Dr. Marian Hatcher
Shared Hope Policy Consultant
Ambassador-at-Large, United Nations

Last month was Mental Health Awareness month and as annual attention to this issue prompted introspection about my own personal experiences, I began to think about how the mental health needs of trafficking survivors so often intertwine with the need for federal vacatur and post-conviction relief for trafficking victims.

While the focus on mental and behavioral health overall gained traction beginning in the 70’s, 80’s and 90’s, finally resulting in the current Substance Abuse Mental Health Services Administration (SAMHSA) established in 1992, the focus on human trafficking didn’t manifest until the year 2000 with the Trafficking Victims Protection Act (TVPA). Even then, it has taken over two decades for human trafficking to become widely understood as a crime that impacts people across the United States and isn’t just a crime that “happens over there,” no less how mental health plays a role in creating vulnerabilities to trafficking.

Has the formal attention and organization of governmental agencies, programs and initiatives focusing on trafficking made a difference in how trafficking victims are viewed and provided services? Yes, and no. When we look at how long it took for the puzzle pieces of mental health and human trafficking to be named, and considering from 1949 to 2000 discussions around mental health didn’t yet have the framing of human trafficking (although many of the impacts on survivors were inevitably part of those conversations), it makes sense that mental health responses to human trafficking victims have been lacking in critical ways and the mental health needs of trafficking victims/survivors are only recently becoming central to how we respond to human trafficking.

On a personal level, both my mother and I have backgrounds which require us to check the box of having a mental health history. Childhood and adult trauma triggered both of our experiences. I was molested by a trusted family member at the age of seven, which perverted my sense of intimacy and I was also a victim of domestic violence as an adult.

Mental health issues are an “outside looking in” multilayered system of good stressors, bad stressors, pain, suffering, joy and feelings one can’t name or label. In Asheville Insights, Chelsea Jennings stated: “From the outside looking in, it’s hard to understand. From the inside looking out, it’s hard to explain.” While this quote is related to an “immersion” trip experience, I feel the words profoundly describe the mental health journey and what trauma means to trafficking survivors.

“There are many complex and varied issues that affect survivors of trafficking, both medical and otherwise. An article by Lederer and Wetzel (2014) found alarming rates of injury and illness among sex trafficking victims. It does not require a stretch of imagination to infer that these adverse physical and psychological health impacts are the direct result of trauma from victims’ time within the sex trade. For example, a peer-reviewed article on traumatic brain injury (TBI) found that prostituted women suffer rates of TBI at much higher rates than the national average. (Farley, Banks, Ackerman, & Golding, 2018).”[1]

Trafficking is a traumatic experience often resulting in verbal and physical abuse, lack of control, loss of liberty, loss of family and more. It stands to reason, if there is an existing mental health problem, additional trauma(s) would exacerbate that. Substance use, existing or introduced in a trafficking environment also has an impact. Survivors look normal until worn down. At the beginning of my trafficking experience, other people on the street said I looked like the “po po.” At the end I was considered just another “crackhead.”

It’s the wearing down, the lack of good nutrition, lack of sleep, lack of good hygiene, lack of love, lack of empathy…lack lack lack. Where does the lack push you if not to the point of no return? Do I have a memory, of, even if off in the distance, of normalcy to instill hope that it is still achievable? The buildup of lack–physical and mental abuse, torture that is a “prostitution/sex trafficking experience”— creates a wall preventing healthy choices, education, stability, love, care, safety, nutrition, financial security, etc.

I was fortunate, in that I did have a normalcy to claw through the fog of trauma, drugs, guilt, shame, confusion etc. I had a family that never stopped looking for me when I was missing for almost two years. I also had a formal education and career, that I would sometimes have glimpses of, through the pain of beatings and rape and hunger.

There is a shade of gray for each person’s trauma. The hues too numerous to quantify. The names of mental health diagnoses are so many. Anxiety, depression, bipolar disorder, OCD, oppositional defiance, borderline personality, PTSD, complex trauma and so on.

Where in this unsavory recipe for disaster, do we realize trafficking victims are surviving, often living exploitative lifestyles with or without nice trappings. These experiences are certainly harsh in many cases, but often so subtle they appear as “willing” participation or cooperation to those without clinical training or personal experience.

What does that mean when it’s time to step out of the darkness of trafficking, into the often blinding light of life?  Mainstream society? Family? Motherhood? Employment? School? Financial health? Criminal justice ramifications of victimization that often exist long after trafficking while gaps in post-conviction relief persist? How do we remedy these harms so survivors can heal?

For me, I was able to emerge from the burden of my criminal history by seeking executive clemency from the Governor of Illinois. However, I am fortunate not to have had federal charges, in which case I would have had to seek an executive pardon from the President of the United States. What a daunting hurdle for survivors of exploitation and abuse to have to face in order to not carry a criminal record as a constant reminder of their victimization? This is why I am now an advocate for federal vacatur.

In the Victim Offender Intersectionality (VOI) report, which I contributed to as member of Shared Hope’s JuST Response Council, there are actually many opportunities for a “just response” to criminalized trafficking survivors, but these can’t happen until…

Until the millions of grey hues in the color pallet of pain that is trafficking are understood.

Until the impact of unimaginable sexual violence trauma bonds is considered.

Until there is less bias and more connective tissue between law enforcement, prosecution, and victim services.

Without this, we will continue to face barriers.

So, what can we do? We must wear them down with the truth and a greater understanding of the impact of mental health on human trafficking. And until federal legislation models/mirrors or learns from many states’ efforts to enact vacatur, survivors with federal convictions will be treated unfairly.

[1] Marian Hatcher et al., Exited prostitution survivor policy platform DigitalCommons@URI, https://digitalcommons.uri.edu/dignity/vol3/iss3/10/ (last visited Jun 16, 2023).

 

Written by Barbara Amaya with Holly Austin Gibbs
Photography by Shanna Parker

After we had been married for a few years, Jose and I got serious about starting a family. I had never been pregnant before, and, until Jose, I honestly hadn’t given the idea much thought, other than being grateful that I had never become pregnant as a child. I was 12 years old when I first came under the control of Moses, a brutal sex trafficker. I was trafficked for commercial sex by this man for over a decade on the streets of Washington, D.C., and New York City.

During that time, I had heard horrible stories of other girls who had become pregnant and searched out ways to have abortions on their own, so great was their fear of what would happen to the baby if it ended up in the hands of their pimp. I knew one girl whose four-month-old child was already being abused by the man who controlled her. A baby wasn’t something I had ever expected or wanted to have in my future. But, after I was married, I felt differently. Having a baby seemed to be part of the “square life”, and I wanted that for us.

Jose and I tried to get pregnant for quite a while, but without success. With the added pressure of his mother asking for a grandchild, I decided to visit my doctor to ask some questions of my own. “It seems that you have some scar tissue that could be blocking your fallopian tubes,” my doctor told me after the examination. “There is also severe scar tissue in the vagina.” My doctor was compassionate as he explained the findings to me. Unfortunately, conversations like this are far too common among sex trafficking survivors and their medical providers.

In the 1990s, the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente partnered to conduct the “Adverse Childhood Experiences (ACE) Study”, one of the largest investigations of childhood abuse and later-life health and well-being. The original ACE Study was conducted at Kaiser Permanente from 1995 to 1997. Over 17,000 Health Maintenance Organization (HMO) members received physical exams and completed surveys regarding ACEs and their current health status and behaviors. This research team continues ongoing surveillance of ACEs by continuing to assess the medical status and behaviors of study participants.

ACEs were described in the study as child abuse (e.g., emotional, physical, or sexual abuse), child neglect (e.g., emotional or physical neglect), and other household challenges (e.g., mother treated violently, substance abuse in the household, mental illness in the household, parental separation or divorce, and/or a household member had been sent to prison).

The three major findings of this study are as follows:

1. ACEs are common across all populations. Almost two-thirds of the study participants reported at least one ACE, and more than one in five reported three or more ACEs.
2. Some populations are more vulnerable to experiencing ACEs because of the social and economic conditions in which they live, learn, work, and play.
3. The ACE score is the total sum of the different categories of ACEs reported by participants. Study findings show a “graded dose-response relationship” between ACEs and negative health and well-being outcomes. In other words, as the number of ACEs increases so does the risk for negative outcomes.

See the CDC figure for examples of the lasting effects of ACEs. Subsequent studies continue to reveal a relationship between trauma, especially trauma experienced in childhood, and other negative outcomes such as autoimmune diseases and diabetes. For an exhaustive list of negative outcomes, the CDC includes links to selected journal publications.

As a survivor of child sex trafficking, I have been diagnosed with post-traumatic stress disorder (PTSD), heart disease, multiple cancers, and an autoimmune disease, as well as infertility and spinal stenosis. The trauma of enduring multiple rapes for over a decade of my young life caused vaginal scar tissue, damage to my fallopian tubes, and, ultimately, infertility.

Trauma isn’t just “all in the mind” – it leaves a direct physical imprint on the physical body.

Experts today believe that there is a direct biological effect that occurs when a person’s body, especially a child’s body, experiences extreme stress such as the trauma of being sex trafficked. For example, a 2010 study of 117 Minneapolis women found that adults who had “first traded sex as juveniles had worse outcomes in several domains, including unstable housing, higher rates of teenage runaways, higher rates of STDs, lower rates of HIV testing, greater number of sex trades per week, higher incidence of street-based sex trading, and drug use at a younger age.”

Of course, trauma, especially prolonged traumatic stress, can cause long-term negative health and well-being outcomes regardless of a person’s age at which they were first exposed to trauma. General adaptation syndrome (GAS) describes how the body responds to stress, as follows:

• The alarm reaction stage prepares the body for the “fight or flight” response, which we now know includes “freeze” and “fawn” responses as well. For example, the heart rate increases and the adrenal glands release hormones like cortisol and adrenaline.
• The resistance stage occurs after a fight or flight response, as the body slowly begins to recover but remains on high alert for a while. For example, the heart rate and blood pressure begin to normalize and the adrenal glands release lower levels of hormones.
• The exhaustion stage is caused by prolonged stress, which can drain a person’s mental, physical, and emotional resources. This wears down a person’s resilience. It can lead to a weakened immune system and puts the person at risk for stress-related illnesses.

For example, in a 2011 study, 105 Native American women engaged in prostitution were assessed for life circumstances. More than half of the participants (79%) reported that they had experienced sexual abuse as children. The participants also reported that, while engaged in prostitution, 92% had experienced rape, 84% experienced physical violence, and 72% suffered traumatic brain injuries. At the time of the interview, 52% had PTSD and 71% had symptoms of dissociation. This is not surprising considering many of the participants seemed to be surviving daily life in the exhaustion stage. Additionally, 80% of the participants had used substance use treatment services, 77% used homeless shelters, and 65% used domestic violence services.

In another 2014 study, researchers explored the health consequences of sex trafficking among domestic survivors, aged fourteen to sixty. The authors reported that, regardless of the age at which participants were first exploited, or for how long, the participants had “suffered tremendously, virtually without exception”. In “Caring for Trafficked Persons: Guidance for Health Providers”, the International Organization for Migration (IOM) reported that “as is the case with victims of torture, individuals who have been trafficked are likely to sustain multiple physical or psychological injuries and illnesses and report a complex set of symptoms.”

I’ve seen this first-hand. People who have experienced commercial sexual exploitation, particularly those who have been trafficked and subjected to physical violence and multiple abuses over a long period of time, may, and very often do, suffer from long term physical and mental health consequences in a manner consistent with victims of prolonged torture.

Too many have suffered in this way, myself included.

Like many victims of sex trafficking, I received no regular health care, no dental care, and no direct services during my time of victimization. I would visit the emergency room only if I had a serious injury or illness. Otherwise, I was too fearful of Moses, my violent trafficker, to disobey his orders and seek any medical help. Moses would only allow me to seek help in life threatening situations, such as a knife or gunshot wound, a severely painful urinary tract infection (UTI), or after being beaten by him or by those who sought to buy my body.

Victims and survivors of trauma, including sex trafficking, need access to health care services. The ACE Study underscores that, the longer we take to acknowledge the trauma caused by commercial sexual exploitation and sex trafficking and address its potentially damaging effects on the health and well-being of survivors, the greater our chances are for long-term negative health consequences, many of which can lead to disease, disability, and even early death.

As a newlywed, I was fortunate to receive care from a physician who was compassionate and invested in my health. He said he could perform a procedure that would reduce the scarring and damage to my body. And he was right; soon after surgery, I was pregnant with my baby girl.

I cried with joy as I lay in that darkened room, watching the blinking light of my baby’s tiny heart on the ultrasound machine. That a baby could grow inside me at all was amazing. I had worried that my body was poisoned and toxic from the abuse I had suffered; I couldn’t imagine how a pure, innocent little baby could grow inside something as ruined and polluted as me.

It was an incredible feeling to know that I held a life inside me, a beautiful, growing life that depended on me. I felt like it was a miracle.

Maybe, I had thought to myself. Just maybe, I wasn’t so horrible inside.

About the Authors

Barbara is an award-winning author, advocate, speaker, consultant, mentor, trainer, and survivor leader in the movement to finally end human trafficking and child exploitation. Barbara experienced first-hand the juvenile justice and child welfare systems. Then, as a vulnerable child runaway, she experienced the horrific extremes of violence, child abuse, human trafficking, drug addiction, and prison when she was trafficked on the streets of Washington D.C. and New York City for over a decade.

Many victims do not survive before or even after escape. Their experiences are so horrific that survivors often never come back to the ‘real’ world. Barbara not only survived and healed, but truly transformed her life. As a survivor of trauma and adversity, she feels called to share her story and has dedicated her life to educating the public about modern-day slavery. Barbara has been actively raising awareness about the exploitation of children and domestic sex trafficking since 2012. She has a background in education (including a credential in early childhood development), and holds a PhD in psychology.

Learn more about Barbara and order her inspirational book, Nobody’s Girl: A Memoir of Lost Innocence, Modern Day Slavery, & Transformation, at BarbaraAmaya.com.

Shanna Parker is a national Survivor Leader and Subject Matter Expert in the field of Human Trafficking. She is the founder and CEO of Angels Go To Work, where she serves hundreds of youth and young adults yearly in local group homes, campuses and the community. Shanna is a  consultant for the Office for Victims of Crime Training and Technical Assistance Center where she assists with program building and specialized training. She sits on panels for multiple research projects with various agencies, and universities.

Shanna also works with multiple tribal agencies to develop responses to trafficking in rural and native lands. Shanna partners with local and federal law enforcement agencies in various capacities including training, consultation, outreach, operations, and victim advocacy. Shanna assists the Arizona Financial Crimes Task Force with the Attorney General’s Office in sex trafficking cases. She also works for Southwest Network as the Anti-Trafficking Coordinator. In this position, she is a consultant for clinical staff and works with several agencies as a specialized mentor and advocate for chronically trafficked youth with a high runaway rate.

To learn more about Shanna and her organization, and to order her memoir, And He Called Me Angel: The Story of a Human Trafficking Survivor, please visit AngelsGoToWork.com.

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If you are victim, or someone you know is a victim, of labor trafficking or sex trafficking, call the National Human Trafficking Hotline at 1-888-373-7888, or text 233733 (BEFREE).