Introduction

Sixteen-year-old Alyssa was terrified the first time she was forced to have sex for money. Her trafficker, approximately 10 years her senior, hid in the bathroom of the hotel room he had rented, while Alyssa held her breath waiting for the heavy, sweating man to lift himself off her small frame. Alyssa was trafficked for 3 months; she was forced to have sex with between 9 and 21 men daily. She was beaten, raped, and drugged by her trafficker, who had convinced her he loved her in the weeks leading up to when he first advertised Alyssa on the Internet website Backpage. Alyssa believed his threat to harm her younger sister if Alyssa didn’t do as he demanded, and that, she said, was the single most powerful method of control he exerted. Alyssa’s story is not uncommon. Sex trafficking occurs in every country in the world and in every state in the United States. Traffickers use lies, manipulation, threats, debt bondage, and other forms of coercion to compel children and adults to engage in commercial sex acts against their will. In the United States, any minor under the age of 18 years involved in commercial sex is a victim of sex trafficking; this is regardless of whether there was use of force, lies, or other forms of coercion. Victims of sex trafficking can be citizens of the United States, foreign nationals, children, women, or men and may be LGBT or straight identified. However, because of the lesser status afforded to girls and women and the myriad sociocultural implications of this status, it is this group that is primarily victimized by sex traffickers.

Underlying Factors: Sexism and Gender-Based Violence

Women and girls worldwide are born into sociocultural systems in which they are disadvantaged in ways that impact their daily lives, both overtly and through means that are less easily identified. This disadvantaged social status of women and girls is socially constructed in the context of patriarchy. Patriarchy is defined as sociocultural practices and beliefs that normalize socially constructed gender differences that benefit men and oppress women (Ebert 1996). Harm and perpetuation of less privileged status are carried out by the institutions of society through structural violence (Brock-Utne 1989), in particular through the institutions of government, education, family, religion, and the economy. This means that the practices, policies, and norms of these institutions are discriminatory and function to oppress women in order to advantage men. This oppression usually takes the form of economic exploitation, although more extreme forms of sexism are characterized by brutality against women, in the forms of commodification of women and their bodies, domestic violence, sexual assault, rape, and sex trafficking. Perhaps the aspect of this process that is most challenging is that when a way of being becomes “normalized,” or taken as the status quo, it seems to be more difficult to interrupt for it is widely accepted as “the way things are” or normative.

Sex traffickers often focus on women because as a result of these discriminatory practices, they experience high rates of poverty; both discrimination and poverty (which is often an outcome of discrimination) hinder access to profitable employment in formal market economies, making it challenging for women to financially support themselves and their children. In addition, the sexualization of women and women’s bodies, which can be considered as both a means of keeping women in a subordinate economic and social position and outcome of this subordination, fuels the commercial market for sex.

Gender-based violence (GBV) is important to any discussion of human trafficking, not exclusively sex trafficking, as it is both a “driver” of trafficking and a tool to control and manipulate victims. Gender-based violence is violence directed against a person on the basis of gender. It constitutes a breach of fundamental human rights including the right to life, freedom, security, dignity, equality between women and men, nondiscrimination, and physical and mental integrity. Gender-based violence affects women, girls, and nonbinary persons disproportionately (in comparison to men and boys). This reflects and reinforces the unequal power relationship between both groups in society. A review of academic research studies and project reports demonstrates a relationship between trafficking and gender-based violence, and while more information is needed, it is clear that gender-based violence plays a role in the vulnerability of women and girls being trafficked, and it is a part of their experience during the trafficking process (Winrock 2012).

Gender-based violence is grouped into the five categories of sexual violence, physical violence, emotional and psychological violence, harmful traditional practices, and socioeconomic violence. Examples of each appear below. It is important to keep in mind that these are examples and that there are many forms of each of these five types of GBV:

  1. 1.

    Sexual Violence – rape and marital rape, sexual abuse and child sexual abuse, sexual exploitation (defined as any abuse of a position of vulnerability, differential power, or trust for sexual purposes); this includes profiting monetarily, socially, or politically from the sexual exploitation of another, forced prostitution, and sexual violence as a weapon of war and torture.

    Note about sexual exploitation and forced prostitution: these are the cornerstone of sex trafficking and are characterized by a woman or girl being forced to perform in a sexual manner (e.g., forced nakedness, forced pornography, forced prostitution, forced or coerced marriage, or forced childbearing) in exchange for money that is given to a third party.

  2. 2.

    Physical Violence – includes physical assault such as hitting, punching, beating, biting, burning, and kicking and the selling, purchasing, or trading in human beings for forced labor (or forced sexual) activities.

  3. 3.

    Emotional and Psychological Violence – stalking, harassment, humiliation, manipulation, coercion, degrading treatment, and confinement (i.e., isolating a person from others, restricting freedom of movement).

  4. 4.

    Harmful Traditional Practices – early or forced marriage, honor killing and maiming, female genital mutilation (FGM), infanticide, neglect of female children, denial of access to medical care including safe legal abortion for girls and women, and denial of education for girls or women.

  5. 5.

    Socioeconomic Violence – discrimination and/or denial of opportunities; harassment in education or employment settings; denial of access to education, health care, remunerated employment, and/or property rights; biological fathers’ abandonment of mothers and children which contributes to increasing feminization of poverty; and obstructive or otherwise biased legislative practices.

While progress has been made with regard to laws, social thinking, and norms on the issue of violence against women and girls, institutionalized and cultural forms of violence against women remain entrenched in the United States and globally. These structures of dominance enforce the vulnerability of women and girls to sexual exploitation and sex trafficking (Heise et al. 2002; Hughes 2005; Reed et al. 2010).

Defining Sex Trafficking in the Context of the Commercial Sex Industry

Sex trafficking is part of the commercial sex industry in which women, girls, and boys are exploited for sex trafficking within their country of origin as well as across country boarders. In the United States, anyone under the age of 18 who is involved in a commercial sex act where a third party is profiting from the exchange is considered a victim of sex trafficking. Sex trafficking is carried out by criminal organizations (e.g., mafias) but also by less structured criminal networks, by individuals (e.g., pimps), and by family members of victims (UNODC 2014). It is estimated that profits from sex trafficking represent approximately 2/3 of what is believed to be $150 billion in illegal funds generated each year by all human trafficking around the world (ILO 2014). Sex trafficking can occur in any area of the commercial sex industry, which takes many forms including street prostitution, strip clubs, outcall services/prostitution, child and adult pornography, Internet pornography/interactive sex play exchange, phone sex, and sex tourism.

All too often, sex trafficking and prostitution are confused. Legally, prostitution is defined as (1) the promotion of or participation in sexual activities in exchange for something of value such as cash or drugs, including attempts or the solicitation of customers or transport of persons for prostitution purposes; (2) the ownership, management, or operation of a dwelling or other establishments for the purpose of providing a place where prostitution is performed; or (3) the assisting or promoting of prostitution. While the exchange of sex for money, even between consenting adults, is illegal in most of the United States, it does not constitute sex trafficking or sexual exploitation. Of significance is that increasingly, it has become clear that the elements of force, fraud, and coercion that are part of sex trafficking are sometimes difficult to identify and therefore may not be readily recognized or screened for by law enforcement, who commonly charge women with the crime of prostitution when they may actually be victims of sex trafficking (Potterat et al. 2001). Women involved in prostitution are arrested far more often than the (usually) men who purchase sex. This has drawn criticism from many and is seen by some as a manifestation of sexism. The authors also note that there is a fierce debate in the anti-trafficking field between the view that prostitution is never a choice but always an activity engaged in under the coercive distress of patriarchal systems which commodify women’s bodies and disenfranchise women from economic security. This view is sharply criticized by organized sex workers, who include men and nonbinary adults and their allies. This second group advocates for policy changes to improve their safety and security and recognizes that not all persons involved in commercial sexual activity are able to determine their own hours, rates, and work conditions within their labor market.

Risk Factors for Sex Trafficking

Those at risk for sex trafficking most often come from vulnerable populations including undocumented migrants; runaways; domestic violence victims; lesbian, gay, bisexual, transgender, and other nonbinary (LGBT+) youth; youth in the juvenile justice and delinquency systems; other at-risk youth, females especially African American girls in the United States; members of other oppressed or marginalized groups; and the poor. Traffickers target individuals in these populations because they have few resources, limited social support, and limited work options. Such factors make these populations easier to recruit through deception or force, and they tend to be easier to control.

At-risk youth and runaways are targeted by traffickers and by pimps for sex trafficking as well as labor exploitation and begging (Estes and Weiner 2002; Finkelhor and Ormrod 2004). Pimps and sex traffickers manipulate victims and are known to use of a combination of violence, affection, and abuse of other victims in a group in order to cultivate loyalty in victims. This can result in Stockholm syndrome , a psychological phenomenon wherein hostages experience and express empathy and positive feelings for their captors or abusers. This is more likely to develop with children and teenagers than with adults. This psychological manipulation reduces the victim’s likelihood of acting out against the trafficker. Research suggests that emotional and sexual abuse in childhood, ever having run away from home, rape, having family members involved in the commercial sex industry, and having acquaintances or friends who have purchased sex are all significantly associated with child sex trafficking within the United States (Fedina et al. 2016).

In the case illustration below, Barbara Amaya shares her story of being a runaway youth and how that led to her being trafficked.

When I was 12 years old, on one of the many occasions I had run away from home, I was gang raped in the streets of Washington, DC. It happened under the street in a maintenance room in the Thomas Circle tunnel.

A man began talking to me on 14th Street and then lured me into the tunnel area, where eight to ten filthy homeless men raped me, repeatedly. They laid me on a table and took turns. I told one of them I needed to pee while he was on top of me. He said “Go ahead.”

I don’t think I was ever quite the same after this trauma. I stopped talking, began to disassociate more frequently, began to pull my hair out, and contracted a venereal disease consequent of this gang rape. When I returned home, I told my mother something was wrong and showed her my body. She took me to the doctor. He examined me, and they gave me medicine. No one in the doctor’s office asked me what had happened, or really talked to me at all; they didn’t seem to be concerned with how a 12-year-old girl from Fairfax Virginia had contracted a venereal disease.

Another time after running away from home, I was kidnapped by a violent man. He took me to his home and raped me multiple times. When I tried to escape, he stabbed me in my neck with a table fork.

By the time I was close to 13 years old, I was under the control of a brutal sex trafficker and remained so for over a decade. It was my experience that when someone paid for my body, they believed they could do whatever they wanted to it. I endured beatings with wire coat hangers from the trafficker if I didn’t bring him enough money. I was robbed, raped, beaten, and threatened with death at the hands of the buyers.

I have been raped and trafficked for sex so many times I cannot remember the exact number, in the thousands no doubt. With each of these traumas, a part of me died, but not completely.

Inside, I still held the will to survive. I think we all have this will to keep going.

Undocumented immigrants are extremely vulnerable to being trafficked due to a combination of factors (Human Rights Watch 2012). Some of these factors include lack of legal status and related protections, poverty, few employment options, immigration-related debt, limited language skills, and social isolation. It is not uncommon for undocumented immigrants to be trafficked by those from a similar ethnic or national background and whom the victims may trust due to their common background.

Regions impacted by political instability and war create situations that foster trafficking. In particular, long-term military occupation and the presence of “peacekeeping” troops feed the commercial sex industry in these areas and facilitate sex trafficking of women and girls (Mendelson 2005; Morris 2010). Natural disaster also increases the risk and likelihood of trafficking. Natural disasters can destroy communities in a matter of minutes and create tremendous physical and economic insecurity. Children can be separated from their caregivers, making them prime targets for sex traffickers. The December 2004 Indian Ocean earthquake and tsunami is an example of one such natural disaster, where the lives of close to a million children were placed in danger. In this situation, seemingly for the first time, a concerted effort was made to stop trafficking before it could begin. Another example, although with a more problematic outcome, is the 2007 drought in Swaziland during which ECPAT International (End Child Prostitution and Trafficking) found increases in trafficking of children; there were reports of parents trading their children for food and water. Natural disasters not only impact children, they also increase adult vulnerability to trafficking. The kind of widespread devastation caused by this type of disaster can seemingly spontaneously create poverty and make it extremely difficult to meet basic needs. This may lead to immigration that can lead to victimization by a sex trafficker.

As illustrated, risk factors for sex trafficking are numerous and at the macro level include exposure to “compromised” or weak social institutions (Heil and Nichols 2015). The institutions of most significance to vulnerability in the United States are education systems, economic systems, criminal justice systems, and family systems.

Risk factors are also closely associated with identity-based oppression. An intersectional perspective indicates that each individual holds unique and intersecting identities that impact one’s lived experience. These identities include sex/gender (as previously noted), race, class, age, sexual orientation, ethnicity, and religion. In the United States and elsewhere, factors such as racism and classism become the structural barriers that oppress those who are politically, economically, or culturally disadvantaged. This ends up to be primarily women and girls who are oppressed by their race and class in addition to their sex (Kurtz et al. 2005). Unfortunately, across cultures, there tends to be marginalization of groups along these lines, and those who embody the marginalized position in one or more of these identity categories are at increased risk of different forms of victimization, including sex trafficking.

Survival sex is closely associated with runaway youth and is also referred to as trading sex and transactional sex. These terms are used interchangeably and refer to a sexual favor in exchange for something of value such as food, shelter, or clothing (Tyler and Johnson 2006). These terms are used mostly to describe the exchange of sexual acts for money or for something of financial value among youth and young women, often as a method of attempting to meet basic needs for survival (Greene et al. 1999; Tyler and Johnson 2006).

Methods of Recruitment

Sex traffickers use a variety of tactics to compel children and adults to engage in commercial sex acts. As mentioned previously, methods employed are often characterized by fraud, coercion, or force. According to federal law in the United States, a minor (someone under the age of 18 years) involved in a commercial sex is considered a victim of sex trafficking. Meaning, the minor is considered a trafficking victim whether or not the trafficker used force, fraud, or coercion; the minor is not of age to consent to commercial sex.

It is not uncommon for the trafficker to trick the victim into becoming romantically involved and then to use force or additional forms of manipulation to compel engagement in commercial sex. Other recruitment strategies may include false promises of employment, such as working as a nanny, model, or dancer. In some situations, family members, including parents or others in the primary caregiver role, sell their children to traffickers or directly broker of commercial sex involving their children.

Sex trafficking can occur just about anywhere. Common locations include businesses such as massage parlors and escort services, in brothels, at truck stops or similar travel rest areas, in hotels or motels, and on the street. In addition, sex trafficking is not limited to in-person exchanges and can exclusively take place online.

Social networks and more personal relationships serve as a powerful tool of recruitment for traffickers. Through these relationships, trust is easily achieved, making it easier for the offender to recruit friends of friends, friends of family members, and friends of other girls they have trafficked. Recruiting can take place in any number of places such as malls, schools, bus/subway/train stations, amusement parks, beaches, and college campuses. As noted previously, some traffickers engage in feigned romantic or physical relationships with young girls and women, preying on the emotional and economic needs of the individual. They begin to build a romantic relationship with the person and then ask that they engage in commercial sex to help support them; this sometimes is done gradually, for example, with the trafficker encouraging or more aggressively pushing the victim into dancing in a strip club to more serious commercial sex acts.

The Internet has become a very active location for both the recruitment of sex trafficking victims and advertising the sale of sex to purchasers. Sites that mirror Craigslist in layout and function are used both to recruit victims (Fig. 1) and to draw in those who want to purchase sex (Fig. 2). Recruitment advertisements tend to appear to be for legitimate employment, typically offering opportunities for modeling or dating services described as “upscale.” In some instances, more traditional jobs are advertised. For example, in the early 2000s, two college-aged women from Russia responded to an ad on Craigslist for office work in Pittsburgh, Pennsylvania. The women were picked up from the airport and transported to a popular Pittsburgh neighborhood where they were detained and trafficked for sex out of a home in a residential area. This story ended well in that the women escaped and were assisted by the Pittsburgh FBI and the Western PA Human Trafficking Coalition.

Fig. 1
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Image of the “entry page” for both Craigslist and Backpage

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Fig. 2
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Sample advertisements from Backpage

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Current victims of the trafficker are often used to recruit additional women and girls. Slang terminology for these individuals is “bottoms” and sometimes the trafficker is “easier” on this person, making it an appealing position for the victim to hold. This creates a tricky situation when law enforcement is involved because despite also being a victim, action as a recruiter places the person at risk for a criminal trafficking charge. Social media platforms such as Facebook are used to recruit girls, boys, and women to sell. For example, traffickers will “friend” an individual, compliment them on their appearance, and offer modeling work. See Fig. 3 for an example of such an online dialogue.

Fig. 3
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Messages provided by US Department of Justice

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The promise of economic support has been repeated time and again by sex trafficking survivors as what initially drew them to the trafficker. Traffickers are aware of this and display their wealth with the intention of attracting victims who often have no social safety net or means to provide for themselves.

Methods of Control

Traffickers use a variety of methods to control victims that broadly include contrived affection, acts of physical violence, and psychological/emotional abuse. In sex trafficking, there is typically a complex relationship between the victim/survivor and the trafficker that makes psychological manipulation a primary method of control. It is not uncommon for the trafficker to have cultivated romantic feelings in the victim as a way to engender attachment, trust, and loyalty. Traffickers use threats of harm to the family of victims as a means of control. For example, traffickers will threaten to pull a sister of the victim into sex trafficking, threaten physical harm to other family members and for victims who have children, the trafficker will often use access to the child to control the victim. Additional methods include sexual abuse, physical violence (hitting, punching, burning, etc.), induced drug dependence or addiction, isolation, confinement, and constant monitoring. Exerting control over seemingly small decisions in the victim’s life is also a way of reducing the sense of autonomy or self-determination of a victim, thereby making them easier to manage for the offender, for example, making rules about what time the victim goes to sleep, awakens, when the bathroom may be used, how much toilet paper is permissible for use, and when and what is consumed at mealtime. Economic abuse is characteristic of trafficking, and survivors by in large note severely restricted access to financial resources, further deepening dependence on the trafficker, even for the most basic of necessities.

Mental Health-Based Implications: Post-traumatic Stress Disorder

Sex trafficking victims often suffer serious physical and sexual abuse, exhaustion, and starvation. Because those who have been trafficked for sex have often been subjected to multiple abuses over an extended period of time, they may manifest physical and emotional health symptoms similar to those experienced by victims of the trauma of domestic violence or prolonged torture. What follows is an explanation of trauma and considerations for therapists and other social service and law enforcement professionals interacting with survivors.

Trauma is defined as an experience that threatens one’s sense of safety and security and may or may not involve physical harm. Trauma is typically experienced as either a single or a repeating event that overwhelms an individual’s coping mechanisms and interferes with one’s ability to integrate and make sense of emotions and thoughts related to the experience. According to the Diagnostic and Statistical Manual of Mental Disorders 5 (American Psychiatric Association 2013), a traumatic event is one that involves “exposure to actual or threatened death, serious injury, or sexual violence” (pp. 271). Exposure does not have to be direct and may include exposure through verbal account of another’s experience of visually through media. Sex trafficking victims, because of their exposure to physical, emotional, and physical violence, are at increased risk for developing PTSD.

Symptoms of PTSD are grouped into four categories: (1) intrusion/traumatic re-experiencing (e.g., flashbacks), (2) avoidance, (3) autonomic nervous system hyperarousal, and (4) negative alterations in cognition or mood. In order to meet the diagnostic criteria of PTSD, symptoms in each of these categories must be present.

Intrusion symptoms include memories of the event which are involuntary, intrusive, and distressing. Distressing dreams, dissociative reactions, distress at exposure to triggers of the event, and physiological reactions to trauma cues are also included in this cluster. Avoidance is the next symptom set. This is characterized by efforts to avoid thoughts or feelings associated with the trauma and/or efforts to avoid external reminders that activate memories of the event.

Negative alterations in cognition or mood is a symptom cluster that was recently added for the DSM-5. This refers to a broad range of symptoms including an inability to remember aspects of the event; exaggerated negative beliefs about oneself, others, or the world; distorted cognitions of guilt; negative emotional state; anhedonia; feelings of detachment; and inability to experience positive emotions.

The final cluster, hyperarousal or hyper-reactivity , is evidenced by irritability, recklessness, exaggerated startle response, problems with concentration, and sleep disturbance.

To meet a PTSD diagnosis, the duration of the four latter criteria must persist more than 1 month and in some cases may last throughout a life span, causing significant distress or impairment in social, occupational, or other areas of functioning. Complicating early and accurate diagnosis is the fact that individuals may not exhibit PTSD for months or years following the traumatic event, only to be triggered by a situation that resembles the original trauma.

An important consideration in working with survivors of the trauma of sex trafficking is understanding the extent to which they have trauma experiences predating victimization in trafficking. Trauma in early life is important for mental health professionals to understand because the way our clients think and feel about themselves and the relative safety of the world around them has meaningful implications for mental wellness and quality of life. The limited coping skill characteristics of infants and young children leave them at increased risk for negative outcomes associated with trauma in later life, such as that of sex trafficking.

Trauma reactions exist on a continuum based in part on the characteristics of the victim and the nature of the trauma (Briere and Spinazzola 2005). One end of the continuum is characterized by less complex reactions that are predominantly single-occurrence, adult-onset traumatic events: one-time trauma events in which the victim is an adult with a normal developmental history, a secure base for attachment, and no other psychological disorders. More complex trauma reactions exist on the other end of the continuum and typically include victims who are more vulnerable at the time of the trauma. This may mean earlier age of onset, multiple incidents as with sex trafficking survivors, and protracted trauma experience. The nature of the traumatic event in these situations is often interpersonal and invasive, such as with sex trafficking, child abuse, or rape.

Survivors of sex trafficking may experience trauma reactions characterized by dysregulation in emotion/affect, behavior, bodily functioning (e.g., somatoform disorders), interpersonal functioning in relationships/attachment, consciousness (e.g., dissociation), self-perception/self-concept, and systems of meaning. Children who have experienced sexual violence will react in various ways to protect themselves and to exercise emotional reactions to the trauma. These reactions are often observable through behaviors and fall into categories of externalizing behaviors (e.g., aggression toward other children or toward self, as with sexual acting out) or internalizing behaviors (e.g., depression, withdrawal). Other protective strategies include the emergence of primary or secondary defense mechanisms (see McWilliams 1999) or dissociation. Symptomology in children that is consequent of abuse is expressed in dysfunction in the educational setting, familial relationships, and relationships with peers.

Dissociative responses to trauma are not specific to any particular type of trauma. However, they are generally thought to be more common in situations of childhood sexual abuse (Freyd 1996) and are a key diagnostic feature of complex trauma in children. Dissociation can be defined as disruption in a person’s psychological integration of experience. In other words, dissociation interrupts “contact” across domains of functioning (e.g., thinking, feeling, emoting, etc.). It begins as a protective factor against feelings and thoughts that seem utterly unbearable. It also exists on a continuum, with one end characterized by normal daydreaming and the other by dissociative disorder that may include depersonalization, psychic numbing, or amnesia regarding details of the traumatic event. Like other protective defense mechanisms, dissociation can become problematic.

For mental health professionals, it is important to approach sex trafficking survivors with an understanding of the implications of sexually based trauma as well as a strong theoretical foundation that will allow for robust explanatory power to deepen understanding of the implications of prolonged and severe abuse on the psychology of the survivor. Trauma expert Judith Herman (1997) has aptly captured the significance of childhood trauma: “Repeated trauma in adult life erodes the structure of the personality already formed, but repeated trauma in childhood forms and deforms personality” (p. 98).

Summary

Sex trafficking occurs in the United States and in countries around the world. Vulnerable populations are frequently targeted by traffickers, including runaway and homeless youth, as well as victims of domestic violence, sexual assault, war, or social discrimination. Victims of sex trafficking are disproportionately women and girls and usually become involved in sex trafficking through fraud, coercion, or force. While no movement is necessary for sex trafficking to occur, when there is movement it is typically toward more densely populated regions with large commercial trade centers or areas with large military bases.

Sex trafficking situations can be widely variable with regard to how victims are entrapped, to the age of the victim to the context in which s/he is being victimized. Some victims are tricked into romantic involvement with the trafficker, while others are responding to online, in-person, or word of mouth advertisement for work. In other instances, some are sold by family members or other primary care givers.

Sex trafficking victims may be trafficked one time or for days, months, weeks, or years. Regardless of the duration of victimization, survivors are subjected to a range of physical and sexual violence and emotional abuse, which often results in post-traumatic stress disorder. It is important that those working with survivors connect them with licensed mental health providers who can treat the psychological effects of sex trafficking.

While legislative and grassroots efforts worldwide have enhanced capacity to identify and reduce cases of sex trafficking, it continues to be misunderstood and goes unnoticed or misidentified. Continued efforts and funding in support of all iterations of anti-trafficking work will allow us to build on what has been done over the past 18–20 years and ideally serve to reduce or eliminate this crime.

Cross-References