Katrina Robertson's stepfather raped her when she was 11. The experience "warped everything I knew about being a little girl," she said, and set her in motion down a too-familiar path — insecurity, rebellion, beer, pot, crack, and then being sold for sex.
Once addicted to drugs, "you don't have a choice. You'll do whatever you have to do to get the drug," she said, including working for pimps. During her 28 years on and off the streets, in and out of jail, "there were lots of rapes by lots of johns, lots of abuse, lots of violence, attacks on the streets in front of people."
But there was precious little health care. Among the many troubles that trafficking victims endure, the disparity in access to care ranks high — and sustained mental health care that models healthy relationships may be the key to escaping the life.
Robertson never went to the emergency room after an attack, but she would stay off the streets for a few days to recuperate. "It was like a dog or a cat licking its own wounds," she said. Her pimp would never hit her in the face, but when others did, she learned to apply ice and mask black eyes with makeup.
She was diagnosed with HIV 19 years ago and would cycle in and out of hospitals, getting healthy enough to go back on the streets. Many health care workers, she said, tried to intervene, but "I wasn't ready to stop using. I didn't have any hope; there was no light at the end of the tunnel." She also had tried several short-term residential treatment programs before Magdalene, in her hometown of Nashville, Tennessee, took her in for two years.
Today, 10 years later, Robertson is national sales director for Thistle Farms, the arm of Magdalene that offers women employment making bath and body products. She is married and owns her house. She is one of the fortunate ones.
AWARENESS HAS GROWN
Sex trafficking always has been difficult to quantify, but awareness has risen in recent years, along with research into possible interventions.
Many sex workers without a pimp were initially trafficked, said Becca Stevens, an Episcopal priest and founder of Magdalene and Thistle Farms in Nashville. But regardless of their current situation, "they're linked together by the common root of childhood trauma," she said, and the new awareness of trafficking "allows people to be more compassionate." Women in the sex trade without a pimp still lack good options, and it is a mistake to create mental groups of trafficked and deserving vs. untrafficked and undeserving. Steve Przedpelski, executive director of Franciscan Peacemakers, an outreach group in Milwaukee, said that almost all women are "re-traumatized with every trick they turn, but they don't want to admit it."
Drug and alcohol use are highly correlated with being trafficked, but causation is complicated. Sometimes a woman turns to prostitution to pay for her habit; sometimes drugs mask the psychological pain; sometimes a pimp uses access to drugs as a means of control.
VICTIMS CAN BE ANYONE
"Anyone can be a victim of sex trafficking," said Rachel Monaco-Wilcox, a criminal justice professor who leads a task force on the issue at Mount Mary University in Milwaukee. "It happens to white cheerleader daughters of two-parent families." The common factor is low self-esteem and vulnerability. "They are snapped up by someone who says, 'I will take care of you,'" she said, and "it's hard to develop protective skills as a young person with that much against you."
Boys and men, too, can be victims. Monaco-Wilcox said that the most typical path is for a gay teen to be kicked out of his home and turn to "survival sex" on the streets. Even more than girls, she said, boys are misunderstood by the justice system and likely to be prosecuted instead of helped. Although data is hard to find, she said that by age 19 or 20, most male sex workers are dead or in prison. "You don't see a lot of 35-year-old male sex trafficking victims," she said, because customers don't want them.
Dominique Roe-Sepowitz, director of the Office of Sex Trafficking Intervention Research at Arizona State University, said her clients are mostly "low-income minority women with very few opportunities, who were conned into it." Surprisingly, her state sees little evidence of international trafficking, but the key word is evidence. Most trafficking across national borders happens in closed networks, in which customers are known to the pimp, she said. Open networks, whether via Facebook, Backpage or the streets, are easier to monitor.
For a successful intervention, housing is the first need to address among many, said Stevens, to give women a stable, long-term shelter. "It's not just fixing their teeth or fixing their hepatitis C," she said. "It takes a while to understand what healing looks like."
Long-term, skilled mental health counseling is vital. Stevens said that in her 20 years of helping women on the streets, the diagnosis of post-traumatic stress disorder has become much more prevalent, because "if people get triggered, they can get right back in that very scary space."
Group therapy can help victims to share common stories and build new, healthier relationships. Most women in what they call "the life" have "burned every bridge along the way, or they didn't have any bridges to begin with." Roe-Sepowitz said.
Stevens asked, "If every relationship you've had since age 12 or 13 has been monetized, what's the way to have a relationship? … Sexual abuse gets its power from shame and secrecy. The conversation is as important as anything we do." Laws and programs are necessary, she said, but "people heal because of a community that loves them."
NEED FOR DATA OVERLAP
When an adult sex worker gets health care, it's most commonly because she has been arrested and police see her immediate need. "Even if you solve the immediate crisis, she's not likely to show up again," Monaco-Wilcox said. She would like to see an integrated database among law enforcement, child protective services and health care providers to track possible victims and provide a way out of the life. At present, "none of the systems overlap."
"Every woman I meet has been raped," Stevens said. "It's a weapon [men] use. They feel they can't go to the police, and after a violent rape, they might just have to get up and start walking."
For similar reasons, sex workers rarely use the emergency room. But Stevens thinks the recent trend toward building smaller, neighborhood clinics may help; they may seem less intimidating and offer a better prospect of building relationships.
Access to health care "since the Affordable Care Act is a whole lot better," Przedpelski said. Common problems include feet and back pain, lost teeth due to drug use, physical trauma and injuries, and mental health. But "a lot of them balk at pursuing mental health care because of the stigma. … It takes six to nine months to have that conversation about mental health in general. There is pride involved."
But even when confronted with suspicious injuries, Przedpelski said, doctors and nurses, like anyone else, can be uncomfortable talking to strangers about sex and abuse, and their time is short. Adult trafficking victims rarely come to the emergency room, and even more rarely will they follow up; any intervention has to happen immediately, or it won't happen at all. However, health care workers can be trained in what to look for, what questions to ask, and possible interventions. (See sidebar.)
Underage victims present separate challenges. A child or teen at a doctor's appointment may be suffering abuse from a trusted adult, and health care workers need to be trained to look beneath the surface.
They "were our patients before, and still are," said Tia Medley, a nurse practitioner in Milwaukee. "It's important to have a high level of suspicion," even in affluent suburban medical practices. High risk factors include an older boyfriend, a history of running away, foster placement or group homes, mental illness, involvement with the court system, or developmental delays.
Getting a child out of trafficking, Medley said, is "very difficult when many children don't identify their involvement as victimization."
Angela Rabbitt, DO, a pediatrician in Milwaukee who specializes in abuse cases, said teens may claim to work alone, but "they're very vulnerable to exploitation." Even if they say they posted their own ads on social media to attract partners, for instance, someone else showed them how to do it. Also, policies and attitudes among child welfare departments vary widely across the country.
Even if a teen wants to escape, she may hesitate to confide in health care workers. Rabbitt remembers one trafficking victim who had been seen by medical providers several times, but didn't know how to bring it up. Getting the suspected victim alone is vital, and "sometimes we have to be a little sneaky about it," Rabbitt said. If the accompanying adult refuses to leave the room, the opportunity to talk may occur in the hallway while showing the teen the way to the bathroom for a urine sample, for instance.
Earlier onset of puberty in girls, particularly among African-Americans and Hispanics, has worsened the problem, Monaco-Wilcox said; if a girl is physically mature at 10, "a younger kid has even less skill set or emotional maturity" to resist an abuser's overtures. And if girls are in relationships earlier, then pediatricians need to be screening for sexual activity and everything that goes with it.
A boyfriend who becomes a pimp fills a need that victims are missing and develops a relationship, Roe-Sepowitz said: "Domestic violence doesn't start with a slap." If prevention begins in schools by identifying and talking to vulnerable kids, she said, then peers can help call out the pimp when he approaches.
Jeanne Geraci, executive director of the Benedict Center in Milwaukee, and other advocates are developing a public health approach to the problem of trafficking. Typically, she said, it is "a domestic violence relationship, with the added layer of selling sex," and law enforcement is not the best tool to address it.
And just like domestic violence, "these relationships can be quite complex," Geraci said. "You can't always rescue women from these individuals. They have to be willing. … They have to believe they're worth it." Generally, she said, "women define themselves in terms of relationships, and (sex workers) haven't had a lot of healthy relationships." A mental health worker may become the first non-transactional relationship they have had since early childhood. Health care providers in this setting need to understand trauma-informed care, she said, and treat possible trafficking victims like the trauma survivors they are.
Rabbitt said that trauma-informed care offers a philosophy of how to respond to patients. Underage victims in particular can be distrustful of authority, she said, and what seems like behavioral problems may really be caused by a trauma reaction, so health care workers need to learn to "take a step back instead of being frustrated."
Under most insurance policies, it is easier to find a psychiatrist to prescribe medication than a counselor who can offer long-term talk therapy, Geraci said, but the latter is vital. "Almost all the women are survivors of complex trauma," she said, beginning with abuse in childhood and continuing on the streets with rape, violence and controlling behavior. When a typical survivor starts to get mental health counseling, forming new relationships is often difficult because of lack of healthy models and the aftereffects of years of hypervigilance.
SAFE HOUSING IS CRITICAL
Geraci's center runs a drop-in site that offers clothing, showers and toiletries, and a six-month diversion program that works with police and law enforcement. But "even six months is just a toehold," she said. "It could be 10 years, depending on how entrenched the woman is, what the level of trauma is, the level of control of her trafficker." Most of the victims are virtually homeless, and recovery begins with housing.
"You don't think of housing as a health care issue, but it's true," Geraci said.
In order to escape the life, Roe-Sepowitz said, women need a safe place to stay; willingness to work on their addictions and face past traumas, such as childhood sexual abuse; and a mentor who will stick with them, go to court with them, and be a safe person to talk to.
"Almost every person who successfully got out said that was the key," she said.
Rachel Thomas, a trafficking survivor who is now the director of Sowers Education Group in Long Beach, California, agreed that mentorship is vital. She knows of several churches in her area that are organizing groups of "kind-hearted mentors who are older women and non-judgmental, who show that you can have a different normal." Thomas, who as a college student was lured into the life by a man who doubled as a modeling agent, got out when one of her coworkers turned the man in to police. She was able to recover through "the love of family and friends," she said.
"Sometimes it changes their mindset to love them unconditionally," said Robertson, the trafficking survivor from Nashville. "They think, 'Wow, the world is not as bad as I thought it was, someone does care.' Sometimes that makes a world of difference."
DAVID LEWELLEN is a freelance writer in Glendale, Wisconsin, and editor of Vision, the newsletter of the National Association of Catholic Chaplains.
Copyright © 2015 by the Catholic Health Association of the United States
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