4   Approaches and
Challenges to
Service Provision

This section describes three approaches to providing victim and support services for victims and survivors of commercial sexual exploitation and sex trafficking of minors: (1) trauma-informed care, (2) case management, and (3) survivor-led and survivor-informed models. As is the case for the initiatives discussed in Section 3, research and evaluation of these approaches is sparse. Thus, the discussion here draws on research from related domains, such as sexual assault and domestic and partner violence. (Box 9 describes one program that reflects recognition of the value of these approaches and of the interrelatedness of commercial sexual exploitation and sex trafficking, intimate partner violence, and sexual abuse.) This section ends with a review of challenges to the provision of victim and support services that must be overcome if victims and survivors are to receive the services they need.

APPROACHES TO THE PROVISION OF SERVICES

Trauma-Informed Care

Trauma-informed care (also referred to as trauma-specific treatment and trauma-focused services) is based on recognizing and addressing the symptoms that commonly occur in response to multiple forms of trauma [29, 30]. Given the nature of abuse and violence experienced by victims and survivors of commercial sexual exploitation and sex trafficking—including exposure to repeated physical, sexual, and in some cases psychological abuse or witnessing violence—services specifically designed to address trauma can provide much-needed help.



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4  Approaches and Challenges to Service Provision T his section describes three approaches to providing victim and support services for victims and survivors of commercial sexual exploitation and sex trafficking of minors: (1) trauma-informed care, (2) case manage- ment, and (3) survivor-led and survivor-informed models. As is the case for the initiatives discussed in Section 3, research and evaluation of these approaches is sparse. Thus, the discussion here draws on research from related domains, such as sexual assault and domestic and partner violence. (Box 9 describes one program that reflects recognition of the value of these approaches and of the interrelatedness of commercial sexual exploitation and sex trafficking, intimate partner violence, and sexual abuse.) This section ends with a review of challenges to the provision of victim and support services that must be overcome if victims and survivors are to receive the services they need. Approaches to the Provision of Services Trauma-Informed Care Trauma-informed care (also referred to as trauma-specific treatment and trauma-focused services) is based on recognizing and addressing the symp- toms that commonly occur in response to multiple forms of trauma [29, 30]. Given the nature of abuse and violence experienced by victims and survivors of commercial sexual exploitation and sex trafficking—including exposure to repeated physical, sexual, and in some cases psychological abuse or witness- ing violence—services specifically designed to address trauma can provide much-needed help. 33

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34 A Guide for Providers of Victim and Support Services BOX 9 Mount Sinai Sexual Assault and Violence Intervention (SAVI) Program The SAVI Program is a hospital-based violence prevention and intervention program that has expanded its scope of work to include services and support for victims and survivors of commercial sexual exploitation and sex trafficking. This expansion is based on SAVI’s recognition of the associations among sexual abuse, intimate partner violence, and commercial sexual exploitation and sex trafficking. SAVI offers individual trauma-informed counseling, group and family counseling, and case management to victims and survivors of commercial sexual exploita- tion and sex trafficking. It also connects victims and 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 (discussed in Box 6 in Section 3) [23]. For more information: Mount Sinai Sexual Assault and Violence Intervention (SAVI) Program. http://www.mountsinai.org/patient-care/service-areas/community-medicine/areas-of-care/ sexual-assault-and-violence-intervention-program-savi Experiences with trauma can exceed a person’s ability to cope, and of- ten have adverse impacts on health and behavior that can last long into the future. Symptoms may include depression, anxiety, anger, disassociation, fearfulness, hopelessness, poor self-image, distrust of the environment, and difficulty maintaining healthy interpersonal relationships [31]. Without treat- ment, traumatic experiences can lead to changes in the brain that may create an inherent sense of distrust toward others, including those trying to help; a distrust of authority; and a sense of betrayal and resentment toward society in general [32]. According to the Substance Abuse and Mental Health Services Admin- istration, the design of trauma-informed systems of care is “based on an understanding of the vulnerabilities or triggers of trauma survivors that tradi- tional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization.” Elements of such a 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 staff and those receiving services in the design and operation of the organization [33].

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Approaches and Challenges to Service Provision 35 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. Trauma-specific services have also been evaluated and found to be effective for women experiencing co-occurring disorders, including substance abuse and depression. The IOM/NRC report notes that trauma-informed care is standard practice for many providers of services to victims and survivors of commercial sexual exploitation and sex trafficking [34, 35, 36, 37, 38]. For more information: SAMHSA. 2012. Working Definition of Trauma and Principles and Guidance for a Trauma-Informed Approach. http://www.samhsa.gov/traumajustice/traumadefinition/index.aspx “Given the nature of abuse and violence experienced by victims and survivors of commercial sexual exploitation and sex traffick- ing—including exposure to repeated physical, sexual, and in some cases psychological abuse or witnessing violence—services specifi- cally designed to address trauma can provide much-needed help.” Case Management Through case management, an individual in need of assistance receives sup- port 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 for those who have 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 Section 3, case management is a common component of a multidisciplinary team ap- proach to assisting victims and survivors of domestic abuse, child abuse, and sexual assault. The IOM/NRC report notes that many providers of services for victims and survivors of commercial sexual exploitation and sex trafficking use and/or support the use of case management [39]. For more information: Clawson and Dutch. 2008. Case management and the victim of human traf- ficking: A critical service for client success. http://aspe.hhs.gov/hsp/07/humantrafficking/CaseMgmt/ib.htm

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36 A Guide for Providers of Victim and Support Services “Case management can be especially beneficial for those who have complex needs (e.g., health care, mental health services, legal ser- vices) or must interact with multiple systems (e.g., criminal/juvenile justice, child protective services, foster care).” Survivor-Led and Survivor-Informed Models Many providers of services for victims and survivors of commercial sexual exploitation and sex trafficking also use and/or support the use of survivor- led and survivor-informed models. For example, survivor-led services and programs are central to GEMS (discussed in Section 3). Youth leadership by survivors of commercial sexual exploitation and sex trafficking was found to be important to the personal growth and development of GEMS participants. According to one service provider quoted in the IOM/NRC report: “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.’” For more information: GEMS (Girls Educational & Mentoring Services). http://www.gems-girls.org Motivating, Inspiring, Supporting and Serving Sexually Exploited Youth (MISSSEY). http://www.misssey.org Challenges to Service Provision Providers of services to victims and survivors of commercial sexual exploita- tion and sex trafficking generally agree that too few services are available to meet current needs. Moreover, the services that do exist are unevenly dis- tributed geographically, lack adequate resources, and vary in their ability to provide specialized care. Some of the challenges to adequate service provision are summarized in this section. The IOM/NRC report stresses the importance of conducting research to identify ways of overcoming these challenges. “Providers of services to victims and survivors of commercial sexual exploitation and sex trafficking generally agree that too few ser- vices are available to meet current needs.”

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Approaches and Challenges to Service Provision 37 Lack of Adequate Shelter and Housing Many law enforcement personnel familiar with sex trafficking cases identify shelter and housing as the most needed service for victims [40]. Yet emer- gency, 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 [15, 41, 42, 43, 44, 45, 46, 47, 48, 49]. Appropriate and ac- ceptable shelter options are in particularly short supply for certain groups [50, 51]. 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. Few Victim and Support Services for Boys Few victim and support service providers work with male victims and survi- vors of commercial sexual exploitation and sex trafficking [42]. As noted in Section 3, there is growing recognition that boys and young men are victims and survivors of these crimes, and greater attention is needed to preventing and identifying these crimes among these youth and providing them with gender-specific services. Lack of Awareness Among Service Providers As noted in Section 3, victim and support service providers working with vul- nerable youth may not recognize those in their care who have experienced or are at risk of commercial sexual exploitation and sex trafficking. As a result, they may fail to connect these youth to appropriate and timely services. Sec- tion 3 describes efforts to train service providers in and raise public awareness of these crimes. Broadening the reach of these existing efforts is one strategy for increasing understanding and recognition of the problem. Lack of Information Sharing and Communication 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). Unfortunately, information shar- ing and communication may be lacking among the various providers of these services. Multisector collaboration (discussed in Section 3) and case manage- ment (discussed on page 35) are potential strategies for closing this gap.

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38 A Guide for Providers of Victim and Support Services Impact on Service Providers of Working with Victims and Survivors Professionals may experience negative effects from working with vulnerable and traumatized individuals [52, 53, 54]. These effects include impacts on physical and psychological health [55], burnout, and secondary traumatic stress (e.g., sleep disturbance). Lack of Consensus on Services and Service Delivery While there is some agreement on specific services needed, consensus cur- rently is lacking on the range of services that should be available to assist and support victims and survivors of commercial sexual exploitation and sex traf- ficking effectively over time. Consensus is also lacking on the most effective or efficient model of service delivery for victims and survivors of these crimes.