the fight against sex trafficking. Many communities also face limitations to provide services due to lack of investment from their local government in short-term housing and other social services. Therefore, possibility of identifying and providing services for victims of sex trafficking within the confines of limited community resources relies in the efforts put forth by the stakeholders.

The education of potential targets and at-risk population for the purpose of prevention paired with the commitment in investing resources to promote comprehensive service delivery, policy changes, and measures for deterrence is the basis for the needed change.

The development of the legislature at a state or federal level has already proven helpful in uncovering organized crime groups and punishing them. It goes without saying that being as it is, a lucrative criminal business, finding ways to progressively reduce the demand from buyers and abolish the appeal for the handlers, needs to be part of the discussion towards ending trafficking once and for all. However, the need for the development of values that support a future without sex trafficking, or any type of human trafficking for that matter, is a challenge that our communities need to assume with responsibility. After all, if people comply with the law only in response to coercive power, they will be less likely to obey the law in the future because acting in response to external pressures diminishes internal motivations to change in behavior [47]. Therefore, a movement towards the improvement of the social organizations of the individual communities and a more cohesive structure is an important piece in this puzzle.

Conclusion

In the last 20 years, the world has witness exciting developments in the fight against human trafficking. However, the work is not complete. There is a great need for more awareness, more support, and better understanding of the dynamics that perpetuate crimes against the very essence of our humanity. The work with homeless populations will undoubtedly intersect with those who have been trafficked and with the perpetrators. It is important for medical and mental health providers to always be alert to the signs of trauma and the red flags that point in the direction of victimization and abuse. It is also essential that we continue to advocate for the support of community and governmental partners in developing a comprehensive network that provides the preventive, supportive, and recovery-oriented structure that our communities need.