Citation
Factors Associated with Successful Reintegration of Sex Trafficking Survivors: A Public Health Perspective

Material Information

Title:
Factors Associated with Successful Reintegration of Sex Trafficking Survivors: A Public Health Perspective
Creator:
Haney, Kanathy N
Publisher:
University of Florida
Publication Date:
Language:
English

Thesis/Dissertation Information

Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Public Health
Behavioral Science and Community Health
Committee Chair:
HART,MARK W
Committee Co-Chair:
MOORHOUSE,MICHAEL D
Committee Members:
YOUNG,MARY E
WALSH-CHILDERS,KIM B
Graduation Date:
12/14/2018

Subjects

Subjects / Keywords:
humantrafficking
prevention
publichealth
rapport
resiliency
sextrafficking
survivor
survivor-centered
trauma-informed
victim-centered

Notes

General Note:
Sex trafficking is a public health issue in the United States. There is currently little understanding of what survivors need to successfully reintegrate into society. Given the scarcity of evidence-based research, a scoping review of sex trafficking in the United States was conducted, along with qualitative interviews with both survivors and key informants. This sort of research is necessary to determine best practices and gaps in service provision. The purpose of this research was to develop an understanding of the experience of reintegration into society of sex trafficking survivors through survivor and key informant perspectives. A scoping review of evidence-based, peer-reviewed research on sex trafficking in the United States was conducted to ascertain known factors regarding sex trafficking and determine next steps for research and practice. A qualitative, grounded-theory, methodological approach was utilized to evaluate the complex social phenomenon of reintegration into society of sex trafficking survivors as reported by law enforcement, case workers, therapists, coalition and task force members and survivors, themselves. Interviews were recorded and transcribed, and the transcripts were analyzed using the constant comparison method until saturation was reached. A total of 24 interviews were conducted, including 18 with key informants and six with survivors. Analysis identified four themes from both survivors and key informants: 1) rapport, 2) a survivor-centered approach, 3) trauma-informed comprehensive care, and 4) resiliency. Two additional themes were identified by key informants: 1) barriers and 2) lack of operational definitions. Based on the experiences of survivors and key informants, specific classifications of services and needs of survivors were identified, which indicated the need for stronger collaboration among service providers to ensure a continuum of care and understanding of survivor needs. For example, a lack of appropriate housing and substance abuse treatment/detox services for this population were identified as critical concerns. Successful outcomes and reintegration measures should be realistic, given the amount of trauma a sex trafficking survivor has endured. As such, a non-linear progression of recovery is evident. This requires a long-term continuum of care, along with appropriately trained, trauma-informed service providers.

Record Information

Source Institution:
UFRGP
Rights Management:
All applicable rights reserved by the source institution and holding location.
Embargo Date:
12/31/2020

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F ACTORS ASSOCIATED WITH SUCCESSFUL REINTEGRATION OF SEX TRAFFICKING SURVIVORS: A PUBLIC HEALTH PERSPECTIVE By KANATHY N. HANEY A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2018

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2018 Kanathy N. Haney

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To all individuals who have been affected by any form of human trafficking, exploitation, or slavery. To promote societal evolution from past mistakes by learning how different forms of slavery have manifested in society across time. And to the participan ts and advocates in the community who made this all possible.

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4 ACKNOWLEDGMENTS I would like to express how much I appreciate Dr. Mark Hart, my primary mentor and chair, for supporting me in my academic and community practice pursuits This project would not have been conducted without his suggestion to shift my focus from volunteer efforts to academic and career approaches. I would also like to recognize my committee members: Dr. Mary Ellen Young, Dr. Kim Walsh Childers, and Dr. Michael Moorhouse. I am thankful for your insight, support, and high standards to which you held me throughout this process. I highly respect and admire each of you. Your experiences have facilitated m y evolution as a public health researcher. I am thankful for your individual and collective mentorship. I would like to give special thanks to Dr. Young for training me in qualitative methods and analysis along with her input throughout the development of the results and preliminary model. Thank you to the University of Florida, College of Public Health and Health Professions, Social and Behavioral Sciences, and Dr. Amy Blue, for acceptance into your doctoral program and providing continual support in my do ctoral studies and research. I would like to acknowledge the following entities which were instrumental in establishing rapport with the community of key informants and survivors of sex trafficking: Rescue Upstream, Hephzibah House, the Human Trafficking C oalition of the Palm Beaches, the Palm Beach State College Human Trafficking Coalition, and the Human Trafficking Task Force of Palm Beach County. I would like to specifically acknowledge Mrs. Tanya Meade for her continuous mentorship in community practic e and training initiatives. I thank her for the consistent review of results from this study. I admire her heart in the community and pursuit in preventing all forms of human trafficking. I would like to thank Mrs. Char Talmadge and

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5 Mrs. Tanya Meade for th eir fearless pursuits of taking an upstream approach to ending human trafficking. I began my journey of fighting human trafficking and working for social justice because of Tanya and Char. You inspired me to work effortlessly to spread awareness. From the first time I spoke with you about human trafficking, I immediately realized I was to utilize my knowledge of the public health and social work professions to assist with prevention efforts. I thank my work colleague, mentor and one of my best friends, Pro fessor Tracy Ciucci for her unwavering support in all my endeavors, professionally and personally. You have been such a blessing in my life. I am so thankful that you chose me to work with you on so many projects in the community and at Palm Beach State Co llege. I thank my mentor and friend, Associate Dean Nancy Zinser, for always supporting me and pushing me to continue moving forward in my educational pursuits. Both of you have challenged me along the way and encouraged all of my ideas. I cannot express h ow thankful I am to work with such amazing women everyday. I would also like to thank all the teachers and professors I have had throughout my academic career. Without you, I may not be here today. Special thanks to Ms. Tammy Schoen and Ms. Sandi Behrens for your support during some of the toughest times in my life, especially when I almost dropped out of high school. I am forever grateful for you. Thank you to all the educators who mentor students, you may never know the impact you have on them but it on ly takes one person to change a life. Never forget that. Because of you, I am now a professor who seeks to mentor all of my students.

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6 I would like to thank everyone who participated in this study. Thank you to all the coalition members, task force members volunteers, service providers, and law enforcement that work tirelessly against human trafficking. I thank the survivors for their fearlessness in participating I this st udy, for you are the strongest women I have ever met. You all inspire me to be a bet ter person, researcher, and advocate. Thank you for everything you have taught me and continue to teach me along the way. It has truly been an honor. Thank you to my mother who let me make my own decisions and told me I could do anything I wanted in life. Thank you to my father who gave me the knowledge and experiences in an unconventional way to better understand life. Thank you for the examples you have given me. I cannot give enough thanks to my grandmother, who loved and supported me for as long as I could remember. I love you. It is with the utmost respect and admiration that I am able to thank you in this way. I hope to be as beautiful of a person as you. You a re the most amazing human being I have ever known. You taught me to stand up for myself, to always work hard, to never give up, to always smile, and to see the good in everyone. It would be impossible to pay you back for all the wisdom me, but I plan to show you I understand. You are appreciated. Finally, I would like to thank God. Without him, none of this would have been possible. I know I am bles sed to be at this point in life. My journey proves that your plans are so mu ch better tha n anything I could ha ve dreamt on my own. Thank you.

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7 TABLE OF CONTENTS ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ .......... 10 LIST OF FIGURES ................................ ................................ ................................ ........ 11 LIST OF ABBREVIATIONS ................................ ................................ ........................... 12 ABSTRA CT ................................ ................................ ................................ ................... 15 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 17 Human Trafficking ................................ ................................ ................................ ... 17 Human Traf ficking versus Smuggling ................................ ............................... 18 The Action Means Purpose Model ................................ ................................ ... 19 Labor Trafficking ................................ ................................ ............................... 19 Sex Trafficking and Commercial Sex ................................ ............................... 20 Theories of Commercial Sex Work ................................ ................................ ... 21 Demand Theory and Consumerism ................................ ................................ .. 22 Laws on Prostitution ................................ ................................ ......................... 23 Sex Trafficking Laws ................................ ................................ ........................ 23 Ethics of Commercial Sex Work ................................ ................................ ....... 24 Extent of Sex Trafficking ................................ ................................ ................... 25 Entry to Trafficking ................................ ................................ ........................... 26 Childhood Risk Factors ................................ ................................ .................... 27 Public Health Approach ................................ ................................ .................... 29 Social Ecological Model ................................ ................................ .................... 29 Th e Present Study ................................ ................................ ................................ .. 32 Specific Aims ................................ ................................ ................................ .... 32 Epistemology ................................ ................................ ................................ .... 33 Reflexivity ................................ ................................ ................................ ......... 35 2 SEX TRAFFICKING IN THE UNITED STATES: A SCOPING REVIEW ................. 42 Methods ................................ ................................ ................................ .................. 44 Research Question ................................ ................................ ........................... 44 Methodology ................................ ................................ ................................ ..... 44 Identification o f Relevant Studies ................................ ................................ ..... 46 Selection of Studies ................................ ................................ .......................... 46 Results ................................ ................................ ................................ .................... 47 Awareness ................................ ................................ ................................ ........ 47 Attitudes / belief s ................................ ................................ ........................ 47 Knowledge / training ................................ ................................ .................. 49

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8 Media framing ................................ ................................ ............................ 50 Prevention programs ................................ ................................ .................. 51 Identification ................................ ................................ ................................ ..... 52 Proper identif ication of victims ................................ ................................ ... 52 Screening ................................ ................................ ................................ ... 53 At Risk Populations ................................ ................................ .......................... 55 Housing for CSE youth ................................ ................................ .............. 56 Juvenile justice system ................................ ................................ .............. 56 Child welfare involvement ................................ ................................ .......... 57 He althcare provider visits ................................ ................................ ........... 58 Current commercial sex work ................................ ................................ ..... 60 Health Issues ................................ ................................ ................................ .... 61 Mental and phy sical health ................................ ................................ ......... 61 Trauma and trafficking experience ................................ ............................. 63 Legislation and Implementation ................................ ................................ ........ 64 TVPA implementation ................................ ................................ ................ 64 Safe Har bor law implementation ................................ ................................ 66 Barriers to services ................................ ................................ .................... 67 Service utilization ................................ ................................ ....................... 68 Program evaluation ................................ ................................ .................... 69 Exploiters ................................ ................................ ................................ .......... 70 Trafficker charact eristics ................................ ................................ ............ 70 Trafficker tactics ................................ ................................ ......................... 71 Sex buyer attitudes and characteristics ................................ ..................... 72 Discussion ................................ ................................ ................................ .............. 74 Limitations ................................ ................................ ................................ .. 76 Conclusions ................................ ................................ ............................... 77 3 FACTORS ASSOCIATED WITH SUCCESSFUL REINTEGRATION OF SEX TRAFFICKING SURIVIVORS FROM THE SURVIVOR PERSPECTIVE .............. 113 Methods ................................ ................................ ................................ ................ 115 Participants ................................ ................................ ................................ ..... 115 Data Collection ................................ ................................ ............................... 117 Data Analysis ................................ ................................ ................................ 118 Results ................................ ................................ ................................ .................. 120 Rapport ................................ ................................ ................................ ........... 120 Survivor Centered Ap proach ................................ ................................ .......... 121 Comprehensive Care ................................ ................................ ..................... 123 Fostering Resiliency ................................ ................................ ....................... 127 Discussion ................................ ................................ ................................ ............ 129 Limitations ................................ ................................ ................................ ...... 133 Conclusion ................................ ................................ ................................ ...... 133

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9 4 FACTORS ASSOCIATED WITH SUCCESSFUL REINTEGRATION OF SEX TRAFFICKING SURVIVORS FROM THE KEY INFORMANT PERSPECTIVE .... 142 Methods ................................ ................................ ................................ ................ 143 Participants ................................ ................................ ................................ ..... 143 Data Collection ................................ ................................ ............................... 144 Data Analysis ................................ ................................ ................................ 145 Results ................................ ................................ ................................ .................. 146 Rapport ................................ ................................ ................................ ........... 146 Survivor Centered Ap proach ................................ ................................ .......... 148 Comprehensive Care ................................ ................................ ..................... 149 Fostering Resiliency ................................ ................................ ....................... 152 Operational Definitions of Success ................................ ................................ 153 Reduce Barriers ................................ ................................ ............................. 154 Discussion ................................ ................................ ................................ ............ 157 Limitations ................................ ................................ ................................ ...... 160 Conclusions ................................ ................................ ................................ .... 161 5 CONCLUSION ................................ ................................ ................................ ...... 171 Public Health Impact ................................ ................................ ............................. 171 National Health Initiatives ................................ ................................ ............... 172 Development of a Model for Public Health Prevention of Sex Trafficking in the United States ................................ ................................ ................................ ..... 174 Framework for Implementation of Public Health Prevention ........................... 174 Social Ecological Model ................................ ................................ .................. 175 Hierarchy of Needs ................................ ................................ ......................... 178 Limitations ................................ ................................ ................................ ............. 185 Recommendations for Future Research ................................ ............................... 186 LIST OF REFERENCES ................................ ................................ ............................. 194 BIOGRAPH ICAL SKETCH ................................ ................................ .......................... 213

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10 LIST OF TABLES Table page 2 1 Scoping Review Themes and Subthemes ................................ .......................... 79 2 2 Top Statistically Significant Risk Factors for Sex Trafficking .............................. 80 2 3 Summary of Scoping Articles ................................ ................................ .............. 81 3 1 Survivor Themes and Subthemes ................................ ................................ .... 135 3 2 Rapport Subthemes ................................ ................................ .......................... 136 3 4 Comprehensive Care Subthemes ................................ ................................ ..... 138 3 5 Fostering Resiliency Subthemes ................................ ................................ ...... 141 4 1 Key Informant Themes and Subthemes ................................ ........................... 162 4 2 Rapport Subthemes ................................ ................................ .......................... 163 4 3 Survivor Centered Approach Subthemes ................................ ......................... 164 4 4 Comprehensive Care Subthemes ................................ ................................ ..... 165 4 5 Fostering Resiliency Subthemes ................................ ................................ ...... 168 4 6 Operational Definitions of Success Subthemes ................................ ................ 169 4 7 Reduce Barriers Subthemes ................................ ................................ ............ 170 5 1 Survivor Centered Approach to Successful Reintegration of Sex Trafficking Survivors: A Public Health Prospective Quotes ................................ ................ 192

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11 LIST OF FIGURES Figure page 1 1 The Action Mea ns Purpose Model ................................ ................................ ...... 39 1 2 The Power and Control Wheel ................................ ................................ ............ 40 1 3 Data Collection P rocess ................................ ................................ ..................... 41 2 1 PRIMSA Flow Chart ................................ ................................ ........................... 78 5 1 Survivor Centered Approach to Successful Reintegration of Sex Trafficking Survivors: A Public Health Prospective ................................ ............................ 191

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12 LIST OF ABBREVIATIONS ACEs Adverse childhood experiences AMA American Medical Association APHA American Public Health Association ASA Sexual assault/sexual abuse CDC Centers for Disease Control and Prevention CEM Child exploitative material CFA Confirmatory factor analysis COREQ Consolidated criteria for reporting qualitative research CSA Child sexual abuse CSE Commercial sexual exploitation CSEC Commercial sexual exploitation of children CST Child sex trafficking DMST Domestic minor sex trafficking ED Emergency department EFA Exploratory factor analysis EMDR Eye Movement Desensitization and Reprocessing EMT Emergency medical technician ER Emergency room GEMS Girls Education and Mentoring Services HIV Human immunodeficiency virus ILO International Labor Organization IPV Interpersonal violence LCA Latent class analysis LGBT Lesbian, gay, bisexual, transgender

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13 LGBTQ+ Lesbian, gay, bisexual, transgender, queer (or questioning) and others MOU Memor an d u m of understanding NASW National Association of Social Workers NCOSE National Center of Sexual Exploitation NIJ National Institute of Justice NSN National Survivor Network OB/GYNs O bstetricians / G ynecologists P2P Peer to peer PDS Posttraumatic Diagnostic Scale PKA HTQ Perceptions, knowledge and attitudes around human trafficking questionnaire PRISMA Preferred Reporting Items for Systematic Reviews and Meta Analyses PTSD Post traumatic stress disorder RHSY R unaway, homeless and street youth SAA Sex Addicts Anonymous SAMHSA Substance Abuse and Mental Health Services Administration SEM Social Ecological Model SLAA Sex and Love Addicts Anonymous STAR Sex Trafficking Assessment Review STAS Sex trafficking attitudes scale STD Sexually transmitted disease TVIT Trafficking victim identification tool TVPA Trafficking Victims Protection Act US United States

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14 USDOS United States Department of State WHO World Health Organization

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15 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy F ACTORS ASSOCIATED WITH SUCCESSFUL REINTEGRATION OF SEX TRAFFICKING SURVIVORS: A PUBLIC HEALTH PERSPECTIVE By Kanathy N. Haney December 2018 Chair: Mark W. Hart Major: Public Health Sex trafficking is a public health issue in the United States. There is currently little understanding of what survivors need to successfully reintegrate into society. Given the scarcity of evidence based research, a scoping review of sex trafficking in th e United States was conducted, along with qualitative interviews with both survivors and key informants. This sort of research is necessary to determine best practices and gaps in service provision. The purpose of this research was to develop an understan ding of the experience of reintegration into society of sex trafficking survivors through survivor and key informant p er spective s A scoping review of evidence based, peer reviewed research on sex trafficking in the United States was conducted to ascertai n known factors regarding sex trafficking and determine next steps for research and practice. A qualitative, g rounded theory methodological approach was utilized to evaluate the complex social phenomenon of reintegration into society of sex trafficking survivors as reported by law enforcement, case workers, therapists, coalition and task force members and survivors, themselves.

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16 Interviews were recorded and transcribed, and the transcripts were analyzed using the constant comparison metho d until saturation was reached A total of 24 interviews were conducted, including 18 with key informants and six with survivors. Analysis identified four themes from both survivors and key informants: 1) rapport, 2) a survivor centered approach, 3) trau ma informed comprehensive care, and 4) resiliency. Two additional themes were identified by key informants: 1) barriers and 2) lack of operational definitions. Based on the experiences of survivors and key informants, specific classifications of services and needs of survivors were identified, which indicated the need for stronger collaboration among service providers to ensure a continuum of care and understanding of survivor needs. For example, a lack of appropriate housing and substance abuse treatment/ detox services for this population were identified as critical concerns. Successful outcomes and reintegration measures should be realistic, given the amount of trauma a sex trafficking survivor has endured. A s such, a non linear progression of recovery is evident. This requires a long term continuum of care along with appropriately trained, trauma informed service providers.

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17 CHAPTER 1 INTRODUCTION Human Trafficking According to the United Nations Palmero Protocol human trafficking is defined as se of individuals for labor, sex, organs, or other means of exploitation through (United Nations, 2004 p. 42 ) T he United States Trafficking Victims Protection Act of 2000 (TVPA) states an individual under the age o f 18 is considered a human trafficking victim if e xploited in sex or labor with no need to prove force, fraud, or coercion. Human trafficking is also defined as the recruitment, harboring, transportation, provision, or obtaining of a person for labor or s ervices, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery ("TVPA," 2000 p. 1470 ) Modern slavery threatens human rights worldwide, and people in the United States are n o exception The National Human Trafficking Hotline active since 2007, has received more than 40,000 calls with a 258% increase since the year it was introduced (National Human Trafficking Hotline, 2018c) In 2017 alone, the hotline received nearly 26,55 7 calls (National Human Trafficking Hotline, 2018b) Each year there has been an increase in calls placed to the hotline from victims themselves and others in the community. Those afflicted by human trafficking do not fit one single profile and represent a wide range of individuals. Victims can be women, men, girls, or boys. They vary across the socioeconomic spectr um and include both documented and undocumented i mmigrants and citizens alike. Although h uman trafficking can affect anyone in a vulnerable situation (United States Department of State, 2014) in the

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18 United States most victims are women and children citizens (Banks & Kyckelhahn, 2011). Human trafficking is an encompassing term that inc ludes labor and sex trafficking. E xploitation o ften occurs unde r the guise of legal industries, including le gal commercial sex venues, agric ulture, mining, and factory work Trafficking also occurs in illicit industries such as prostitution. Human trafficking is a global public health issue with an est imated 21 million current victims in both sex and labor trafficking (International Labour Organization, 2018). Although prevalence is high, it is difficult to measure the extent of the se crime s due to its underground nature and reluctance of victims to com e forward (Institute of Medicine and National Research Council, 2013). According to the Trafficking in Persons Report, published yearly by the U.S. State Department, between 600,000 and 800,000 men, women, and children are trafficked annually across border s worldwide (US Dept of State, 2018) Trafficking estimates in the United States are scarce with around 300,000 children trafficked each year (Ijadi Maghsoodi, Bath, Cook, Textor, & Barnert, 2018). These numbers are estimates d ue to limited research and t he clandest ine nature of human trafficking, which makes it difficult to pinpoint the exact number of human trafficking victims (Weitzer, 2013) T hus, there are discrepancies in reporting the true number of persons trafficked worldwide. Human T rafficking v e rsus S muggling Many people confuse human trafficking for smuggling because the word trafficking suggests transportation of a person. It should be noted that smuggling is a consensual crime involving broaching a border to enter a foreign country illegally, while trafficking is a crime against a person and exploits human rights (US Dept of State, 2017). Trafficking includes trans portation of individuals to various destinations, like

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19 another country or a brothel, where they are forced or coerced into sex or la bor. Trafficked people could be smuggled into a country, but it is important to note that s muggling is a crime against the country to which the person is transported, whereas trafficking is a exploitative crime against the individual (Powell, 2014; US Dept of State, 2017). The Action Means Purpose Model Human trafficking is specifically categorized using the Action Means Purpose (AMP) Model to describe the United States definition (Polaris, 2012) as seen in Error! R eference source not found. To be convicted, the perpe trator or trafficker must have engaged in activities like inducing, recruiting, harboring, transporting, providing or obtaining individuals through the means of for ce, fraud, or coercion for commercial sex or labor exploitation (Polaris, 2012) Force involves any form of physical assault, restraint, or sexual assault. Fraud involves false promises regarding employment, payment, working conditions, marriage, love, or a better life. Coercion is psychological and involves threats of harm or manipulation, sham ing and confiscating legal documents to keep the individual in fear (Office on Trafficking in Persons, 2017) The minimum requirement to convict an individual of tr afficking requires at least one element from each category of action, means, and purpose. Force, fraud and coercion illustrate the lack of choice for the individual exploited (Office on Trafficking in Persons, 2017) Labor Trafficking Human trafficking is represented in two distinct categories: labor and sex. Labor trafficking accounts for approximately 80% of trafficking worldwide (International Labour Organization, 2018) and includes the following: au pair or nanny services, lawn services roofing, nail salons, hotel maids, fishing, factory work, cocoa farming, diamond

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20 mining, and drug harvesting. Human trafficking is usually associated with females but can target anyone in a vulnerable situation (Deshpande & Nour, 2013) Traffickers prey on those who exp erience severe difficulty filling economic or social needs including money, jobs, a ttention, or support. Youth in foster care, group homes, and public housing areas are deemed the most vulnerable (Institute of Medicine and National Research Council, 2013) T he largest study to d ate on human trafficking showed that men are more likely than women and children to be used in labor trafficking and experience extreme occupational hazards. The conditions described by those exploited in this study included long da ys at sea fishing, excruciating factory work a nd exposure to harsh chemicals. Men were less likely to be identified as trafficking victims, since in many cultures men are expected t o be rugged and hard workers (Kiss, Pocock, et al., 2015) L abor trafficki ng is less prevalent in the United States due to strict labor laws. Overall, more research is needed on labor trafficking in the United States. Sex Trafficking and Commercial Sex The TVPA and the U.S. Department of State define sex trafficking as recruitment, harboring, transportation, provision, or obtaining of a person for the ("TVPA," 2000 p. 1470 ) A c ommercial sex act is defined as a ny person ("TVPA," 2000) Commercial sex includes but is not limited to prostitution, peep shows, escort services, strip clubs, online live sex shows, pornography, and massage parlors (Deshpande & Nour, 2013) It should be noted that gender i nequalities throughout society have contributed to the cultural acceptance of female sex trafficking and exploitation. Sex trafficking is currently estimated as a $ 150 billion a year industry

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21 (Kara, 2010) with an estimated 500,000 600,000 new sex trafficking victims added each year (Kara, 2010) S ex trafficking has been recognized as globalized prostitution with estimates of 70 95% of prostitutes meeting the criteria for trafficking (Farley et al., 2003) Further, children younger than 18 involved with the commercial sex industry are considered to be a sex trafficking victim s because they are not old enough to consent to sex legally and are therefore being exploited (Gerassi, 2015a; Sanders, 2015) Theories of Commercial Sex Work V arious viewpoints exist regarding com mercial sex venues such as prostitution and legality has become a topic of heated debate (Gerassi, 2015b) Feminist theory examines the experiences and roles of gender and questions whether commercial sex work can be voluntary (Wilson & Butler, 2014) Typically the debate has been divided into two general sides The first, neo abolitionism, opposes any commercial sex work and the oppression of women. This group views commercial sex as inherently degrading to women resulting in an inferior status with male s a nd increased violence against women (Farley, 2005) Another theoretical viewpoint include s radical feminism, includes all porn ography prostitution, escort services and other forms of commercial sex are sex trafficking because they exploit power and gender imbalances in society (Farley, 2005) A similar theoretical standpoint is Marxist feminism, which views all forms of commercial sex as abuses against women that tak e away their power (MacKinnon, 1982) The alternate position, neo liberalism, suggests that women have a right to choose to participate in sex work Those who take this position do not see all individuals involved

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22 in commercial sex work as sex trafficking victims because the y may not be under control (FitzGerald & Munro, 2012) Th e n eo liberal and liberal feminist perspectives o n prostitution assert that individuals can decide to participate in sex work (Ferguson et al., 1984) These perspectives, however, may b e oversimplifications, since they disregard evidence that most prostitutes have been prior sex trafficking or sexual assault victims and are at risk for subsequent victimization (Farley & Barkan, 1998; Sanders, 2015) For example, it has been shown that 64% of prostitutes were in foster care and 60% are currently homeless or have been homeless previously (Farley et al., 2003) Although this does not necessarily mean they will be trafficked, homelessness makes them vulnerable and does increase the risk. Demand T heory and C onsumerism According to demand theory, sex trafficking woul d not be an issue if there were not such a high demand for commercial sex (Lutya & Lanier, 2012) The demand for prostitution exists due to sex buyers, those who benefit financia lly, and the sociocultural attitudes toward sex in society (Hughes, 2004) S ex tourism along with co nsumption of commercial sex, produces high demand and a need for new sex trafficking victims each year (Lutya & Lanier, 2012) This was illustrated in 2005 when state law enforcement efforts led to the conviction of more than 26,000 sex buyers for obtaining sex services (US Dept of State, 2018) There is also a demand for more younger females to be trafficked i n the United States, with 44% of survivors repor ted being involved in commercial sex when they were 17 or younger (Polaris, 2016)

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23 Laws on P rostitution Currently, prostitution in the United States is illegal because the US has taken a prohibitionis t stance although it is legal in some counties in Neva da with fewer than 7 00,000 residents (Nevada Legislature, 1987) U.S. citizens participating in s ex touri sm in other countries is a big business, however, despite sanctions. For instance, if an American goes to another country for child sex tourism, they c an be charged with participation in sex trafficking of a minor under the Prosecutorial Remedies and Other Tools to end the Exploitation of Children Today (PROTECT) Act of 2003 ("PROTECT Act," 2003 p. 654 ) Supporters of legalized prostitution have claimed this would help with sex workers rights and decrease sex trafficking but unfortunately it has had the opposite effect and increased sex trafficking in those areas Tourist locations such as Amsterdam have higher ra tes of sex trafficking because of an increase in overall demand for sex tourism (Farley, 2006) On the contrary, countries that have decriminalized sex work for the workers and criminalized buyers and traffickers have been much more successful in decreasin g sex trafficking. For example, Sweden has followed what has been termed the Nordic model, which has decreased prostitution by 30 50% (Ekberg, 2004) Sex T rafficking Laws Overall, laws are neither consistent for sex trafficking across states nor are thei r enforcement This is why traffickers are mostly charged with other crimes just to get them off the streets (Albonetti, 2014; Bouche, Farrell, & Wittmer, 2015) Even with trafficking laws in place, the issue s of recognizing trafficking and holding traffic kers accountable remain problematic (Albonetti, 2014) Currently, most news reports on sex trafficking focus on child pornography rings and are exposed by the media (Johnston,

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24 Friedman, & Shafer, 2014) Recently, the Communications Decency Act 230 pardoned websites from any illegal activity that occurred on their sites however, was overturned and now it is being considered their legal responsibility. This ruling resulted in the seizure of online sites such as BackPage, which posted ads of prostituted women and children ("Allow States and Victims to Fight Online Sex Trafficking Act of 2017," 2017 p. 1253 ) Ethics of C ommercial S ex W ork T he American Medical Association (AMA) recently evaluated all models of decriminalization or criminalization of sex work ac cording to its code of ethics. After careful assessment of guidelines the AMA decided t decriminalize sex workers and criminaliz e buyers and traffickers (Rothman, 2017) The overall conclusion was that decriminalizing sex workers would allow them to get proper medical care while decreasing stigma and blame The AMA association believes human trafficking is a medical, public health, social service, and legal issue that must be addressed for public health (American Medical Association, 2015) Human trafficking is a global public health issue. Many question if it is a medical or public health issue. Regardless, it is a responsibility for both fields (Powell, 2014) The American Public Health Association st ates that to fight human trafficking, it must be recognized as a multifaceted issue, requiring collaboration across public health, social work, criminal justice, and healthcare systems (American Public Health Association, 2015) Furthermore, it is part of the public health ethical code to fight for social justice among marginalized groups (Public Health Leadership Society, 2002) Indeed, along with its criminal element, the United States Department of Justice has stated it is also a public health issue whic h must be addressed (Department of Justice, 2018)

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25 Extent of S ex T rafficking Sex trafficking survivors have various experiences but share commonalities of violence and abuse in their stories (Deshpande & Nour, 2013). In an economic model the trafficker w ho is supplying the product functions as intermediary by providing a human for sexual purposes to a meet buyer demands (Wheaton, Schauer, & Galli, 2010). A commercial sex trafficker is someone who exploits others for profit such as a person one may have c ommon ly heard referred to as a pimp (Logan, Walker, & Hunt, 2009) An estimated 91% of female and 4% of male prostitutes were found to be controlled by a pimp, with more than 78% reporting they want to leave prostitution (Farley et al., 2003) Moreover, ap proximately 84% of the women in prostitution are Kennedy, 2014). It has been found that prostitutes ar e raped an average of once per week (Farley et al., 2014). Most individuals report violence (95%) during trafficking with the majority (60%) reporting vict imization prior to it (Farley et al., 2003) Traffickers target those who are vulnerable because they are easy to manipulate and vi ctimize (Reid, 2016) Many survivors experience the boyfriend tacti c (Toney Butler & Mittel, 2018) Here, the trafficker confess es his love, offer s affection, and give s them items they may not have otherwise all to encourage compliance While some victim s are abducted, most are considered willing victims as they are easily manipulated into submission (Austin Smith, 2014). The majority are manipulated by traffickers who look for vulnerabilities and pretend to fill the void until they have them under psy chological control ( Reid, 2016) Trafficking victims are often raped to desensitize them to sex work and break them in (Farley et al., 2003) T rafficking violence has been associated with intimate

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26 partner violence and domestic abuse. Typically, the boy friend or pimp will use power and control tactics to manipulate the individual to comply without physical force being needed The power and control wheel ( Figure 1 2 ) from domestic violence has been adapted to use with trafficking victims (National Human Trafficking Hotline, 2010) mentally and emotionally, while teaching them the rules and subculture of prostitution (Heyl, n.d.) Over 49% of prostitutes report ed being forced into pornography and 79% were forced to watch porn to learn what was expected of them. Traffickers often uti lize pornography viewing as a form of grooming to perform acts requested by buyers customers (Farley et al., 2003) Entry to Trafficking There is no single risk profile that makes an individual more likely to be trafficked; people of all ages races, ethnicities, legal status es and income levels can be trafficked (Kiss, 2015). However, s ex trafficking disproportionately affect s women and children (Deshpande & Nour, 2013) T he largest risk factor overall is low socioeconomic status, extreme po verty and lack of professional opportunities (Nichols, 2016). There is limi ted research explain ing how individuals first enter human trafficking. Risk factors include physical or sexual ab use in childhood, involvement in the child welfare or juvenile just ice system, a history of viole nce against the individual, incarcerated parents, substance use in the home, runaways, LGBT (Lesbian, gay, bisexual, or transgender) and those with current mental health or substance abuse disorders (Smith, Vardaman, & Snow, 20 09; Varma, Gillespie, McCracken, & Greenbaum, 2015) Overall, however, poverty appears to be the highest correlated factor to being targeted for trafficking purposes (Logan et al., 2009)

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27 Childhood Risk Factors The average age of children to be sex traffic ked in the US i s 12 14 (J. Reid & Jones, 2011) Adolescents are extremely vulnerable as their brains are not completely developed leading to lesser ability to assess risk (Casey, Jones, & Hare, 2008) This helps support the general consensus that older me n can easily manipulate adolescent s (Gerassi, 2015). It has been suggested that under no circumstance should children be blamed for their exploitation ; they are victims and should never be treated as criminals (Austin Smith, 2014; Sanders, 2015) In 2003, the National Center for Missing and Exploited Children (NCMEC) was created receiv ing more than 2.3 million reports of sexual exploitation since then (Gerassi, 2015a) In most cases, children who have been physically or sexually abused become co nditioned to the abuse. It becomes normal in their experience because it is all they have known. This makes it difficult for them to despite the fact that they abuse and explo it them (Sanders, 2015) A dverse childhood experiences (ACEs) should also be considered. A seminal study determined that traumatic experie nces like abuse, neglect, and domestic violence are linked with substance abuse and mental health issues. The results concluded that children with four or more ACEs tend to experience a reduction in life expectancy by twenty years (Felitti et al., 1998) Considering ACEs, most sex trafficking victims are also victims of childhood abuse (Sanders, 2015) Due to these childh ood experiences, many of the children end up in foster care. Furthermore, LGBT (lesbian, gay, bisexual, transgender) teens have significant disparities in sex trafficking. The LGBT population makes up 5% of the general population, 10% of the youth populati on, and 20 40% of homeless youth. Most homosexual, bisexual and transgender men participate in

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28 survival sex as exchange f or food, shelter, money and other means of survival (Greenbaum, 2017) Intellectual disabilities pose significant risk for children sin ce they may be easily manipulated, making them frequent targets (J. Reid, 2018) Forty percent of c hildren in the juvenile justice system report that they were sexually abused with 21% experiencing child sexual abuse (CSA) from a close family member (Smi th et al., 2009) Frequently, juveniles in the criminal justice system are treated as criminals rather than victims, with little consideration of the trauma s they have face d (Sanders, 2015) For instance, survivors stated that prostituted children should be considered victims and not be charged with crimes but given services (Austin Smith, 2014; Lloyd, 2011; Sanders, 2015) Children should not be arrested for prostitution as the TVPA ruled that children involved in commercial sex work are automatically con sidered victims of sex trafficking ("TVPA," 2000) Studies have shown individuals with childhood sexual abuse are more likely to engage in sex work as adolescents and adults (Kiss, Pocock, et al., 2015; Vaddiparti et al., 2006) C hildhood victimization is also likely to lead to substance ab use which subsequently lead s to vulnerability for sex work (Vaddiparti et al., 2006) I ndividuals who experienced childhood victimization tend to use substance s to numb themselves mentally, emotionally and physically, w hich then make s them even more vulnerable to sex traffick ing (Ijadi Maghsoodi et al., 2018) Furthermore, individuals engaging in chronic substance ab use have recurring victimizations, which could increase severity of mental illness (Kurtz, Surratt, Inciar di, & Kiley, 2004; Surratt, Inciardi, Kurtz, & Kiley, 2004)

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29 Social media is used to recruit unsuspecting victims with the prospect of friendships, relationships, or financial assistance (Institute of Medicine and National Research Council, 2013; Smith et al., 2009) The constantly growing numbers of social sites increase the likelihood of teens being trafficked Mass media consumption, sexualization, social media, and social networking sites often lead m iddle class suburban children to the hands of traffic kers (Austin Smith, 2014) and children may learn unhealthy messages about sex from online sites and pornography (Walsh Childers, 2017) The Pa lm Beach County School District in Florida is modeling a new approach that presents an opt in method for district schools to have human trafficking awareness and prevention training (Human Trafficking Coalition of the Palm Beaches, 2017) Trainers in the Human Trafficking Coalition of the Palm Beaches give presentations to local middle and high schools to heighten awareness and teach skills to st udents to decrease risk factors and vulnerability (Human Trafficking Coalition of the Palm Beaches, 2017) Public Health Approach Public health involves three levels of prevention: primary, secondary, and tertiary (Powell, 2014) Primary prevention is for the general population, secondary is for at risk groups, and tertiary is for those affected by the specific public health issue being addressed To be comprehensive in the public health issue of sex trafficking, all levels of prevention should be considered Social Ecological Model The socioecological model was derived from ecodevelopmental theory of human development which occurs and changes over time (Bronfenbrenner, 1979) The adolescent is at the center of th is model Microsystems are at the first level; this

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30 includes all relationships the individual may be in includ ing family functioning, school functioning, peer relationships, social roles, and physical environment. The next level is the mesosystem This consists of relationship s between microsystem factors that impact the individual, such as school or work environments. The exosystem involves people in life but it does not directly impact the individual. Examples of the exosystem include parental st ress, parental support, and school or community resources. The macrosystem consists of overarching sociocultural factors that tend to have a trickle down effect on the individual. The macrosystem i nclude s culture, acculturation gaps (dependent on race/ethn icities), sociocultural attitudes and various policies (Bronfenbrenner, 1979) al psychology to fit health promotion and behaviors (Glanz, Rimmer, & Viswanath, 2015; McLeroy, Bibeau, Steckler, & Glanz, 1988) The socioecological model also has the individual at the base of the model surrounded by various levels of behavior including intrapersonal, interpersonal, organization/institutional, and policy factors. Intrapersonal factors are those spec ific to the individual such as knowledge, attitudes, beliefs, self efficacy, and risk/protective factors. Interpersonal factors are relationships with other people such as support systems, family, and peer influence. Organization and institutional factors are schools, work, and servic e providers. Community factors are school districts, community groups, cultural norms and neighborhoods. Policy factors are local, state, and national laws, mass communication, and overall culture (McLeroy et al., 1988) Socioe cological models have five central components that guide health interventions: (1) they should be

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31 intrapersonal, organization, community and policy levels, (3) behav iors are influenced across levels, (4) multiple levels impact individual behaviors, and (5) interventions should use multiple levels of influence (Glanz et al., 2015) T ranslating the socioecological theory into guidelines for community health promotion, t he focus is shifted from individual behavior to the environment. I ndividuals can have high self efficacy ; however, if the environment is not conducive to behavior change, the y may not be successful (Stokols, 1996) Furthermore, theory should be integrated into behavior change interventions (Glanz et al., 2015; Stokols, 1996) The active living domains model for physical activity is an excellent reference to explain how the social and physical environment affects individual behaviors across the socioecologic al model (Sallis et al., 2006) This can be applied to other health behaviors for a more encompassing version of the model. Although this has been done ex tensively with health behaviors like physical activity, it can serve as a model for other public healt h concerns such as human trafficking. I t has been suggested that public health professionals take more upstream action s by evaluating the social determinants of health to facilita te individual behavior change (Watt, 2007) As public health professionals, m ore emphasis should be placed on evaluating the sociocultural and built environments in which individuals reside to better understand health behavior. The socioecological model can be u s ed to show considerations across all levels in which public health pro fessionals plan to incorporate an intervention or program to address sex trafficking and reduce vulnerabilities among different populations Essentially, the model can be implemented for survivor reintegration back into society through a collaborative app roach.

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32 The Present Study The purpose of this study is to determine what methodologically rigorous research exists on sex trafficking and to develop an understanding of survivors experience of reintegration into society. The focus i s on reintegration bec ause there are many factors that contribute to how and why people were vulnerab le to initial exploit ation, which lead s to the complex issue of facilitating survivor healing and recovery after being trafficked. It is helpful to understand the background of trafficking and resulting health disparities survivors encounter in order to appreciate the complex process of reintegration. A qualitative, grounded theory methodological approach will be undertaken to evaluate the complex social phenomenon of reintegration experienced by sex trafficking survivors as told by survivors and key informants. A scoping review will also be conducted t o understand the research base o n sex trafficking in the United States as it utilizes specific search criteria to identify the extent, key concepts, and gaps in literature to inform practice and policy. Specific Aims General goals of this study are to e xplore what information currently exists about human trafficking and the process of reintegration in order to facilitate survivor success. The first aim will include a scoping review conducted to identify the scientific research base, to determine potentia l voids in the literature and to categorize f indings to guide research. The scoping review of evidence research on sex trafficking focuses on the United States. Most research has focused on trying to identify the extent of trafficking, prevalence and risk factors or issues for healthcare providers T herefore, a full examination of available peer reviewed research will be conducted.

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33 The second aim is focused on develop ing an understanding of the experience of reintegration into society of sex trafficking s urvivors through survivor and key informant p er spectives. For A im 2 a qualitative, grounded theory methodological approach will be undertaken to evaluate the complex social phenomenon of relapse prevention in sex trafficking survivors as told by survivors and key informants. Data collection methodology : Grounded theory methods provide a set of general values, strategies, tactics, and exploratory devices rather than prescribed preparations. Constructing grounded theory involves specific steps, which utilize an iterative process of data collection and analysis C onstant comparison and continual connection with the data and emerging thematic content will serve to cultivate theoretical analyses from the start of the research study (Charmaz, 2014) It is importa nt to attempt to retain the knowledge in the research settings while remaining aware of the lived experience of the research participants. The goal is to study how participants explain their statements and actions along with what logical sense can be formu lated based on their statements, experiences and perceptions (Charmaz, 2014) The process of grounded theory starts with formulation of a research question followed by purposive recruitment and theoretical sampling of participants. Data collection consist s of gathering rich data though the use of intensive interviewing (Charmaz, 2014) See Figure 1 3 (Tweed & Charmaz, 2011) Epistemology Epistemology molds the expectat ions in which reality is formed and the knowledge associated with the generated reality. Based on these assumptions, various logic, methods, and focal points are then generated. An epistemological view is formed by providing a philosophical basis for the d etermination of knowledge that is suitable

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34 and valid (Crotty, 1998) In this study, epistemology is a lens through which the data are recognized, explored, and evaluated by including the underlying beliefs and values associated with the researcher. Instead of accepting views of professionals in terms of a top down approach, this analysis seeks to integrate a bottom up approach to empower those involved in the research question to have respect for all involved and value all contributions (Duran et al., 2012) The epistemological viewpoint to be employed is subjectivism with a theoretical perspective of social justice from the American Associaiton of P ublic H ealth (APHA) and National Association of Social Workers (NASW) professions. One of the primary focuses of public health is to enhance social justice and to empower disenfranchised groups (Public Health Leadership Society, 2002) In the ethical practice of public health, social justice comes from empowering d isenfranchised groups : of disenfranchised community members, aiming to ensure the basic resources and (Public Health Leadership Society, 2002 p. 7 ) The profession of social work includes social justice as part of its code of ethics : Social workers pursue social change, particularly with and on behalf of vulnerable and oppressed individuals and groups of people. Social efforts are focused primarily on issues of poverty, unemployment, discrimination, and other forms of social injustice. These activities seek to promote sensitivity to and knowledge about oppression (National Association of Social Workers, 1996 p. 2 ) Int egration of public health and social work theoretical perspectives also points toward cultural competency to address inequality and injustice present in society. A qualitative account of events has been recommended as necessary to gather

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35 community perspect ives as a basis for social change (Mertens, 2007) When striving for social justice as the primary aim of the research, it does not matter if you use qualitative or quantitative methods to find your answers, but rather one becomes a biocular in which you construct meaning out of any and all tools possible in order to advocate for the oppressed and marginalized (Denzin, 2010) Further, reflexivity is a way of emphasizing the importance of self awareness and ownership of one's perspective. The perspective of qualitative researchers should be considered as the context for results and utilizing humans as instruments of qualitative methods. As a qualitative inquirer, it is vital to understand the information and individual have knowledge of, what forms the vie wpoint of the individual, how to express the perspective, and the next step of utilizing the findings (Patton, 2002) Therefore, a reflexivity statement is included to further explain the epistemological lens in which this research was conducted. Reflexivi ty help children especially those in the foster care system. I received a certificate in child welfare as part of my degree, which included several classes regarding the vuln erabilities of children and an internship with a child welfare agency. I started out as an intern for the Department of Children and Families in 2007. My next internship was with a private foster care agency, which licensed foster homes. My position includ ed individual and group counseling sessions as well as visiting children in their homes and at their schools. One thing I found was that most of the children had experienced some form of sexual abuse.

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36 At that point, I decided to work on obtaining my maste so I could do advanced therapy with children who had been sexually abused. Another thing I had learned as my internship continued was that many of the children in foster care would regularly run away would eventually be found but some would not. I never understood why there were not greater search efforts. I was highly discouraged by the manner in which the foster care system operated. These are our children, our vulnerable ch ildren, and as wards of the state we are to protect them. Through the next year of being in the field I learned I could not work in that capacity due to the feeling of helplessness. I left social work and moved into the health field in 2010. I wanted to h elp people gain a health status that included mental, physical, emotional and spiritual wellness. As the next few years went on, I learned about the human rights issue known as human trafficking. Being a social worker at heart and an advocate for social j ustice, I felt the call to learn more about human trafficking and how I could help those who are exploited. What I did not realize at the beginning was that one of the highest risk groups for human trafficking were those children in the foster care system. This deeply affected me and encouraged me to get involved to spread awareness and work with survivors. I became involved with a ministry at my church and also with the Human Trafficking Coalition of the Palm Beaches in 2013. My efforts included conductin g trainings, helping with documentary screenings, starting conversations and participating in child sexual abuse awareness efforts. I was asked to chair the committee at Palm Beach State College in 2015 due to my experience in social work and with my human trafficking efforts. In this position, I have held several awareness events each semester

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37 and have collaborated with Career Source of Palm Beach County to develop a scholarship fund for in demand jobs for survivors. I also started an exercise program at a local safe house, Hepzibah House, for human trafficking survivors in order to decrease their anxiety, depression and PTSD symptoms, and also became involved in outreach efforts to find sex trafficking victims online, specifically children on the missing c All of these efforts are important in order to spread awareness to stop the demand for human trafficking as well as to work directly with survivors to empower them to develop tools to heal from traumatic experiences and reintegrate into soc iety. I have found, however, that most people do not understand the complexity and impact of the crime of human trafficking. I learned that we need to conduct more research in order to best determine how to assist those who have been trafficked by meeting needs they can identify. Teaching people about trafficking is important W e can encourage others to decrease activities that may support trafficking and to know the warning signs so they can call in suspicions of trafficking to the human trafficking hotli ne. While this is all very important, I have found that we also need to figure out how and why this all started. What do these trafficking survivors have in common that put them at risk and made them vulnerable to traffickers? We need to help victims find their voices and listen carefully, so we can learn how to best help them. What do they need, what do they think would help them heal, and how can we assist them in adjusting to a new life? Can we help them dream? I believe in human rights and fighting for social justice, that as a society we must advocate for those in vulnerable positions who need assistance. I feel I must be in this

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38 field due to my awareness of the issues and the experiences and resources I have a vailable resources that can elevate awareness, decrease risk, and help survivors reintegrate. M any aspects need to be focused on to end this epidemic. Not enough is understood about the issue of human trafficking, what to do about it, how to stop the deman d, and how to help those who have been affected. My goal is to shed some light on this dark issue to bring awareness and prevention as well as create systemic change and to empower survivors to live a better life.

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39 Figure 1 1 The Action Means Purpose Model (Polaris, 2012)

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40 Figure 1 2 The Power and Control Wheel

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41 Figure 1 3 Data Collection Process (Tweed and Charmaz, 2011)

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42 CHAPTER 2 SEX TRAFFICKING IN THE UNITED STA TES: A SCOPING REVIEW The issue of human trafficking exists worldwide. Human trafficking is often referred to as modern day slavery in that traffickers exploit individuals to make a profit through sex or labor. The prevalence and incidence of trafficking is difficult to estimate because trafficking is illegal. The International Labour Organization (ILO) estimates more than 40.3 million individuals are trafficked globally, with more than 4.8 million forced into sexual exploitation (International Labour Orga nization, 2018). In 2017, the U.S. human trafficking hotline received 26,557 reports from across the country, which led to the identification of 8,524 human trafficking cases. They also provided resources and referrals to 10,615 victims and received 4,687 direct calls from victims themselves. In 2017, 6,081 calls were related to sex trafficking alone (National Human Trafficking Hotline, 2018b) Further, calls to the hotline provided information on 4,863 suspected traffickers and 1,698 businesses involved i n the trafficking of persons (National Human Trafficking Hotline, 2018b) Although there is no official estimate of total individuals affected by human trafficking, figures in the United States are estimated to be hundreds of thousands of adults and minors in sex and labor trafficking extrapolated from number of reports because many cases go unidentified (National Human Trafficking Hotline, 2018a) Although estimates of total individuals affected by sex and labor trafficking are extrapolated from reports, s ince many cases go unidentified Polaris estimates US figures to be in the hundreds of thousands of adults and minors per year. For the purpose of this study, victims refer to individuals affected by the crime of human trafficking. Survivors refer to indiv iduals who have somehow escaped the trafficking situation and are in the recovery process. Survivor will be used

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43 more often as a form of empowerment in recognition of the strength required for people to escape from human trafficking. This study examines the issue of sex trafficking in the United States. According to the Trafficking Victims and Protection Act (TVPA) of 2000, sex trafficking is a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age; or the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servit ude, peonage, debt bondage, or slavery ("TVPA," 2000 p. 1470 ) Extreme health disparities exist among sex trafficking survivors, with disproport ionate morbidity and mortality compared to those who have not been exploited in this way (Kiss, Pocock, et al., 2015) This makes sex trafficking a public health issue As such, public health professionals must examine the implications of this occurrence to reduce health disparities, enhance health equity, and improve quality of life (US Department of Health and Hu man Services, 2018b) A variety of health issues affect s a wide range of trafficking survivors, including those related to reproductive health, child and maternal health, chronic disease, violence, mental health and substance use disorders Research exami ning the health consequences for those who have been trafficked is limited but the health consequences can include sexually transmitted diseases (STDs) including HIV, multiple pregnancies, miscarriages, abortions, a nd undiagnosed chronic disease (Macias K onstantopoulos et al., 2013; Zimmerman et al., 2008) Those trafficked for sex experience significant health disparities in the rates of STDs, infertility, reproductive damage, broken bones, burns, physical trauma to the head, and sexual violence by traffi ckers and buyers (Davis, 2000; Deshpande & Nour, 2013) Many trafficked

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44 individuals may be forced to have abortions or are beat en for being pregnant leading to miscarriages (Deshpande & Nour, 2013) Further, the a verage lifespan of a prostitute d individual is 35 years of age, with a mortality rate 40 times high er than that of the general population (Farley et al., 2003) Abuse and victimization can occur in many forms. R esearch findings on childhood trauma and violence indicate short and long term morbidity and mortality consequences (Ouellet Morin et al., 2015; Rossiter et al., 2015) an d trafficked individuals report being subjected to regular physica l abuse and other use of force (Kiss, Pocock, et al., 2015) S urvivors may also report restriction of movement to locations specified by their trafficker s as another aspect of mental and physical abuse (Kiss, Pocock, et al., 2015) Due to the extent of health disparities associated with sex trafficking, further review of the research is warr anted to better understand related public health implications. Therefore, a scoping review is necessary to ascertain the extent of the current peer reviewed literature base. Due to the current state of sex trafficking in the United States and associated he alth disparities, it is imperative to evaluate the evidence based literature in the U.S. to determine appropriate actions, including the need for additional research. Methods Research Question This scoping review seeks to answer the following research que stion: 1. W hat peer reviewed research is available on sex trafficking in the United States? Methodology A scoping review was conducted to identify the scientific research base, to determine potential gaps in the literature and to categorize findings to gui de research.

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45 Because the focus was describing the volume of existing research, a scoping review methodology was selected rather than a systematic review which would include a formal quality assessment. Only peer reviewed published studies, including prima ry or secondary data analyses, were included. I t is necessary to have a standardized gu ideline to normalize reporting in proper reporting of scoping reviews (Tricco et al., 2016) The most widely used scoping review framework s are utilized in this study ( Arksey & O'Malley, 2005; Levac, Colquhoun, & O'Brien, 2010), a methodology that will adhere to reporting guidelines to advance knowledge in the field provide direction for future research and influence policy recommendations. There are five different sta ges in conducting a scoping study: 1) identifying the research question, 2) identifying relevant studies, 3) study selection, 4) charting the data, and 5) collating, summarizing and reporting the results. A scoping review utilizes logical context and thema tic structure so that a narrative account of present literature may be depicted (Arksey & O'Malley, 2005). Thus, a scoping review was chosen the extent of the sex trafficking peer reviewed research literature in the United States Building on the research of Arks (2005) recommendations are provided to explain and improve each stage of the scoping review process in order to increase the consistency in which scoping studies ar e reported. This includes consultation with clearly identified stakeholders to incorporate knowledge transfer to those in the field (Levac et al., 2010).

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46 Identification of Relevant Studies O nline databases PubMed, Science Direct, Sage, EBSCO, Web of Science, Ovid and Proquest were reviewed for articles published from January 2000 March 2018. Eligible articles were initially screened for relevance using titles and abstracts, followed by more in depth review of each study for final article inclusion. Further, backward s earches were conducted to examine references in included articles and these articles underwent the same selection process Three researchers independently reviewed initial papers for eligibility. If there was disagreement, further discussion would occur to come to a final decisions. Grey literature was not included in this study as the methodologies are not always clear. Selection of Studies Final selection of studies met the following criteria: a) collected and analyzed either primary or secondary data, b) qualitative or quantitative analysis c) peer reviewed research and d) focused on the United States. After full examination of all identified studies (n=78) articles were considered to meet all inclusion criteria Only papers published in English in p eer reviewed journals were considered for inclusion ( Figure 2 ). Three researchers reviewed full articles select ed for inclusion and summarized the data to be charte d. Quality control was u s ed among discussion of reviewers to ensure agreement on final study selection and data abstraction from the studies. Three researchers reviewed the initial categorization of studies along with subsequent themes identified. All res ults were presented to stakeholders within the human trafficking field to

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47 ensure appropriateness of the themes reported. Final reporting of study selections were done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) statem ent flow chart and checklist to enhance transparency (Moher, Liberati, Tetzlaff, Altman, & Group, 2009) Results Six themes were identified in this scoping analysis: awareness (n=17), identification (n=9), risk factors (n=19), health issues (n=5), legislation and implementation (n=18) and exploiters (n=10) ( Table 2 1 ) with outline of article inclusion (Figure 2 1). Awareness The theme of awareness inclu des the subthem es of attitudes and beliefs (n=5 ), knowledge and training (n=5), media framing (n=4), and prevention programs (n=3). Attitudes / beliefs Five studies were included in the attitudes and beliefs subtheme. Of these, two studies were qualitative, two were quantitative, and one was mixed. These studies included data collected from students (n=3) and nurses (n=2). One quantitative analysis review ed myths around sexual violence and prostitution among undergraduate students (n=409); this study employed vignette; students then completed a myths scale. Gender and myth acceptance affected the scores, whereas personal sexual trauma history did not. Male s were more likely to accept myths and blame victims, and they were more accepting of human trafficking. Women had much higher rates of victimization, which translated to them better understanding gender based violence (Cunningham & Cromer, 2016)

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48 A seco nd study focused on development and validation of the perceptions, knowledge and attitudes around human trafficking questionnaire (PKA HTQ). Data from social work students (n=325 and n=212) were evaluated in an exploratory factor analysis (EFA) and replic ation study to confirm the findings, which reduced the questionnaire to 16 items (Nsonwu et al., 2017) Another study involved an exploratory (EFA) (n=301) and confirmatory (CFA) (n=300) factor analysis of the preliminary Sex Trafficking Attitudes Scale (S TAS), using psychology students as respondents. Women were more likely than men to express empathy overall and empathetic attitudes toward (Houston Kolnik, Todd, & Wilson, 2016) A qualitative study of human trafficking perceptions among nurses (n=10) in an emergency department revealed that they viewed those trafficked as young, female and foreign. No screening was performed in the emergency department (ED) for human trafficking; however, screening is conducted to determine if patients have been subjected to interpersonal violence (IPV). Individuals who have been victimized were emergency room nurses did not receive education on trafficking (Long & Dowdell, 2018) A mixed attitudes toward child sexual exploitation (CSE); qualitative interviews were conducted with those interested in parti nurses did not know how to approach a suspected case of CSE and felt separated from the rest of the school community. The nurses also reported being in a unique position to identify, protect, and incre ase awareness of students at risk (Fraley, Aronowitz, & Jones, 2018)

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49 Knowledge / t raining Within this subtheme, there were five quantitative studies, including those involving medical professionals (n=3), those working with at risk youth and/or crime vic general knowledge and training about human trafficking. A study of professionals working with at risk youth and crime victims (n=289) found that those in metropolitan areas thought trafficking was more serious, received training, and were familiar with state and federal laws (Cole & Sprang, 2015) An evaluation of mandatory reporters (n=577) across the United States found that 60% had no specific training and 25% believed tha t domestic minor sex trafficking (DMST) did not occur in their areas (Hartinger Saunders, Trouteaud, & Matos Johnson, 2017) A quantitative analysis (n=1648) of medical students, residents, and practicing physicians found that participants considered traf ficking important in their practices, as well as correctly estimating the number of trafficked youth and how to report trafficking. Still, practicing physicians knew more about how common trafficking is and how to report it (Titchen et al., 2017) In anoth er study, a training intervention was piloted with individuals working in the emergency department (ED), which included physicians, residents, nurses and social workers (n=180). After a 20 minute intervention, confidence tify sex trafficking victims increased from 4.8% to 53.8%, 56.7% (Chisolm Straker, Richardson, & Cossio, 2012) Another study of training for medical professionals, phy sicians, nurses, physician assistants, social workers, and family advocates (n=168) across multiple hospitals found that 63% had received no previous training. However, after reviewing two cases, 48% correctly identified a sex

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50 trafficking victim and 42% we re able to distinguish DMST from child abuse (M. Beck et al., 2015) Media f raming Studies examining media framing of the issue of sex trafficking (n=4) were qualitative (n=1), quantitative (n=2) and mixed (n=1), focusing on media framing (n=3) and sex wo rk advocacy framing (n=1). An analysis of United States newspapers in 2009 found that most stories used episodic framing of sex trafficking as a crime without discussing any proposed remedies and with little involvement from survivors or advocates (Johnsto n et al., 2014) Another study reviewing New York Times articles (n=270) and CNN videos (n=22) from 2000 2012 found a small number of stories while reporting a yearly increase. Further, the media were not addressing the root of these issues, along with per sonal and community implications of trafficking (Martinelli, 2012) In a larger 1990 2006 study, articles (n=2,462) were reviewed to determine framing regarding human rights, crime and national security. A change in public perception over time appeared to correlate with adopted policies, which s hift ed away from treating human trafficking as a human rights problem to ward framing it as a criminal justice problem. The problem of human trafficking, however, is more complex than simply arresting traffickers and rescuing victims, as portrayed in the media (Farrell & Fahy, 2009) A study reviewing anti analysis (n=19) from 2010 2012 in Las Vegas found that not everyone views sex work as a social problem. Jackson (2016) argued that labor/equal rights around criminalization should be distinguished from sex trafficking as not all sex workers are victims (Jackson, 2016)

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51 Prevention programs Three studies evaluated prevention programs for at risk groups. A quan titative study for an at risk population tested a 10 week psychoeducational intervention for runaway, homeless and street youth (RHSY) (n=23) to increase resiliency. A pre posttest design was utilized. The results showed that a safe, encouraging and friend ly environment was conducive to building resiliency in this population. Protective factors against sex trafficking included self esteem, increased knowledge about exploitation and manipulation, and healthy relationships. The most important factor was havin g a safe place to explore their values among parents, peers, and significant others (Countryman Roswurm & Bolin, 2014) A mixed methods study to pilot knowledge and attitudes about CSE among adolescents (n=48) used pre and post tests among those deemed p otentially at risk, as identified in a sexual health clinic in Atlanta. The intervention included the use of a website, videos, and interactive features, including excerpts from a documentary, Very Young Girls, developed by Girls Education and Mentoring Se rvices (GEMS). The results demonstrated increased knowledge and less tolerance of CSE among these adolescents. Focus group interviews revealed that self worth, asking for help and healthy relationships can prevent CSE (Murphy, Bennett, & Kottke, 2016) An other preventative intervention was conducted among African American middle school girls (n=36), who received an 8 week curriculum. Focus group data showed that the girls often had difficulty trusting in relationships; many had experienced peer aggression and were familiar with prostitution and sex as a commodity. Limited social support was noted as a risk factor and it was encouraged to foster resilience in interventions (Kruger et al., 2013)

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52 Identification The theme of identification included subthemes of proper identification of victims (n=4) and screening tools (n=5). Proper identification of victims Identification of victims included three studies involving criminal justice populations. Studies were quan titative (n=1) and utilized mixed methods (n=2). This subtheme centers on assessing whether law enforcement personnel properly identify sex trafficking survivors. A study reviewing differences between sex workers and trafficked women (n=38) found that thre e of four sex workers had experienced crimin al victimization. Most of these were violent; two of three had experienced arrests (drug or prosti tution related), with one in four r eporting that pol ice officers paid them for sex. These women were rarely consi dered v ictims when working with social services. Trafficked and non trafficked women were equally likely to be arrested, thus indicating that the justice system fails to recognize victims. Victims are not likely to attend cour t without criminal involvement (Finn, Muftic, & Marsh, 2015) Another supporting study reviewed closed human trafficking cases (n=140) and interviewed professionals (n=166); the researchers found that the culture of local police agencies and police officials perceptions about human tr afficking do not support identification of a b road range of cases. Police primarily focus on minor sex trafficking, which they perceive to be more serious. Additionally, local police were unclear about what constituted human trafficking (Farrell & Pfeffer, 2014) A study with juveniles (n=126) analyzed six agencies involved in prostitution stings. The results showed that law enforcement identified 60% of juveniles who had been arrested as victims, while 40% were classified as offenders. Classification

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53 appea red to be influenced by prior history, cooperation, identification of exploiters, and whether the juveniles had been reported initially as victims. The researcher pointed out, however, that in keeping with current law, this form of CSE should be considered child abuse, and necessary services should be provided (Halter, 2010) A qualitative study of youth (n=901) in the criminal justice system examined commercial sexual exploitation of children (CSEC). A risk tool, called the Sex Trafficking Assessment Revie w (STAR), was created to identify youth as being at high, moderate or low risk for sex trafficking. High risk STAR statuses were associated with depression, sexual abuse, and gender (Andretta, Woodland, Watkins, & Barnes, 2016) Screening Studies within t he subtheme of screening (n=5) evaluated questions or specific screening tools that may be used to identify victims. All studies were quantitative and included populations of survivors (n=1), prostitutes (n=1), and healthcare facilities (n=3). In one study survivors (n=117) were surveyed about which types of establishments they frequently visited during their time being trafficked. This study revealed that emergency and urgent care (56%) facilities, followed by primary care, dental clinics and obstetrician s/gynecologists (OB/GYNS), were most likely to encounter victims. Survivors reported that helpful screening questions included those asking about their current living situation 61% (n=31) and current work 84% (n=4 3). Of those who spoke to a health care pro vider about their situation, 72% (n=36) re ported being offered information on how to escape (Chisolm Straker et al., 2016) Three studies were conducted in healthcare facilities to ascertain the ability of screening tools to predict which adolescents were most vulnerable to sex trafficking. Children 12 to 18 who were identified as victims of sexual exploitation / children/child

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54 sex trafficking (CSEC/CST) were compared with similarly aged victims of sexual assault/sexual abuse (ASA). A six item screening to ol examined the relationships of CSEC/CST and ASA with reproductive history, high risk behavior, sexually transmitted infections, and violence. The screening tool was sensitive enough to accurately determine those trafficked (sensitivity of 92%) and to det ermine those not trafficked (specificity of 73%). Significant differences were found across both populations, indicating that the questions could provide a short and effective screening tool for high risk adolescents (Greenbaum, Dodd, & McCracken, 2018) A nother screening tool utilized in the ED (n=143) included 14 questions, which revealed 39 screened as sex trafficking victims and 10 ultimately identified as sex trafficking victims. Sensitivity was better on the survey (100%) than physician report in this study (40%). However, specificity was better for physician reports (91%) when compared to the survey (78%). The researchers noted that one screening question regarding abuse might be sufficient to identify all victims: [or anyone you work with] ever beaten, hit, yelled at, ra ped, threatened or made to feel physical pain for working slowly or for trying to (Mumma et al., 2017) Another study tested the impact of training ED employees (n=102) to use a screening protocol algorithm that increased identification of victims, with 97% of employees reporting commitment to identifying victims. Within five months, employees in this emer gency department had identified 38 potential victims, and five were given assistance to escape their situations (Egyud, Stephens, Swanson Bieman, DiCuccio, & Whiteman, 2017) Another study utilized the Trafficking Victims Identification Tool (TVIT) at a se rvice agency for sex workers. Based on application of the tool, 54% (n=15) were likely

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55 to have been trafficked at some point. Three specific questions were found to be most linked to sex trafficking and distinguishable from labor trafficking: Did anyone yo u worked for or lived with trick or force you into doing anything you did not want to do? (TVIT15), Did anyone ever pressure you to touch another person or have any unwanted physical or sexual contact with another person? (TVIT16), Did you ever have sex fo r things of value (for example money, housing, food, gifts, or favors)? (TVIT18). This indicates the potential for using shortened measures for initial screening for sex trafficking (Williams, Wyatt, & Gaddis, 2018) At Risk Populations Studies (n=19) inc luded primary or secondary data from housing for CSE youth (n=2), juvenile justice system (n=4), child welfare involvement (n=3), healthcare provider visits (n=7), and current commercial sex work (n=3). Although risk factors were generally assessed, across studies potential risk factors were different, therefore studies were categorized by population assessed. Studies included minors (n=14), adults (n=3) or both (n=2). Study participants were only female (n=5), only male (n=1), or both genders (n=13). Studi es qualitative in nature (n=3) had smaller sample sizes (n=21 22). In quantitative studies, most sample sizes were greater than 100 (n=12). However, a few studies had smaller sample sizes of 23 64 (n=5), and one was a case study. Top statistically signific ant risk factors for sex trafficking, as found in the articles of this section, are shown in (Table 2 2). The most represented risk factors were substance use disorders (n=16), adolescent sexual victimization and child abuse (n=13), mental health concerns (n=12), running away (n=9), involvement with child welfare (n=8), and emergency medical visits (n=7). Not all risk factors were discussed in each study; therefore, counts were done only for studies in which these characteristics

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56 were mentioned. This does n ot mean those risk factors were not present, only that they were not all assessed. Housing for CSE y outh Individuals sexually exploited as children were significantly more likely to engage in substance abuse, sexual abuse victimization, and have histories of arrests and school suspensions (Shaw, Lewis, Chitiva, & Pangilinan, 2017) One study of minor females (n=22) living in a group home for those who have experienced CSE presented with low IQ, PTSD and depression. Thirteen of the participants had IQs that would make them eligible for special education services in the mild to moder ate mental retardation category, thus indicating the need for understanding the increased risks for those with intellectual disabilities (Twill, Green, & Traylor, 2010) Juvenile justice s ystem Four studies on minors in the juvenile justice system included commercial sexual exploitation (CSE). An interesting finding was that a majority of participants in these samples were males, who tend to have more involvement in the criminal ju stice system but are also an under recognized population when it comes to sex trafficking. A study (n=114) of males (86%) and females (14%) suggest s that CSE/prostituted youth are involved with substances (using or selling) year to year but are not always subjected to CSE/prostitution from year to year. A ssociations between CSE/prostitution and substances were found throughout the study Further substance involvement at one year was linked to CSE/prostitu tion during the subsequent year (J. Reid & Piquero, 2014b) Another study from a sample of juvenile offenders (n=2,354) reported that eight percent of males and females reported having been paid for sex (n=189). Findings depicted African American males at increased risk for CSE, but there was no racial

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57 diff erence in risk among females. For all participants, educational attainment, maternal substance use disorders and earlier onset of sexual activity were risk factors. For males, rape and substance abuse was associated with earlier onset of CSE, whereas only substance abuse for females was associated with earlier onset of CSE (J. Reid & Piquero, 2014a) In a study of (n=1,354) serious youth offenders, 113 reported being paid for sex or had received a prostitution charge. Interestingly, there was no significan t difference between males and females reporting CSE. Results showed that parental substance use and arrests, running away, and their own substance use significantly affected both genders. For males, negative self image and earlier onset of sexual activity were associated with CSE, whereas for females, only earlier onset of substance use was related to CSE (Reid J. & Piquero, 2016) One study, of males (n=800), was conducted in the juvenile justice system with 10% (n=70) of those who answered the domestic m inor sex trafficking (DMST) question. Child sexual abuse, substance use, and lack of sexual discomfort were significantly associated with DMST (O'Brien, Li, Givens, & Leibowitz, 2017) Child welfare involvement Three studies included in this subtheme invo lved child abuse hotline allegations (n=2) and those already in the child welfare system (n=1). In a study of labor and sex trafficking allegations in minors (n=3,240) among the child welfare system in Florida from 2009 to 2016, out of approximately 300,00 0 case files was reviewed. Children with trafficking allegations were twice as likely to have had previously reported child abuse and out of home placement, five times more likely to have been placed in group foster homes, ten times more likely to have run away, and 15 times more likely to have run

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58 away multiple times compared to children with non trafficking related case files ( Gibbs, Henninger, Tueller, & Kluckman, 2018) In a study of calls to the Florida Abuse Hotline for suspicion of human trafficking (n=913), calls were matched to non trafficking calls, in which researchers found that adverse childhood experiences (ACEs) scores of six or higher were associated with human trafficking abuse reports. ACEs include factors such as domestic violence, parenta l incarceration, child sexual abuse and neglect (Felitti et al., 1998) The strongest predictor of trafficking was prior child sexual abuse, with odds of 2.52 times greater for females and 8.21 times greater for males (Reid, Baglivio, Piquero, Greenwald, & Epps, 2017) A study of Illinois child abuse allegations from 2011 2015 found allegations of human trafficking (n=563) among 697,062 total child abuse allegations. Of this sample, participants were female (90%), African American (53%), living in urban are as (56%), had run away or lived on the streets (96.8%), had mental health/behavioral concerns (93.7%), had a previous child abuse allegation (61%), at least one out of home placement (28%) and received care at a pediatric hospital within the past year (82. 5%). Additionally, only one male was identified as a victim of CSE, indicating under recognition and underreporting of males (Havlicek, Huston, Boughton, & Zhang, 2016) Healthcare provider visits Seven studies conducted analyses of emergency room, pediatric medical and healthcare facility visits. A study found that 82.5% of children in the child welfare system had received care at a pediatric hospital in the past year (Havlicek et al., 2016) Anoth er study on medical DMST evaluation (n=41) found that youth evaluated for DMST presented with complex medical and psychiatric conditions; this sample included only one male. Risk factors associated with DMST included recent medical care (81%),

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59 sexual abuse (57%), parental substance use disorders (60%), STDs (32%), psychiatric needs (46%), previous suicide attempt (20%), substance use (88%), running away (63%), lived in a group home (42%), or lived at home (68%) (Goldberg, Moore, Houck, Kaplan, & Barron, 201 7) In another study of minors (n=63) referred to emergency care for CSE, n=52 were identified, with only one male. Risk factors included participants who were African American (54%), gay/bisexual (33%), obese (34.9%), had early sexual activity (58.7%), hi story of running away or living on the streets (98.6%), had 10 or more partners (34.9%), previous child sexual abuse (73%), previous medical sexual abuse assessment (39.6%), mental health/behavioral concern (93.7%), STDs (69.8%), and substance use (79.3%) (Horner & Sherfield, 2017) A study of commercial sexual exploitation of children (CSEC) in the pediatric healthcare setting found CSEC patients (n=84) were more likely to have experiences with substance use, running away, violence, involvement with child welfare and criminal justice (Varma et al., 2015) In a propensity score matching study among 215 youth from 56 U.S. juvenile justice, child welfare and health care agencies onl y 43 youth met criteria for CSE, which was measured by one question on prosti tution. More youth may meet the criteria for CSE ; however, there was no mention of quality control of records in this study. Those participants demonstrated much higher rates of externalizing behavioral problems, posttraumatic stress disorder ( PTSD ) child hood sexual abuse, problems skipping school, hypersexualized behavior, substance use, running away, and criminal activity compared to 172 youth who were sexual abused/assaulted but not exploited in prostitution (Cole, Sprang, Lee, & Cohen, 2016)

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60 In a cas e study, a 29 year old female who had been trafficked visited the emergency room with a past medical history of intravenous (IV) drug abuse, recent relapse, and reported sexual assault. She was released upon her request but returned the next day with suici dal tendencies and a heroin relapse. At this time, she reported having been locked in a closet and forced into commercial sex to repay her drug dealer. Per patient agreement, the situation was reported to the trafficking hotline and she was moved to an i n patient psychiatric unit. She also had a history of child abuse, substance use, previous sui cide attempts, and PTSD (Gibbons & Stoklosa, 2016) In another study aimed at categoriz ing survivor encounters in healthcare key informants (n=6) and survivors (n =12) were interviewed. Half of the survivors reported seeing a physician while being trafficked ; another was currently working in a health care facility. Sex trafficking survivors are more likely than non trafficked individuals to be seen for STDs and abor tions ; however, survivors felt shame in disclosi ng to medical providers that they were being trafficked (Baldwin, Eisenman, Sayles, Ryan, & Chuang, 2011) In a nother qualitative study of key informants (n=277) across eight US counties researchers found that 50% of sex trafficking su rvivors sought medical care while being trafficked. L ow awareness and the inexperience of healthcare providers resulted in fewer survivors being treated appro priately (Macias Konstantopoulos et al., 2013) Current c omme rcial sex work Three studies were conducted among minors and adults currently involved in commercial sex work. A study of individuals 16 and older and currently involved in the commercial sex industry (n=273) found n=116 current or former DMST victims. Th e strongest predictor of DMST was running away from home. Childhood abuse, sexual assault, running away, having family members in sex work, and having friends who

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61 purchased sex were all significant risk factors for DMST involvement. Additionally, DMST vict ims were more likely to be racial/ethnic minority runaways than adults in the study who had not been trafficked previously (Fedina, Williamson, & Perdue, 2016) Another study of commercial sex workers (n=328) found that substantial percentages of minors (n =61) and adults (n=54) were sex trafficking survivors. Survival sex for food or shelter and peer influence increased odds of DMST. Lack of perceived support while attempting to exit trafficking increased the odds children proceeding into adult human traffi cking (Chohaney, 2016) One study of adult females (n=174) who were previously victims of CSE was conducted to ascertain risk factors during childhood. The study found that child sexual victimization, younger onset of substance use, and intimate partner vi ctimization were factors associated with onset of CSE. Educational attainment differed among those who continued from adolescent into continued exploitation as an adult. Two thirds of those no longer exploited as adults had completed their high school educ ation, whereas only 13% of those exploited as adults had completed high school (J. A. Reid, 2014) This suggests that educational attainment is a protective factor. Health I ssues Five studies directly evaluated health issues associated with sex traffickin g, including subthemes of physical and mental health (n=3), trauma, and trafficking experience (n=2). Mental and physical health A study of prostitution and sex trafficking of American Indian/Alaskan Natives (AI/AN) (n=105) aged 18 60 was done to assess existing health issues. The study found 98% were current ly or previously homeless. Reported physical health symptoms included muscle pain (72%), impaired memory (69%), impaired concentration (69%),

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62 headaches (57%), vision problems (55%), stomach pain (48%) neck pain (44%), shortness of breath (39%), nausea (36%), pain or numbness in hands and feet (33%), asthma (32%), and dizziness (30%). W omen experienced more severe physical symptoms when higher levels of PTSD and dissociation were found. Of women with P TSD symptoms (74%), more than half (54%) met full clinical criteria for PTSD diagnosis. Seventy two percent of women had suffered traumatic brain injury as a result of violence R ecommendations from women concluded counseling and peer support would be help ful for them to leave their situations. Additionally, 39% were younger than 18 wh en they were first prostituted, and 45% met criteria of sex trafficki ng per the TVPA. T he rates of violence were extreme while being prostituted. Victims were threatened with a weapon (78%), physical assault (84%), raped (92%), raped more than 5 times (of those raped) (68%), injured by a caregiver as a child (56%), and sexual abuse as a child (79%) (Farley et al., 2016) A qualitati ve study of incarcerated wome n (n=21) was conducted to identify experiences healthcare access, reproductive health and infectious disease s during their trafficking Common healthcare locations were emergency departments, jails, Planned Pa renthood offices, and health departments. F or some, jail was the only source of healthcare provision. All participants used either cocaine or heroin while being trafficked. W omen stated that traffickers would not give them access to healthcare, being fearful of their trafficker, fear ful of hospitals a nd law enforcement and substance use. These were reasons for not getting proper healthcare despite fears of disease. Women reported using condoms when they could but J ohns (buyers) would beat them, sometimes the trafficker would refuse to let them use co ndoms and sometimes

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63 condoms broke. T hey would make excuses to providers for repeated HIV tests, emergency contraception, and engag ing in practices such as drinking antibiotics and cleaning themselves out to decrease infections. To illustrate, t wo of the w omen were HIV positive and were sca red to tell their traffickers or to infect the buyers (Ravi, Pfeiffer, Rosner, & Shea, 2017) A study assessing runaway adolescents (n=62) using a mixed methods survey and forensic exam found the following characterist ics among this population: healed hymeneal laceration ( 20.4%), positive chlamydia screen (38.5% of females and 28.6% of males), lived with a pimp (26.2%), lived with at least one parent (53.4%), homeless (32.2 % ), individual education plan (IEP) (40.4%), on free or reduced lunch (81.5%), greater than ten days truant (100% of males and 45.1% of females), PTSD (78%), DSM criteria SUD (54%), cutting (71%), suicidal ideation (75%), and suicide attempts (50%). Interestingly, males accounted for 12.7% of the study sample and more often engag ed in commercial sex without a pimp. Higher r ates of suicide attempts, PTSD and substance use was found among those with a pimp (Edinburgh, Pape Blabolil, Harpin, & Saewyc, 2015) Trauma and trafficking experience Despite forms of child sexual exploitation due to previous abuse histories, adolescents may experience cognitive dissonance while participating in sexual acts with buyers (Edinburgh et al., 2015) M ultiple issues need to be addressed including buyers having sex with mi nors, high rates of PTSD substance use and childhood abuses (Edinburgh et al., 2015) As told by key informants (n=6) in a qualitative study, the trauma experience included pimp enculturation, aftermath, and healing the wound. The t rafficking experience l eads to prevalence of PTSD, depression and shame in women

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64 who have been sex trafficked (Hom & Woods, 2013) An analysis of survivors (n=6) found t here were many predisposing vulnerabilities leading to their entry in sex trafficking and increased barriers t o leaving their situations. Reports included environments that desensitized them to prostitution and previous abuses that normalized the behaviors. To successfully leave their situations they require safe relationsh ips and increased self esteem. Likewise, their substance use, severe trauma symptoms, and pregnancy were factors leading them to attempt leaving (Cecchet & Thoburn, 2014) Legislation and Implementation All studies (n=18 ) were related to current laws including TVPA legislation i mplementation ( n=6), implementation of Safe Harbor laws (n=2) barriers to services (n=4), program evaluation (n=4), and service utilization (n=2). Studies were quan titative (n=2), descriptive (n=4) and qualitative (n=12 ) in nature. TVPA implementation A r eview of polic y diffusion of human trafficking l egislation across all 50 states found wide discrepancies in comprehensive legislation. Findings include the following: legislatures with more women are more likely to pass legislation and states with neighboring states (t hat have already p assed legislation), are more likely to pass more comprehensi ve policies (Bouche et al., 2015) Another study review identified trafficking cases in Rhode Island from 2009 2013; these included six sex trafficking cases and one labor traffi cking case. The analysis found the cases consistent with other United States trafficking cases but with more in depth analysis of online ads and creation of a higher risk environment for traffickers (Skodmin, Dunham, & Hughes, 2016) The assessment took pl ace from 2001 to 2010 During this decade the federal sentencing of 2,258 cases

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65 were evaluated. Since the passage of the TVPA, few sex trafficking cases were actually sentenced under those statutes, despite passage of the TVPA a nd subsequent reauthorizations Moreover, the changes mainly reflect increased mandatory minimum sentencing requirements and longer prison sentences (Albonetti, 2014) The TVPA review passed in 2000 and stated it was important to ascertain cases of human trafficking si nce all 50 states have passed legislation against perpetrators. Logistic regression was performed to determine law enforcement organizational response s to human trafficking using data from national criminal justice survey s (n=255). As such, size of the org anization, openness to change, and early reports of hate crimes played large roles in identifying cases (Farrell & Pfeffer, 2014) Another study utilized interviews with criminal justice professionals (n=34) in a southern United States area known for DMST This study was conducted to determine the imp lementation and effects of TVPA, specifically with minors. One important finding was the lack of survivor participation in prosecution of traffickers because of trauma bonding, relapse int o trafficking, and lac k of self identification. R esults of the study found existing loopholes create d a low risk an d high reward crime of DMST. Another critical finding reflecting risk factors was congruent with studies in the juvenile justice system. Results showed that the cr iminal justice system is not identifying sex trafficking victims, minors are being charged with prostitution, DMST and that there is a lack of collaboration among prosecution of child pornography. It has been suggested that the lack of a standard victim c entered approach might explain why there are less convictions, as a victim is needed to prosecute a case. Moreover, the trafficker victim bond in minors is especially difficult to counter (J. Reid, 2013)

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66 Another study evaluated T Visa issues, a form of visa potential offered to human trafficking survivors if they cooperate with criminal justice proceedings. Unseen injuries, including mental health and trauma may interfere with survivor cooperation Authors evaluated T visa requirements, which all ow for receipt of services and work permission in t he United States for four years Mental health disorders however, are not fully recognized as health disparities faced by sex trafficking survivors and often impact complying with law enforcement cases (Gre er & Dyle, 2014) Safe H arbor l aw i mplementation which aim to take DMST victims out of the criminal justice system and place them into the child welfare system. One study reviewed nine states who enacted the law in 2012 by conducting interviews with Safe Harbor experts (n=32). Findings indicated that some states decriminalized prostitution only (n=2), diversion (rehabilitation) programs only (n=5), and decriminalization and diversion (n=2). Overall the st udy depic ted a paradigm shift, which treated CSE minors as victims and in need of services H owever, implemen tation varied widely. M any states lacked funding for diversion programs and some were detaining minors as a safeguard to not put them back on the streets vu lnerable to their traffickers. The following components were ascertained as necessary in Safe Harbor laws: implementation J or turns 18, type of protection, guidance for diversion, placements, services, funding, data collection, coordination/ task force, and oversight (Barnert et al., 2016) Another study evaluated four states that had safe harbor laws prior to 2011 to obtain s ufficient data to review minor prostitution charges during pre and post

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67 legislat ion. The four states evaluated were Connecticut, Texas, Washington and New York. All had declining prostitution arrests ; however, minors continue d to be arrested and charged with prostitution. Based on arrests as of 2011, New York and Texas had increased arrests for minor prostitution whereas Connecticut and Washing ton saw decreases. Since 1994 there was a n overall decrease of arrests in all states through 2011 but in 2011 Connecticut had two New York had 136, Washin gton had 24 and Texas had 108 (Mehlman Orozco, 2015) Barriers to services All studies with barriers to services were qualitative in nature with small sample sizes, (n=13 30). Two included participants w ho had experienced sex trafficking as children, one of minors and one of adults. The adult study included 30 women and 20 service providers. Results indicated survivor disclosure facilitated the processing of complex feelings and these individuals expresse d a desire to help other women in the same positions. Barriers included needing meaningful space to process, fear of judgment from providers, and fear of judgement from other women (Gerassi, Edmond, Fabbre, Howard, & Nichols, 2017) A study on youth found barriers to services including fear of judgment, confidentiality, perception of low quality services, and providers understanding of the streets, which assisted with their sur vival. However, stigma, fear of providers, and fear of law enforcement present common reasons for not accessing services (Ijadi Maghsoodi et al., 2018) Disclosure of intimate partner violence (IPV) and human trafficking to healthcare providers among surv ivors (n=25) was also evaluated. Two fifths of the sample were found to be survivors of human trafficking. Themes included patient provider

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68 connectedness, children, and social support. Those who had been trafficked disclosed a higher degree of fear regardi ng judgment of their situations ( Williams, Gonzalez Guarda, Halstead, Martinez, & Joseph, 2017) One study looked specifically at exiting trafficking with women ages 21 25 (n=13) who had been exploited between 8 17 but exited by 17. These researchers sough t to understand how these women were able to leave. Motives for exiting included the following: naming some one who ha d exited, others depending on them thinking about leaving, the role of family, pending motherhood, wanting to be free, sustaining exit, an d pro fessional systems not accessed, but feelings of it not being pr ofitable to exit and overall fear keeps them in This study also found that women felt they were judged by providers and law enforcement they encountered; therefore, they pushed back again st efforts of assistance (Corbett, 2018) Service u tilization A study (n=13) of youth ages 14 22, evaluated factors which impacted service utilization. Participants mostly reported first being sex trafficked around the age of 13, that they were in the pre contemplative stage of accessing services, and that they had attempted to leave the life. Girls primarily expressed combined issue s of the use of drugs to coerce and keep them performing, being homeless, being moved from foster care and substance abuse treatment, often engaging in survival sex for a place to sleep, exploitation across various venues, fear of judgment from outreach wo rkers, and their desire for outreach workers to bring service information, hygiene supplies, and condoms (Holger Ambrose, Langmade, Edinburgh, & Saewyc, 2013) Another study reviewed service utilization among pre certified human trafficking survivors (n=13 6). This study found that sex trafficking survivors were less likely to utilize services, and since foreign

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69 nationals who were trafficked to the United States were evaluated, they found that the lower tier country of origin indicated higher utilization of services. The most likely used services were mental health, referrals, social and legal services. However, due to fear of immigration status they were not partaking in services (Dewan, 2014) Program evaluation Women (n=85) in two different recidivism div ersion programs for prostitution related charges were evaluated over the course of 12 months. The study found no differences between the two day program, whether they were arrested and given the program as a plea deal, or if they were offered the service in place of arrest. Benefits of the pilot intervention include d: similar diversion results, cost savings, intelligence gathering, and a community per spective of victim centered services for prostituted adults (Roe Sepowitz, Gallagher, Hickle, Loubert, & Tu telman, 2014) A mixed method study of a residential treatment facility for adolescent girls (n=13) compared outcomes quantitatively with previous facility programs to a newer program for those who had been sexually exploited. This led to improvements in o utcomes for committing to staying in the program and transforming their lives, rather than running away. Specifically, the newer program was separate for sexually exploited youth focusing on issues unique to them, which included an adult survivor administe ring the My Life, My Choice curriculum, survivor mentor programs, a warm home like environment and culturally competent treatment (Thomson, Hirshberg, Corbett, Valila, & Howley, 2011) Another study on stakeholders (n=20) working with individuals who work with survivors of DMST included professionals from law enforcement, child welfare agencies, and nonprofit agencies. The overall findings included conflicting perceptions of runaway status, models of restrictiveness for service provision, and use of cell ph one and technology among youth

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70 in services. Discrepancies were centered on allowing runaway youth from facilities to come back, whether youth should be arrested or put into an enriched and comfortable environment, and whether access to technology kept yout h in contact with their traffickers or to recruit other youth (Sapiro, Johnson, Postmus, & Simmel, 2016) In another study, a mixed methods approach was used to evaluate three comprehensive programs for minors who had been sex trafficked. These researcher s found that services included crisis intervention, safety planning, educational support, mental health services, and employmen t services. Although diverse in terms of demographics and circumstances, two common patterns emerged: homeless young people exch anging sex to meet survival needs and emotional engagement with their trafficker ( Gibbs, Hardison Walters, Lutnick, Miller, & Kluckman, 2015) Exploiters The theme of exploiters (n=10) includes subthemes of traffickers and sex buyers. There were six studi es specific to buyer characteristic s: buying sex online as told by key informants (n=1), buyer online forum use (n=2 ), child exploitation ma terial (CEM), sharing online (n=2 ) and buyer attitudes/beliefs (n=1) Of these studies two sampled sex buyers directly, one focused on key informants, and another focused on online material available from peer to peer sharing networks. Four studies involved research regarding traffickers These includ ed qualitative (n=2) ; quantitative (n=1) ; mixed (n=1) based on minors trafficked (n=2) ; adults trafficked (n=1) ; and evaluations of traffickers (n=1). Two studies were on trafficker tactics a nd two on trafficker characteristics. Trafficker characteristics Trafficker characteristics involved two studies, one including traffickers themselves and one through the perspective of minor survivor s One study examined

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71 minors (n=31) in the child welfare system who were trafficked by family members f or substance use habits (81.8%). M ore often children had been sexually abused and lived in more rural areas. Mothers (64.5%), fathers (32.3%), or other family members (3.2%) s; however, when the mother was the primary trafficker, a secondary trafficker was involved (65%). Care giver thr eats, intimidation, authority (86.3%), and prostitution (86.3%), pornograph y (50%), and strip clubs (18%) (Sprang & Cole, 2018) Further, a study that reviewed psychopathy of offenders (n=1 17) who engage in sex trafficking of juveniles (STJ) found traffickers exceed the average score of incarcerated males in the United States. A latent class analysis (LCA) depicted that two types of traffickers aggressive/antisocial or charismatic/manipulati ve pose the greate st threat to society (Hargreaves Company, Patterson, Muirhead, & FBI., 2016) Trafficker tactics Trafficker tactics were evaluated through the survivor perspective in two studies. Through a study of exploited youth (n=79) and interviews w ith service providers (n=10) trafficker tactics included boyfriend scripts, giving money and gifts, friendship/family scripts, providing a place to stay, providing drugs, conspir ing against a caregiver, picking up at bus stops, threats regarding children and abortion, normalization of commercial sex and coerced co offending of criminal activity. Manipulation and exploitation of youth with intellectual di sabilities was also seen (J. A. Reid, 2016) In a nother study of women trafficked in the Los Angeles area (n=12) researchers found that psychological coercion forced the m into submission without physical force. This type of psychological and emotional abuse caused chronic stress which manifested as acute and chronic physical and mental health issues. C oercion included isolation from

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72 any social support, foster ing dependence on the trafficker, weak ening mental and physical stamina to fight against the trafficker, constant threats resulting in anxiety, occasional positive mo tivation for compliance, reducti on of self esteem, foster ing an attitude of the uselessness of resisting, and forcing victims to devel op habits of compliance (Baldwin, Fehrenbacher, & Eisenman, 2015) Sex buyer attitudes and characteristics One study compared a ttitudes and beliefs of s ex buyers (n=101) to men who do not buy sex (n=101). B oth groups were aware of trafficking, unsure about the nature of prostitution and felt time in jail and public exposure of crimes were more likely to be a deterrent for sex buying. The sex buyers score d higher concerning impersonal sex, hostile masculinity and expressed less empathy for prostituted women, seeing them as fundamentally different from other women (Farley, Golding, Matthews, & Malamuth, 2017) S ex buyer characteristics subtheme included fiv e studies of behaviors. One study interviewed law enforcement key informants ( n=40) in a qualitative study to assess how men buy sex and what words they use. Buyers wanted young girls 12 14 or girls closer to 18 who looked mature, so they would not be charged with a crime against a child. Key words included flowers fresh girlfriend college girl new new in town new here roses student young meat fillies and bunnies A lthough not the aim of the study, the researchers found that not all key informants had adequate knowledge about human trafficking. It was also found that victims were being treated as criminals in many instances. Key informants did acknowledge the need for prevention, interventions and assessment for programs as well as sa fe places for the girls to stay. Key informants recommended regulatory procedures among escort services,

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73 consistency of laws for sex buyers across states and areas, and rehabilita tion schools for buyers (Tidball, Zheng, & Creswell, 2016) Another study exa mined posts (n=666) on an online forum expressing three primary characteristics of buyers: the presence of youth or desire for youthfulness, presence of pimps, and awareness of vulnerability. The individuals on this site explicitly expressed the desire to buy sex from those who appeared younger and could be minors (Bounds, Delaney, Julion, & Breitenstein, 2017) One study reviewed sex buyers across 10 U.S. cities that have the highest rates rmation th rough online forums on how to find sex workers, learn services and prices, and learn how to avoid law enforcement (Holt, Blevins, & Kuhns, 2008) Another study examined child exploitative material (CEM) in online peer to peer (P2P) sharing networks. There are networks with severe CEM including sadistic acts with infants and to ddlers. Among five P2P networks, there were 840,000 downloads per month worldwide, with 9.5% of those arrested for trafficking P2P CEM who were identified by investigations of crimes against children offline. Further, arrests rates varied between 8 21% across these networks M ore severe CEM ha d higher share rates up to 29% compared to least severe share rates of 15% indicating more sharing among severe CEM materials. On a P2P networ k, BitTorrent CEM survival rates were almost 100% (Bissias et al., 2016) Another study used a software program RoundUp on 244,920 computers online in the United States. Eighty percent of the sample had less than 10 files during the specified year H owe ver, a small number of the computers less than 1% -shared more than 100 files on a P2P network i ndicating a need for law enforcement to focus on the high contributors in order to decrea se files available online (Wolak, Liberatore, & Levine, 2014)

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74 Discus sion This scoping review reported on a wide range of factors involved with sex trafficking in the United States H owever, all thematic areas require additional research to confirm findings. There was almost an equal number of qualitative and quantitative studies, which is appropriate considering that qualitative research facilitates a better understanding of a phenomenon prior to more quantitative assessments. Overall, the research shows that those working in health profess ions and students training for those professions need more awareness of how to identify sex trafficking victims as they may encounter individuals affected by human trafficking. This should include training to enhance identification of victims and better p rovide appropriate service s There app ears to be a clear problem regarding proper identification of trafficking victims among law enforcement, coupled with lack of self identification among victims themselves This demonstrates a need for better professio nal identification of victims in order to provide needed services and detour them from unnecessary incarceration (Farrell & Pfeffer, 2014; Finn et al., 2015; J. Reid & Piquero, 2014b) There is a particular need to cease criminal arrests of minors who are being prostituted without using this as a way to link them to services. R esearch demonstrates minors are mostly involved with traffickers while a smaller percentage is engaged in survival sex due to lack of other options. Throughout these studies, minor v ictims have been the primary recipients of criminal charges of prostitution T he larger issue to be addressed, according to the TVPA, is legal recognition of prostituted minors as sex trafficking victims Further, it is clear that in the case of sex traffi cking, there needs to be widespread adoption of similar laws regarding DMST so minors are protected, offered services, and not treated as criminals ( Barnert et al., 2016; Mehlman Orozco, 2015 ;

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75 Reid, 2013 ) For adults, many of whom were victimized as childr en, programs and services should be provided in the community rather than repeated arrests. Much evidence has been gathered to authenticate the fact that i ndividuals with a history of childhood sexual abuse are more likely to engage in sex work as adolesce nts and adults (Kiss, Yun, Pocock, & Zimmerman, 2015; Vaddiparti et al., 2006) The scoping review did identify several screening options that may be effective and efficient for determining if an individual is being trafficked. One screening question regar ding abuse may be sufficient to identify all victims : with] ever beaten, hit, yelled at, raped, threatened or made to feel physical pain for (Mumma et al., 2017) Additionally, a study t hat reviewed the TVIT found that three questions were most linked to sex trafficking, compared to labor trafficking, in identification of victims ( Williams et al., 2018) These shorter assessments should be evaluated to determine if they could be used across larger populations. Despite the number of studies exposing the risk factors for sex trafficking only three studies evaluated prevention programs for at risk groups. From a public health perspective, there should be significant evaluation of programs across the spectrum of prevention to determine the most effective and sustainable approaches to reducing sex trafficking. The risk factors most frequently linked to sex trafficking victimization were substance use, pa rental substance use, c hild sexual abuse, running away mental health concerns, being in foster care or reports to the child abuse hotline involvement in juvenile justice, emergency medical visits, earlier sexual activity, repeated STDs or HIV infection, homelessness, intellectual disabilities and current involvement in sex work.

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76 Service provision models have not been evaluate d enough to ascertain what may be more effective for sex trafficking survivors. Overall, the results of this scoping review indicat e the need for more research to (1) determine the most effective practices to increase awareness and identification of victims, (2) to ensure widespread legislation implementation, (3) to reduce risk factors and resulting health disparities, and (4) to off er an array of diverse services to survivors and to potential victims to combat exploitation and continued abuse. Limitations The limitations of this scoping review are that this study only includes research conducted on sex trafficking in the United Stat es. It does not include studies conducted internationally or on labor trafficking Second, this study did not evaluate the quality of the research but rather included any studies that involved qualitative or quantitative analysis of primary or secondary da ta. Analyses of the results of each study were not evaluated as a meta analysis, but rather codes were solicited from studies to categorize and build overall themes that presented similarly to qualitative analysis. This was done to determine the primary fo cus areas for sex trafficking research in the United States and to identify research gaps Third, although the study used multiple databases and multiple search terms to identify relevant studies as well as reviewing reference lists from selected papers, additional studies may have been left out of this review The review included searches of any databases the research team believed would contain pertinent studies but not all databases were searched Lastly, i ndividuals in potentially worse sex traffickin g conditions may not have been represented in any of the scoping review studies. Therefore, there could be even worse health disparities and more underreporting than what has been noted in this review.

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77 Conclusions Despite these limitations, the review has provided a relatively comprehensive picture of the research on sex trafficking in the United States. This scoping review provides a starting point for expanding the current peer reviewed research base to be furthered investigated with larger sam ple sizes and across more locations. Given that the research documents health disparities associated with both vulnerability to being trafficked and the aftermath of being trafficked public health professionals need to better understand how to prevent vul nerabilities and subsequent trafficking. Overall, more studies are needed to determine the best evidence based practices in the field of sex trafficking including prevention, identification of victims and provision of services for survivors While these studies did involve various populations, it is important to remember the mostly underground nature of sex trafficking in the United States. There should be significant efforts to enhance all facets of sex trafficking research in the United States i ncluding our understanding of health issues, risk factors, awareness, identification, legislation, implementation, and exploiters in order to implement effective and sustainable public health interventions.

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78 Figure 2 1 PRIMSA Flow Chart

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79 Table 2 1 Scoping Review Themes and Subthemes Themes (count) Subthemes (count) Awareness (18) Knowledge / Training (5) Attitudes / B eliefs (6) Media Framing (4) Prevention P rograms (3) Identification (9) Screening (5) Proper I dentification of Victims (4 ) Legislation and I mplementation (18) TVPA Implementation (6) Safe Harbor Laws (2) Barriers to S ervices (4) Service U tilization (2) Program E valuation (4) Risk Factors (17) Substance U se (16) Sexual A buse (13) Running A way (9) Mental H ealth C oncerns (12) Child W elfare I nvolvement (8) Emergency D epartment V isits (7) Health Issues (6) Mental and P hysical H ealth (3) Trauma (3) Exploiters (9) Trafficker C haracteristics (2) Trafficker Tactics (2) Sex Buyer Attitudes / B eliefs (1) Sex Buyer Characteristics (4)

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80 Table 2 2 Top Statistically Significant Risk Factors for Sex Trafficking Top statistically significant risk factors for sex trafficking n % Substance use 16 84.2 Adolescent sexual victimization and child abuse 13 68.4 Mental health concerns 12 63.2 Running away 9 47.4 Involvement in child welfare system foster care and group homes 8 42.1 Emergency medical visits 7 36.8 Arrests 6 31.6 Homelessness 5 26.3 Parental substance use 4 21.1 Childhood abuse and ACEs 4 21.1 STDs and HIV 4 21.1 Earlier onset of sexual activity 3 15.8 Current commercial sex work 3 15.8 Educational attainment 3 15.8 Impaired social or school activities 3 15.8 Intimate partner violence 3 15.8 Suicide attempts 3 15.8 Family members involved in commercial sex 2 10.5 Lack of sexual discomfort 2 10.5 Negative self image 2 10.5 Aggression 2 10.5 Family members involved in commercial sex 2 10.5 Lack of sexual discomfort 2 10.5 Family members involved in commercial sex 2 10.5 Lack of sexual discomfort 2 10.5 School suspensions 1 5.3 Survival sex 1 5.3 Friends who purchase sex 1 5.3 10 or more sexual partners 1 5.3 Younger onset of substance use 1 5.3 Selling drugs 1 5.3 Caregiver arrests 1 5.3 Intellectual disability 1 5.3 LGBT sexual orientation 1 5.3

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81 Table 2 3 Summary of Scoping Articles Theme Subtheme Article Article focus/research question Study Design Results Awareness Attitudes/ Beliefs (Cunningham & Cromer, 2016) Examined gender, sexual trauma history, and attitudes about human trafficking as they related to belief of a sex trafficking scenario and willingness to blame the victim for the situation 409 participants, Quantitative Responded to a vignette, Reported personal trauma history and completed a Human Trafficking Myths Scale The acceptance of human trafficking and gender myths is significantly related to the beliefs hold of sex trafficking scenarios. This acceptance alters responsibility, but sexual trauma history has no effect. Awareness Attitudes/ Beliefs (Nsonwu et al., 2017) To develop and evaluate the psychometric properties of a tool designed to assess knowledge of, perceptions, and attitudes toward human trafficking. To examine the initial validation and internal consistency of the PKA HTQ questionnaire 325 participants and cross validation of 212 participants (two in depth. Samp les), Quantitative A three factor structure confirmed that self appraisal of knowledge skills, worldview, and help seeking behavior is a valid measurement of attitudes, perception, and knowledge toward human trafficking. Awareness Attitudes/ Beliefs (Houston Kolnik et al., 2016) Review the Sex Trafficking Attitudes Scale (STAS) examining cognitive, behavioral and attitudes toward the sex trafficking of women and girls. 301 participants for EFA and 300 participants for CFA, Quantitative A six factor a nalysis evolved from the EFA and CFA analysis on sex trafficking attitudes. The subscales of attitudes toward sex trafficking were knowledge, awareness, the ability to leave sex trafficking, helping survivors, empathetic reactions, and the ability to reduc e sex trafficking.

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82 Table 2 3. Continued Theme Subtheme Article Article focus/research question Study Design Results Awareness Attitudes/ Beliefs (Long & Dowdell, 2018) The purpose of this qualitative study is to examine the perceptions of emergency nurses about human trafficking, prostitution, and victims of interpersonal violence so that they can better identify and screen for these victims. 10 participants, purposive sample, qualitative, descriptive study using a semi structured interview Several themes emerged from the interviews that made it obvious that education and awareness is vital to the identification of human trafficking victims. Emergency nurses are consistently exposed to an environment that has a high rate of human traffickin g victims, this makes nurses in a key position to identify and treat these victims. Awareness Attitudes/ Beliefs (Fraley et al., 2018) awareness, attitudes, and role perceptions in the prevention of commercial sexual exploitation of children. 124 participants, 2 phased sequential mixed methods study The themes identified were exposure/knowledge, collaboration, role boundaries, and creating respite space. Policy efforts should focus on improvement to enable prevention of CSE with school nurses. Awareness Knowledge /Training (Titchen et al., 2017) Assess medical trainee and practicing physician awareness about DMST & see if awareness of trafficking is important to their practice. 1648 participants, Quantitative Practicing physicians were more aware of prevalence and procedure concerning trafficking. They agreed that knowledge about human trafficking was important to their practice when compared to medical trainees and residents.

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83 Table 2 3. Continued Theme Subtheme Article Article focus/research question Study Design Results Awareness Knowledge /Training (Cole & Sprang, 2015) awareness, knowledge, and experiences working with youth victims of sex trafficking in metropolitan and non metropolitan communities. 289 participants, mixed methods, surveys included closed and open ended questions Professiona ls in metropolitan communities received more training, as they perceived CSEC as being a serious problem. However, metropolitan and rural communities described similar trafficking situations for the youth they worked with. Awareness Knowledge /Training (Chisolm Straker et al., 2012) Identification issues with human trafficking victims in emergency departments. A piloted training intervention for emergency providers was conducted. 180 participants, quantitative, questionnaire. Many of the participants al so completed a post intervention educational survey (104 participants) 97.8% of participants reported never receiving formal training on the clinical presentation of trafficking victims and most were not confident in their ability to identify and treat a v ictim. After receiving educational intervention, 90% of the participants felt more confident and found the training useful. Awareness Knowledge /Training (M. Beck et al., 2015) To evaluate the knowledge gaps and training needs of medical providers, to highlight the importance of training for needs, and to demonstrate the barriers to the identification of and response to victims. 168 participants, qu antitative, Likert style survey In two vignettes, 48% health care providers correctly classified a minor as an ST victim, while 42% could tell an ST victim from a child abuse victim. 63% of participants said they had not received training on how to identif y ST. These results illustrate gaps in knowledge and awareness due to lack of training and experience.

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84 Table 2 3. Continued Theme Subtheme Article Article focus/research question Study Design Results Awareness Knowledge /Training (Hartinger Saunders et al., 2017) To explore whether mandated reporters who work with adolescent females, ages 10 to 17, recognize domestic minor sex trafficking (DMST) and associated risk factors. Because mandated reporters are required by law to report c hild abuse, neglect, and child exploitation, lack of specific DMST training or not believing DMST exists in communities continues to place young females at risk for revictimization. 577 participants across the United States classified as a mandated reporter of child abuse and neglect. Quantitative online survey 60% of mandated reporters in the sample did not have specific training on DMST while fewer than 10% received specific DMST training. Additionally, almost 25% of participants did not believe D MST existed in their communities. Awareness Framing (Johnston et al., 2014) Framing analysis to determine the way events and issues are organized and made sense of, especially by media, media professionals, and their audiences Major US new stories in 200 9 searching 'sex' and 'traffic', Quantitative Media is likely to frame sex trafficking as an episodic crime issue without proposing solutions. Human trafficking survivors and advocates were the least referenced demonstrating a need for more reliable sour ces of information. Awareness Framing (Martinelli, 2012) Media failure for covering sex trafficking 270 stories from 2000 to 2012 on New York Times and 22 videos on CNN, Quantitative Media is failing to highlight this issue by bringing forth personal and public implications, as the number of stories are increasing each year.

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85 Table 2 3. Continued Theme Subtheme Article Article focus/research question Study Design Results Awareness Framing (Farrell & Fahy, 2009) To analyze the public framing of the trafficking problem through newspaper articles and how views have changed over time corresponding with new policies focusing on national security and the identification, apprehe nsion and prosecution of trafficking perpetrators 2462 newspaper articles from 1990 2006 scanned. Frames included: human rights, crime/criminalization and national security, mixed methods Stage 1: recognizing the problem of HT as a violation of human right s (1990 1999) Stage 2: defining trafficking as a crime US legislation (2000 2002) Stage 3: redefining claims and the rise of national security. The shift away from a human rights issue to a criminal justice issue is due to official responses. Public perc eption has changed over time and correlates with the policies adopted. The goal is to help policy makers evaluate anti trafficking issues. Awareness Framing (Jackson, 2016) Examines how U.S. sex worker rights activists based counter work and sex trafficking. 19 participants, qualitative interviews Two frames of labor and equal rights redefine the criminalization and stigmatization of sex work as a social problem, rather than just prostitution itself. Explains the intent and outcomes of anti sex trafficking efforts to save and protect.

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86 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Awareness Prevention Programs (Countryman Roswurm & Bolin, 2014) To examine the factors that may put youth at risk for DMST. Over three months, 10 psychoeducational sessions with the primary goals of: (a) increasing awareness of healthy versus unhealthy relationship patterns, (b) incre asing knowledge on how to set healthy relationship boundaries, (c) increasing the desire and expectation of mental, physical, and sexual respect, and (d) assisting in safe exits from abusive and/or exploitive relationships. 23 participants, quantitative, P urposeful convenience sampling Psychoeducational intervention in a safe, encouraging, and youth friendly environment allows for RHSY to develop protective factors against trafficking. Awareness Prevention Programs (Murphy et al., 2016) To develop an educa tional website about CSEC for adolescents and evaluate it through pre and knowledge and attitudes about CSEC. 48 participants, mixed Web based content is a relevant and useful mode to educate adolescents about CSEC. Themes of how CSEC is preventable is made through valuing one's self, asking for help, and healthy decision making in relationships.

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87 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Awareness Prevention Programs (Kruger et al., 2013) To construct a systematic description of the students served in a preventive intervention, African American urban middle school girls at risk of CSEC and interpersonal violence. To understand personal strengths and weaknesses and about the challenges and s upports in their environments. 36 participants, qualitative interviews Language girls used throughout the group session contained 4 themes: difficulty forming trusting relationships, frequent peer aggression, familiarity with adult prostitution, and sex uality as a commodity. Identification Proper Identification (Finn et al., 2015) To examine reported victimization and sex work to identify demographic/behavioral overlap between women who were presented as victims or offenders or between those identified as trafficked persons or prostitutes and how the justice system responds to each identification. 41 participants, mixed methods, qualitative semi structured interviews 3 of 4 sex workers experienced violent criminal victimization. 2 of 3 arrests were p rostitution or drug related, while 1 in 4 officers paid for sex. Non trafficked and trafficked women were equally likely to be arrested due to the justice systems failure in recognizing victims. Identification Proper Identification (Farrell & Pfeffer, 2014) To examine police accounts of how human trafficking cases are actually identified. 140 closed human trafficking cases, mixed methods, qualitative interviews of 166 participants The culture and perceptions of police officials regarding trafficking doe s not support the identification of a broad range of cases. The focus remains primarily on minor sex trafficking as it is perceived as the most serious problem because of the lack of education surrounding these cases.

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88 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Identification Proper Identification (Halter, 2010) The conceptualization of juveniles involved in prostitution identified as either victims or delinquents. 126 participants, quantitative Police find youth as victims more often because of cooperation, no prior record and presence of identified exploiters. 60% were recognized as victims and 40% as offenders. Identification Risk Assessment (Andretta et al., 2016) To build on CSEC screening options available for use in the juvenile justice system, where screenings must be brief, objective, and nonintrusive. 901 participants, quantitative interview In accordance with CSEC literature, STAR statuses were linked with depression and other clini cal symptoms as well as perceptions and attributions known as common in sexual abuse victims, and gender, but not age. Immediate referrals were needed for adolescents with high risk status. Identification Screening (Chisolm Straker et al., 2016) To describe the health care settings most frequented by victims of human trafficking. 173 participants, qualitative interviews from individuals who completed an online survey 68% of participants reported going to a healthcare provider during their trafficki ng. Frequently visiting emergency/urgent care practitioners (56%), followed by primary care providers, dentists, and obstetricians/gynecologists (OB/GYNs). 68% of screening questions asked about their living situations (n=31) and 84% asked about their work (n=43). Health care providers do not consistently identify victims in this population.

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89 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Identification Screening (Greenbaum et al., 2018) To describe characteristics of CSEC/CST victims and to develop a screening tool to identify victims among a high risk adolescent population. 108 participants, cross sectional quantitative, 2 groups were compared on variables related to medical and reproductiv e history, high risk behavior, mental health symptoms, and injury history. 16 variables were analyzed between 2 groups. These involved reproductive history, high risk behavior, sexually transmitted infections, and previous experience with violence. A 6 item screen produced a score of 2 positive answers, which had a sensitivity of 92%, specificity of 73%, positive predictive value of 51%, and negative predictive value of 97%. Identification Screening (Mumma et al., 2017) To evaluate the feasibility of a screening survey to identify adult victims of sex trafficking in the ED. 143 patients participants, qu antitative survey, convenience sample 39 victims screened positive, 10 identified as victims of sex trafficking. Sensitivity of the screening survey was better than physician identification of victims, difference 60%, 95% CI [30% 90%]. Physician specificit y was slightly better than the screening, difference 13%, 95% CI [4% question regarding abuse. A screening survey had greater sensitivity than physician concern, however a single screening question may be enough to identify all adult victims of sex trafficking in the ED.

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90 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Identification Screening (Egyud et al., 2017) Implement a screening system and treatment algorithm in emergency departments to improve the identification of human trafficking victims due to the lack of recognition by health providers. 102 participants, qualitative interviews 97% of participants wanted to change p ractices (education/screening/treatment protocols for emergency providers to help guide identification/rescue of HT victims). Compliance with these trainings and implementations improved the number of victims identified. Identification Screening ( Williams et al., 2018) Using the Trafficking in Victims Identification Tool (TVIT) (Short Version) to identify t victims of sex trafficking. 28 participants, quantitative Over a period of 90 days, 54% (n = 15) of participants were likely to have been traff icked for sex at some point. Three specific questions were found to be most linked to sex trafficking and distinguishable from labor trafficking which include: 1) TVIT15 Did anyone you worked for or lived with trick or force you into doing anything you did not want to do? 2) TVIT16 Did anyone ever pressure you to touch another person or have any unwanted physical or sexual contact with another person? 3) TVIT18 Did you ever have sex for things of value (for example money, housing, food, gifts, or favors)?

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91 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Risk Factors CSE Housing (Shaw et al., 2017) To examine differences between adolescent victims of sexual exploitation to those adolescents with a history of sexual abuse. 25 participants, quantitative, case files Individuals in foster care, those who have been arrested, suspensions from school, and a history of running away; to abuse drugs; to be more impaired in social and school activities; to be withdrawn and depressed; to manifest social and thought problems and aggressive and rule breaking behaviors; and to have a diagnosis of mood or conduct di sorder are more likely to be victims of sexual exploitation. CSEAs engage in substance abuse and have a history of arrests and suspensions from school significantly more often. Risk Factors CSE Housing (Twill et al., 2010) Descriptive study of a 90 day tr eatment program designed for adolescent girls who engaged in prostitution. 22 participants, qualitative All participants had low IQs, multiple mental health disorders, including PTSD, and depression. 13 of the IQs were in the mild to moderate mental reta rdation category, making them qualify for special education services. 50% reoffended after discharge, but not for prostitution.

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92 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Risk Factors Juvenile Justice System ( Reid & Piquero, 2014b) To examine key criminal career parameters of CSE/prostitution including age of onset and rate of recurrence through structural equation modeling (SEM) 114 participants, quantitative part of larger study A general sequence of events by age of onset with substance abuse and selling drugs happening before CSE/prostitution. Evidence suggests that a small group has chronic CSE/prostitution, which accounts for the majority and frequency of these occurrences. S EM results imply that the CSE/prostituted youth engages in drug involvement from year to year but usually does not experience perpetuation of CSE/prostitution from year to year. Risk Factors Juvenile Justice System ( Reid & Piquero, 2014a) To assess wheth er risks associated with age of onset of CSE for girls and young women operated similarly in boys and young men. 2,354 participants in which 8% (189 participants) were included in final quantitative analysis Young African American males were at higher ri sk for CSE; however, female youth of all races/ethnicities were at similar risk. Maternal substance use and early sex were associated with CSE at a younger age. CSE puts male youth at risk for experiencing rape and substance use dependency with early onset For all, lack of education was associated with CSE in late adolescents or young adulthood. Substance use dependency correlates with late onset for female youth.

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93 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Risk Factors Juvenile Justice System (Reid & Piquero, 2016) Structural equation modeling to explore similarities and differences in vulnerability to CSE across gender. 1,354 participants, quantitative, retrospective data Both genders were impacted by arrests and substance use among caregivers. This neglect was linked to early sex, higher negative psychosocial emotions, and running away. In males, CSE correlated with negative psychosocial emotions and early sex. Females were strongly linked to earlier substance use. Risk Factors Juvenile Justice System (O'Brien et al., 2017) To examine DMST prevalence and potential risk factors among a unique population of adjudicated male youth. 800 participants, quantitative surveys Over 10% of males re ported DMST victimization, this was positively associated with the probability of DMST victimization. Sexual discomfort had a negative association. Factors associated with DMST victimization are childhood sexual abuse, substance misuse, and sexual discomfo rt. Risk Factors Child Welfare Involvement ( Gibbs et al., 2018) To compare children with and without allegations of human trafficking within data system, including their characteristics and child welfare experiences. 300,000 participant case files, quantitative Participants were twice as likely to have experienced maltreatment when compared to other children. Children with previous child welfare involvement were twice as likely to experience out of home placements, more than 5 times as likely to have experienced congregate care, and more than 10 times as likely to run away from these placements.

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94 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Risk Factors Child Welfare Involvement ( Reid et al., 2017) To examine the link between human trafficking of minors and childhood adversity. 913 participants, quantitative, retrospective reports ACE scores were higher and 6 were indicative of child maltreatment that were prevalent among those who had human trafficking abuse reports. Sexual abuse was the strongest predictor of human trafficking, girls were at 2.52 times greater risk and boys were a t 8.21 times. Risk Factors Child Welfare Involvement (Havlicek et al., 2016) To compare the prevalence of investigated allegations of human trafficking with the investigated allegations of other types of maltreatment 563 participants, quantitative, retr ospective 563 human trafficking investigations carried out from July 2011 to June 2015 compared to 697,062 investigated allegations for other forms of maltreatment. Of these 563 allegations 419 were children, 90% were female, 53% African American, and 56% residing in an urban county. These children were 14 1/2 years on average and 61% had previous investigations of maltreatment, and 28% had at least one entry into out of home care Risk Factors Healthcare provider visits (Goldberg et al., 2017) To describe the clinical characteristics of patients referred for DMST to improve identification and intervention. 41 participants, quantitative, retrospective 81% of children were seen in the year prior to referral for DMST. Family dysfunction and childhood maltre atment were identified in the 41 patients, 57% had sexual abuse and 60% parental substance abuse. In this study, 32% of children had a sexually transmitted infection, 20% psychiatric needs, 46% at least one previous psychiatric admission, 88% substance use 63% runaway, 42% lived in a group home, 68% lived at home currently, and 71% lived with parent/guardian or relative.

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95 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Risk Factors Healthcare provider visits (Horner & Sherfield, 2017) To describe pediatric health care use, familial psychosocial factors, child sexual abuse case characteristics and patient demographic characteristics of adolescents before or at the time of their most recent identification as a CSEC victim. 42 participants, retrospective chart review, Quantitative 63 adolescents were referred to ED or CAC for CSEC concerns. 82.5% identified as potential CSEC victims at the pediatric hospital within a year. A single male was included in the study, emphasizing the need for male victims to be better identified. 34.9% had more than 10 sexual partners and 93.7% showing a mental health/behavioral concern before being identified as a CSEC victim. 69.8% tested positive for STIs (0 11 times), and 79 .3 reported drug/alcohol use, 73% reported sexual abuse prior to identification, and 39.6% had completed more than one sexual abuse assessment. Risk Factors Healthcare provider visits (Varma et al., 2015) To describe distinguishing characteristics of CSEC who present for health care in the pediatric setting and to develop an effective screening tool that identifies youth at high risk for CSEC when they present for medical care 84 participants, 2 groups, 27 CSEC group and 54 CSA matched group, retrospec tive quantitative study age matched sexually abused/assaulted adolescents to compare with suspected CSEC youth All of the CSEC (100%) and 94.6% of CSA patients were female. Both groups differed significantly in 11 evaluated areas where CSEC patients were m ore likely to experience, violence, substance use, running away from home, and involvement with child protective services and/or law enforcement. They were also sexually active longer. The CSEC victims differ from other sexual abuse victims by reproductive history, high risk behavior, involvement with authorities, and histories of violence. 46% of these victims had been to a medical provider in the past 2 months.

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96 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Risk Factors Healthcare provider visits (Cole et al., 2016) To examine the demographic features, trauma profiles, clinical severity indicators, problem behaviors, and social utilization characteristics of youth victims of CSE compared with a matched sample of sexually abuse/assaulted youth who were not exploited in commercial sex. 215 participants, 2 groups, 43 CSE and 173 non CSE youth, quantitative data analysis and propensity score matching Youth who experienced CSE were more involved with juvenile justice and child welfare, had higher functional impairments and risk behaviors, problems that are more clinical, higher levels of trauma symptoms compared to sexually abused youth. CSE is linked to emotional, developmental, psychological, and behavioral dysregulation in those involved, this prompted significant challe nges and opportunities for service providers. Risk Factors Healthcare provider visits (Gibbons & Stoklosa, 2016) Examine features of presentation and treatment options for human trafficking victims upon presentation to the ED. One Case Report: A 29 year old woman with a past medical history significant for intravenous drug abuse and recent relapse presented to the ED after a reported sexual assault. Emergency care providers are in key positions to identify human trafficking identification and pro vide care. Victims may be accompanied with a controlling individual who may not allow them to speak and answer on their behalf, delay in seeing illness, story does not match clinical presentation, and may be fearful or unaware of their surroundings. Sex tr afficking victims have STIs, vaginal or rectal trauma, and retained rectal or vaginal foreign bodies.

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97 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Risk Factors Healthcare provider visits (Baldwin et al., 2011) To characterize trafficking health care settings. 12 survivor participants and 6 key informants, qualitative semi structured interviews Of the 10 survivors, eight experienced domestic servitude, three survived sex trafficking, and one experienced both. Half of survivors visited a physician while in their traffickers' control, and one worked in a health care facility. Domestic servants were prompted to seek medical care because of injury or systemic/respiratory illness, while sex trafficking victims were seen for sexually transmitted infections and abortion. Reasons victims were unable to disclose their status included fear, shame, language barriers, and limited interaction with personnel. Risk Factors Healthcare provider visits (Macias Konstantopoulos et al., 2013) To understand the intersection of sex trafficking and public health 277 participants, Snowball sampling, qualitative intervie ws with key informants Family poverty, child sexual abuse, and gender inequality were all predictors of sex trafficking. Themes of the study were key determinants of sex trafficking, insufficient response of local health systems, and barriers participation in the health system. Factors at macro and micro levels of the socioecological model of health produced detrimental effects on the health and psychosocial development of females. This placed them at higher risk and produced negative health outcomes.

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98 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Risk Factors Current Commercial Sex Work (Fedina et al., 2016) Retrospectively examines associations between multiple risk factors and domestic child sex trafficking 273 participants, retrospective survey using Respondent Driven Sampling (RDS) Individuals age 16 and older currently involved in the commercial sex industry There were 115 participants all of which were current or former victims of child sex tr afficking. DMST victims were significantly more likely to be runaways and to be a racial/ethnic minority than non trafficked adults engaged in the commercial sex industry. Other risk factors included: having family members in sex work, having friends who p urchased sex, childhood emotional and sexual abuse, and rape. Risk Factors Current Commercial Sex Work (Chohaney, 2016) To analyze direct sex trafficking risk factors in Ohio within a life course theory framework among street based sex workers 328 participants, Quantitative, using respondent driven sampling (RDS) Minor victimization is associated with survival sex and peer influence, while lack of support and resources to escape increases the chances of adult victimization. Risk factors for sex traf ficking need to be prioritized, especially minor victimization and the assistance available for escaping victims. Risk Factors Current Commercial Sex Work ( Reid, 2014) To examine variables associated with adolescent versus adult onset of commercial sexual exploitation and identify potential risk and resiliency factors differentiating adolescence limited sexual exploitation and early onset adult persistent exploitation. 174 participants, quantitative interviews, matched sample Variables associated with adolescent onset of CSE: adolescent sexual victimization, young age at first alcohol/drug use, being a victim of intimate partner violence and stigma of sexual self/others Education was associated with ending exploitation by adulthood; over two thirds of those who completed high school education were at less risk, however, 13% of those exploited in adult life ever finished. This suggests at risk girls who complete high sch ool education reduce the likelihood of exploitation.

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99 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Health Issues Mental and Physical (Farley et al., 2016) To examine social and physical violence experienced by American Indian/Alaska Native (AI/AN) women in prostitution and their impacts on the mental and physical health o 105 participants, mixed methods, quantitative survey and semi structured qualitative interviews Prostitutes often had historie s of childhood abuse, foster care, arrests, prostitution, homelessness, rape, assault, racism, and pimping. The most common physical symptoms were: severe muscle pain, impaired memory or concentration, headaches and PTSD. Severe psychological symptoms were correlated with poor health. Almost all women wanted to leave prostitution and stated the need for counseling and peer support as vital to escape. Health Issues Mental and Physical (Ravi et al., 2017) To identify experiences of domestically sex trafficked women who are incarcerated survivors regarding healthcare access, reproductive health and infectious disease while trafficked 21 participants, qualitative interviews Both chronic and acute health issues occurred during trafficking because of m any obstacles, such as traffickers and substance use, in receiving proper medical care. Violence from perpetrators was heightened with unintended pregnancy, STIs, and condom use. Drug use and poor socioeconomic status increased the risks of pregnancy and i nfection. Health Issues Mental and Physical (Edinburgh et al., 2015) To describe the abuse experiences of sexually exploited runaway adolescents seen at a Child Advocacy Center and to identify risk behaviors, attributes of resiliency, laboratory results for sexually transmitted infection (STI) screens, and genital injuries 62 participants, mixed methods, retrospective charts, current forensic interviews and physical exams Adolescent and adult females recruited youth working for a pimp. Half of the youth disclosed that a trafficker was not involved in setting up their exch ange of sex for money or substances. 78% scored positive on the UCLA PTSD tool; 57% reported DSM IV criteria for problem substance use, 71% reported cutting behaviors, 75% suicidal ideation, and 50% had attempted suicide. Exploitation is not always linked to having a pimp and youth are quickly solicited as runaways.

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100 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Health Issues Trauma and Trafficking Experience (Hom & Woods, 2013) To explore the stories of trauma and its aftermath for commercially sexually exploited women as told by front line service providers. 6 participants, qualitative interviews Three elements were formulated around the experience of trafficking Pimp Encultur ation, Aftermath, and Healing the Wound and seven subthemes. These findings draw attention to PTSD, depression, and shame in CSE women. These women experienced multiple traumas, which created a unique set of symptoms. This is why it is essential service p roviders and others in healthcare recognize and intervene with a trauma informed approach. Health Issues Trauma and Trafficking Experience (Cecchet & Thoburn, 2014) To assess factors that influenced survivors of child and adolescent sex trafficking to survive, leave the sex trade, and reintegrate back into the community. 6 participants, qualitative interviews The survivor microsystem illustrated that insecure attachments led to recruitment because of increased vulnerability, which let to unsafe relation ships and increased emotional insecurity. The macrosystem depicted women who were raised in environments that desensitized them to prostitution. Escape and resilience occurred in the survivor microsystem when they left due to pregnancy or mental health sym ptoms, comparatively at the mesosystem survivors needed safe relationships and more self worth, and the macrosystem because they began processing their trauma. Legislation and Implementation TVPA Implementation (Bouche et al., 2015) To identify the factors that impact the comprehensiveness of state human trafficking legislation 6 years of quantitative data from all 50 states, 300 observations on legislative comprehensiveness from the House Competition based diffusion occurs across states, with a high er proportion of neighboring states who have criminalized trafficking correlates with higher probability of the state passing better legislation.

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101 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Legislation and Implementation TVPA Implementation (Skodmin et al., 2016) To determine outcomes of a criminal case using a new human trafficking statute on fraud in foreign contracting and a civil suit, (b) how online prostitution ads are used to market v ictims to sex buyers using ethnicity of the victims and age and social standing of the sex buyers, and (c) how mothers of victims are involved in locating their daughters and making reports to the police that initiated investigations 7 Law Enforcement Cas es from 2009 2013, qualitative analysis Seven human trafficking cases in Rhode Island were found to be consistent with other cases in the US. Much research is based on victim interviews reflecting the need for more information on actual operations. There is extreme need for understanding of advertisements with respect to the role played by race and ethnicity. Traffickers perceived the state to be lenient towards prostitution and therefore a low risk destination to exploit victims. Legislation and Implementation TVPA Implementation (Albonetti, 2014) To review changes in the legalities of federal sentencing for sex trafficking offenses and length of imprisonment imposed with variables affecting timeline 59 cases that included two statues, 2258 cases involving one or more sex trafficking federal offenses, descriptive Mandatory minimum sentences increased, penalties are present, females made up a large percentage of the offenders when compared to other offenses, African Americans represented the large st percent in forced labor trafficking that were convicted, and a wide range of ages for forced labor trafficking defendants with a more narrow range with sex trafficking defendants. Legislation and Implementation TVPA Implementation (Farrell & Pfeffer, 2014) To examine competing explanations for the adoption of responses of new human trafficking laws among medium to large municipal police agencies in the United States. 255 participants, quantitative Most states have criminalized human trafficking but t here are very few cases identified and even less offenders who have been prosecuted.

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102 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Legislation and Implementation TVPA Implementation ( Reid, 2013) To assess the implementation and effects of the TVPA and its reauthorizations on the protection of child sex trafficking victims and on the prosecution of sex traffickers exploiting U.S. minors in one metropolitan area in the United States. 34 participant s, Rapid assessment methodology, qualitative interviews Complex psychological factors deter the victim from helping prosecute traffickers trauma bonding between victims and traffickers, and frequent flight and r evictimization. Other complex issues such as the failure of juvenile justice staff to identify victims and the encouragement of minors to plead guilty to reduce court expenses, may contribute to why sex trafficking continues to be a low risk/high reward cr ime. Legislation and Implementation TVPA Implementation (Greer & Dyle, 2014) To explore/expand on the legal discussion of t visa requirements and the implication of improved support for victims of sex trafficking Did not specify, review of T visa applications Lack of research with mental health trauma survivors and trafficking victims influences policy makers to not take holistic/grey area cases into consideration. The current requirements on t visas fail to recognize mental health injuries from se x trafficking, illustrating the need for change. Legislation and Implementation Safe Harbor Laws (Barnert et al., 2016) To analyze the nine state Safe Harbor laws enacted by 2012 to guide state legislators, health professionals, law enforcement agents, child welfare providers, and other responders to the commercial sexual exploitation of children on the development and implementation of state Safe Harbor laws 32 participants, Purposeful sampling, qualitative semi structured interviews Connecticut (3), Fl orida (4), Illinois (1), Massachusetts (1), Minnesota (5), New York (3), Tennessee (1), Vermont (3), and Washington (6). Safe Harbor legislation caused a significant shift in the treatment of CSE youth from criminals to vulnerable children. This law alone is not sufficient without substantial funding for other services. This lack of funding prompted providers to go around these laws and incarcerating CSE youth to act in the best interest of the child. Stipulations of the law should include a implementation timeline, prevention, of protection, guidance for diversion, placements, services, funding, data collection, coordination/task force, and oversight.

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103 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Legislation and Implementation Safe Harbor Laws (Mehlman Orozco, 2015) To explore the efficacy of criminalizing offenders and protecting victims via social and political implementation and funding associated with the Safe Harbor Law across 4 states, 18 observations for each state that used juvenile prostitution arrests (those that passed safe harbor laws), n=72 participants, quantitative Juveniles continue to be criminalized through arrests with charges like prostitution leading to detainment. This inevitably leads to more trauma of the victims. There were insignificant changes in the number of arrests for prostitution after Safe Harbor was passed. Legislation and Implementation Barriers to Services (Gerassi et al., 2017) To identify perceived barriers and facilitators to service access and engagement with social services among women involved in CSE. 30 adult women who traded sex and 20 service prov iders, semi structured qualitative interviews maximum variation sampling (n = 24) and women not in services (n = 6) snowball sampling. Providers were recruited through purposive sampling coalition (n = 10) and nominations sampling (n = 10) Although some w omen saw disclosure as helpful in addressing the complex feelings stemming from sex trading, as well as the desire to help or relate to other women in similar situations, they also identified risk of harm and multiple barriers to disclosing during intake m eetings and individual sessions with providers as well as group sessions with providers and other clients. Facilitators to disclosure and addressing sex trading included the following: (a) personal motivation to address complex feelings associated with sex trading and (b) emotional desire to help or relate to other women with similar experiences (in groups). Barriers included the following: (a) needing meaningful communication and space to process sex trading, (b) fear of being viewed differently by provide rs, and (c) judgment from women in other groups.

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104 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Legislation and Implementation Barriers to Services (Ijadi Maghsoodi et al., 2018) To understand commercially sexually exploited (CSE) experiences, barriers to care, and recommendations for improving health care services. 5 focus groups with 18 participants, qualitative Availability of services like testing for sexu ally transmitted infections, knowledge about sexual health, and a strong motivation to stay healthy were helpful in identification. Barriers were feeling judged, confidentiality concerns, fear, perceived low quality of services, and self reliance. Youth fo cused on self reliance and significant health risks and needs, including violence exposure, worry about STIs, and mental health problems, however, the availabili ty of health services was not the limiting factor to accessing healthcare. The multiple barriers that youth experienced when engaging in services that affected their access to healthcare. Certain barriers seem to overlap with other youth involved in the ju venile justice system, such as being afraid of being caught by police, and confidentiality. Legislation and Implementation Barriers to Services ( Williams et al., 2017) To better understand regarding decisions to disclose gender based violence, namely, intimate partner violence (IPV) and human trafficking, to health care providers and what outcomes matter to them when discussing these issues with the ir provider. 25 participants, semi structured qualitative interviews Two fifths were victims of human trafficking, t he rest experienced IPV. Three themes focused on factors that facilitate or impede disclosure: patient provider connectedness, children and social support. The fourth theme was related to obscurity of the health care system when addressing gender based violence. The fifth theme focused on results participants wanted to accomplish when discussing their experiences with health care provide rs. Victims of human trafficking were more afraid of judgement and wanted to keep their experiences private. Cultural factors played vital role in decisions around disclosure and related to racial/ethnic disparities in the medical system.

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105 Table 2 3. Conti nued Theme Subtheme Article Article focus/ Research question Study Design Results Legislation and Implementation Barriers to Services (Corbett, 2018) To explore the factors that assist youth with exiting the life associated with CSEC. 13 participants, semi structured qualitative interviews 20 themes were identified via thematic analysis and then assigned three primary categories. The first category is Self Defined Wellness (4): naming of self outside the Life, positive family connections, breaking the c ycle, and embracing the term survivor. The second, Describing the Life (6): sex for goods, surviving the Game, pimp control, wanting to be loved/look good, contributing family factors, and the grooming process. The third, Exiting Process (10): naming one w ho has exited, others depend on me, not profitable to exit, fear keeps you in, thinking about leaving, the role of family, pending motherhood, wanting to be free, sustaining exit, and professional systems not accessed. Four recommendations from survivors w ere active listening, encouragement, non judgment, and do not leave when we push. Legislation and Implementation Service utilization (Holger Ambrose et al., 2013) To explore sexually perspectives of how street outreach workers can effe ctively provide outreach and connections to services 13 participants, qualitative interviews, venue based sampling w All participants had a pimp, used the internet as a catalyst for sexual exploitation, experienced homelessness, and substance abuse. Survivors wanted outreach workers to use "soft words" when talking about exploitation and "boyfriend" pimps, they also want ed workers to "provide resources", "be non judgmental", "listen", and "care". Street outreach can be used to support sexually exploited youth but should occur in a variety of settings like private homes, spas, strip clubs, hotels, brothels and street prost itution. Most girls reported more than one kind of placement, including: foster homes, juvenile detention centers, and hospitalized for mental health issues or substance abuse.

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106 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Legislation and Implementation Service utilization (Dewan, 2014) To examine factors associated with service utilization among pre certified victims of human trafficking 136 participant case records, quantitative The majority of survivors are undocumented and are from countries with poor anti trafficking policies, making them unaware of the US protection to victims. Sex and labor trafficking victims were referred to service providers by law enforcement and non gove rnmental organizations equally. However, sex trafficking victims used less resources compared to labor trafficking victims. Legislation and Implementation Program Evaluation (Roe Sepowitz et al., 2014) To explore a pilot arrest alternative for sex trafficked and prostituted adults regarding diversion program attendance, completion, and 12 month recidivism 43 participants with a prostitution related crime compared to 42 women arrested and charged with p rostitution, 2 groups, mixed methods There were no differences between groups with diversion attendance, and completion or prostitution related recidivism. The pilot intervention found similar diversion results, cost savings, intelligence gathering, and a community perspective of victim centered services. The project ROSE outcomes were similar if they were arrested, jailed, and brought in front of a judge when compared to those who are identified by police as prostituted or sex trafficked adults that get he lp in a respectful and dignified manner. The arrest alternative and traditional arrest technique have similar impacts supporting the shift towards a service focused alternative. Legislation and Implementation Program Evaluation (Thomson et al., 2011) To increase our understanding of residential treatment for sexual exploitation by providing an in depth case study of a group home for sexually exploited adolescent girls in New England. 13 participants, mixed methods, qualitative interviews and case reviews In comparison to an earlier treatment program at the same facility, this program had a 78% decrease in the number who failed to complete treatment goals due to running away, hospitalization or incarceration (p=b.05). Reasons include using the trans theoret ical model to guide admissions, and the practice of admitting youth to a more restrictive on campus program before moving them to the less restrictive group home. Follow up interviews at 3 months revealed some at risk behaviors continue.

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107 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Legislation and Implementation Program Evaluation (Sapiro et al., 2016) How to best serve youth involved in DMST, specifically with regard to youth running away from services, models of service provision, and the use of technology by these youth 20 participants, qualitative key informant interviews Professionals with a variety of backgrounds disagree about the extent in which youth involved in DMST are able to make dec isions. There are also disparities in determining if runaway youth should be allowed back and if they should be arrested or placed in an enriched and comfortable environment. There is also a lack of understanding around technology access enabling youth to contact their traffickers or recruit others. Legislation and Implementation Program Evaluation ( Gibbs et al., 2015) This paper reports selected findings from an evaluation of three programs serving domestic minor victims of human trafficking. 113 participants, mixed methods of qualitative interviews and data from three programs The majority of patients needed crisis intervention, safety planning, educational support, mental health services, and employment services. There was diversity in terms of demographics and circumstances, however, two patterns identified were of homeless young people exchanging sex to meet survival needs and young people who were emotionally engaged with their trafficker. Key findings include: diversity of trafficked mino rs, challenge of initial and continued engagement with service delivery, the structural and resource barriers to long term support for young people, and the potential contribution of programs specifically addressing trafficked minors. Exploiters Trafficker Characteristics (Sprang & Cole, 2018) To address the gap of how child sex trafficking can be perpetrated by family members 31 participants, mixed methods Major findings were high rates of family members trafficking children for illegal drugs; high severity of abuse as measured by the Sexual Abuse Severity Score, there was higher abuse for children in rural communities; clinical threshold level scores on Child Behavior Checklist (CBCL), and the Trauma Symptom Checklist for Children (TSCC A). Boy s had higher CBCL externalizing scores, and females had higher TSCC depression scores. Over half of the children in this sample attempted suicide at some point.

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108 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Exploiters Trafficker Characteristics (Hargreaves Company et al., 2016) Given the complex nature of cases, involving the sex trafficking of juvenile offenders it was of paramount importance to conduct latent class analyses (LCAs) in order to obtain an enhanced understanding of their characteristics. 117 offender participants and 179 victim participants, quantitative Psychopathy is common among offenders who engage in STJ as 75% (n=27) of offenders with sufficient data to assess the PCL R (n=36) met the were close to the t hreshold (n=3 with a score of 29.5) and 25% (n=9; M=26.78) surpassed the average score of North American adult male inmates. The victims/offenders were used to substantiate findings. Two broad classes emerged: Primarily Aggressive/Antisocial Offenders and Charismatic/Manipulative Offenders with varied by subtype. The main findings from this study indicated that the majority of STJ offenders have violent criminal histories (Mean CHSS Score = 7.01; n = 117) and en gage in acts of violence towards victims (Mean VSS Score = 2.96; n = 117). Exploiters Trafficker Tactics ( Reid, 2016) To advance understanding of the tactics employed by sex traffickers to recruit or initially entrap U.S. minors and identify tactics of sex traffickers and/or specific circumstances that facilitate prolonged or repeat exploitation and prevent youth from exiting 61 participants of trafficker data, 43 participants of sexually exploited girls involving non relative traffickers, and 10 partic ipants of service providers, semi structured qualitative interviews A number of scripts and schemes are used by sex traffickers to capture victims including boyfriend/lover roles, ruses involving debt bondage, friendship or faux family scripts, threats of forced abortion or to take away children, and coerced co offending. These findings educate potential prevention efforts and highlight the need for multi systemic, victim centered approaches to intervention. Sex traffickers use familiar scripts like flatte ring or romancing the youth, building trust, normalizing sex and selling sex, isolating the youth from all other forms of support, intimidation, and disorienting the youth by moving them to unfamiliar places to enmesh them in their scheme.

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109 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Exploiters Trafficker Tactics (Baldwin et al., 2015) To examine coercive conditions experienced by trafficked persons based on Framework of Coercion and understand psychological coercion and its potential effects on patient's health in adult trafficked women 12 participants, Snowball sampling method and fliers, qualitative semi structured interviews Victims are forced without physical force or restraints b ecause of coercion tactics that reinforce their compliance. This psychological abuse creates excessive stress, which leads to acute or chronic, physical and mental health problems. Exploiters Sex Buyer Attitudes and Beliefs (Farley, Golding, Matthews, Malamuth, & Jarrett, 2017) To compare the attitudes and behaviors of men who buy sex with age ethnicity and education matched men who do not buy sex. 202 participants of 101 men who buy sex and 101 age education and ethnicity matched men who did n ot buy sex. Mixed methods, semi structured qualitative interviews and validated scales Both groups had a tendency to accept rape myths, were aware of consequences associated with prostitution and trafficking, expressed ambivalence about prostitution, and b elieved that jail time and public exposure were best at discouraging the buying of sex. Sex buyers were more likely than non sex buying men to be sexually aggressive and rape. Sex buyers scored higher on measures of impersonal sex and hostile masculinity. These men also had less empathy for prostituted women and viewed them as different from other women. It is important to be noted that differences were found in the acceptance of rape myths, resulting from this acceptance among sex buyers.

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110 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Exploiters Sex Buyer Characteristics (Tidball et al., 2016) To learn from NGO representatives, law enforcement officials and public officials their experiences about how men buy girls on line for sex, and the words that the men use in the transactions. 40 participants, purposeful criterion sampling, qualitative in terviews The six themes were: (1) familiarity of the interviewees with sex trafficking and its research: (2) law enforcement anti trafficking practices, (3) the buying side of sex trafficking, (4) the criminal treatment of victims, (5) lack of safe places for girls to stay, and (6) the prevention, intervention, and assessment of sex trafficking programs. The majority of officials in this study were aware of the human trafficking issue, though few admitted to a basic understanding of it. Those who were famil iar had voluntary experiences or were exploited themselves. The majority of these public officials, law enforcement, and NGO representatives received information on trafficking through non academic books, news reports, or taking classes. Nearly all (90%) e xpressed concern for the wrongful prosecution of trafficked women. Exploiters Sex Buyer Characteristics (Bounds et al., 2017) To identify linguistic indicators of potential commercial sexual exploitation within the online comments of men that were posted on an Internet site (site provides a forum for men who are interested in discussing their experiences around buying sex) 666 internet posts, Convenience sample, qualitative Buyers were aware the people were being sold and desired to purchase sex fr om those who could be minors due to youthful appearance. The three main indicators were: desire for youth, presence of pimps, and awareness of vulnerability.

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111 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Exploiters Sex Buyer Characteristics (Holt et al., 2008) To examine the displacement practices of customers of prostitutes. 10 city specific (those that reported highest arrest rates for prostitution) public web forums for individuals who post about or visit prostitutes, city level qualitative analysis Sex buyers use web forums to exchange information on sexual services. Thi s allows for easy identification of sex workers based on location, appearance, and sexual practices. Content involving law enforcement, stings and patrol affected individuals in that location. Clients have an important role in the continuation of sex trade because police tactics are avoided with online communication. Exploiters Sex Buyer Characteristics (Bissias et al., 2016) To determine how many peers in these five networks are sharing known CEM (Child exploitation material), what are the trends, and how do the numbers vary by network and country, proportion arrested, prevalence of severe CEM and number of files shared Across five P2P networks, files that had been identified by law enforcement during trafficking investigations using instrumented P2P s oftware to rec ord over a billion observations, quantitative analysis 3 in 10,000 Internet users worldwide were sharing CEM with about 840,000 unique installations per month of P2P programs. There was an overall decline in trafficking of CEM during the stu dy. Of those arrested for P2P based CEM trafficking, 9.5% of persons were identified as having sexually offended children offline. Arrests varied by network: 8% on Gnutella, and 21% on BitTorrent. The rate of contact offenses was highest for the most sever e CEM (29%) compared to least severe CEM (15%). This material has very high survival rates, BitTorrent being nearly 29%.

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112 Table 2 3. Continued Theme Subtheme Article Article focus/ Research question Study Design Results Exploiters Sex Buyer Characteristics (Wolak et al., 2014) To inform researchers, practitioners, law enforcement, and policy makers in the child maltreatment field about how CP trafficking in P2P networks can be measured and how such measurement can lead to strategic responses to combat and possibly even reduce the amount of CP available online. 244,920 computers at locations in the software to measure a year of online child pornography (CP) trafficking activity by U.S. computers on the Gnutella peer to peer netwo rk. RoundUp was used almost continuously by law enforcement during that time and recorded over 870 million observations of known CP files being shared by computers in more than 100 countries. Mixed methods 244, 920 US computers shared 120, 418 CP files on Gnutella, more than 80% of these shared less than 10 files during the study year or shared files for less than 10 days. Less than 1% of computers (n=915) made high annual contributions to the amount of known CP files available. If these contributors were a rrested these files would be reduced as much as 30%. These findings show prevalent low level CP trafficking using P2P network and a small number of computers uploading most of the content.

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113 CHAPTER 3 FACTORS ASSOCIATED WITH SUCCESSFUL REINTEGRATION OF SEX TRAFFICKING SURIVIVORS FROM THE SURVIVOR PERSPECTIVE ("TVPA," 200 0 p. 1470 ) In the United States, the Department of State has approximated that 14,500 17,500 individuals are victims of human trafficking, in the form of labor and sex, each year (US Dep artmen t of State, 2018). It is difficult, however, to ascertain specific estimates due to the underground nature of this crime (Institute of Medicine and National Research Council, 2013). According to the Polaris Project, the current estimates of calls to the hotline are 26,557 in 2017 (National Human Tra fficking Hotline, 2018b) This number has continued to increase each year ; however, it is not clear if this is due to increased awareness and identification or an actual increase in the rate of human trafficking. There are extensive public health concerns for those who are trafficked including vast health disparities and lack of understanding regarding appropriate service models among professionals in the field Health disparities in this population result from both early childhood experiences (Ijadi Maghs oodi, Cook, Barnert, Gaboian, & Bath, 2016) that make traffickers more likely to exploit these individuals as well as health issues resulting from being trafficked (World Health Organization, 2012; Zimmerman & Kiss, 2017) Those who are trafficked are more likely to have had adver se childhood experiences (ACEs), various childhood traumas such as parental incarceration and types of abuse or neglect (Felitti et al., 1998) T hose who have been trafficked are more

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114 likely to have experience d six or more ACEs, wi th childhood sexual abuse the most predictive of later sex trafficking ( Reid et al., 2017) Traffickers exploit vulnerability for their gain. Vulnerabilities includ e childhood sexual and physical abuse, involvement in the child welfare or juvenile justice systems, a history of assault victimization incarcerated parents, substance abuse parental substance abuse, those identifying as LGBT (lesbian, gay, bisexual, or transgender) intellectual disabilities and those experiencing mental health issues (Smith et al., 2009; Varma et al., 2015) Health issues that result from sex trafficking include sexually transmitted diseases (STDs), HIV, pregnancies, abortions, undiagnosed chronic disease s physical injuries, and mental health issues (Macias Konstantopoulos e t al., 2013; Zimmerman et al., 2008) P overty appears to be the overarching factor strongly related to being targeted for trafficking (Logan et al., 2009) Factors associated with i ncrease d health issues among trafficking survivors include restriction of m ovement (not permitted to leave specific areas), extensive working hours, withholding of identification, withholding of wages, physical and sexual abuse, along with deplorable living condition s while being trafficked (Kiss, Pocock, et al., 2015) Survivors of sex trafficking have been found to have increased symptoms of depression, anxiety PTSD, and more suicide attempts (Abas et al., 2013; Hossain, Zimmerman, Abas, Light, & Watts, 2010). Due to the extensive health issues associated with sex trafficking, it is imperative to establish appropriate reintegration programs for survivors (Hom & Woods, 2013) with recommendations for global health professionals to provide critical services in physical and mental health care, as well as other assista nce services (CdeBaca & Sigmon, 2014). As there is a lack of evidence based reintegration programs in the United States.

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115 A qualitative study of survivors of sex trafficking in Nepal found survivors felt unheard in this process which included a call to acti on for developing more sustainable practices for rehabilitation (Dahal, Joshi, & Swahnberg, 2015). Because there are no evidence based programs for reintegration it is critical to study interventions that may be efficacious for this population (D. C. Beck Choi, Munro Kramer, & Lori, 2017; Zimmerman, Hossain, & Watts, 2011) There is a public health need to create sustainable programs for this population Limited research exists on evidence based best practices for reintegration (Dell et al., 2017; Muraya & Fry, 2016) Therefore, this study aims to describe the re integration experience from the perspective of survivors to determine what factors may assist in successful reintegration into society To focus on empowering survivors who have experienced success ful recovery to voice what is needed for successful reintegration. Methods Participants Participants were selected through purposive sampling of sex trafficking survivors in south ern Florida enlarged by snowball sampling that expanded across two states. All participants were recruited through key informants, such as service providers and recommendations by human trafficking coalition members who served to act as gatekeepers to protect this population from any potential exploitation. Six survivors were i ncluded in this study. Recruitment differed from that in most studies for several the reintegration process. Second, no participation incentives were available. Af ter

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116 speaking with a national survivor group, they suggested survivors should be compensated to avoid further exploitation. All participants provided consent to be contacted for the study and all were scheduled for three 30 to 60 minute, face to face int erviews, with the choice to finish in one to three interviews. The overall time of interviews for each participant ranged from 90 to 120 minutes. Participants had the choice to opt out at any time during the study. Interviews were digitally recorded and tr anscribed. Due to the sensitivity of the topics discussed, one survivor chose not to be recorded; therefore, the primary researcher simultaneously transcribed the interview via a laptop computer Inclusion criteria included the following: at least 18 year s old, considered a victim of human trafficking according to the Action, Means, Purpose definition (Polaris, 2012) a minimum of six months since exiting the traffick ed situation, able to speak and understand English, able to provide informed consent, and considered stable to participate by the recommending key informant. All participants were given an informed consent document, and the consent process was discussed with the primary researcher prior to the interview and again prior to each subsequent interview There were no incentives for participation Ongoing discussions occurred with the research team, key informants and mental health professionals to ensure the wellbeing of those participa ting in the study. A licensed mental health therapist was available to none of the survivors accessed the therapist. Unsolicited, all survivors did contact the primary r esearcher to express positive feedback regrading participation in this study.

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117 Data Collection All surviv or interviews followed a trauma focused approach which incorporated : R ealize the individuals have faced traumatic events R ecognize symptoms they may have R espond to trauma needs R esist retraumatization of the individual (Substance Abuse and Mental Health Services Administration, 2014) A semi structured interview guide founded on building respect and rapport w ith the participants was developed and approved by the University of Florida Institutional Research Board. The questions were created to determine how participants were able to be successful after trafficking, including but not limited to their traffickin g experience, substance use, coping mechanisms, services recommended for survivors, services they received, experiences with professionals in the field, and prevention. The primary researcher developed questions specifically to include what services and en vironments would be more conducive to successful reintegration for survivors. Questions were partially based on results from a preliminary study the primary researcher had conducted with secondary data of survivor interviews. After asking questions the i nterviewer provided time periods of silence for respondent s to speak recognizing that it m ight be difficult for them to discuss various issues. P articipants were empowered to choose if they would like to take a break every 30 minutes (Substance Abuse and Mental Health Services Administration, 2015) reconvene another day, or continue with the interview process. Motivational interviewing techniques were employed, including (1) resist the urge to right, (2) understand the

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118 individual, (3) listen with empathy, and (4) empower (encourage confidence in) the individual (Miller & Rollnick, 2012) All individuals who participate d in the study were given re ferrals as needed Four of the six participants were given referrals for services such as college assistance and student loan reduction for mortgage qualification. The goal of data collection was to empower the individuals and meet them where they wer e, being careful to not coerce them in any way to get a desired response. Grounded theory methods were u s ed and the interviews were semi structured but open ended to allow participant s to answer in a manner comfortable to them (Charmaz, 2014). Data collection and analysis occurred in an iterative process using constant comparison of data and emerging thematic content (Charmaz, 2014) Data collection and analysis continued until saturation was reached meaning that new c ategories and themes stop presenting themselves (Charmaz, 2014; Richards, 2015; Strauss & Corbin, 1998) Recruitment and interviews ceased after content saturation occurred through the iterative process of data collection and analysis. Data Analysis Grounded theory methods were used to identify themes from the interview transcripts. To confirm reliability of this practice, two trained qualitative researchers (KH and LM) coded all six survivor interviews. The researchers examined the complete set of transcriptions of interviews individually, followed by direct comparisons of researcher results to establish associations among themes and subthemes presented in the data. In this study, quotations that were relevant to the research aims were coded and converted into themes that present ed themselves in the analysis (Morgan, 2018). As each interview proceeded, concurrent analysis t hrough constant comparison was conducted (Charmaz, 2014; Strauss & Corbin, 1998). This process starts with line

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119 by line coding in which researchers start to make sense of meanings in the data to develop emergent theory (Charmaz, 2014) The second stage co nsists of more focused coding and categorization for analytic significance to raise questions and further the research (Charmaz, 2014) The third stage includes theoretical coding to solidify the analytic proce ss to emergent t heory building (Charmaz, 2014) as categories reach saturation and no new categories emerge from the data (Charmaz, 2014; Richards, 2015; Strauss & Corbin, 1998) Memos and audit trails were s and thoughts to form the central basis of the analysis (Charmaz, 2014) As results are formulated outcomes are represented as descriptions by the researcher without presenting data The typology of finding s present in this study signify interpretive descriptions which reflect explanatory qualitative findings (Sandelowski & Barroso, 2003) Triangulation was applied to corroborate findings and test for accuracy of results by evaluating the literature to concl ude if it was consistent with findings. This method was implemented to ensure quality of the data. The use of multiple analysts to evaluate results and data was used as a form of triangulation to seek numerous outlooks of the data (Angen, 2000). The primar y researcher discussed codes and categories at the University of Florida interdisciplinary data analysis group, the Qualitative Research Colloquium to confirm findings Q ualitative methods and analysis are in alignment with the consolidated criteria for r eporting qualitative research (COREQ) to ensure high quality qualitative data to increase reliab ility and validity of findings (Tong, Sainsbury, & Craig, 2007). Results were also discussed with research participants to ensure their voice s w expressed.

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120 Con flicts may arise between aims of research and professional ethics and worth, independence, confidentiality, and welfare (Estroff, 1995) In qualitative research, it is importan t that participants are empowered while giving them the ability to evaluat e their needs to inform decision making in the research process. This highlight s outcomes that matter to survivors of sex trafficking and would be inclusive of their preferences, autonomy, and needs to enh ance their health related quality of life. By doing so, the researcher aimed to incorporate the diversity of this population to address indivi dual differences and barriers. Results Reintegrating back into society after being trafficked is a complex issue The data in this analysis illustrat es the experience of the process of healing. Several aspects are involved with reintegration and survivor success ( Table 3 ). T he mes that emerged from the data that facilitated successful survivor reintegration include: 1) rapport, 2) a survivor centered approach, 3) trauma informed comprehensive care, and 4) fostering resilienc y Rapport Establishing rapport with survivors is fund amental to f acilitating reintegration. Without establishing rapport with professionals in the field, survivors may have difficulty making progress. S ubthemes that emerged regarding rapport are seen in ( Table 3 2 ) and include d the following: 1) trusting others, 2) relationship s with providers, 3) safety, and 4) understanding. Survivors of sex trafficking have typically lost much of their tru st in others and in the world. I n order to provide services, the professionals must develop a relationship with an established foundation to work from as discussed by a survivor,

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121 ou're not sure if you are making the right decision, because once you make one, you tru st somebody, and they can trust the individual and feel safe. C reating such a relationship may be difficult and can take time, as people have repeatedly let them down in the past. Survivors need to feel secure with the professionals they are working with, as this is the first step of the engagement process with this population. unselor has to be a very patient person. And she ha s to know a lot (about) trauma. I t's hard, so you're going to be like I don't want you, I hate you. Even tho ugh they're going to counseling, sometimes you have to click with a counselor. The counselor needs to know how to ask, how to get out everything ou t of you. Once you open up like that, yes, healing can start co S ince survivors have not met many people who have genuinely wanted to assist them, creating a sense of safety can help them feel more secure in the process. A feeling of understanding is another component of rapport expressed by survivors. If survivors do not feel understood, it makes it harder for them to disclose to professionals. Only in an environment of mutual understanding and empathic response can a safe place for survivors be esta blished to begin their recovery. Survivor C entered A pproach The subthemes identified under this theme encompass the factors of a victim centered approach H owever, for this study these elements will be referred to as a centered approach. The subthemes include the following: 1) survivor based, 2) empowerment, 3) survivor led process, 4) collaboration and 5) a trauma informed approach. These subthemes are summarized in Table 3 3 along with representative quotes from participants

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122 Among survivors in this study, the term survivor was preferred to victim because it acknowledges that the individual has survived and overcome something rather than being a victim of a circumstance. This focuses attention on the preferences of the survivor. I probably wouldn't tell them that I'm a victim of trafficking, I would use the word survivor A survivor led approach produces a sense of empowerment, allowing survivors to feel heard and respected regarding their choices. Restoring choice allows for greater autonomy. A survivor who now works with other survivors explains: hen we're working with ad ults, somebody might want to get out of a DV (domestic violence) situation but not necessarily get out of sex work And you kind of like lump people together with their individual circumstances. And so one thing I do try to ask is f you could wave a magi c wand and you wanted to get out, what would that look like for you? Okay, do you want support in doing that? If you want to stay, okay, great. How can w e support you while you stay? Is there any safety concerns you have? No? You've got that han dled? Grea This example shows how to facilitate the process of survivors determining what is best for them, along with support from professionals. Fostering a survivor led process allows for survivor chosen goals, which lets survivors progress at a pace that may be more comfortable and empowering for them. This also allows for more collaboration between survivors and professionals to determine appropriate plans for their reintegration. Collaboration and advocacy between survivors, law enforcemen t and service provider professionals may be beneficial for this process. Another survivor explains how collaboration is currently lacking: omething that I'm really big about is education especially with law enforcement, with the jud icial system, all th e judges with anybody that's in some sort of social work aspect of things. Because once they start to understand what trafficking is and what it's like, they'll start treating

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123 trafficking survivors or people that are being trafficked differently, and then they'll start putting the Another component is having professionals take a trauma informed approach This appears to be necessary when working with survivors due to the repeated trauma they have experienced as a result of trafficking Reducing the risk of retraumatization and revictimization during service provision needs to be considered. This may be offset through professional understanding of trauma. In addition, as described below by a survivor who teaches professional s about trauma, professionals need to work through their own trauma issues before attempting to work with survivors: hen you do your own trauma work, you don't need training in trauma informed care because you just get it I think all those trainings are great, but that's what I tell people when I give trauma informed training. I'm like, you are not trauma informed after this training. They're' like, "That's why we brought you here." I'm like, I don't care. You're not trauma informed after this training. It's a certificate you're getting. I've started wanting to do trauma informed retreats where we like get to the bottom of your sh t before you can call yourself trauma informed. Learning about trauma appears to be one thing, but it may be necessary for pr ofessionals to examine trauma in their own lives in order to have a better understanding of how it may affect survivors. This would make them better equipped to work with them. C omprehensive C are For survivors to be successful in reintegration, a continuum of comprehensive care was identified in ten subthemes: 1) immediate care, 2) substance use treatment / detox, 3) coping skills 4) building self esteem, 5) healthy relationships/ boundaries 6) continued trauma informed therapeu tic interventions, 7) mentoring/life coaching 8) legal issues, 9) education/occupational skills and training, and 10) independent housing. These subthemes are summarized in Table 3 along with quotes

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124 from participants As part of a survivor centered approach, all comprehensive care services should follow those guidelines as well. It is relevant to start immediate care by meeting the basic needs and sa fety concerns of survivors. Survivors may have many service needs depending on their specific situations, but first need to have a safe place to go. One time I did get away. I went over to a friend's house that lived down the street from where I was bein g held in the apartment. I was like, I'm in a You ca n come here, and we'll The next day I went over there. I was lik here, but we'll help you fin As soon as they said that, I ran out the door and ran back. I thought, h my gosh, he's going to know that I left now. For some reason before I left, it wasn't as big of a fear, not quite as much, unti l I didn't know what was next. When pe ople are going in for services and going to shelters they get told no Y ou don't k Survivors are generally unsure of others. While they were in a bad place while being trafficked, they knew what to expect from their traffic kers. In this instance, the survivor thought she was going to be able to stay with her friends, but when they and immediate help when they are ready to leave, as th ey do not know when they will have that opportunity again. They risk their lives when they attempt to escape, so once they have left, going back is dangerous. Substance use treatment or detox is another immediate need to assist survivors in the stabilizat ion process. Substance use is a barrier to exiting and utilizing services. Traffickers sometimes give victims substances as a form of coercion or survivors may start using during or after being trafficked to cope with their trauma. This is important to recognize because many survivors have addiction issues that could interfere with any services or assistance being provided. As one professional stated:

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125 The population I was with for the most part out on the street I t was based on sub stance abuse. That was like they were feeding a habit or feeding somebody else's habit. Like every girl that I knew that worked out there had a drug addiction. Due to extent of trauma faced by survivors, it is relevant to assist them with developing healt hy coping skills. Many may have turned to substances to numb their symptoms, which can be counterproductive to interventions. Additionally, many survivors may ch o o se not to discuss thei r past because they want to move forward. They often need assistance wi th managing any symptoms to achieve higher level of daily functioning. have to be more conscious of where I am, so I start counting five to one backwards. Five things I can see. And then four things I can smell, and things like that and breathing. Or that I'm at the beach and I can hear the After being trafficked many survivors may need to build their self esteem to address self doubt. This can restore value and feelings of self worth after being treated as if they did not matter. I just had to sit on the couch while everybody ate and did this life. I just remember feeling like a throw pillow. I was just sitting on the couch waiting to be told where to go, what to do. I didn't have a name. I was literally just like a t hrow pillow. To compound low self esteem, many s urvivors have experienced dysfunctional relationships and may not have been able to enforce proper boundaries. Therefore, learning about healthy relationships may be necessary, as many survivors have correla ted sex to romantic relationships. I started working consensually for an escort service ... I literally was young enough to think h this sounds like a good idea to meet people. In my mind, that was the type of people I wanted to me et and that if I sle pt with these guys, I would end up having what I thoug ht were relationships

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126 Complete trauma informed therapeutic interventions by use of alternate therapies may be a good way to work with individuals who are working through traum a without havin an ything can be therapeutic de pending on their interests. For example, arts and crafts, horticulture, music, attending sex and love addicts anonymous (SLAA), or brain spotting therapy have all been successful therapy alternatives. Based on survivor accounts, anything they enjoy or that helps them regulate their emotions could be considered a trauma informed intervention. This is a trauma informed approach because they are not re quired to directly address their past traumas, which could trigger retraumatization. Brain spotting, wherever your eyes move, it activates that part of the brain... s o what happens is they move their finger. So I would stop and I would think about feeli ng rejected. And then I would see w here I felt rejected in my body Then they would move their finger once over and I would say, Oh the pain gets worse to the left. And then they would move their finger up and down and I said Oh, the pain gets much wors e when you go up. So then wherever that point was, I would stare at that point on the wall a nd I would listen to music that activated both the right and left hemispheres of my brain. Brain spotting was also mentioned as a good therapeutic option for this population, as it may reduce anxiety and stored tension in the body from the traumatic event memories stored in the brain. One survivor in this study expressed how beneficial it has been in the reduction of her posttr aumatic stress disorder (PTSD) symptoms. Depending on legal status in the country, obtaining services can be difficult for survivors facin g incarceration or deportation. This stress may place the i ndividual at risk for further exploitation because of lack of service provision and legal consequences. Therefore, legal advocacy may offer survivors protection following disclosure. Many survivors may have a criminal record which could include prostitution because they were involved in commercial sex as part of being trafficked. They could have drug or

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127 petty theft charges, which may have accumulated during their trafficking. It appears this may lead law enforcement, support services agencies and employers to treat survivors as criminals, rather than victims. As one survivor asserted: With everything that is required now for background screenings, your record follows you around to move into an apartment building, an HOA, or job. Even after 7 years it is not clear. They are not supposed to charge someone with pros titution if they are being trafficking. It s shameful and stigmatizing. We need to figure out how to take this off their records so it does not follow them around for the rest of their lives. Many survivors may have not have ever had traditional jobs and may not be sure how to approach finding a focus for their lives The process of having a mentor or life coach could not only help survivors figure out which direction to take their lives but empower them to become the people they want to be After survi vo rs reach a level of stability they may need education, occupational skills or training, as many of them are ready and looking forward to working or going to school. Some survivors want to become entrepreneurs since they do not feel they could work for some one again. I have this friend. She works for somebody I admire her for being able to have a job. I don't see myself having a job. I don't see myself working for anybody n o women, no man. I will never work for somebody in my life again. I have to be an e ntrepreneur, because I'm not going to put my life and risk on somebody else. They can change in a flip. Once a survivor is emotionally stable enough to function and maintain employment, it may be an appropriate time for independent housing. All survivors in this study expressed the desire to have their own place and how it was part of their healing. Fostering Resiliency The survivors involved in this study are extremely strong willed, determined and have the motivation and strength to recover and heal. F ostering resiliency seems to be a needed component of reintegration. Subthemes ( Table 3 ) include the following: 1) a

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128 paradigm shift, 2) regulation of trauma, 3) utilization of social support, and 4) go als/purpose. It is evident these characteristics depict how survivors use their experiences and grow from them. A paradigm shift revealed the way survivors talk abo ut how their views about l ife and how t heir mindsets and perceptions have changed since exiting trafficking. Since they had been conditioned to the circumstances they were involved with, it became difficult to adjust their thinking. I t's just that cycle of abuse that goes on. And that person just has to be ready. And it's harder, just being here and watching the girls come in and out of here I t's a complete paradigm shift, you know? When you want help, and you've been brought up in all this, you've gotta look at life completely d ifferently and have to be willing to do the uncomfortable and let go of old mindsets Letting go of old mindsets sounds simple, but survivors have been submerged into a subculture of society. Re gulation of their trauma symptoms appears to be a key compone nt of recovery which has been shown to decrease symptoms and increase daily functioning It takes practice to better regulate emotions as one survivor explained: I can have been having a good day, everything is fine, and then a smell of a specific perfu me triggers me and I start getting anxious. I start sweating. My heart start pumping. While I recognize what's going on, that I'm having an anxiety attack and I calm down. It's like 10 minutes. I'm dealing with it almost every day. I'm not like a regular p erson that just live s their life ; I have to be careful and be aware of what might trigger me. So I have another duty all d ay, which I have to be focused o n ju st trying to Various forms of social support have been reporte d to assist survivors in their recovery process : survivor based support/mentorships, peer relationships, support groups, community involvement, service provider support, fami ly/surrogate family, or friends. S urvivors want to connect with someone in a meani ngful way that helps them feel understood and less isolated This is illustrated in the quote below.

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129 Having a person who actually tells me, I passed that, I was already in that role, there's going to be some bumps B ut you know, if somebody tells you that and they lived it, it's even better than talking to your counselor to let them know that it looks like there's no light at all, but there is one right there That is something you have to start describing to a non survivor. Goals and purpose seem to create a r enewed sense of meaning in the lives of survivors. During trafficking, they were not allowed to pursue their own dreams ; now they finally have that opportunity. This may look different for each survivor because they are individuals who finally ha ve a chance to decide what their hopes and dreams are for the first time. Discussion Overall the reintegration process is complex but taking a su rvivor centered approach with comprehensive care and therapeutic interventions facilitates survivor success. F ocus ing on meeting basic needs a nd establishing rapport fosters resiliency and facilitate s succe ss. Rapport building should be the first step when engaging with this population and t his has to take place before a survivor can begin to trust the professi onals they are working with Although all of these factors appear to be relevant to successful reintegration of sex trafficking survivors, all are likely to be costly endeavors. Unfortunately, adequate funding is difficult to obtain; therefore, use of ex isting community resources should be considered. From a public health prospective, this study sought to uncover information that could help develop feasible and sustainable solutions. The time needed to build rapport and foster effective relatio nships bet ween professionals and survivors should be accounted for in the planning process. P roviders may consider their approach by treating survivors as competen t and capable to establish initial trust (Sanders, 2015). Due to issues with rapport building, a single case

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130 manager coordinating services for survivors would be appropriate (Clawson & Dutch, 2008a) Given survivor histories, relationships need to be established, and long term approach es to outcome measures should be considered (Epstein & Edelman, 2013). S urviv ors should be included as a vital component of the team in anti human trafficking efforts (National Survivor Network, 2017; Office for Victims of Crime, n.d.). Further, survivor led safety planning is a form of empowerment in which the individuals can exert a sense of control over their lives (Ullman & Townsend, 2008). Short term, trauma specific therapies should be considered in this population. EMDR (eye movement desensitization and reprocessing), a known treatment for PTSD (posttraumatic stress diso rder) has been shown to be effective (n=31) with complex trauma and dissociation, in which 100% of the sample found at least some improvement in symptoms after eight sessions (Gonzalez Vazquez et al., 2017). Another short treatment was highly recommended a s effective by a survivor in this study the practice of brain spotting. Whereas traditional psychotherapy occurs within the cerebral cortex, brain spotting affects trauma stored deeper in the brain. A study (n=76) using three sessions with e ither EMDR or brain spotting revealed that both were effective in reducing PTSD symptoms (Hildebrand, Grand, & Stemmler, 2017). Therapeutic modalities should be better researched with in this population (Altun, Abas, Zimmerman, Howard, & Oram, 2017). Emphasis should be p laced on developing individual approaches for survivor s to address root issues and reduce triggers to assist them in everyday functioning. Seeking Safety (SS) is a trauma based intervention that applies cognitive behavioral strategies of reducing substanc e use and the negative impact of

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131 trauma exposure ; this approach can be peer led (Najavits, 2002) and could be considered for this population Despite the need for comprehensive care no studies have been aimed at determining effective interventions for re integration of human trafficking survivors (Zimmerman et al., 2011) T rauma informed interventions should be considered in addition to evidence based programs with survivors, but unfortunately this area is lacking. M odalities such as yoga (West, Liang, & S pinazzola, 2017), mediation (Hilton et al., 2017), vigorous physical activity (Harte, Vujanovic, & Potter, 2015), art therapy (Schouten, de Niet, Knipscheer, Kleber, & Hutschemaekers, 2015), music therapy (Landis Shack, Heinz, & Bonn Miller, 2017), horticu ltural therapy (Annerstedt & Wahrborg, 2011), and animal therapy (Mims & Waddell, 2016) may be suitable options to consider for survivors. Community based programs such a twelve step programs offer social support (Donovan, Ingalsbe, Benbow, & Daley, 2013) and sex and love addicts anonymous (SLAA) groups have been found to be effective to address attachment insecurity and love addiction (Kwee, 2007) Results of this study found that positive social support can foster resilience in survivors. Assisting survi vors with resilience by practicing skills to regulate symptoms hav ing a paradigm shift, engaging in appropriate social support and development of goals and purpose appear to be mechanisms that lead to greater healing. Several survivor led programs and rec ommendations developed by su rvivors in the field, could be evaluated to develop evidence based programming. A paradigm shift has been described by as unlearning the pimp and trafficking subculture, which has its own rules, norms, language, and social mores (Lloyd, 2011). A survivor entrepreneur, and social

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132 justice advocate has created curriculum for professionals and has programs in which she di rectly mentors other survivors (Sanders, 2015) T o decrease relapse providers have to understand th at recovery is a circular model. Survivors should develop new skills, a sense of belonging, empowerment, love and value through discovery of hidden talen ts separation fro m their trafficker, and connect ions with the right people. People connect to people, not programs (Lloyd, 2011) The literature supports protective effects of social support on physical and psychological health, inc luding modification of gene expression (Ozbay et al., 2007). Another study supported this by showing the human adaptation process in connection with u s ing social support as a way to foster resilience in an individual (Southwick et al., 2016). Therefore, so cial support may create positive biological changes to foster resilience Support systems should be fostered in order to develop more sustainable practices to rehabilitate this population (Dahal et al., 2015) with the goal of empowering survivors to be in volved in recovery. Studies show that when an individual has a purpose in life it will predict better emotional recovery from traumatic events, over autonomy, personal growth and self acceptance alone (Schaefer et al., 2013). Further supporting the result s of this study, it was found that various facets of resilience including optimism, positive coping skills, flexibility, perceived support from social networks, and self car e should be integrated into intervention s (Lacoviello & Charney, 2014) Survivors have access to various services within the community; however, approaches that foster resilience appear to predict a more success ful life reintegration for them after being trafficked

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133 Limitations P articipants were limited to those in stable positions af ter their trafficking situations. Survivors who have experienced significant barriers to exiting trafficking would not be included in this study as they may not have experienced success upon leaving their trafficking situations or may still be with their traffickers Therefore, more research is needed on barriers and how facilitation of exiting trafficking can be conducted. Additionally, this study does not include any survivors who may have relapsed back into trafficking. Participants in the study have met some level of success and stabilization. Therefore, we can learn from this study what has been helpful for them so that professionals working in the field against human trafficking can integrate these findings. Further, only six individual s were involved in this study; five were from the south Florida area and one participant was a well known survivor of sex trafficking located out of state. Due to the vulnerability of this population, many individuals were hesitant to participate as they did not always feel successful, were experiencing higher PTSD symptoms, or felt they should be compensated. Conclusion The path to successf ul reintegration is difficult. By facilitating survivor led and empowerment based therapy survivors are given back control and choice in their lives. Finding a new purpose and meaning in life gives them more drive and mo tivation to continue the path of recovery and healing. Examining the recommenda tions of survivors who have recovered provides insight into how su rvivors can be best served to elicit successful recovery Fostering resiliency and rapport among a trauma informed continuum of care increases survivor success It is worthwhile to explore the feasibility and sustainability of integrating community based a nd victim services currently in place

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134 to include specific training for sex trafficking survivors. A public health approach is warranted to address sex trafficking across primary, secondary and tertiary levels of prevention given the abuse histories evide nt in survivors. Further research should assess views of key informants working in the field with survivors to determine similarities and differences in order to keep trafficking initiatives survivor based.

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135 Table 3 1 Survivor Themes and Subthemes Theme (count) Subtheme (count) Rapport (6) Trusting others (4) Relationship with P roviders (6) Safety (6) Understanding (3) Survivor Centered Approach (6) Survivor based (4) Empowerment (3) Survivor led process (3) Collaboration (3) Trauma Informed Approach (4) Comprehensive Care (6) Immediate Care (5) Substance Use/Detox (6) Coping Skills (3) Building Self Esteem (4) Healthy Relationships /Boundaries (5) Mentoring / Life Coaching (5) Continued Trauma Informed Therapeutic Interventions (6) Legal Issues (2) Educational/Occupational Skills and Training (5) Independent Housing (4) Paradigm Shift (6) Resilience (6) Regulation of Trauma (6) Utilization of Social Support (5) Goals / Purpose (6)

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136 Table 3 2. Rapport Subthemes Subtheme Description Quotes Trusting others Survivors experience mistrust of the world You're not sure if you are making the right decision, because once you make one, you trust somebody, and they fool you, that's the issue. Relationship with providers Building a relationship with professionals working with them The counselor has to be a very patient person. And she has to know a lot (about) trauma. It's hard, so you're going to be like, I don't want you, I hate you. Even though they're going to counseling, sometimes you have to click with a counselor. The counselor needs to know how to ask, how to get out everything out of you. Once you open up like that yes, healing can start coming. Safety Survivors need to feel safe and secure I'm learning to take risks with safe people. I'm fortunate to be in a place where everybody has a background check before they can come in Understanding Mutual understanding and empathic response So, all those questions regarding if I'm telling the truth, really, it hurts every time somebody acts like that, so I had to adopt a very conscious ... way to say things.

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137 Table 3 3. Survivor Centered Approach Subthemes Subtheme Description Survivor Quote Survivor B ased Focus on needs and wants of survivor I probably wouldn't tell them that I'm a victim of trafficking, I would use the word survivor. Empowerment Survivors feeling heard and respected Somebody might want to get out of a DV (domestic violence) situation, but not necessarily get out of sex work. So one thing I do try to ask is, if you could wave a magic wand, and you wanted to get out, what would that look like for you? Okay, do you want support in doing that? If you want to stay, okay, great. How can we support you while you stay, is there any safety concerns you have? Survivor L ed P rocess Survivor chosen goals and going at pace I look back on it now and I look at like my therapist who for all intents and purposes did not do any therapy with me really because ... I... learned to say just what I needed to say, you know? That there wasn't any therapeutic help and I have to realize that I think that my therapist, who allowed me to do my own therapy as far as like ... Go through her files and pull out handouts, she'll go, "What do you think, you know, you've done this a lot of times what do you think you need to work on? Collaboration Advocating for the survivor by everyone involved and including the survivor with the judicial system, all the judges, with anybody that's in some sort of social work aspect of things. Because once they start to understand what tr afficking is, and what it's like, they'll start treating people that are being trafficked differently, and then they'll Trauma Informed Approach Reducing retraumatization and revictimization through unde rstanding and dealing with your own issues trauma informed care because you just get it. I think all those trainings are great, but you are not trauma informed after this training. They're' lik e, "That's why we brought you here." I'm like, I don't care, it's a certificate you're getting. I've started wanting to do trauma informed retreats where we get to the bottom of your sh*t

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138 Table 3 4 Comprehensive Care Subthemes Subtheme Description Survivor Quote Immediate Care Basic needs and safety One time I did get away. I went over to a friend's house that lived down the street from where I was being held in the apartment. I was like, I'm in a bad situation, I need to get out. They're like, You can come here and we'll help you. The next day I went over there. They're like, You can't stay here, but we'll help you find some place. As soon as they said that, I ran out the door and ran back. I thought, oh my gosh, he's going to know that I left now. For some reason before I left, it wasn't as big of a fear, not quite as much, until I didn't know what was next. When people are going in for services and going to shelters, they get told no, you do n't know what choice they just made. Substance Use treatment / Detox Substance use as a barrier to exiting and services, however, also a lack of proper treatment professionals After struggling for four years, she decided that she didn't know what to do in a party, a trafficker was there, offered her cocaine, which she used to do when she was being trafficked, that was the hook, and she end up being trafficked. Not on coercion, b ut on half way agreement. I said, a half way agreement, because you're sick. You're mentally ill. So, every decision, even though somebody wants to tell me, oh she consciously went and looked for her, she doesn't know any better. She was broke down alread y. So, the trafficker took advantage of her knowing that she was already depressed and that she was trafficked, she knew already what to do. Coping Skills Methods for reducing mental health symptoms I have to be more conscious of where I am, so I start counting five to one backwards. Five things I can see. And then four things I can smell, and things like that and breathing. Or that I'm at the beach and I can hear the sounds so my anxiety goes down. Building Self Esteem Restoring value and self worth I just had to sit on the couch while everybody ate and did this life. I just remember feeling like a throw pillow. I was just sitting on the couch waiting to be told where to go, what to do. I didn't have a name. I was literally just like a throw pillow. Healthy Relationships /Boundaries Learning health relationships and maintaining healthy boundaries I started working consensually for an escort service ... I literally was young enough to think, oh this sounds like a good idea to meet people. In my mind, that was the type of people I wanted to meet, and that if I slept with these guys, I would end up ha ving what I thought were relationships with them.

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139 Table 3 4. Continued Subtheme Description Survivor Quote Continued Trauma Informed Therapeutic Interventions Interventions that do not require addressing trauma directly and reduces risk of triggers Gardening has been my hobby lately. I love it. That takes my mind away so much, that I'm able now to do a lot of stuff on my own, that I couldn't do six months ago. I love sports. I used to practice TaeKwonDo and I'm still a fan of it. I love to listen to music. It's just like, it can take you wherever you want, at the moment you want. It's like magical. And I enjoy reading. Brain spotting, wherever your eyes move, it activates that part of the brain... So what happens is they move their finger. So I woul d stop and I would think about feeling rejected. And then I would see where I felt rejected in my body. Then they would move their finger once over and I would say, "Oh the pain gets worse to the left." And then they would move their finger up and down and I said, "Oh, the pain gets much worse when you go up." So then wherever that point was, I would stare at that point on the wall and I would listen to music that activated both the right and left hemispheres of my brain. I see God's involvement in my life and I see how he strategically placed people in my life along the way. For a long time I was so angry, angry at everyone and everything, including myself and God. And I think once I finally hit my bottom, to a place where I could give God a fresh start. A nd then as far as healing goes, I think just forgiving. Forgiveness has been a huge thing. Not just to other people, but to myself. Mentoring / Life Coaching Empowerment approach to discovering goals and obstacles to becoming the person you want to be I think a coach; a life coach can help you to express yourself. Make you get your way to speak it up. It doesn't have to be with words. They (survivors) need a life coach who sits down with them, and send them to counseling, to educational places, to sit d own with her, what do you want, do you want to study in a specific profession? Do you want to train in a profession? Or do you want to do something like crafting? You don't want to be in touch with people, because you don't feel secure, do you want to be a n entrepreneur? Finding a life coach that actually works with you and brings out what you really like and try to make that a job. And when you don't trust yourself, and you have to relearn how to live life after trauma, you actually need somebody to see wh at you don't see in yourself. Legal Issues Clear criminal charges accumulated from being trafficked With everything that is required now for background screenings, your record follows you around to move into an apartment building, an HOA, or job. Even after 7 years it is not clear. They are not supposed to charge someone with prostitution if they are bei ng to take this off their records so it does not follow them around for the rest of their lives

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140 Table 3 4. Continued Subtheme Description Survivor Quote Educational/Occupational Skills and Training Employment / entrepreneurial skills / leadership training / education I have this friend. She works for somebody, I admire her for being able to have a job. I don't see myself having a job. I don't see myself working for anybody. No women, no man. I'm not in that. I will never work for somebody in my life again. I have to be an entrepreneur, because I'm not going to put my life and risk on somebody else. They can change in a flip. Independent Hou sing Long term housing to call their own I first contacted IRC (International Rescue Committee), and they were very, very helpful into financially help me for six months. I got this house because of them, they helped me out with the deposit and all this s tuff.

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1 41 Table 3 5 Fostering Resiliency Subthemes Subtheme Description Quotes Paradigm Shift Changing old mindsets and perceptions of the reality It's just that cycle of abuse that goes on. And that person just has to be ready. And it's harder, just being here and watching the girls come in and out of here. It's a complete paradigm shift, you know? When you want help, and you've been brought up in all this, you've gotta look at life completely differently, and have to be willing to do the uncomfortable and let go of old mindsets. Regulation of Trauma Decreasing trauma symptoms and increasing everyday functioning I can have been having a good day, everything is fine, and then a smell of a specific perfume triggers me and I start getting anxious. I start sweating. My heart start pumping. While I recognize what's going on, that I'm having an anxiety attack and I calm down. It's like 10 minutes. I'm dealing with it almost every day. I'm not like a regular person that just lives their life, I have to be careful and be aware of what might trigger me. So I have another duty all day, which I have to be focused ust tryi ng to be another normal person. For a very long time I thought that healing was a lifelong process. And I don't believe that statement anymore, and I've told a lot of people that. And I don't regret, because I was in a different place when I said it. I also think that that's something that we need to be careful of doing because I feel like it puts a ceiling on people. Utilization of Social Support Creating a healthy support system spectrum Engaging with peers who have been successful Recov ery should be more about building your support system. Let's get you stabilized with a roof over your head, a strong support system, and then we'll start doing the trauma work. Like the trauma therapy was great, but my support systems were way more helpful than, not more helpful but like in a different way helpful. I've had different therapists and done different things at different times, but having a really strong support system of people that have done their healing has been my most supportive thing beca use they just get me. Having a person who actually tells me, I passed that, I was already in that role, there's going to be some bumps, but you know, if somebody tells you that, and they lived on it, it's even better than talking to your counselor. To le t them know that it looks like there's no light at all, but there is one right there. That is something you have to start describing to a non survivor. Goals / Purpose Finding meaning in life again I was given a lot of support to figure out what I wanted to and I really didn't know what I wanted to do. I thought being a phlebotomist was the end goal. But I was given support, "Okay, we'll help you do that." What are your dreams? And even when you don' t know what your dreams are because you never allowed yourself to dream.

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142 CHAPTER 4 FACTORS ASSOCIATED WITH SUCCESSFUL REINTEGRATION OF SEX TRAFFICKING SURVIVORS FROM THE KEY INFORMANT PERSPECTIVE Human trafficking is a significant public health problem throughout the world In the United States it is a major criminal, social justice, and human rights issue. According to the Trafficking Profile produced by U.S. Department of State, the U.S. is a source, transit, and de stination country for men, women, transgender individuals, and children both U.S. citizens and foreign nationals subjected to sex trafficking and forced labor (US Dept of State, 2018) Sexual exploitation is the dominant form of human trafficking in Europ e, Central Asia, and the Americas. In 2016, it was estimated 3.8 million adults were victims of forced sexual exploitation and 1.0 million children were victims of commercial sexual exploitation (CSE). Women and girls accounted for more than 99 % of victim s, indicating that women and girls are more vulnerable to sex trafficking (Organization, 2017). The demand involved in sexual exploitation has been described as a triad among sex buyers, traffickers and the culture that tolerates or promotes it (Hughes, 20 04) It has been estimated that approximately 200 ,000 incidents of sexual exploitation of minors occur annually in the United States and t he Trafficking Victim Protection Act of 2000 (TVPA) suggests that close to 50,000 persons are trafficked into the Un i ted States every year (Clawson, Dutch, Solomon, & Grace, 2009) A barrier to providing services for survivors has been identified by a lack of awareness and training (Clawson et al., 2009) Most of the research on human trafficking training has occurred within healthcare professionals (M. Beck et al., 2015; Stoklosa, Lyman, Bohnert, & Mittel, 2017; Titchen et al., 2017) indicating a need to

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143 encourage training and research in other key prof essions. A study on mandatory reporters of abuse across the United States found that 60% had no formal human trafficking training (Hartinger Saunders et al., 2017) which means they may not have realized trafficking if they did see it. Overall, there is a lack of research based interventions with a severe need identified for further research on effective interventions for survivors and successful recovery (Oram et al., 2016) Without clear indications of what can be done to effectively help survivors in the recovery process, it is difficult to determine appropriate program components. Therefore, key informants working directly with people who have been trafficked should be utilized to determine baseline best practices. Limited research exists on evidence bas ed best practices for professionals working with sex trafficking survivors. This study was conducted to ascertain if key informant perspectives were in accordance with a previous study on factors associated with successful reintegration according to the su rvivor perspective (Chapter 3). This study focuses on the perspective of key informants in facilitation of reintegration of sex trafficking survivors. Methods Participants Key informants were recruited through purposive sampling of professionals from huma n trafficking coalitions, law enforcement task forces, victim service provide r s, safe houses, domestic violence and mental health professionals in Palm Beach County in Florida, who work directly with human trafficking survivors in 2018 Subjects were also recruited through the Human Trafficking Task Force, a joint effort between law enforcem ent and victim service providers. Q uestionnaires were emailed to members of the Task Force and to members of the Human Trafficking Coalition of the Pa lm

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144 Beaches, which i ncluded details about the types of services they provide. The primary researcher contacted all participants who provided consent to be contacted for the study. All interested individuals were scheduled for a one time 30 to 60 minute face to face intervie w; interviews were digitally recorded and transcribed. Due to the nature of not permitted by their respective agencies to be recorded; therefore, the se interview s were simultaneously transcribed via a laptop computer by the primary researcher. Inclusion criteria was as follows: worked directly with sex trafficking survivors, worked in the field for at least one year, and belong to an organization providing direct service for human trafficking su rvivors. Therefore, all individuals in this study have specific experiences with survivors despite different professional backgrounds. All subjects were given an informed consent document and discussed the consent process with the primary researcher. There were no incentives for participation Data Collection A semi structured interview guide approved by the University of Florida Institutional Research Board was used to conduct interviews, and the primary researcher conducted all interviews to ensure consis tency. Participants were asked questions about the reintegration process for sex trafficking survivors, including but not limited to services needed for survivors, proper approaches/skills used by professionals in the field, treatment, prevention, and issu es in the field. The primary researcher developed questions specifically around what services and environments would be more conducive to successful reintegration for survivors. Grounded theory methods were used in this study, provid ing strategies and expl oratory means to understand a phenomenon Data collection and analysis occurred in an iterative process, using

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145 constant comparison of the data and evolving thematic content. Data collection and analysis continued until saturation was reached, which occurs when there are not any new c ategories or themes identified (Charmaz, 2014; Richards, 2015; Strauss & Corbin, 1998) Recruitment and interviews concluded after content saturation occurred, meaning that no new themes or significant topics emerged from additi onal interviews. Data Analysis Grounded theory methods were used in this study to develop themes and categories from the interview transcripts. To ensure reliability of this process, two trained qualitative researchers (KH and LM) coded 18 key informant in terviews. The researchers analyzed the entire set of transcriptions of interviews individually, then met to compare their results and determine associations between themes and subthemes. As each interview was conducted, simultaneous analysis occurred in a n iterative process (Charmaz, 2014; Strauss & Corbin, 1998). This process begins with line by line coding in which researchers begin to fit the meanings of the data to develop emergent theory from the commen cement of data collection (Charmaz, 2014). This p rocess includes open coding, which is the development of codes from large portio ns of the raw data into categories (Charmaz, 2014; Strauss & Corbin, 1998) As constant comparison continues, these categories are analyzed with axial coding which is the proc ess of relating codes into subthemes and themes to form theory (Charmaz, 2014; Strauss & Corbin, 1998) Memos and audit trails were kept throughout the procedure to record the logical decisions and thoughts (Charmaz, 2014) Anal ysis was completed through hand coding. Analysis continued until saturation occurred and no new catego ries or themes were identified (Charmaz, 2014; Richards, 2015; Strauss & Corbin, 1998)

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146 When formulating the results, findings are depicted as explanations by the researcher without using data The typology of findings in this study represent interpretive descriptions that mirror explanatory qualitative findings (Sandelowski & Barroso, 2003) All analysis was d iscussed throug h peer briefing and the p resentation of findings at the University of Florida Qualitative Colloquium to enrich validity. All methods and analysis are in agreement with the consolidated criteria for reporting qualitative research (COREQ) to i ncrease reliab ility and validity of findings (Tong et al., 2007) Results Both survivors (Chapter 3) and key informants agreed that 1) rapport, 2) survivor centered approaches, 3) comprehensive care, and 4) fostering resiliency are driving factors in facil itating successful reintegration. Key informant themes also included 5) reducing barriers and 6) operational definitions of success. (Table 4 1). Rapport Despite the role professionals take in the field of human trafficking, the initial focus should be o n rapport and relationship building. The subthemes ( Table 4 ) are as follows: 1) establishing trust, 2) feeling safe, 3) survivor based processes, and 4) reducing sti gma, shame and guilt. If the survivor does not trust the service provider, no progress can be made. Rapport is about making survivors feel safe, establishing trust, and reducing shame and guilt they may be experiencing. Service providers can do this by mak ing them feel understood and withholding judgment. Key informants reported the need to first establish trust with the survivors they are working with in order to progress in reintegration. Many people who have come into them at some point. This makes survivors wary of

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147 establishing new relationships because they feel like everyone they encounter is trying to get something from them. Survivors are very hesitant to disclose information even to those trying to help them becau se of their experiences. he client's willingness to trust is based on past experiences. They're afraid to be seen T hey're afraid to give anybody their information T hey're afraid to leave their environment. Another important aspect of rapport building is facilitating a sense of safety for the survivor. Survivors most likely are reaching out to professionals because they no longer have safety with their trafficker, so they are looking for this sense of safety to be replaced. One victim said ask for help ut does she know there are better things out there for them we know Establishing trust and feelings of s afety appear to occur through survivor led processes, which further enhance rapport building. Allowing the survivor to lead the process with key informant support provides a space for them to be empowered in any service provision or criminal proceedings. T empathetic and nonjudgmental to reduce stigma, shame, and guilt among survivors. I think that's education. I think it's training. I think it's opening their eyes to just because someone is being prostituted or prostituting themselves doesn't make them a bad person. Doesn't mean they like it. Doesn't mean they're there because they want to be. The stigma society holds toward those prostituted keeps them in these situations. Many survivors may not feel worthy of receiving help or a different lifestyle. These negative emotions can prevent them from disclosing. Trauma informed key informants would be nonjudgmental and patient, showing survivors they believe in them.

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148 Survivor Centered Approach Key informant intervie centered approach. Subthemes ( Table 4 ) included 1) empowerment, 2) survivor led processes, 3) trauma info rmed approaches and 4) collaboration. As key informants specified, the term survivor is more appropriate because it is empowering. This is important because survivors often do not self identify as trafficking victims, as they have become conditioned to the culture and are unaware of the definition of trafficking. I think it's more appropriate to use the word survivor because I think that's more strength based, and I think it's a more empowering term I think if we're calling them victims I think it just kind of reinforces that victim mindset, and they had to survive a lot. They're very resilient. Oftentimes they do Through a survivor led approach, empowerment focuses on facilitating self efficacy, knowing how to ask for hel p, and becoming a leader. This approach can also help reduce victim mentality and helplessness while enhancing collaboration between professionals and survivors. It can be a daunting process so we do what we can to help B ut th e flip side of our mission is to promote independence so they can come to us A nd we are huggers not hand holders, so there is accountability and responsibility for us to continue with the case pl A trauma informed approach considers how survivors respond behaviorally and emoti onally to the trauma they have endured. When working with survivors, professionals must take into account how trauma affects survivors during treatment. This requires special attention to reduce and avoid any retraumatization or revictimization from the se rvices provided. you have a program that's trauma informed, the most important thing that you need to do is have a balance between the use of boundaries and being flexible, because they could be being triggered, and that's going to look like inappropr iate behavior. I f your program transition s someone out

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149 for behavioral issues and they're being triggered, their amygdala and their emotional response is so powerful that they don't have access to their frontal cortex. I think that that's insensitive to Many survivors have experienced such extreme trauma it has changed their brain functioning to the extent that emotional regulation has been affected Survivors may act irrationally due to functioning from their primal brain which includ es the limbic system and is responsible for the fight or flight response. Professionals need to recognize they were conditioned to have these emotional responses and need to be flexible until survivors are capable of proper emotional regulation. C omprehens ive C are Fourteen subthemes emerged from the spectrum of comprehensive care and services. These included the following: 1) replace needs met by trafficker, 2) basic needs housing, food, and clothing, 3) appropriate trauma informed, safe and stable environm ents, 4) substance use detox/treatment, 5) coping skills, 6) healthy relationships/boundaries, 7) life skills, 8) financial support, 9) legal issues, 10) therapeutic interventions, 11) educational/occupational skills and training, 12) long term housing, 13 ) continual follow ups while receiving services, and 14) survivor led long term follow ups. Table 4 shows the subthemes with descriptions and sample quotes. Although dysfunctional, traffickers often met the most basic needs of their victims such as housing and food, substandard as these may have been. This makes key informants responsible for meeting survivor needs, so they do not look elsewhere for support. Housing financial support, a cell phone. You're basically taking over all of their financial needs, all of their needs are met by their trafficker. And so, if you want them to rely on you instead of the trafficker, then you have to be able to provide what they d

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150 Therefore, all basic needs must be met before starting additional support services to have a better chance at successful recovery. his is difficult because you can go to all the therapy in the world but if won t matter. It s basically spinning your wheels. Sex trafficking survivors may have a substance abuse issue, which may have started before, during or after their trafficking experience. Substance abuse may have predisposed them to trafficking. It may h ave been used as a form of coercion or developed as a copi ng mechanism before, during, or after being trafficked. Regardless of when or how it started, substance ab use has to be addressed before providing therapeutic services to ensure the effectiveness of said services. We have had cases where traffickers have given drugs to victims to keep them performing, to keep them ou t of their minds so they comply. W e have also seen a lot of them use drugs to cope w ith the trauma from trafficking. T hey may pick up drugs after getting away from the trafficker so it s important to provide healthy coping mechanisms rather than drugs. Due to the high rates of mental health issues, such as PTSD, depression, anxiety, and dissociative disorders experienced among survivo rs, it is recommended to teach healthy coping skills to avoid substance abuse relapse. Survivors may have experienced previous dysfunctional relationships before being trafficked, coupled with f love, making it hard for them to maintain healthy relationships and boundaries. Love addiction those kinds of behaviors are the hardest we have to deal with and has been engraine d in part of their being. A year is still not enough time to make a dent i n the time they have been brainwas Many survivors do not have typical life skills and need to learn basic skills, such as how to open a bank account, balance a checkbook, obtain identification, and apply for various programs and jobs. These skills ass ist survivors with everyday life, so they

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151 can become more independent. Some survivors may not be legal residents, so assistance with T or U visas would be helpful. Survivors with criminal records face significant challenges when obtaining employment, atten ding school, and finding permanent housing, which can further hinder their rein tegration success. They may also require an advocate while prosecuting their traffickers to reduce retraumatization. uge rap sheets not just for the trafficking offenses but all the petty crimes and maybe even selling drugs on behalf of these pimps. We have to get their records expunged to give them a fair chance when they apply for a job, assuming they can get past all Various therapeutic interventions (Chapter 3) should be considered part of comprehensive care because they create new coping skills. Key informants discussed horticulture, martial arts, biofeedback, music and exercise as trauma info rmed processes because they are not directly dealing with trauma. Educational and occupational skills and training, employment, entrepreneurial skills, internships and college opportunities give survivors ways to support themselves with a long term goal. S urvivors with criminal records may face difficulty in obtaining employment, making it crucial to have other options available. We decided women needed more concentration on employment training E comm erce online like Et*y has been useful. We receive items from the thrift store more high end to offer online though the US. They are being trained on research for market value, photography of the items Once survivors are stabilized, employed and ready to become independent, long term housing options should be offered. Continuous follow up while receiving services is important, so professionals can check in on survivors and be a supportive network they can rely on. Survivor led, long term fol low ups may be useful, as additional referrals for treatment could be needed if trauma resurfaces after reintegration.

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152 ervices. Knowing that there's somebody there that's from law enforcement that' s there following up with them because they care about them Many survivors do not have family support; therefore, knowing that someone cares about them keeps them active in the community and links them to healthier relationships. This ultimately fosters s uccessful reintegration. Fostering Resiliency Resiliency ( Table 4 ) among survivors has components of the following: 1) experiencing a paradigm shift away from old mindsets, 2) regulation of trauma, 3) utilizing social support, and 4) finding goals/purpose. An important aspect of resiliency among sex trafficking survivors is changing their views of what happened to them and reinforcing that they were doing what was n ecessary to survive. Although this is part of reintegration, this subtheme represents a change in the mindset and life perspectives of survivors. It must be recognized that during their trafficking they were part of an entirely different subculture that ma y impact their current thinking. happening to them was not normal. People don't have sex with children; therefore, after being trafficked sometimes they repeat behaviors thinking that sex is going to get you fav Many survivors are emotionally triggered from the trauma they endured. If survivors are continually triggered and having emotional reactions, it may be difficult to work with them without t he development emotional regulation skills. Reduce the acute traumatic sequala you want to reduce nightmares, dissociation, flashbacks, anxiety, depression Y ou want those numbers to go own because those things prevent people from living productive lives A healthy support network fosters relationships that will be healthy and consistent. These could be peer, mentoring or community relationships. Appropriate

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153 survivor based peer support can let a s uccessful, stable survivor serve as a role model for the success of another. Survivors could benefit from role models they can relate to regardless of the issue so they do not feel alone and can maintain a sense of community. If you don't have that sup port system to call, to jump in a car and get to you when your heart is broken if you don't have that late night person to call and say, Hey, I'm thinking about doing something stupid. I need somebody to talk to, Developing goals a nd purpose is another factor of resiliency wherein survivors can give new meaning to their lives. Purpose lets them explore their dreams, and goals shape what they can do to make them come true. I think that they need some kind of employment that they fee l good about, where they feel fulfilled, something that they're passionate about essentially knowing that they're worthy and capable and living in pursuit of their dreams. That would be my dream for them. And they get to decide what that looks like for the m. But I promise you that trafficking is not in their dreams Allowing survivors to decide what their goals and purpose may look like to them would be ideal. Everyone has different passions, so professionals working with survivors should help them develop what their dreams may be. Operational Definitions of Success O perational definitions of success among professionals in the field are not clearly defined Subthemes ( Table 4 ) include the following : 1) how to measure success, 2) nonlinear processes, 3) realistic survivor chosen goals, and 4) individualized plans of care. Thus, the process of m easuring success and outcomes has not been well defined in this population. about there not being a specific defined success. What your program deems successful is different from this person's success

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154 Nonlinear progress has been identified in recovery since survivors may experience setbacks as they recover. However, the main goal, as agreed upon by several key informants, is not relapsing back to trafficking. et's start with the first positive outcome, which is that they don't go back to being trafficked. Understanding that progress isn't linear, and are you going to transition them from the program because they're not reaching their goals ? O r are you going to take a closer look to see what happened that potentially triggered them and sen t t Each survivor has unique goals, so it is ideal they take the lead when developing their goals as it empowers them. Thus, key informants in this study supported survivors identifying and taking control of their goals. Indi vidualized plans of care were deemed necessary as each survivor and his or her situation is unique. Providers can work with survivors to determine what work s b est for them, and then help facilitate a process for them to achieve their chosen goals I would ask survivors how they would measure success Live gainfully employed, married with children, how ever they would define. Some going back into education and the end is hoping they never get trafficked again. Even if she was off the street for 6 month s and goes back to the lif e she still was exposed and learned new things she may not have therefore necessary to keep a positive outlook on how provider efforts impa ct recovery. All progress should be considered successful. Reduce Barriers The primary barriers to reintegration ( Table 4 ) include the following: 1) lack of self i dentification, 2) inadequate collaboration and communication among service providers and law enforcement, 3) lack of appropriate substance use treatment and detox, 4) absence of trauma informed training among providers, 5) insufficient self care

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155 of profess ionals, 6) lack of housing that includes flexible placements and addresses safety concerns, and 7) poor rapport between professionals and survivors. An important barrier is the lack of self identification, as many survivors do not know they have been or a re currently being trafficked. Additionally, when survivors think they are going to be arrested they may be reluctant to report. This lack of identification is an issue when providing services but also when law enforcement is trying to persecute trafficker s. identify ; T he t help them if they can t disclose. You can t force it. No victim then no crime. I know you re a victim o get their trust. They just think you are another person manipulating them to get what they need just like the traffick Another barrier is inadequate collaboration and communication between service providers and law enforcement which hinders efforts to stop trafficking. The difference in responsibility between these fields allows for different interests, however, overarching goals should be similar. law enforc ement will only talk to law enforcement because they have the task of prosecution and getting the criminals (traffickers) off the street. W e are trying to not just help the current s urvivor but to help all of getting the traffickers off the street Despite services available, lack of rapport was identified among key informants. There may be insufficient time or ability to create a relationship with a survivor when they first come into care, causing barriers to services. There may be situations in whi ch survivors are in need of housing or substance use treatment/detox but it is not available to them. This can cause survivors to not partake in other services as a consequence of this basic need not being met. Unfortunately, housing and substance treatmen t are both costly.

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156 I remember having a case with a young lady picked up in a truck trying to get away from her trafficker and momentarily wanted services but then they put her into juv enile det ention. She said she was better off where she was so what can we do ? W using. A vailability of housing is important but not a detention cent e r Due to minimal time and lack of trauma informed training among providers, it may be difficult for survivors to initially engage and continue with servi ces. The key informants in this study received trauma informed training; however, not all service providers and law enforcement have. nderstanding the ramifications of your actions on the person you are trying to help U nderstanding their perspective an d how things might appe ar to them. B eing cautious in things that could trigg er traumatic events with people. To us it s just everything we do and our frame of m ind. W e have to get rid of this tough love By viewing survivors through a trauma lens, it will facilitate a better understanding for professionals as well as foster greater potential for success among survivors. Another aspect of being trauma informed is proper self care among professionals This w as deemed necessary for working in this fi eld to reduce vicarious trauma, or secondary trauma, which may lead to higher rates of burnout. Without self care we will experience high rates of vicarious trauma and take on services that impact SP (service pro viders) with anxiety and helplessness. Our agency has generous leave packages, so when sick stay home or if you need a break you can plan for that because you have enough leave time to take a break Key informants expressed the need to debrief and check in with colleagues to provide additional support. Although, caseloads are high and many agencies do not offer enough personal time, it is important to ensure mental health among key informants.

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157 Discussion Both survivors (Chapter 3) and key informants emph asized themes of rapport, a survivor centered approach, trauma informed comprehensive care, and fostering resilience as factors associated with the successful reintegration of sex trafficking survivors. Similar themes were identified, although rapport was viewed by key informants in a more professional aspect compared to survivors. A survivor centered approach was also slightly difference regarding collaboration as survivors wanted to be better understood by professionals in the field, whereas key informant s emphasized informed comprehensive care that were different among key informants included directly discussing the needs the trafficker was meeting and how to replace them, lack of transportation for survivors, p roviding safe environments that will not discharge survivors for expected trauma related behaviors, the importance of being trauma informed, continuous follow up during provisionary services, and that survivors should provide long term follow ups. However key informants identified significant barriers to survivor success and a lack of operational definitions of success. Although solutions included more funding, along with all services outlined in the results, increased funding was unlikely. The two primar y areas needed for success were substance use treatment/detox and housing. Without first stabilizing survivors, other services would not be effective. More importantly, these resources would potentially be wasteful in terms of public health spending. From a public health perspective, this study aims to outline feasible solutions and integrate community resources for the successful reintegration of survivors. It has been difficult for service providers to determine how to best measure success without agreem ent on program success. Outcome measures may be more

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158 individualized, based on what each survivor desires for recovery. However, survivor leader Savannah Sanders (2015) states that we are an outcome orientated society and that may not be the best foundation for survivor programs. In fact, the most successful programs have been client centered, choice driven supportive programs that address for themselves (Sanders, 2015). Desp ite unclear operational definitions of success across human trafficking professionals, it is important and relevant to describe those being used in current programs or research as a way to better understand methodological approaches (Tyldum, 2010). However it is necessary to address the fact that after traumatic experiences the general assumption of psychotherapeutic approaches as linear is incorrect and that research depicts significant nonlinear change (Hayes, Laurenceau, Feldman, Strauss, & Cardaciotto, 2007). Results of this study found that nonlinear progress could be a general occurrence. Therefore, relapse in various areas should not necessarily be considered as unsuccessful but rather part of the process. To reduce barriers, r elationship s and rappo rt should be built with sex trafficking survivors and long term approach outcome measures may need to be considered when there is a long history of trauma and abuse (Epstein & Edelman, 2013). It is key to improve trust, communication and rapp ort to suppor t efforts of care (Leach, 2005) In a sample of youth in the criminal justice system it was shown that empathy, client centered care, s equencing and positive rapport were paramount to suppor ting therapeutic relationships (Brown, Holloway, Akakpo, & Aalsma 2014). However, it takes time to establish rapport and build trust with those exploited (Greenbaum, 2017) Longer

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159 service periods and smaller caseloads should be considered when possible. Due to the complex issues survivors face it has been recommended that they have consistency among case managers (Clawson & Dutch, 2008b) indicating a strong need for professionals to reduce turnover and burnout of their employees (Leach, 2005). A mong sex trafficking survivors it is critical to provide resources and tr aining for providers on victim centered, human rights based care, and developmental appropriate interview strategies to increase identification of victims and to provide subsequent care (Greenbaum, 2017) Reintegration after trafficking is a very personal experience and differs among survivors. Appropriate survivor centered training is needed among professionals who are working with human trafficking survivors to ensure a higher level of effectiveness. As such, use of existing community resources could be m ore feasible. It may be more cost effective to conduct training among those already conducting services and working in law enforcement, so they will be better able to work with survivors, as opposed to creating all new service provisions. The largest barr iers of working with current survivors are a lack of trauma informed approaches, appropriate housing, and substance use treatment/ detox. There is a clear need for a trauma informed comprehensive approach to reintegration of those sex trafficked (Hom & Woods, 2013). A trauma informed approach is essential ; however, it has become more medicinally oriented and can lead to further stigma against the survivor as t he medical model fails to address the individual and socio cultural collective perpetrators ( Gilfus, 1999). There are many vulnerabilities and predispositions that may have led survivo rs to their current position. Therefore, focusing

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160 on a trauma informed, patient centered approach to care can create a safe environment for survivors (Hachey & Phill ippi, 2017). Along with efforts to train all public agencies, create partnerships, enhance support systems and raise awa reness throughout communities, a collaborative approach is necessary to address survivors by building a team of partners with complemen tary expertise (Epstein & Edelman, 2013) It is time that all law enforcement and health care professionals understand the true nature of human trafficking in order to bring about change through comprehensive training, appropriate protocols, and interagenc y collaboration (CdeBaca & Sigmon, 2014). Additionally, collaborations should be supported by memor andums of understanding (MOUs) to enhance service provision (Clawson & Dutch, 2008a) Limitations The participants in this study were limited to those in the S outh Florida region. Most service providers were from Palm Beach County, Florid a, but many services cross county lines. Depending on the specific individual, job functions span across S outh Florida counties and o nly law enforcement and service providers are on the Human Trafficking Coalition of the Palm Beaches or the Palm Beach County Human Trafficking Task Force were included in this study. O f the 18 participants included in this study all had significant experience with this population Additionally, human trafficking presents differently by county, state, and country. This study only focuse d on sex trafficking key informants in the S outh Florida region. It should be noted that the extent of trafficking is estimated to be much larger than what is curr ently documented as key informants only have expertise to share based on survivors they have interacted with. Not all survivors self identify, come forward, or ask for help.

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161 A larger study on providers across the count r y in high sex trafficking areas sho uld be conducted to ascertain similarities and differences. Additionally, the area in which this study took place is in a high volume area for sex trafficking, so barriers stated in this analysis may be more significant in areas where there is less underst anding and awareness of human trafficking. Further, views were not assessed of service providers or law enforcement personnel who do not specifically work with sex trafficking survivors T herefore, additional studies should be conducted regarding their att itudes and knowledge. It should be recognized that survivors involved in this study reached a point of success as defined by other survivors and the professionals they work with. Survivors who have experienced too many barriers exiting trafficking or have relapsed back into trafficking would not be part of this specific research. Conclusions The findings of this study have the potential to enhance the efforts of law enforcement and service providers to become more effective at collaborating with survivors as they reintegrate into society. Future research might consider exploring how the relationship of professionals and survivors may impact successful survivor reintegration. In order to provide appropriate support to enhance successful reintegration, servic e providers and law enforcement should enhance training and awareness as suggested. Integration of community services already available may be a cost effective solution for providing training to those entities who work with this population. From a public health prospective, professionals working with sex trafficking survivors may consider using the findings of this study as a guide for community based practice. Through reducing barriers to successful reintegration, survivor health disparities can be decrea sed while providing opportunities for reintegration.

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162 Table 4 1. Key Informant Themes and Subthemes Themes (count) Subthemes (count) Rapport (15) Feeling S afe (6) Survivor B ased P rocesses (12) Establishing T rust (11) Reduce S tigma, S hame and G uilt (3) Survivor Centered Approach (16) Empowerment (9) Survivor L ed P rocess (10) Trauma I nformed A pproach (6) Collaboration (8) Comprehensive Care (16) Replace N eeds that T rafficker M et (2) Basic N eeds Affordable H ousing and S ubstance U se D etox / T reatment (9) Financial S upport (2) Appropriate T rauma I nformed, S afe and S table E nvironments (8) Appropriate T ransportation (3) Legal Issues (5) Therapeutic I nterventions (10) Life S kills (5) Coping S kills (6) Healthy R elationships / B oundaries (8) Educational/Occupational Skills and Training (10) Continual F ollow U p while R eceiving S ervices (6) Survivor Led Long T erm F ollow U p (8) Resilience (15) Paradigm Shift (8) Utilization of S ocial S upport (12) Regulation of Trauma (7) Goals / Purpose (6) O perational D efinitions of Success (8) How to M easure S uccess / Level of F unctioning (5) Nonlinear P rocess (3) No R elapse into T rafficking (5) Realistic Goals/Survivor C hosen G oals (7) Individualized B ased on E ach S urvivor (7) Reduce Barriers (13) Collaboration and C ommunication about S ervice P roviders and L aw E nforcement (6) Trauma I nformed T raining of A ll P roviders (10) Appropriate S elf C are (11) Lack of H ousing and F lexible P lacements/Safety C oncerns (9) Lack of S ubstance U se T reatment and D etox (6) Lack of Rapport (5) Lack of S elf I dentification (6)

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163 Table 4 2 Rapport Subthemes Subtheme Description Quotes Establishing T rust Survivors do not trust anyone since everyone exploits them willingness to trust based on past experiences. They're afraid to be seen, they're afraid to give anybody their information, Safety, consistency, trust is a really huge, establishing trust with providers, obvio usly they have a lot of trauma work to do eventually but before they can do that they have basic needs that need to be met over a consistent duration. Feeling S afe Establishing safety and security It takes a while to rebuild from that kind of trauma and so much started with childhood and family of origin failure. I think they just need support longer than I had penciled in. I thought a year was plenty or 18 months but sometimes it takes 6 months to build trust to work on with deep and rooted established patterns and beliefs and takes time no fast forward. facil ity something warm and inviting and the environment to feel safe, that they can come into. Motivational interviewing has come into place. Meeting a client where they are when they are ready. The relationship with the case manager and myself as we serve as their mentors and sounding boards. The ability to be in a safe environment and open up to someone and bui Survivor B ased P rocesses Empowering survivors to take the lead in initatives Reduce S tigma, S hame and G uilt Being nonjudgmental and displaying empathy eyes to just because someone is being prostituted or prostituting themselves doesn't make them a bad person. Doesn't mean they like it. Doesn

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164 Table 4 3 Survivor Centered Approach Subthemes Subtheme Description Quotes Empowerment Encouraging self efficacy think that's more strength based, and I think it's a more empowering term. I think if we're calling them victims I think it just kind of reinforces that victim mindset, and they had to surv ive a lot. They're very resilient. Oftentimes they don't identify as victims the flip side of our mission is to promote independence so they can come to us and we are huggers not han dholders so there is accountability and responsibility for us to continue with the case Survivor L ed P rocess Restoring and honoring survivor choices Being able to exert their own self control over their situation and make decisions for themselves. Being self sufficient, being able to support themselves and tap into resources they have established and be resourceful. Trauma I nformed A pproach Professionals showing empathy and understanding to survivors to reduce retraumatization and revictimization If there were tiers of trauma, if there are hurricane categories, this is a Cat 5 of trauma. It means that with everything you do, with every response, with every development of a program, with every curriculum, with every staff that we h ire, we look at it from a trauma lens. We are not going to hire certain people if they cannot see whatever they're looking at in the trauma lens. It is really seeing the strengths in everything that you do and understanding that every reaction from that su rvivor is coming from their trauma and not judging them for it, and not taking it personally either. Collaboration Human trafficking professionals and survivors working cohesively Peers are really important beyond just those of us in the field that think that we're so great at counseling. I do think that there's a large proportion of survivors that are going to relate to somebody who's been there and done that. I think we should bri ng in survivor groups of legitimate survivors.

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165 Table 4 4 Comprehensive Care Subthemes Subtheme Description Quotes Replace N eeds T rafficker M et Meeting survivor needs so they do not look elsewhere basically taking over all of their financial needs, all of their needs are met by their trafficker. And so, if you want them to rely on you instead of the trafficker, then you have to be able to provide what they did. Which was food, clothing, shelter, an d cash Basic Ne eds H ousing, F ood, C lothing Basic needs should be met before other needs are addressed basically spinning your wheels. In an ideal situation it should all happen at once but not the always the case and you need a firm foundation of basic needs and talking about Appropriate T rauma I nformed, S afe and S table E nvironments Safe and trauma informed housing and therapeutic environments trafficking whose let's say she's a 15 year old girl who has just been picked up off run, potentially coming off drugs, and does not want to look at your face, because she doesn't want your help, b ecause she can do it on her own. You think it's a good idea to prop her into a group home where there is a very innocent 10 year old little girl, and another 15 year old girl whose going to school every day and making straight As, and you feel that that's appropriate, we're in trouble.It's just because their minds are so tormented by the trauma that they had been under, that they do need an environment that's Substance U se D etox / T reatment Substance use is a significant barrier to survivors receiving services and cooperating with law enforcement abuse detox. If there is a history of substance abuse, that's the informed because its not just to the medical model that these individuals need because there was a reason they turned to the substance so if we are not dealing with that and combined trauma and substanc e use at the same time. So we can deal with safety emotionally and so that I can give up my substance Coping S kills Mechanisms to reduce mental health symptoms victims to keep them performing, to keep them out of their minds so they comply. We have also seen more so than the latter a lot of them use drugs to cope with the trauma from trafficking. They may p ick up drugs after getting away from the trafficker so its important to provide healthy coping

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166 Table 4 4. Continued Subtheme Description Quotes Healthy R elationships / B oundaries Learning and maintaining health relationships and boundaries explore new ventures, but they want to know that you're still there. Again, that goes back to attachment theory, because if you're a healthy person in their life, y ou look at attachment theory, the healthy child begins to wander away from the parent so that they can go out and explore new things. I think have to deal w ith and has been engrained in part of their being. A year is still not enough time to make a dent in the Life S kills Every day living skills to be successful in society terms, they need an advocate that's going to be a voice for them when they just don't know how to get through whether it'd be a court system or legal documents, or how to get a driver's license, or how to apply for a school, which sounds so easy for some o Financial S upport Providing a sense of other options, instead of going back to their trafficker have anything better going back to and you put them in a facility but if where they were with a trafficker was better than where you are putting them then you have to give them hope Legal Issues Protection from traffickers and from legal persecution ople have huge rap sheets not just for the trafficking offenses but all the petty crimes and maybe even selling drugs on behalf of these pimps. We have to get their records expunged to give them a fair chance when they apply for a job, assuming they can ge t need housing services and if they chose to be a part of support services go into outreach therapy, planning, collaborate arrangement for therapy and receiv e support, immigration related so they have legal advocacy and can help

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167 Table 4 4. Continued Subtheme Description Quotes Therapeutic I nterventions Interventions that do not require addressing trauma directly and reduces risk of triggers happened requires a tremendous amount of psychological services. For those that don't respond to traditional therapy, I like alternative therapies offering with art therapy, informed is best and feel like if people have access it more self defense they could physical protect themselves When you are in the class and they ask for a specific example how do I get out of this Educational/Occupational Skills and Training Employment, entrepreneurial skills, internships and education opportunities their record. E commerce on line like E t*y has been useful. We receive items from the thrift store, more high end, to offer online though the US. They are being trained on research for Long T erm H ousing Long term housing for survivor independence would make that referral. Sometimes they move in with a friend and they need rent assistance, and sometimes they want to move out on their own, and then we would provide Continual F ollow U p while R eceiving S ervices Reaching out to survivors throughout the duration of service provision and criminal cases while having multiple ways to contact them change their addresses frequently. And so, it's very possible that you wouldn't be able to get a hold of them. If they don't want you to get a hold of them, it's very challenging. Also, they don't typic ally meet you at your office, rarely do they services. Knowing that there's somebody there that's from law enforcement that's there fo llowing up with them, caring S urvivor L ed Long T erm F ollow U p Survivor based continued relationship the women have my personal cell number and those who graduate half 3/4 are still in contact so not as formal so they know they can reach out for support.

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168 Table 4 5 Fostering Resiliency Subthemes Subtheme Description Quotes Paradigm Shift Changing old mindsets and perceptions of the reality happening to them was not normal. People don't have sex with children; therefore, after being trafficked sometimes they repeat behaviors thinking that sex is going to get you favor with peop le. After being trafficking they get used to prostitution. When you are in that environment for so long it starts to become normal for you time goes by. It coerced, but then after a while it becomes routine. Regulation of Trauma Decreasing trauma symptoms and increasing everyday functioning This isn't just an isolated carjacking. You could work through that and maybe become desensitized. This is again and again. I think the brains of these victims literally gets ... their wiring gets changed. I think we're going to see definite neuronal chang es in these victims. It takes a long time to recondition that over time, just like it took so long to make them different. Every single rape, every single interaction. That's not even getting into the trauma that you're getting from your pimp w ho's beating you, starving you. All these horrible things add up, so it's cumulative trauma. nightmares, dissociation, flashbacks, anxiety, depression, you want those numbers to go own because those things prevent people Utilization of Social Support Creating a healthy support system spectrum Engaging with peers who have been successful get to you when your heart is broken, if you don't have that late night person to call and say, "Hey, I'm thinking about doing I think its been encouraging for people to just come out of the lif e to listen to someone speak and has their feet under then they feel they can do it and she did it. Those who are stable can reach back and help gals that just got out. Goals / Purpose Finding meaning in life again employment that they feel good about, where they feel fulfilled, something that they're passionate about. Essentially knowing that they're worthy and capable, and living in pursuit of their dreams. That would be my dream for them. And they get to decide wh at that looks like for them. But I promise

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169 Table 4 6 Operational Definitions of Success Subthemes Subtheme Description Quotes How to M easure S uccess Measurable outcomes I feel really passionate about there not being a specific defined success. What your program deems successful is different from Nonlinear P rocess Discontinuous pattern of change is that they don't go back to being trafficked. Understanding that progress isn't linear, and are you going to transition them from the program because they're not reaching their goals, or are you going to take a closer look to see what happened that pote ntially triggered them Realistic Survivor C hosen G oals Empowerment for survivor led goals (Survivors) have been traumatized beyond just their experience as victims of trafficking that is important to respect their need to have some control of their situation and not just jump in and rescue without giving them options and give them decision making and not get frustrated for coming in and out of care and not get frustrated or if they go back to traffickers like domestic violence Individualized T reatment P lans Tailored treatment for each survivor gainfully employed, married with children, however they would define. Some going back into education and th e end is hoping they never get trafficked again. Even if she was off the street for 6 months and goes back to the life, she still was exposed and

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170 Table 4 7 Reduce Barriers Subthemes Subtheme Description Quotes Lack of self identification Survivors unaware they have been 'trafficked' or fear of disclosure need. But They just think you are another person manipulating them to get what they need just like the trafficker has been Inadequate c ollaboration and communication among service providers and law enforcement Law enforcement and service providers better working together to law enforcement because they have the task of prosecution and getting the criminals (traffickers) off the street. We are trying to not just Lack of substance use treatment and detox Lack of funding for treatment Number one gap is drug rehab. Without them getting clean, we can't focus on their restoration. Lack of housing, flexible placements and safety concerns Insufficient housing and appropriate placements for survivors truck trying to get away from her trafficker and momentarily wanted services but then they put into juvenile detention. She said she was better off where she was so what can we do, we Absence of t rauma informed training of all providers Appropriate TI training is needed for all professionals working with survivors you are trying to help. Understanding their perspective and how things might appear to them. Being cautious in things that could trigger traumatic events with people. To us its just everything we do and our frame of mind. We have to get rid of this tough Lack of r apport Insufficient time/ability to create relationships with survivors as a first point of service provision I think in the application of services what it really means is to be flexible, to be patient, to be forgiving, and to empower them to make their own choices, understanding that trauma can look like different things. It's easy to have compassion for somebod y who's triggered and their response is to cry, but what if their response is aggression? What if their response is avoidance or bad behavior? Are you able, do you have the capacity to clear that off so that you can work with them again, and again, and aga in, and again Insufficient self care of professionals Proper self care practices for professionals working with survivors as part of a TI approach care we will experience high rates of vicarious trauma and take on services that impact SP (service providers) with anxiety and helplessness. Our agency has generous leave packages so when sick stay home or if you need a break, you can plan for that because you have enough leave time to take a

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171 CHAPTER 5 CONCLUSION Public Health Impact The aims of this study were to understand the factors that contribute to successful reintegration of sex trafficking survivors (Chapters 3 and 4) and to understand what knowledge can be gained from a scoping review of the peer reviewed literature (C to promote and protect the health of people along with the communities they reside in. While physicians treat individuals, public health professionals treat populations and aim to prevent disease and injury from occurring by promoting healthy behaviors (American Public Health Association, 2018) Human trafficking is a global public health issue (CdeBaca & Sigmon, 2014) M ental and physical health issue s associated with sex traff icking along with comorbidity of diseases, create a critical public health problem (Welch, 2012) T he research on sex trafficking, which is still preliminary, reveals that sex trafficking survivors experience significant health disparities with an increas ed risk of morbidity and mortality. Findings of this study inform future research and interventions that aim to improve health outcomes and equity among human trafficking survivors. Results of the scoping review (Chapter 2) illustrate a clear need to impr ove public health with development and testing of intervention methods. Identification of successful methods will reduce trafficking of those most at risk and the improve health of those who have already been affected. There appears to be a need to enhance professional awareness, identification, screening, and evaluation (Chapter 2). Results of survivor (Chapter 3) and key informant (Chapter 4) studies illustrate how essential survivor centered approaches,

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172 trauma informed therapeutic interventions, and rein tegration services are for successful recovery. Research efforts should target policy level interventions, which trickle down to other levels of intervention. National H ealth Initiatives Each decade the United States Department of Health and Human Services releases an updated set of goals and objectives, which are meant to direct the public health of the nation. This vision is guided by the prospect of a society in which all individuals li ve long, healthy lives. The mission of Healthy People 2020 includes increasing public health awareness and determinants of health as well as identifying critical research needs. Overarching goals include long lives that are free of preventable disease and premature health issues along with achieving health equity through the elimination of health disparities. Additionally, Healthy People 2020 aims to promote the construct ion of social and physical environments that improve public health (US Department of He alth and Human Services, 2018b) The results of this study, in conjunction with Healthy People 2020 objectives, revealed significant areas that align across levels of prevention in sex trafficking T hese include the following : injury and violence preventi on, substance abuse, mental health and mental disorders, adolescent health HIV, STDs, and maternal, infant and child health (US Department of Health and Human Services, 2018a) Although the objectives do not specifically mention sex or human trafficking these were identified as risk factors in the scoping review studies (Chapter 2). The survivor (Chapter 3) and key informant (Chapter 4) studies include violence, substance abuse and mental health disparities within this population many of whom are childre n or adolescents Further, the scoping review (Chapter 2) found that risk factors include intellectual disabilities and those who

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173 identify as LGBTQ+ (lesbian, gay, bisexual, transgender, queer or questioning) This supports the present stud goal of iden tifying an overall picture of the health disparities involved with sex trafficking and how professionals across disciplines can assist in identifying factors associated with successful reintegration of survivors. The framework for Healthy People 2020 incl udes the following two objectives to be utilized specifically for prevention models. This would include the implementation of their objectives. This study emphasizes the need fo r sex trafficking to be included in those topic areas as well. Further, emerging public health issues in this topic have been identified, including the development of evidence based interventions and documentation of their impact and effectiveness. This sh ould be conducted on sex trafficking prevention programs to increase sustainability. Additionally, there is a need to increase the number of skilled community health workers to help achieve this objective. Utilizing this approach would produce trauma infor med survivors to assist with guiding, developing, and working in these education and community based programs. Furthermore, t expanding to include public and school health (Lewallen, Hunt, Pott s Datema, Zaza, & Giles, 2015) which should focus on substance abuse, all forms of violence, mental health, STDs, HIV, and sex trafficking. Another topic area of Healthy People determinants of health goal is to create social and physical environments to promote public health for all. Areas of health include the home, schools, places of work, neighborhoods, the built environment, and communities that

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174 directly impact overall well being and safety. The s ocial determinants of health also include social norms and attitudes, public safety, social support, exposure to crime and violence, mass media, and culture to name a few. These factors all play a role in the current dysfunction in our social systems that have led to the unintended development of sex trafficking in the United States. Policies should be established to impact social, economic and cultural conditions that allow for the perpetuation of sex trafficking. As such, findings from this study were us ed to develop a model of public health prevention for sex trafficking survivors in the United States Development of a Model for Public Health Prevention of Sex Trafficking in the United States Framework for I mplementation of P ublic H ealth P revention The s ocial e cological m odel (SEM) is a multi level framework that can be used as comprehensive guide for public health prevention programs across each level of influence to create sustainable change from policy level to individual level (McLeroy et al., 1988) Based on the results of this study, childhood risk factors (Chapters 2, 3, and 4), lack of knowledge/training and identification o f sex trafficking (Chapter 2), differences in implementing human trafficking policy (Chapter 2), and significant health issues associated with trafficking (Chapter 2), make it apparent an upstream approach be taken to address the social conditions associated with trafficking. An upstream approach to underlying social determinants of health may reduce poor health outcomes (Rose, 1 992) The TVPA directly states that who are disproportionately affected by poverty, the lack of access to education, chronic unemployment, discrimination, and the lack of economic opportunities in countries of origin ("TVPA," 2000 p. 1466 ) T aking an upstream approach ultimately may reduce

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175 the risk factors that contribute influencing policies of the systems that need strengthening to reduce sex traffickin g. B ehavior s and risk factors can be affected across various levels of interventions; therefore, interactions would be present across levels. The five levels referenced include the individual, interpersonal, organizational, community, and policy influence s (McLeroy et al., 1988) The results of this study began to naturally represent the social ecological model as the data emerged. Thus, the model developed for reintegration of sex trafficking survivors includes all levels of the social ecological model wi Hierarchy of needs representing the individual level in more detail (Figure 5 1) with quotes (Table 5 1). Social E cological M odel Policy level interventions have trickle down effects for the individual through policy and law implementation. As discovered in the scoping review (Chapter 2), interventions can include minimum standards set to be federally implemented by all states regarding the Trafficking Victims and Protection Act (TVPA) (Albonetti, 2014; Bouche & Wittmer, 20 14; Farrell & Pfeff er, 2014; Reid, 2013; Skodmin et al., 2016) Safe Harbor Laws (Barnert et al., 2016; Mehlman Orozco, 2015) modifications to prostitution laws (Bouche et al., 2015; Finn et al., 2015; Halter, 2010; Reid & Piquero, 2014a) and increase d prosecution of child sex buyers (Bounds et al., 2017; Tidball et al., 2016) and child pornography networks (Bissias et al., 2016; Wolak et al., 2014) Through these policy level interventions, the goal of implementation is reduction in incidence and prevalence of sex traffick ing along with increase s in prevention programs for those at risk (e.g., reduction of child sexual abuse and substance use as they were the most reported risk factors for sex trafficking victims ) (Chapter 2). Policy level

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176 interventions would affect the de mand and increase the difficulty for traffickers and sex buyers to continue their behaviors (Chapter 2). Sociocultural views of sex impact lack of awareness regarding sex tr afficking and the people involved in it overall prevention and successful reintegration of survivors is negatively impacted Without more awareness about sex trafficking and prostitution, it is difficult to prevent and reduce its occurrence. ot know about being sex trafficked. They just know what a prostitute is. Since prostitutes are seen as the worst of the worst in the society, people pretend that it's not going on or it won't happen to your daughters. They do not educate the guys. I don't know why. They don't want to talk about th ese hard topics with them. Community level i nterventions would focus on collaborations across coalitions, task forces, academic research, schools, public safety providers, and communit ies. The way media frames is sues around sex trafficking has the potential to impact how communities and individuals perceive these issues (Farrell & Fahy, 2009; Martinelli, 2012) Professional awareness and view s of sex trafficking greatly affect the treatment of this issue in the co mmunity (Cole & Sprang, 2015; Hartinger Saunders et al., 2017) Increasing understanding and awareness with a public health perspective can support reintegration and prevention efforts to influence communities, which ultimately affect individuals. There al so appears to be a need for a comprehensive care available to survivors to support reintegration (Chapters 3 and 4). The TVPA specifically mentions that support services should be d esigned to assist individuals and and secure permanen t housing, integrate the individual and dependent into a community, including transportation, counseling, child care services, case management, employment counseling, and other assistance ("TVPA," 2000 p. 1506 ) Despite this law, there appears to be a lack of implementation in the community. This suggests that

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177 more efforts should be made to ensure support services are available for survivors and their dependents. as a society have to figure out how to really provide long term comprehensive services. I think we all know it's absolutely a necessity for At the organizational level, the climate surrounding public health issues is greatly impacted by the e ffect institutions have on individuals. For instance, depending on community awareness and understanding of human trafficking (Fraley et al., 2018) there may be local safe houses and other services for survivors. Examples include (1) healthcare profession als screening for trafficking (Chisolm Straker et al., 2016; Egyud et al., 2017; Greenbau m, 2017; Mumma et al., 2017; Williams et al., 2018) (2) adopting survivor centered and trauma informed approaches to human trafficki ng (Chapters 3 and 4) among first responders, law enforceme nt, and service providers, and (3) education in schools and prevention programs with at risk groups (Countryman Roswurm & Bolin, 2014; Kruger et al., 2013; Murphy et al., 2016) To influence change at the org an izational level, prof essional s should consider adopting a survivor centere d and trauma informed approach to their community practice to support reintegration. organization with a child who never takes a shower B ecause we are trauma informe d, we had to learn how to bathe that child differently, to reduce that fear and that trauma trigger. That might mean allowing them to adjust the water and touch it. It might mean putting water in a bucket and you do bathing differently. That's trauma At the i nterpersonal level, interventions include relationsh ips between individuals, t heir famil ies service providers, and peers (Chapters 3 and 4). Interventions should include building rapport between survivors and service providers or law enforcement, survivor led support groups or mentoring, and peer education (Chapters 3 and 4). Utilization of social support was found to be a factor involved with fostering resiliency

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178 (Chapter 3 and 4) ; therefore, healthy support systems should be fostered to encourage success ful reintegration. Survivors stated how helpful it would be for them to have positive peer support from those who have been successful. big sister or big brother in the healing process would be helpful because it's really a lot to process. Like in AA (Alcoholics Anonymous) with the sponsors and everything, which I think there should be for trafficking but there's not an association of survivors yet. The individual level includes attitudes, knowledge, beliefs, and self efficacy. Interventi ons include knowledge of human trafficking and attitudes toward sex trafficking held by the general public, including students and professionals (Cunningham & Cromer, 2016; Houston Kolnik, Soibatian, & Shattell, 2017; Nsonwu et al., 2017) Service provider s are in a key position to utilize the individual level by ensuring their beliefs and attitudes are based on education and training, which support anti trafficking efforts and support identification. Interventions that increase healthy coping skills and fo ster resiliency among individuals were shown to positively influence reintegration (Chapters 3 and 4). It is important to increase self efficacy of survivors and facilitate reduction of negative coping skills as part of fostering resiliency to enhance surv ivor success. Empowering individuals and increasing their autonomy makes them feel more confident in their decisions. I wouldn't give any cr edit to anybody else because people have asked me "Do you want me to pick you up?" I was risking my life just to answer that. So, when I actually got out, it was the right moment for me. That is really hard to actually Hierarchy of N eeds At the i ndividual level of the social ecological model, the data depicted con flicts (Maslow, 1943) The hierarchy is illustrated as a pyramid of needs, with the individual meeting lower levels of basic needs before

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179 increasing through the stages to the ultimate goal of self actualization. As explain ed in the key informant data ( C hapter 4), survivors of trafficking have had some of these basic needs met by the ir trafficker and these needs must be replaced in order to facilitate successful reintegration. This was further supported by the interviews wi th survivors (Chapter 3) who eloquently state d their surviv al needs. These began with the basics of safety and security, regulation of trauma, and utilization of social support Once these were in place, survivors spoke of working on healthy relationships and love addiction, wanting to get past feelings of shame and stigma, and ultimately gaining purpose and meaning in their lives, which included having the family they never had, becoming entrepreneurs, going back to school, and helping other survivors. There are several books on pimp culture, which is another term for what is considered a trafficker in human trafficking. One such book is called How to Be a Pimp: by RJ Martin, Jr. (Martin) Strategies among pimps include getting victims to fall in love with them so they can turn them out on the streets. He even states in his book that the girl probably has a need fo r love that is not being met ; she was probably sexually abused as a girl and her family does not care about her. The goal is to lie to her, to make her believe there is a relationship so she will go out and make money for the trafficker (Martin) This perv erse use of is something professionals can turn around to help victims become survivors. Yes, it is certainly possible, even probable, that many victims lured into trafficking are looking for the fulfillment of safety, security, love and self esteem needs. If professionals keep these needs firmly in mind while working with this population, it may serve to help them

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180 help their clients to transfer their trust to people who actually have their welfare in mind. In many instances, due to the i abus ive history, the way their trafficker treated them may not seem any different than what they are accustomed to. However, it is important to distinguish that not everyone involved in prostitution is trafficked, but there may be a history of abuse among those involved with commercial sex. A survivor points out that most individuals in commercial sex are exploited due to their histories. pimp, trafficker, family, bo yfriend, exploiter, then yes. And even though the person may say it is a cho ice, no one wants this life. There is a small population that does cho o se to do it for money and the fame they think they might get. I have never met anyone in commercial sex that did not have some form of abuse in their When working with survivors, efforts should address the needs outlined by Maslow along with the public health findings of this study to foster the recovery process. could also be used in prevention programs to most fundamental need s are phys iological : food, water, clothing, shelter, sleep, and breathing (Maslow, 1943) For sex trafficking survivors, basic needs include safe housing, food, clothing, emergency medical care, and if necessary substance use detox/treatment (Chapters 3 and 4). ousing, financial support, a cell phone. You're basically taking over all of their financial needs; all of their needs are met by their trafficker. And so, if you want them to rely on you instead of the trafficker, then you have to be able to provide what they did w hich was food, clothing, shelter, and cash After individual s ha ve met these basic physiological needs, they can address their safety needs. Trauma before, during, and after th eir trafficking situations can

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181 involve the following: childhood adverse experiences (ACEs), sexual abuse/assault, physical violence, witness / survivor of domestic violence, and potential hostile environments. Safety needs include job security, health and we ll being, emotional security, and financial security (Maslow, 1943) Survivors need help to transfer from the trafficker to a safe environment, to work on emotional regulation (e.g., regulation of trauma symptoms ) to be with professionals who have adopted a trauma informed approach, and to have developed some trust in the people helping them and in t heir environments (Chapters 3 and 4). If a survivor does not feel safe then not much progress can be made Thus establishing rapport and sense of security sh ould be a priority. Providers need to understand that survivors may be reluctant to trust others, so it is imperative they take the time to establish baseline trust and do not expect immediate rapport. One of the most important components of our program i s that we meet with them as soon as the identified. In that moment of opportunity they can see our face. Even if they're refusing services, I just want them to know who I am, what I look like, what does my voice sound like. And that way, if they chang e their mind, then we're available. But if they don't know The next two levels are considered psychological needs, which include love and belonging as well as est eem needs. Love and belonging include utilization of social support, family/surrogate family, friends, and connecting with others. All individuals want love, but survivors of abuse may view their abusive or dysfunctional relationships as love since that is all they ever knew (Maslow, 1943) In sex trafficking survivors, and especially children who have been abused, there is an extreme need for love and belonging, which manifests in dysfunctional relationships and can supersede their need for safety (Chapter s 3 and 4). It is important for survivors to be exposed to

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182 healthy relationships as many have never experienced them before. This makes it necessary to provide skills training for healthy relationships and teach appropriate boundaries (Chapters 3 and 4). P rograms like Sex and Love Addicts Anonymous (SLAA) can be valuable resources. I'm still learning about not going back to similar situations. It feels right, for myself personally I overlook the red flags. That's why I go to SLAA i I 's the whole love addi ction you want someone to care for you and you want it so badly. And I don't know, you just, for myself I got sucked into relationships that were, I don't know, that promised the world, but really The next level esteem needs, include feelings of accomplishment, obtaining for acceptance and value from others. Mental health issues, however, can cause an imbalance and hinder feelings of esteem. There are two levels in this stage: a lower version which focuses on respect from others and a higher version which focuses on respect for self (Maslow, 1943) Sex trafficking survivors have a significant amount of shame and guilt from their t raumatic pasts. This includes the stigma they feel they receive from others in society (Chapters 3 and 4). P rograms which increase self esteem, paired with facilitation of survivors reaching their chosen goals, can lead to a higher sense of overall esteem and accomplishment, and potentially increasing self efficacy. M any survivors continue to q uestion their worth, no matter how much they have accomplished. scared that if I'm not here then they're going to realize they don't need me e ven though I know that's a lie. Sometimes I feel like it's not enough. Is it ever going to be enough ? Am I ever gonna have enough letters behind my

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183 The highest level is considered to be self fulfillment needs, Maslow termed this self encompassing what is meaningful to that individual. Examples include creative pursuits such as paintings or inventions, becoming an ideal parent, or achieving the end result of a dream career path. All previous levels must be mastered before an individual can truly self actualize. Post traumatic growth may include establishing safety first, since to reach sel f actualization, the individual must continually choose to move forward and overcome fears (Maslow, 1943) For survivors, this includes being resilient achieving goals and finding purpose and meaning they want in life. Some survivors may want the ideal f amily they never had, while other s may aim to inspire others healing with their art (Chapter 3). Self actualization is different for each person depending on what they consider to be their vision of their best self. nowing that they're worthy and capable, and living in pursuit of their dreams. That would be my dream for them. And they get to decide what that looks like for them. But I promise you that Th e above quote from a survivo r illustrates how once replacement of needs has been achieved, survivors begin to look for new ways to bring happiness to their lives. This desire to create their own happiness is the beginning of the journey of recovery and fundamental to practicing self love, which will hopefully lead to self actualization. Years later, however, Maslow critiques his idea of self actualization (Maslow, 1996) He developed the term self transcendence, which means an individual can only truly reach actualization through the act of altruism, spirituality, and dedication of self to an outside cause (Maslow, 1969) For survivors, this can be in the form of helping fight against trafficking or to mentor survivors as a survivor leader (Chapter 3). It is important

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184 to note that a lt hough many survivors will do something to give back and help others many survivors do not want to be directly involved in anti trafficking efforts, as they want to move on to other parts of their lives. Of the ones who do want to help other trafficked peo ple, however, it is wonderful to see how they can turn their pain and experience into their passion. spaces T hat's relative, but they're stable. They have their careers and homes but are wanting to take their healing to the next level. I don't do therapy but I help guide people, given where they're at in life, to help move their processes along a little bit more seamlessly. My goal is to address the horrific aspects of how trauma affects women in their Survivors who have successfully reintegrated based on their goals have become productive members of society and can reach self actualization or self transcendence based on their own terms and definitions. Without reaching a level of mental stability a nd regulating symptoms, however, it is more difficult for survivors to have a high level of functioning and master all levels of the hierarchy. Criticisms and alternative understandings: There are criticisms of attain ment of self actualization. Viktor Frankl, a concentration camp survivor and renowned psychiatrist, feels the only way to find meaning in life and ultimately experience self transcendence is through experience in the world rather than within the self. Fran directed toward something other than oneself, actually forget ting ing Frankl believed that self self transcendence. Moreover, the meaning of life is possible even in spite of suffering (Frankl, 1959) In this study, it became clear that despite the pain and suffering these

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185 survivors have been through, they have been able to find purpose and meaning in their lives. Limitations The sample size of key informants and survivors was small which limits generalizability. Although elements of a model have begun to emerge in the data, a larger study across locations should be conducted to confirm the structu re. Survivors were mainly from Florida with one survivor from out of state. Due to similar findings, the study may be more generalizable if conducted with a larger population of women affected by sex trafficking in the United States. Further, this study only included women, despite the fact that males are a suspected underrecognized group affected by sex trafficking. As depicted in the scoping review (Chapter 2), males were primarily identified in criminal and juvenile justice systems, child welfare, and presentation at healthcare facilities. D ue to the underground nature of sex trafficking many survivors go unrecognized and therefore would not be included i n this research. Additionally, human trafficking presents differently by county, state, and country. This study only focuses on sex trafficking key informants from the S outh Florida region. It should be noted that the extent of trafficking is estimated to be much larger than what is currently documented as key informants only have expertise to share based on survivors they have interacted with. Not all survivors self identify, come forward, or ask for help. Therefore, this study only presents findings base d on known survivors and services provided. A larger study o f survivors and providers across the county in high sex trafficking areas should be conducted to ascertain similarities and differences. There is also potential that some studies may have been ove rlooked in the database searches for the scoping review

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186 (Chapter 2) or that the scoping review did not evaluate the quality of the research conducted. Additionally, many survivors are reluctant to participate in research efforts due to fear of stigma and d iscussion of traumatic incidents and all k ey informants do not refer survivors they work with to research, so those potential participants may have had a different perspective regarding barriers to reintegration. Only key informants who work with survivor s were included in this study so the experiences of law enforcement and service providers who lack the same level of expertise are not reflected. The primary researcher also brings biases into the analysis and presentation of findings based on her underst anding of sex trafficking in society. These biases, however, also assist her in the ability to understand the public health perspective involved. Reintegration is a complex phenomenon which this study attempts to explain T hese findings however, are not exhaustive although saturation of codes, subthemes and themes had been obtained. Further, it is important to note the richness of the data conveyed in this study despite the fact that space restrictions required the researcher to leave out the majority of survivor quotes respected. It is also important to note the goal of the research team was to depict the findings as accurately as possible while giving voice to each participant. Recommendations for Future R esearch This study examined the current peer reviewed research in the United States on sex trafficking and attempted to convey the reintegration experience of sex trafficking survivors as told by both key informants and survivors. These topics explored th e phenomenon of sex trafficking in the United States in a meaningful way by studying inherent health disparities faced by those affected by sex trafficking, in particular, and all

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187 other forms of human trafficking. This research can directly influence the f ield of public health and the socio cultural attitudes and norms that create an environment that fosters sex trafficking. A strength of this study is the inclusion of survivors to give their perspectives and to give voice to their experiences in the reinte gration process. By i nvolving survivors in the research process and by including a review of the results, the research remains survivor based, which should be the goal of human trafficking research. Understanding the social institutions in the United State s which have led to vulnerability of exploitation is paramount to constructing meaningful research and public health interventions. As discussed with the social ecological model, interventions should ch by affecting the social determinants of health. These public health actions at the societal and policy levels create a trickle down effect, which would be present to affect survivor reintegration success as well as public health interventions across the spectrum of prevention levels. Future research should aim to include survivors in all research inquiries; this approach would incorporate their expertise and train survivors in research methodology to give more credibility, practicality, and sustainabili ty to research endeavors. Future research should include a larger sample of survivors to ensure generalizability of results; however, it should also focus on different regions in the United States to ascertain whether findings would be geographically disti nct. Moreover, barriers to exiting trafficking are essential to a complete understanding. More survivors may be assisted as this study only included survivors that have reached a level of stability and successful reintegration. Relationships built with sex trafficking survivors and long term approaches may be necessary when there is a long history of trauma and abuse

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188 (Epstein & Edelman, 2013). Additionally, samples of males should be included to determine if the reintegration experience is different by gend er. Research should be conducted to better understand labor trafficking and if similar findings would be applicable. Appropriate interventions need be tested in this population to ascertain evidence based practices. Policy level interventions and implement ation need to be assessed to ensure a standard minimum level requirement for reducing sex trafficking across levels of prevention. Additionally, due to a lack of self identification among survivors, it is dire that professionals develop and test methods of screening and identification and implement them, as opposed to waiting on survivors to disclose. There should be a way for professionals in the field to properly identify those who have been affected by human trafficking without requiring them to specify those terms. Further recommendations are also provided elsewhere in the scoping review discussions (Chapter 2). The research study utilized a cross sectional design; therefore, causality cannot be determined. Additionally, qualitative analysis has been st ated to not be ca usal by positivist researchers as its reliability and validity is questionable. As stated by Kramer (1988 exposure) will be successful in altering outcome only to the extent that the exposure (p. 255). Therefore, this study attempted to understand what factors were associated with the reintegration of sex trafficking survivors to help formulate an appropriate public health response to address the health disparities experienced by survivors.

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189 The epistemological view in this study is subjective and concerned with social justice as relevant to the field of public health social wor k. The integration of theoretical perspectives relevant to the fields of public health and social work gravitate toward cultural competency aimed to address the state of inequality and injustice adherent in society. As such, a qualitative interpretation of events has been advised as essential to obtain community perspectives as a foundation for social change (Mertens, 2007) When research is inspired for social justice, it is not relevant whether one implores qualitative or quantitative methods to ascertain answers, but rather one symbolizes a for oppressed and marginalized populations (Denzin, 2010) Based on the findings of this study, future research should aim to be bas ed in a trauma informed approach Current research has become more medicalized and can lead to further stigma against the survivor because fails to address the individual and socio cultural collective perpetrators (Gilfus, 1999) Therefore, a public heal th response should consider address ing the societal levels of social institutions and inequalities that allow for the victimization of individuals in society through a social justice approach (Zimmerman & Kiss, 2017) Human trafficking is a critical public health issue that needs to be addressed with multidisciplinary, trauma informed, strengths based, and survivor based approaches to eliminate health disparities, enhance health equity, and restore social institutions that allow human trafficking to exist. Findings depict the need to enhance resi liency among survivors by providing opportunities for rapport building which takes a long term approach to comprehensive care (Chapter 3). Many barriers should be considered

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190 among professionals in the field (Chapter 4) in order to maximize successful rein tegration of survivors. Research suggests that operationalizing definitions of trafficking, as well as outcome measures, would be advantageous to practice and research efforts. A key finding of this study is the impact of societal views and attitudes towar d commercial sex and exploitation. Without a collaborative approach among criminal justice and victim service professionals across the country, sex trafficking in the United State s will manifest with continual revictimization and retrauma t ization of those who have been exploited through human trafficking and from prior traumatic experiences. Professionals need to better understand the vulnerabilities targeted by traffickers and to recogniz e the systems in place that that do not identify victims and those at risk Then professionals, legislators, and researchers can work collaboratively to facilitate positive change through development of public health prevention s and intervention strategies across levels of the social ecological model utilizing an upstream a pproach.

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191 Figure 5 1. Survivor Centered Approach to Successful Reintegration of Sex Trafficking Survivors: A Public Health Prospective

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192 Table 5 1 Survivor Centered Approach to Successful Reintegration of Sex Trafficking Survivors: A Public Health Prospective Quotes Model Component Description Quote Policy Interventions have trickle down effects to the individual through policy and law implementation They just know what a prostitute is. Since prostitutes are seen as the worst of the worst in the society, people pretend that it's not going on or it won't happen to your daughters. They do not educate the gu ys. I don't know why. Th ey don't want to talk about these hard topics with them. Community lnterventions would focus on collaborations across coalitions, task forces, academic research, schools, public safety providers, and addressing community norms think we as a society have to figure out how to really provide long term comprehensive services. I think we all know it's absolutely a necessity for this Organizational The impact of institutions on individuals can greatly affect the climate around public health issues never takes a shower. Because we are trauma informed, we had to learn how to bathe that child differently, to reduce that fear and that trauma trigge r. That might mean allowing them to adjust the water and touch it. It might mean putting water in a bucket and you do bathing differently. That's trauma Interpersonal Interventions would include relationships between the individual and their family, service providers, and peers process would be helpful because it's really a lot to process. Like in AA (Alcoholics Anonymous) with the sponsors and everything, which I think there should be f or trafficking, but there's not an association of Individual Includes attitudes, knowledge, beliefs, and self efficacy. Interventions might include knowledge of human trafficking and attitudes toward sex trafficking in the general public, students, and professionals wouldn't give any credit to anybody else, because people have asked me, "Do you want me to pick you up?" I was risking my life just to answer that. So, when I actually got out, it was the right moment for me. That is really hard to actually do. M aslow include getting them to fall in love with them so they can on the streets. someone setting it up, a pimp, trafficker, family, boyfriend, exploiter, then yes. And even though the person may say it is a choice, no one wants this life. There is a small population that does chose to do it for money and the fame they think they might get. I have never met anyone in commercial sex that did not have some form of abuse in their lives, not one.

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193 Table 5 1. Continued Model Component Description Quote Physiological Needs The most fundamental need includes physiological needs of physical requirements necessary for survival. These aspects include food, wat er, clothing, shelter, and sleep. basically taking over all of their financial needs; all of their needs are met by their trafficker. And so, if you want them to rely on you instead of the trafficker, then you have to be able to provide what they did. Which was food, clothing, shelter, and cash assistance. For some, their immediate need is Security Needs Safety needs can also include job security, health and well being, and emotional security, and financial security. For survivors, they need to be able to establish a safe environment. program is that we meet with them as soon as their identified. In that moment of opportunity they can see our face. Even if they're refusing services, I just want them to know who I am, what I look like, what does my voice sounds like. And that way, if they change their mind, then we're available. But if they don't know who you are and they didn't see you, it's Love and Belonging Needs Love and belonging includes utilization of social support, family/surrogate family, friends, and connecting with others. situations. It feels right, for myself personally, I overlook the red flags. That's why I go to SLAA, it's the whole love addiction, you want someone to care for you and you want it so badly. And I don't know, you just, for myself I got sucked into relationships that were, I don't know, that promised the world, but Esteem Needs F eelings of accomplishment, obtaining respect from others, and feeling important. Esteem of acceptance and value from others. off because I'm scared that if I'm not here then they're going to realize they don't need me. Even thought I know that's a lie. Sometimes I feel like it's not enough. Is it ever going to be enough? Am I ever gonna have enough letters behind my name to make Self actualization The potential and what is meaningful to t hat individual, becoming an ideal parent, or perfecting their career path. worthy and capable, and living in pursuit of their dreams. That would be my dream for them. And they get to decide what that looks like for them. But I Self transcendence An individual can only truly reach actualization through the act of altruism, spirituality, and dedication of self to an outside cause necessarily in bad spaces, that's relative, but they're stable. They have their careers and homes, but are wanting to take their healing to the next level. I don't do therapy but I help guide people, given w here they're at in life, to help move their processes along a little bit more seamlessly. My goal is to address the horrific aspects of how trauma affects women in their

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212 Wilson, B., & Butler, L. (2014). Running a gauntlet: A review of victimization and violence in the pre entry, post entry, and peri /post exit periods of commercial sexual exploitation. Psychological Trauma: Theory, Research, Practice, and Policy, 6 (5), 494 504. doi: 10.1037/a0032977 Wolak, J., Liberatore, M., & Levine, B. (2014). Measuring a year of child pornography trafficking by U.S. computers on a peer to peer network. Child Abuse Negl, 38 (2), 347 356. doi: 10.1016/j.chiabu.2013.10.018 World Health Organization. (2012). Understanding and addressing violence against wom en: Human trafficking. from http://apps.who.int/iris/bitstream/handle/10665/77394/WHO_RHR_12.42_eng.pdf ;jsessionid=45E5A53C1C40F2A36C824F22DEF89699?sequence=1 Zimmerman, C., Hossain, M., & Watts, C. (2011). Human trafficking and health: A conceptual model to inform policy, intervention and research. Social Science & Medicine, 73 (2), 327 335. doi: https://doi.org/10.1016/j.socscimed.2011.05.028 Zimmerman, C., Hossain, M., Yun, K., Gajdadziev, V., Guzun, N., Tchomarova, M., . Watts, C. (2008). The health of trafficked women: a survey of women entering posttrafficking services in Europe. Am J Public Health, 98 (1), 55 59. doi: 10.2105/AJPH.2006.108357 Zimmerman, C., & Kiss, L. (2017). Human trafficking and exploitation: A global health concern. PLoS Med, 14 ( 11), e1002437. doi: 10.1371/journal.pmed.1002437

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213 BIOGRAPHICAL SKETCH Kanathy Haney is a Health Sciences Professor at Palm Beach State College and instructo r at the University of Florida. She has been working in public health social wor k since 200 7. She obtained her b achelor s of social w ork in 2008 from Florida Atlantic University (FAU) magna cum laude along with a child welfare certificate. She then rec eived her Master of Science in exercise science and h ealth p romotion from FAU. Kanathy obtained doctoral level epidemiology and biostatistics education and training from the University of Miami Miller School of Medicine Department of Public Health Sciences She is also a Certified Health Education Specialist (CHES) and is Certified in Public Health (CPH). Kanathy has worked in community agencies focused on promoting health across the spectrum of prevention since 2007. She understands how to translate research into sustainable community practice to influence communities By utilizing existing resource s there can be feasible, multi disciplinary approaches to prevention. Her long term research goal involves developing a comprehensive understanding of sexual exploitation, sex work and human trafficking. She believes that by better understanding the spectr um of human trafficking she can develop effective interventions across levels of prevention Haney also places importance on the ability identify risk factors in order to reduce rates of human trafficking She has a desire to work towards social justice and health equity among all individuals by re aching across cultural barriers and empowering populations to engage in h ealthy, longstanding behavior change. Her goal is to address the public health issue of human tra fficking across the United States and around the globe to reduce health disparities and enhance health for all global citizens