#56313: Human Trafficking and Exploitation

In 2019, the National Human Trafficking Hotline recorded 14,597 sex trafficking cases to their hotline in the United States [150]. The TVPA of 2000 is a U.S. federal statute passed by Congress to address the issue of human trafficking and offers protection for human trafficking victims [10]. This statute defines sex trafficking as, "the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act" [10]. A commercial sex act is, "any sex act on account of which anything of value is given to or received by any person" [10]. In other words, it usually involves the illegal transport of humans into another country to be exploited in a sexual manner for financial gains [11]. However, it does not always involve the transport of victims from one region to another; such cases are referred to as "internal trafficking" [112]. Victims of sex trafficking could be forced into sex work, stripping, pornography, escort services, and other sexual services [12]. Victims may be adult women or men or children, although there is a higher prevalence of women and girls. The term "domestic minor sex trafficking" has become a popular term used to connote the buying, selling, and/or trading of children younger than 18 years of age for sexual services within the country, not internationally [12,113,156]. An element of force, fraud, or coercion is not necessary, as the victims are children and inherently vulnerable [113]. In the United States, the children most vulnerable to domestic minor sex trafficking are those who are homeless, abused, runaways, and/or in child protective services [12].

Although highly controversial, it is said that sex trafficking victims differ from sex workers in that sex trafficking victims are forced to involuntarily perform sexual services and are often not paid for their "work." Sex trafficking involves the use of force and coercion and can encompass other forms of criminal sexual activities, including forced erotic dancing, "mail-order brides," and pornography [112]. On the other hand, individuals involved in sex work make a decision to provide sex services for a fee. The decision to enter sex work does not eliminate the possibility of being a victim of trafficking if one is held against his/her will through physical and/or psychological abuse [27]. It is also important to remember that this does not necessarily mean sex work is a choice these individuals would have made if other options were available or that they have a choice in selecting their sexual partners and/or sexual activities [13]. Controversies continue, and in the United States, the definition of sex trafficking appears to have broadened in recent years. For example, persons who pay for sex using online platforms are not often classified as sex traffickers [155].

Visit the PBS Frontline website (https://www.pbs.org/wgbh/pages/frontline/slaves/map) and read the transcripts of interviews with a sex trafficker and five Eastern European female victims who were deceived into sexual slavery.

The United Nations has defined debt bondage as [14]:

Essentially, because the individual does not have money as collateral for the debt owed, the individual pledges his/her labor or, in some cases, the labor of a child or another individual for an unspecified amount of time [15]. These individuals may be transported or trafficked into another country for the purpose of forced labor.

In many cases of bonded labor, the initial loan may be welcomed by the individual. However, the victims do not realize that with the low wages, unspoken high interest rates and other continually accruing fees, and the perpetrator's manipulation of the "accounts," laborers can never repay the loans. Some estimate that half of all persons in forced labor are bonded laborers. The majority of bonded labor cases occur in India, Bangladesh, and Pakistan [114]. Some families find themselves in a cycle of poverty as the debt cannot be paid off and is passed down from generation to generation [15]. Bonded labor can involve laborers in brick kilns, mines, stone quarries, looming factories, agricultural farms, and other manufacturing factories [15]. In the United States, individuals may be trafficked to work long hours in garment factories, restaurants, and other manufacturing sectors. Frequently, the employer/captor will take away victims' identifications, monitor their movements, socially isolate them, and/or threaten deportation if they do not comply [16]. Migrant workers are at high risk of forced labor [27].

In the United States, forced labor is predominantly found in five sectors [16]:

Forced labor in the construction and fishing industries is also common [152]. It is speculated that most of the forced labor in the United States occurs in California, Florida, New York, and Texas, all major routes for international travel [16]. In 2019, 4,934 cases of labor trafficking were reported to the National Human Trafficking Hotline [150].

Domestic servitude refers to a category of domestic workers (usually female) who work in forced labor as servants, housekeepers, maids, and/or caregivers, often in private homes. In some cases, young women are lured with the promise of a good education and work, and when they arrive in the United States, they are exploited economically, physically, and/or sexually. Their passports or identification papers are taken away, and they are told they have to pay off the debt incurred for their travel, processing fees, and any other bogus expenses. Because they do not speak English, they find they have no other recourse but to endure exploitive working conditions [17]. Unfortunately, as in many sectors of forced labor, there are no regulations to monitor the conditions under which domestic servants operate [16].

The following documentary, A Global Alliance Against Forced Labour, was produced by the International Labour Organization in order to tell the stories of men and women forced to labor and show what is being done globally to combat modern day slavery.

For more information, visit the International Labour Organization at https://www.ilo.org.

Child labor can be viewed as a specific form of bonded labor or forced labor. However, not all child laborers have been trafficked. Child labor is defined by International Labour Organization (ILO) as economic labor performed by a child younger than 15 years of age or hazardous labor done by a child 18 years of age or younger. Child labor is deeply rooted in poverty and the infrastructure and political stability of the country as well as market forces [18]. The ILO estimates that there are 152 million child laborers in the world [48]. Between 2000 and 2016 there was a nearly 38% decrease in the number of children in child labor. The reduction was greater for girls (43%) than for boys (34%). The largest numbers of child laborers are found in Asia and the Pacific region; however, there is evidence that the number of child laborers in Africa is increasing [48].

The definition of child labor is controversial because the definitions for "work" and "childhood" are ambiguous and often culturally defined [20]. On a conceptual level, work may be beneficial for the socialization and educational processes of children [20,56]. So, it is important to differentiate between child work and child labor. Child work has been defined as activities that are supervised by an adult and that promote the development and growth of the child, while child labor does not benefit the child [18]. Many definitions of child labor create a dichotomy whereby child work is considered not harmful while child labor has negative emotional, intellectual, and social consequences [21]. Work that is exploitive for children has been defined as working long hours at a young age, work that is poorly compensated, and work that produces physical, social, and psychological stress that will hamper development, access to education, and self-esteem [23]. The ILO adds that child labor is work that interferes, deprives, and interrupts schooling and places children in the position of trying to balance school and long work hours [56].

It is important to remember that child labor occurs in the United States. Runaway and homeless youths are at greatest risk, often lured by promises of work and housing [115]. The Polaris Project found that the top three forms of child labor trafficking in the United States were begging, peddling, and traveling sales crews [115]. Children are most often trafficked to work in agriculture, drug sales, domestic service, door-to-door sales, hotels, and restaurants [157]. Some are recruited and trafficked through organized crime or through family members. Youths who are poor and/or who have mental or substance use disorders are often recruited with promises of a better life, high pay, and fun. However, after they start to work, they find they have been assigned unattainable quotas and are subject to physical and psychological abuse, denied food and shelter, and isolated [157,158].

In some cases of trafficking, persons younger than 18 years of age are kidnapped and trafficked to serve as soldiers. However, forced conscription can also include children who are used by the military for noncombat tasks, such as cooking, delivering messages, spying, or sex [159,160]. Other times, children are coerced by a narrative indicating they will be serving a higher purpose and avenge the deaths of family and friends; this is known as comradeship [116]. Some children are actively recruited and may be promised a small salary to "voluntarily" join. In a study of 132 cases of child conscription in Columbia, 18% of the children were motivated by perceived economic rewards [117]. Many children lack educational opportunities or hope for a better future, perceiving soldiering as the only option [116]. Conscripted girls often cite educational opportunities as a motive [116]. In Nepal, former female soldiers also indicated they were driven to volunteer in the armed groups by a fear that if they stayed with their families they would be married away as children or raped [116].

It is estimated that at any one time 250,000 to 300,000 children younger than 18 years of age are currently serving as child soldiers [72]. Traffickers prefer to recruit children to serve as soldiers because they are inexpensive and more easily molded and shaped to comply and obey without question [25]. They are also more likely to kill fearlessly and recklessly. Child soldiers are treated as adults, without any regard to how the physical and psychological rigors of war will affect them psychologically and developmentally. In Uganda, where children are kidnapped or recruited as child soldiers relatively often, the Lord's Resistance Army has been known to initiate new child soldiers in brutal ritualized killings of others so as to terrorize them into submission and annihilate any moral conscience they may have about killing [25]. In Afghanistan, children have been recruited by the Taliban and have served as suicide bombers [114].

It can be difficult to comprehend the atrocities that these children witness and experience. Bayer, Klasen, and Adam conducted a study involving 169 former Ugandan and Congolese child soldiers who were an average of 15.3 years of age [26]. Almost all (92.9%) reported having witnessed a shooting, 89% witnessed someone wounded, and 84% witnessed someone seriously beaten. A total of 54.4% reported having killed someone, and 27.8% reported that they were forced to engage in sexual activity [26]. In another study, the researchers found that the experience of conscription among children produced significant emotional and psychological traumas and a host of cognitive and behavioral problems [27]. In this study of 19 child soldiers, 18 had volunteered to join the army and one had been abducted. Although most of the children volunteered into the army, their participation became involuntary. Some tried to run away or disobey, which resulted in beatings and imprisonment. If captured, they were told to commit suicide [27]. Commanders often psychologically abuse children by enforcing rules such as forbidding them to bathe or eat. In some cases, children are given special amulets that they are told make them invincible in battle. Threats of torture and killing are omnipresent [159]. The reintegration of child soldiers is not easy. Many are stigmatized when they return to their home villages, as their families and friends fear that these former child soldiers may be violent [72,118]. Many are traumatized and cannot easily obtain the support they need to reintegrate successfully [159].

Listen to a National Public Radio interview with Ishmael Beah, a former child soldier, at https://www.npr.org/2007/02/21/7519542/ishmael-beahsmemoirs-of-a-boy-soldier.

Human trafficking has been called one of the "darkest sides of globalization" [35]. Globalization is the term used to describe the interconnectedness of countries and nations, which facilitates easy communication, exchange of ideas, and flow of goods, capital, and services [35]. As globalization increases so does the flow of capital and trade, and with economic growth will come social disintegration in some areas [161]. This prompts those adversely affected to move in search of better living conditions. This migration movement makes some vulnerable to crimes such as human trafficking [45; 161]. Furthermore, the ideals of Western capitalism may reinforce human trafficking as a business or industry, with its emphasis on the free market and the flow of goods and services across international borders [45].

Globalization has also created the need for cheaper labor [114,119]. A study involving 160 countries examined the effects of globalization and human trafficking trends [120]. Researchers found a positive relationship between globalization and trafficking for forced labor, sex work, and debt bondage. In a 2021 study, data on human trafficking and globalization were analyzed, and the researchers found globalization was positively related to the incidence of human trafficking [161].

Poverty and incessant economic stressors caused by civil wars, natural disasters, and collapses of government systems all contribute to human trafficking [9,113,121,156,162]. Families entrenched in deep poverty may feel they have no other recourse but to sell a child or may be more easily lured with promises of money and a better future [78,79,121]. In one study, the odds of being trafficked were nine times greater for those who felt extremely hopeless about upward mobility compared with those with lower levels of hopelessness [121]. In the first few months of the COVID-19 pandemic in 2020, there was a decrease in migratory movement, which is not surprising given the closing of borders. However, economic stressors increased and acted as push factors for people in search of better opportunities, which in turn increased the risk of human trafficking [163].

Community factors (such as high social disorganization characterized by violence, unemployment, and high crime) contribute to higher risk of trafficking [113]. In addition, families marked by instability (e.g., domestic violence, child abuse, continual unemployment) are also at higher risk of having a member trafficked [113,149].

Human trafficking cannot occur without the existence of corruption within existing infrastructures. Public officials, police officers, and local leaders in many developing countries have been known to take bribes to provide protection to parties involved in various aspects of human trafficking [35,120,122,162].

The rampant use of digital technology, such as the Internet, greatly facilitates sex trafficking. The relative anonymity of online contact can empower traffickers to recruit or sell victims. Graphic images of women and children engaged in sexual acts can be easily disseminated over the Internet [46]. Traffickers may employ the Internet for advertising, marketing to those interested in making pornography [46]. In addition, social media sites such as Facebook, Craigslist, and Instagram have been used as a means of facilitating trafficking (e.g., by connecting and grooming potential victims) [80; 123; 124; 164; 165]. Newsgroups offer opportunities for those interested in locating women and children for sexual exploitation.

In a 2013 qualitative study, smartphones were found to be integral in the business of trafficking [80]. Researchers indicated the phones were used "to maintain contact with each other, in order to facilitate the business 'transactions' and stay in touch with transnational 'partners' and other traffickers who remained in the country of origin" [80,123]. It is important to note that while digital technology has been used to facilitate abuse, it also has a role in identifying and preventing potential trafficking [164].

Race and ethnicity have been inextricably linked to sexual violence and victimization. Myths regarding sexuality in certain cultures or racial fetishization may affect trafficking patterns. For example, there is an over-representation of Asian women on American Internet pornography sites in part due to popular myths sexualizing, eroticizing, and exoticizing Asian women. This has translated into trafficking, as traffickers respond to the demand for young Asian women and girls in part fueled by these stereotypes of exotic, docile, submissive, and eager-to-please Asian women [17]. These stereotypes devalue and dehumanize people, which is the underlying core of human trafficking. This contributes to the acceptability of the exploitation of individuals, particularly members of marginalized groups [125].

These racial stereotypes go beyond simply framing the victims in a particular manner [81]. They raise implicit questions regarding how the powers of state are depicted. In other words, the patriarchal attitudes of certain countries lead to "bad" or "backward" cultural practices or ways of being that then cause trafficking—setting up is a dichotomy of the "West" and "others" [81].

Although many are careful in linking cultural factors to the etiology of human trafficking for fear of imposing judgment on a particular culture, many maintain that cultural ideologies that tolerate sexual trafficking, bonded labor, and child labor may be a stronger factor than poverty in predicting trafficking rates [17,23]. For example, some cultures emphasize collectivism and prioritizing the needs of the family and group first before the needs of the individual. Some children may feel they have to sacrifice themselves for their family when traffickers promise money [17]. Traffickers also know that they can threaten to hurt victims' families to keep them from escaping [17].

Furthermore, in many cultures, boys are more highly valued than girls, and as a result, girls are considered more dispensable [17]. Sons are considered the family's social security, staying with the family while daughters marry into other families. Therefore, girls may be more likely to be sold into slavery than boys. In a study using court documents in China, in places where there was a higher sex ratio balance (i.e., fewer women than men), there were more instances of trafficking of women for forced marriages and the price was higher for women who were trafficked in these areas [166].

Child labor is also inextricably tied to cultural factors. In India, for example, child labor is common because it is believed that children in the lower levels of caste system (i.e., the "untouchables") should be socialized early to understand their positions in society [23]. It has been observed that when traditional cultural and societal norms about women's roles were relaxed in some European countries and more women entered the labor force, child labor decreased [23]. Ultimately, it is difficult to unravel the effects of poverty and culture because the pressures of poverty can lead families to use tradition as a justification to sacrifice young men, women, and children [23].

Ultimately, the conversation about human trafficking is complex, and to attempt to isolate the causes is beyond challenging. Multiple factors have been suggested as possibly predicting human trafficking, including macroeconomic factors (e.g., gross domestic product per capita), unemployment rates, female inequality, cultural oppression, and lack of protection of women's rights [82,126,162]. In one study, ease of land access to the destination country appeared to be a powerful predictor in terms of the number of individuals trafficked [82].

The feminist perspective frequently equates human trafficking with sex work or sexual slavery [34]. Feminist scholars argue that human trafficking is an extreme form of violence against women or a form of commodification of women's bodies [1]. Female victims are often coerced and threatened physically and psychologically by a third party. The women's economic situations and their families' poverty reinforce their powerlessness [30]. According to this perspective, gender inequality is perpetuated by the devaluation of women, which results in violence against women, ideologies that promote masculinity as superior to femininity, and beliefs that facilitate the subordination of women [127; 169]. When viewed from the feminist perspective, human trafficking, particularly sexual trafficking, entails coercion and exploitation perpetuated by systemic and structural dimensions, including patriarchal norms and institutions [1; 166; 169]. Feminists would maintain that social and economic circumstances that lead to gender inequality ultimately result in women and children being vulnerable to human trafficking schemes.

A second lens used to frame human trafficking is a criminal justice or criminology perspective, which focuses on assigning blame and guilt, potentially charging the victim for criminal activities such as illegal migration or sex work [36]. Studies using a criminal justice/criminology approach attempt to understand the criminal processes and procedures (from arrest to prosecution) and barriers that emerge in each stage [170]. For example, entering the United States illegally is a crime, and law enforcement could view the trafficked person as a criminal co-conspirator [37]. This is important because the United States government is struggling to address the illegal immigration issue; those adhering to this perspective would view all "irregular" migrants in the United States as criminals first. When individuals are shown to have been abused and exploited, they are then recast as victims [28]. Similarly, human sexual trafficking is often equated with sex work and is viewed as morally sinful and evil [36]. This perspective conceptualizes trafficking as an elaborate system of organized crime networks that sponsors a hugely profitable industry [38].

The migration and labor perspective focuses on the illegal movement of people across national or international borders [1]. The labor dimension is concerned with workers who are exported from economically weak to affluent countries who may end up being exploited and abused [39]. This perspective classifies countries as either sending or receiving [35]. Some countries, such as Ukraine, are considered sending countries, as they tend to experience the recruitment and transit of citizens to other countries. Other countries, such as the United States, are predominately receiving countries, the destinations of trafficked individuals [35]. This perspective highlights the "push-and-pull factors" that lure the poor to more affluent countries [35]. Push factors are those environmental conditions that "push" or motivate individuals to leave their country [82]. A key push factor for many countries is poverty and the incessant economic stresses of civil wars, natural disasters, collapses of governmental systems (as in the Soviet Union), and lack of economic growth [9]. Another push factor is a perceived lack of political and/or religious freedom [149]. These push factors allow traffickers to lure individuals with promises of employment and better lives in another country and may prompt families to agree to sell their children [121]. On the other hand, the pull factors generally involve the needs of businesses to find laborers to fill low-wage jobs [9; 120; 149]. These types of conditions create an excess pool of potential victims from which traffickers select [82].

To further complicate matters, the issue of transit countries should also be considered. Transit countries are found in the middle of a trafficking route [85]. For example, traffickers in Asia, and specifically South Korea, commonly send victims through Canada with the ultimate destination of the United States. In this chain, Canada would be considered a transit country. Transit countries share several common characteristics [85]:

In 2018, North America and Western and Southern Europe were destination countries with high flow of trafficking [165].

The human rights perspective focuses on the link of human trafficking to historical forms of slavery and the denial of human rights and dignity. Advocating for social change on the structural level is at the heart of human rights work [169]. Human rights are often considered the natural and universal rights or laws for human beings [81; 128; 169]. However, the issue is not this simple—it is important to consider what these universal conditions are and to what extent Eurocentrism is instilled in the work of human rights activists [81].

As with slavery in the 18th and 19th centuries, trafficking victims today have no choice over their abusive and exploitive conditions. Unlike the "older" forms of slavery, this modern form is an outcome of globalization [28]. The human rights perspective also argues that, to some extent, the general public indirectly contributes to the problem of human trafficking as consumers in the global market [28]. In a study of how human trafficking is socially constructed, the videos being examined portrayed general consumers and corporations as perpetrators of human trafficking in addition to pimps, crime organizations, and middlemen recruiters [40].

The labor rights perspective is concerned with the rights of illegal migrant workers in the United States. This perspective incorporates elements of the human rights, feminist, and migration/labor perspectives; however, the difference is that this perspective encompasses all forms of labor and frames sex work as an economic activity [34]. For example, some women engage in sex work intermittently to supplement their income while others rely on sex work for their main or sole income [86]. Advocates in this camp fight for laws and policies that create rights to protect migrant workers and lift the legal restrictions on illegal immigration [34].

These wide-ranging perspectives help to frame the problem and influence public response. When human trafficking is framed as an illegal immigration activity, the public response is generally unsympathetic [1]. When human trafficking is viewed as a cultural remnant of patriarchy and inherent to the institutional landscape and when victims are portrayed as young women and girls, the public may be more sympathetic to their plight. It is important to remember that each perspective will also highlight the different victims involved. For the most part, the media does not portray trafficked victims to include agricultural workers, domestic workers, or factory workers [47].

Much attention has been focusing on victims of trafficking; however, it is important to also understand the perpetrators.

Victims of trafficking experience a host of psychological, mental health, and emotional distress. Depression, suicidal ideation, substance use, and anxiety are typically cited mental health problems [113,174]. Post-traumatic stress disorder (PTSD) is also common given the trauma many victims experience, including physical and/or sexual violence and abuse; victims forced into sex work experience continual, daily sexual assault [49,174]. In a study of 192 European women who were trafficked but who managed to escape, the overwhelming majority (95%) disclosed that they experienced physical and sexual violence during the time of their trafficked experience [50]. More than 90% reported sexual abuse, and 76% reported physical abuse.

Trafficked victims experience fear from the start of their capture through the transit phase and after they arrive at their destination. During the transit stage, many victims experience dangerous border crossings, risky types of transports, injury, beatings, and sexual assault [41]. Upon arrival to their destination, many trafficking victims have been socially isolated, held in confinement, and deprived of food [134]. All sense of security is stripped from them—their personal possessions, identity papers, passports, visas, and other documents [41,134]. The continual fear for their personal safety and their families' safety and the perpetual threats of deportation ultimately breed a sense of loss of control and learned helplessness. It is not surprising that depression, anxiety, and PTSD are common symptoms experienced by trafficked victims.

In a study of 164 survivors of human trafficking who returned to Nepal, the authors examined the extent to which they experienced PTSD, depression, and anxiety [51]. All of the survivors experienced some level of these disorders, but the survivors who were trafficked for sex experienced higher levels of depression and PTSD compared to those who were not trafficked for sex. In a study with Moldovan survivors of human trafficking, researchers found that six months after their return, 54% had diagnosable mental health issue. Specifically, 35.8% met the diagnostic criteria for PTSD, 12.5% met the criteria for major depression, and 5.8% were diagnosed with an anxiety disorder [92].

There is also some evidence that trafficked victims may experience complex PTSD, a type of PTSD that involves an acute change of the victims' sense of self, their relationship with others, and their relationship with God or higher being [93]. These persons direct anger inwardly (toward themselves) in addition to toward their perpetrators, which results in a loss of faith in themselves and the world [93,129,134]. Perhaps due to self-directed anger and shame, some will engage in risky sexual behaviors, self-harm, and substance abuse. Some victims also have difficulty managing and expressing how they are feeling, while others experience dissociation [134]. In a systematic study, 41% of victims had signs of complex PTSD [175].

Substance abuse is also common among victims. In interviews, trafficked women discussed how traffickers forced them to use substances like drugs and/or alcohol so they could work longer hours, take on more clients, and/or perform sexual acts that they could not normally [41]. Other victims used substances as a means to cope with their situations. Trafficked individuals who are gender and/or sexual minorities report shame, confusion, and sexual identity issues if forced into heterosexual relationships [129].

Children forced into labor experience grueling hours and are frequently beaten by their captors. According to Clawson and Goldblatt, underage victims of domestic sex trafficking fluctuate through a range of emotions from despair, shame, guilt, hopelessness, anxiety, and fear [52]. Depending upon the level of trauma, some engage in self-destructive behaviors like self-mutilation or suicide attempts [174]. For some, their ambivalence toward the perpetrators may be confusing. On the one hand, they want to escape the abuse, yet simultaneously, they may have a sort of traumatic bond with the perpetrators [52]. Some may experience auditory hallucinations; however, it is important to not simply attribute these symptoms to psychosis [174,176].

Children forced into conscription will also experience a host of psychological symptoms. In a study comparing former Nepalese child soldiers and children who were never conscripted, former child soldiers experienced higher levels of depression, anxiety, PTSD, psychological difficulties, and functional impairments [53]. In another study of former children soldiers from the Congo and Uganda, one-third met the criteria for PTSD [26]. The researchers found there was a relationship between greater levels of PTSD symptoms and higher levels of feelings of revenge and lower levels of openness to reconciliation [26]. In-depth narrative interviews of former child soldiers from northern Uganda found that the children spoke of the violence and atrocities they witnessed without any emotion, as if they had removed themselves from their experiences [94]. This speaks to how the victims have to numb themselves psychologically in order to cope. The researchers also found that the children who lost their mothers were more traumatized by this experience than the violence they witnessed as soldiers.

Some have argued that the diagnostic criteria of PTSD may not be easily applied to those from different cultures. As a result, it is important to assess for other psychiatric disorders, such as depression. Japan, for example, never used the PTSD diagnosis prior to 1995, despite the fact that they have a large and intricate mental health system [54]. Ultimately, PTSD cannot be universally applied to every culture and for every humanitarian crisis; therefore, if a human trafficking victim does not necessarily fall within the Diagnostic and Statistical Manual of Mental Disorders criteria for PTSD, one cannot necessarily conclude that they have not experienced trauma or are not traumatized [54].

When rescued and attempting to reintegrate into their communities, victims of human trafficking often experience stigma, ostracism, and marginalization [53,135]. For example, in Nepal, community members perceived returning child soldiers who had performed acts such as carrying dead bodies or coed sleeping as in violation of Hindu cultural norms [53]. One documentary following former child soldiers living in a refugee camp in northern Uganda found that preconceived notions and myths about children soldiers often led to ridicule and ostracism after they were liberated from the army and returned home.

However, girls who were recruited as soldiers, who were forced to have sex, or who return with children appear to be the most marginalized group [55]. In a qualitative study of former girl soldiers in Sierra Leone, researchers found that, compared to returning boy soldiers, girls were perceived to have violated gender norms and values about sexuality. Although psychologically and developmentally they were still children, the community perceived and treated them as "damaged" or "unclean" women. Girls tend to experience higher levels of shame and guilt than boys [177]. Their communities were not able to integrate them back in despite the victimization they experienced. These girls lacked voice and experienced shame, marginalization, poverty, and powerlessness upon their return [55]. In a study of former child soldiers in Uganda, the children reported having difficulty finding jobs or getting married when they returned home. Girls who had been raped were stigmatized and made to feel unwelcome in their communities. Others stated that their community perceived them as murders [118]. Boys' greatest concerns dealt with finances such as being able to get a job, concerned about their family's economic status [177].

In studies of trafficked women, headaches, fatigue, dizziness, back pain, pelvic pain, stomach pain, sexually transmitted infections (STIs), unwanted pregnancies, and gynecologic infections were common, generally the result of continual physical, psychological, and sexual abuse [50,113,178]. Victims of labor trafficking also experience health issues related to the type of work, including malnutrition, burns, hearing loss, respiratory symptoms from exposure to toxic chemicals, and traumatic injuries (e.g., limb amputations, broken teeth, bruises, abrasions) [136,157].

It is important to remember that some of these somatic complaints, such as headaches, fatigue, and gastrointestinal problems, may be underlying symptoms of anxiety, depression, and stress [50]. Some cultural groups might not use the terms "depression," "sad," or "anxious," but may use metaphors and somatic symptoms to describe their pain, all of which are embedded within cultural ideologies. The most common culture-based idioms of distress are somatic symptoms. Some groups tend not to psychologize emotional problems; instead, they experience psychological conflicts as bodily sensations (e.g., headaches, bodily aches, gastrointestinal problems, and dizziness). A longitudinal study of human trafficking victims from Ghana, researchers found a delayed somatic effect [179]. Psychological violence tended to predict higher number of physical symptoms after exiting trafficking. However, sexual violence appeared to predict even longer lasting physical symptoms during the reintegration phase.

Using an in-depth, direct interview survey designed to explore each stage of the trafficking experience, a multi-country European study identified a range of aversive health, sexual, and reproductive consequences common among women and adolescent victims of human trafficking [41]:

The British Association for Sexual Health and HIV has identified trafficked women/commercial sex workers as a group vulnerable to sexual violence. Inquiries about such vulnerabilities will help to identify those in need of additional support and help to facilitate appropriate referrals to mental health services, general practitioners, and support agencies. Access to interpreter and advocacy services may be helpful.

(https://www.bashhguidelines.org/media/1079/4450.pdf Last Accessed: September 27, 2022)

Level of Evidence: Expert Opinion/Consensus Statement

In the context of forced sex work among trafficked victims, safeguards against infection (e.g., regular condom use), early diagnosis, and adequate antimicrobial treatment are inconsistently employed or absent entirely [41]. Consequently, in addition to unwanted pregnancy, the risk for pelvic inflammatory disease and subsequent infertility is relatively high. Moreover, the relationship between forced sex work and HIV infection is stronger when sexual violence is involved. Women who are forced into sex work are 11 times more likely to become HIV-infected than women who entered sex work voluntarily [95]. Sexual violence may increase the transmission risk as a result of open abrasions and injuries to the vagina. Furthermore, sexual violence can negatively impact self-esteem, which could then deter victims from advocating more strongly for condom use [95].

Among child victims of human trafficking, healthy growth and development is especially problematic. Malnourishment and poor hygiene often lead to delayed bone growth, poorly formed teeth, and early dental caries [59]. The intense nature of child labor also has severe negative physical and health consequences. It is not uncommon to find children in forced labor conditions, working long hours every day. Boys tend to work longer hours and sustain more injuries than girls in forced labor situations [177]. Children working in unsafe conditions without protection, such as in mines or mills, can lead to respiratory problems such as asthma and bronchitis [57]. A study of adult and child laborers on tobacco farms in Kazakhstan found that the workers were unaware that exposure to tobacco and pesticides could affect their health. Protective garments were also rare, with many children not even having gloves [96].

Under normal circumstances, young children are still developing physically; however, such adverse conditions can halt their development. The lungs of adolescent boys typically experience the most rapid growth around 13 to 17 years of age; working in conditions characterized by excessive toxic dust or unclean air makes them more vulnerable to developing silicosis and fibrosis [57]. In the United States, young children participating in agricultural work are at risk of the major traumas associated with farm work, such as injuries caused by tractors or falling from heights, in addition to those injuries associated with repetitive stress and exposure to toxins. Children have thinner layers of epidermis, which make them more vulnerable to the toxicity of pesticides, and this can ultimately increase their risks for certain cancers [57]. Children working in gold mines do intensive digging, lifting, and transporting and mix mercury with the crushed ore, often with their bare hands. Mercury toxicity can lead to neurologic symptoms such as loss of vision, tremors, and memory loss [96].

Bruises, scars, and other signs of physical abuse may be missed on examination, as victims are often beaten in areas hidden by clothing (e.g., the lower back) so as not to affect the victim's outer appearance. Physical trauma symptoms may be present, commonly on the torso, breast, and/or genital areas [132]. Burns, broken bones, pelvic pain, and/or STIs (particularly in children) may also be red flags [137]. However, more common physical injuries are also typical with other circumstances, making physical exam of limited value. The entire clinical picture should be considered.

It may also be helpful to assess for tattoos and/or other modifications (e.g., branding, piercings). Some perpetrators use tattoos to identify victims or to signify "ownership" [124,180].

With regard to episodic clinical encounters, recommendations for providing safe assessments in a culturally sensitive manner are lacking. The Department of Health and Human Services Administration for Children and Families maintains a useful website that addresses practical issues of human trafficking for allied professional groups, known as the Rescue and Restore Campaign [59]. Included are diagnostic and interviewing tips to help healthcare providers recognize, intervene, and refer trafficking victims. Emergency and primary care providers should be cognizant of clues that a patient may be the victim of trafficking and prepared to engage in greater depth of inquiry with special attention to the following indicators [59,65,97,137,180]:

A qualitative study of health professionals revealed that they tended to rely on behavioral indicators, particularly when accompanied by a medical indicator and especially in cases of sex trafficking [181]. For example, if a patient appears nervous or frightened and if this is accompanied by a medical indicator such as a sexual transmitted infection, this would be a prominent red flag for the provider. Stereotypical behavioral indicators were also identified as red flags. For example, the presence of a controlling male figure was a red flag; providers were not as concerned when a patient was accompanied by a controlling female figure.

If answers to these questions indicate that an individual may be a victim of human trafficking, one should contact the National Human Trafficking Hotline at 1-888-373-7888. Under the child abuse laws, practitioners who are mandated reporters and who are suspicious that a minor is being abused should immediately report the abuse. For more information regarding specific states' reporting requirements, please visit https://www.childwelfare.gov/topics/systemwide/laws-policies/state.

Examples of questions to screen for human trafficking include [138,139,140]:

The Polaris Medical Assessment Tool and the U.S. Department of Health and Human Services Adult Human Trafficking Toolkit include five yes/no questions to serve as a rapid assessment. The second question is reverse scored [182]:

The Polaris Project has developed a flow chart for the assessment of potential trafficking victims, available at https://www.traffickingresourcecenter.org/sites/default/files/Assessment%20Tool%20-%20Medical%20Professionals.pdf. If a person is thought to be a victim, one should follow workplace protocols and/or contact the National Human Trafficking Resource Center at (888) 373-7888 for next steps.

According to the World Health Organization, a minimum condition for healthcare providers to ask women about violence is that it is safe to do so (i.e., the perpetrator is not present); they must be trained on the correct way to ask and on how to respond to women who disclose violence.

(https://apps.who.int/iris/bitstream/handle/10665/85240/9789241548595_eng.pdf Last Accessed: September 27, 2022)

Level of Evidence: Expert Opinion/Consensus Statement

Service providers should repeatedly weigh the risks and benefits of various actions when interviewing human trafficking victims [88,99,100]. The following interviewing recommendations were published by the World Health Organization to encourage service providers to continually and ethically promote human trafficking victims' safety during every phase of the interviewing process [66; 137; 183]:

It is important to use a trauma-informed approach when assessing and caring for potential victims, which requires that practitioners understand the impact of trauma on all areas of an individual's life [141]. Physical, emotional, and psychological safety is at the heart of trauma-informed care. Providers should assume that human trafficking victims are describing their reality to the best of their ability, given the trauma they have experienced. Responses and behaviors (e.g., being guarded, defensive, belligerent) may be coping mechanisms [141].

Education is believed to be a key ingredient in the prevention of human trafficking. Raising awareness through advertisements, campaigns, and other creative vehicles regarding recruitment threats, the various deception techniques employed, the different forms of human trafficking, and the consequences of human trafficking can decrease the incidence [42,58]. Because the general public often believes human trafficking is a problem that only occurs in developing countries, there is a clear need for public education about trafficking and safety for young children and women in and outside the United States [12]. The Office on Trafficking in Persons provides brochures and posters about human trafficking, which are available to be ordered (at no cost) from https://www.acf.hhs.gov/otip/resource-library [59]. Posting these brochures or posters increases the possibility that a trafficked victim will self-report [100].

Education about human trafficking has become a higher international priority. Innovative and creative approaches are being implemented to disseminate information about human trafficking, particularly how perpetrators recruit high-risk groups (e.g., youths with disabilities, runaways) [131]. For example, groups have used street plays to educate communities about child labor dangers in India [61].

India: Fighting Child Labour with Street Plays was produced by the International Labour Organization to explore the use of street plays to educate communities about child labor in India.

For more information, visit the International Labour Organization at http://www.ilo.org.

Although the topic of human trafficking has become more common in public discourse, service providers and law enforcement authorities remain under-educated about human trafficking. They are not sure what to look for, what to ask, and what to do if they do identify individuals who are victims of human trafficking [58]. Law enforcement officials require training to identify and assess potential victims at various borders and ports of entry. If a minor is accompanied by an adult who is not the child's parent or legal guardian, this should raise a red flag [58]. Furthermore, to work effectively to identify human trafficking victims, there is a need for service providers to navigate and collaborate with a complex host of government, social service, mental health, and nongovernment legal entities [58]. The Office on Trafficking in Persons, under the Administration for Children and Families, has developed the SOAR Training, with the objectives of [183]:

To learn more about this training, visit https://www.acf.hhs.gov/otip/training/soar-health-and-wellness-training.

Care and services provided to victims can be organized into three distinct categories: immediate and concrete services at the time of rescue; services related to recovery; and long-term services pertaining to reintegration [142]. When trafficking victims are rescued, a great deal of counseling services and practical, day-to-day assistance will be required. Housing, transportation, food, clothing, medical care, dental care, financial assistance, educational training, reunification (for those who wish to return to their homeland), and legal aid are some of the concrete services needed [91]. Practitioners should connect, coordinate, and case manage these services as much as possible. During this stage, it is also important to understand victims' needs, their strengths, and their risks and vulnerabilities [134].

Safety planning is also crucial in the immediate rescue stage. Traffickers may be continuing to try to locate some victims; placing victims in safe houses may be necessary [129]. The National Human Trafficking Hotline encourages that safety planning be based on the unique needs and circumstances of the individual.

During the recovery and reintegration stages, as discussed, human trafficking victims experience an array of mental health and psychological issues. Mental health counseling is vital, but it is important to remember that the concept of counseling or talk therapy may be foreign to victims from non-Western cultures [88]. The expression of emotions may be in opposition to cultural values of emotional restraint, which can be intensified by feelings of shame and guilt resulting from experiences with sexual and physical assault. Beyond the paramount importance of the practitioner gaining the patient's trust, practitioners may educate patients about the counseling process and explore their patients' expectations about counseling, healing, and recovery [60]. As noted, victims' symptoms may not only be a manifestation of the trauma but also coping mechanisms to cope with self-blame, shame, and trauma [124]. Group therapy can serve as a safe place for human trafficking survivors to connect with others who share their experiences and can help reduce isolation. For those who may benefit from this approach, the group setting can help them to share with others who can truly empathize with their feelings and experiences [178].

Given differing cultural beliefs about healing, it is crucial that practitioners be open to alternative treatment and explore with patients the use of traditional healing methods [88]. There are many indigenous healing interventions victims may be using, including cultural rituals, faith healing, therapeutic touch, herbal remedies, and spiritual practices [62]. These interventions are multi-layered, taking into account the physical, psychological, communal, and spiritual [62]. These healing methods are historically rooted in specific cultures, and therefore, practitioners should become familiar with traditional healing methods and how they can be integrated with Western counseling techniques [60]. For example, given many cultural groups' beliefs that unmarried girls are defiled if raped, a cultural cleansing ritual may be needed as a first step to help a community accept a returning victim who was sexually assaulted during her trafficking experience [17]. After this ritual is performed, it is possible that both the patient and her family may be more open to counseling and other services.

Although there is no specific evidence-based research about the effectiveness of trauma-informed care for human trafficking survivors, many have written about its application to this population [184]. There are six guiding principles of trauma-informed care [185]:

Whenever possible, persons involved in the care of trafficking victims should assume a trauma-informed approach. For more information on this approach to care, please visit:

Other trauma interventions that might be beneficial include cognitive-behavioral therapies, eye movement and desensitization reprocessing therapies, mindfulness techniques, and expressive therapies [124,129].

Physicians, social workers, nurses, therapists, and counselors must be familiar with legal, case management, educational, job and life skills training, and housing services in the community. Human trafficking victims are not only unfamiliar with navigating the social service system, but many are also not proficient in English. Therefore, practitioners will serve as coordinators and advocates, linking necessary services. In one study, the majority of agencies had to rely on collaboration in order to refer clients [101]. Social workers and practitioners relied on word-of-mouth and community meetings to learn about services in order to better meet the needs of human trafficking victims. Furthermore, because many community organizations and agencies are not familiar with human trafficking, practitioners must take a primary role in educating colleagues about the complex dynamics of human trafficking.

It is important to remember that the evidence supporting interventions and therapies for victims of human trafficking is in its infancy [142]. Most efficacy studies of therapies and interventions do not involve experimental designs, which makes it difficult to draw definitive conclusions regarding efficacy. Future work is needed to develop and evaluate interventions that address the multilayered and complex needs of human trafficking survivors.

For more information on how to identify and assist victims, watch the information video Labor Trafficking Awareness: Medical Clinic, produced by the Blue Campaign public awareness campaign, an initiative of the U.S. Department of Homeland Security, at https://www.dhs.gov/medialibrary/assets/video/21856.

Interprofessional collaboration is defined as a partnership or network of providers who work in a concerted and coordinated effort on a common goal for patients and their families to improve health, mental health, and social and/or family outcomes [186]. It involves the interaction of two or more disciplines or professions who work collaboratively with the patient on an identified issue [187]. Providers come together and view and discuss the same issue from different lenses, which can ultimately produce more out-of-the-box solutions [188]. The patient is not also an active member of the care team [186].

Human trafficking is a complex and multifaceted problem, and survivors require different services depending upon the type of trafficking they have experienced, how long they have been trafficked, and the severity of the trauma experienced. The level of collaboration also depends upon the community's and/or organization's infrastructure and the resources available [189]. Collaboration with a wide variety of professionals can be beneficial in addressing the array of needs of the trafficked victims and survivors' health, psychological, legal, and social circumstances [167,178,189,190].

One of the challenges to effective interprofessional collaboration is that professionals are typically socialized to their discipline's professional cultural norms and have not been exposed to other professional value systems. When they enter the workforce, they often continue to work in silos. Consequently, team members are not familiar with the professional goals, language, roles, and tasks of their colleagues from other disciplines [191]. Furthermore, continuity of care can be a significant challenge due to the various systems that are involved and the fact that marginalized and vulnerable populations are more at risk of inadequate care [192]. Consequently, information sharing, communication, and mutual respect are essential.

Physicians, social workers, nurses, allied health professionals, counselors, and psychologists will find themselves in multiple roles when working with victims of human trafficking. Advocacy is one of these roles and involves the practitioner being an agent for change. This consists of engaging in activities that alter the social conditions at the individual, family, community, and institutional levels [63]. One way to advocate on behalf of human trafficking victims is by signing petitions or joining credible organizations concerned with changing the circumstances that lead to human trafficking. Many organizations have petitions established on their websites for individuals to persuade policymakers, legislators, and government officials to advocate for the protection of human trafficking victims, create greater awareness of the problem, and prosecute traffickers, including:

International and political countertransference can occur when practitioners work with patients from other countries and cultural groups [67; 194]. This is manifested on several levels. First, practitioners may assume that what works in the United States can be applied to immigrants and refugees. This ethnocentric view presupposes that Western paradigms about healing and well-being are universal to all cultures. Second, the Western construct of the healthcare or social service provider as an expert may promote unequal power relationships [67]. Third, negative media portrayal of refugees and other "othered" groups can play a role internalizing political messages that these groups are violent or not safe. Such internalized messages could potentially be transferred to patients [194]. These attitudes can be quickly picked up by victims of human trafficking, which can negatively impact the rapport and trust building phases of the therapeutic relationship.

The most prevalent assumption is that because the victim has been abused and has undergone dehumanizing treatment, he or she will want to leave. Yet, trafficked victims have been known to miss their traffickers, have ambivalent feelings about leaving their situation, or feel that sex work is the only viable option for them [99]. This can be difficult for practitioners to accept. Furthermore, practitioners may experience countertransferential regression, the phenomenon of feeling one needs to parent and rescue victims [145].

Practitioners may be, consciously or unconsciously, affected by media depictions of particular cultural groups and the social problem of human trafficking [67]. Media portrayals can mold social norms and beliefs, which can then translate into ethnocentric, imperialist, or negative reactions and responses toward the victim. For example, human sex trafficking and sex work are often linked by the media, and the practitioner's beliefs about sex work can affect his or her relationship with the victim. A common instinctive reaction to sex work is to remove the individual from the situation, with force if necessary [67]. Similarly, the media often shows young female human trafficking victims being collected by police officers. This may cause practitioners to believe on some level that victims of human trafficking are criminals. Furthermore, if they respond to practitioners, by being withdrawn, resistant, or behaviorally disruptive, this could then reinforce the belief that they do not truly want help [195].

In many cases, the media perpetuates racialized and colonizing views of women of color who are victims of sex trafficking [34]. The colonizing depictions reinforce the myth that women from developing countries are helpless and powerless, deserving of our protection and worthy of being saved [34]. In other cases, victims may be vilified rather than viewed as wounded [196]. To what extent have these messages been internalized and how might these messages ultimately affect practitioners' attitudes and beliefs systems about human trafficking victims?

The terms "secondary traumatization," "secondary traumatic stress," "secondary victimization," "vicarious traumatization," and "compassion fatigue" refer to the psychological impact of being in close contact with those who are directly affected by trauma and helping or wanting to help the victim. Figley has defined secondary traumatic stress as, "the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other" [68]. Vicarious traumatization consists of a "transformation of the inner experience of the therapist that comes about as a result of empathic engagement with patients' trauma material" [69]. Vicarious traumatization can include emotional and cognitive arousal symptoms such as increased emotional sensitivity, lack of well-being, intrusive thoughts, and difficulty concentrating [70].

Shared trauma is another consideration. This refers to ''the affective, behavioral, cognitive, spiritual, and multi-modal responses that clinicians experience as a result of dual exposure to the same collective trauma as their patients/clients'' [146]. Shared trauma can have negative impact on practitioners, causing them to become increasingly detached and desensitized. In a 2022 study with 89 mental health professionals who work with human trafficking victims, practitioners' trauma histories served as a protective factor against burnout and secondary traumatic stress [197]. Along with self-care practices and advocacy work, shared trauma can help contribute to professionals' sense of satisfaction and resilience. Practitioners may also feel helpless and unable to assist patients/clients [147]. However, given their close proximity to victims, they also develop a continual sense of vigilance that their work is urgent and of great service. This can serve as protective factor as well [198].

Secondary trauma can affect practitioners' beliefs about the world, others, and self [71]. For example, humans have beliefs about safety, trust, sense of control, intimacy, and sense of esteem and competence [71]. But trauma, even indirect trauma, can disturb these beliefs. Trauma that is caused by another human (e.g., abuse) may be more difficult for practitioners to cope with because it is related to the issue of human evilness. Human trafficking certainly raises questions about how one human can inflict such terror upon another. Ultimately, this profoundly affects existing beliefs, more so than trauma caused by natural events (e.g., natural disasters) [71].

In a study of clinicians who work with sexual abuse survivors, clinicians were asked what parts of their work were enjoyable. They indicated that they enjoyed being part of the journey and process of patients' growing, healing, and changing. Witnessing patients' resilience and strength also spurs clinicians' own personal growth. However, one cannot ignore that when practitioners who work with victims of trauma, including human trafficking, they enter the world of victimization, horror, and abuse through their patients' detailed and graphic stories. As a result of building a rapport and relationship with their patients, practitioners share their emotional burden. This can affect clinicians socially, psychologically, spiritually, and/or interpersonally. Self-care is integral to the prevention of negative symptoms such as burnout, secondary traumatization, and compassion fatigue. Practitioners' education, training, and licenses do not necessarily provide effective shields to these types of stressors [73]. To some extent, practitioners might be more vulnerable to neglecting self-care because rigorous academic studies and early professional training may have overlooked this aspect of professional life [73]. Self-care practices alone are not effective in protecting professionals' well-being [197]. Increased frequency of self-care activities is predictive of lower levels of burnout but does not predict higher levels of vicarious resilience or decreased secondary trauma stress.

Self-care can consist of an array of activities that touch on the following domains: physical (e.g., exercise, nutrition, sleep), recreational (e.g., play activities, vacation time, hobbies), social support (e.g., interaction with friends, family members), and spiritual/religious (e.g., prayer, meditation) [70]. Self-care activities exist along a continuum, with proactive planning and reactive intervention on either end [70]. Practitioners should determine where along this continuum they will implement self-care activities. To be most effective, self-care should be viewed as proactive rather than reactive when a specific stressor occurs. Practitioners should spend some time asking themselves about the specific behaviors they are currently engaging [70]. For example, what type of exercise regimen is the practitioner currently engaged in? How frequently? How often does the practitioner interact with friends (with whom specifically) [70]? A self-care plan might also include cognitive and stress management techniques, such as biofeedback, hypnosis, and other cognitive strategies. A self-care plan could also actively incorporate rest into day-to-day practice. Committing time daily to a meditation or deep breathing practice can be beneficial [104].

Practitioners are often told to "leave their work at work," but this is often not as simple as it sounds. A ritual may be needed to make a concrete transition from work to home, such as walking in silence around the block for 5 minutes before getting into the car to drive home [104].

The monitoring of self-care is as important as establishing a plan. Self-care check-ins can be established, whereby practitioners are assigned to peers so they can hold each other accountable to their self-care plans [75]. Or if a practitioner is comfortable, a supervisor can incorporate this monitoring into his/her regular supervision.

When providing education and interventions to practitioners about self-care and secondary traumatization, a message of "blaming the victim (practitioner)" can inadvertently be conveyed [76]. Practitioners may feel that they are perceived as weak because they are encouraged to take care of themselves. Along the same lines, organizations should determine if their culture and climate may implicitly convey a message that hinders practitioners from engaging in self-care activities. For example, is taking vacation time implicitly associated with a lack of commitment or dedication? If practitioners do not work overtime, do they feel they will be perceived as less motivated than their colleagues who are working overtime [77]? Is there space in the work environment for practitioners to relax? Ensuring that there is a designated space for practitioners to take breaks after emotionally difficult meetings with patients and their families can encourage self-care behaviors [77].

Victims of tremendous trauma may experience PTSD and a range of negative consequences socially, emotionally, and relationally. However, post-traumatic growth can also occur. Post-traumatic growth refers to a set of positive changes that develop in response to trauma [105]. A related concept is vicarious resilience, which refers to the growth practitioners experience as a result of witnessing and participating in patients'/clients' journeys overcoming adversity [199]. Some will grow relationally, with enhanced relationships with others and a greater sense of compassion for others. Some will grow in terms of seeing themselves in a new way and developing a stronger sense of identity and a recognition of their own resiliency [148]. Others will acquire a new personal life philosophy of life and greater appreciation for life [105,148]. Practitioners witnessing post-traumatic growth may also experience a positive impact in their professional and personal lives. A personal trauma history can be both a risk factor and a protective factor in for vicarious resilience and possibly post-traumatic growth [197,199].

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