Human trafficking is associated with acute psychiatric sequelae, and survivors may benefit from a variety of mental health and substance use services. However, due to a plethora of gaps in acute and chronic mental health care, their complex mental health needs frequently go unaddressed. Many survivors experience sporadic, fragmented care in varied settings, rendering them vulnerable to continued exploitation. HEAL Trafficking hosted Round Table Discussions with healthcare professionals, including some with lived experience. These discussions form the basis of this call to action, with recommendations for improved services to address acute and chronic mental health care for survivors of human trafficking.

This follows two previous blog posts by HEAL, Developing a Response to Human Trafficking Victims in Health Care Settings: A Protocol Toolkit, Peer-Reviewed & Survivor-Informed and Understanding Healthcare Utilization and Occupational Exposures of Labor-Trafficked People

Article

Jorge (fictitious vignette names) is a 27-year-old non-English speaking farmhand who presented to an emergency department for symptoms of altered mental status, dehydration, tachycardia, and acute renal failure. Ryan is a 20-year-old unhoused gay male who was brought to a crisis stabilization unit due to suicidal ideations, symptoms of mania with psychosis, and extreme emotional outbursts. Bella is a 21-year-old Black female diagnosed with Post-Traumatic Stress Disorder (PTSD), Schizoaffective Disorder, and a history of Substance-related Disorders, who was placed under conservatorship after cycling in and out of psychiatric facilities since adolescence; she eventually disappeared. Nodin is a 25-year-old Transmale with a diagnosis of PTSD, Bipolar I, Borderline Personality Disorder, and Amphetamine Use Disorder who has spent years in and out of psychiatric hospitals. What do these four individuals in the de-identified vignettes have in common? They are human trafficking survivors (hereafter referred to as ‘survivors’) whose exploitation was never identified, and who were not connected to adequate services in spite of repeated interactions with the health sector.

Human trafficking (HT) is an egregious human rights violation with well documented medical and psychiatric sequelae (1). Psychiatric consequences of labor and sex trafficking may be acute or long term, and exacerbated by pre-trafficking trauma exposure (2) and severe mental illness, such as psychotic disorders (3). Acute mental health symptoms may include non-suicidal selfharming behaviors, suicidal ideation and attempts, acute psychosis, manic episodes, and destabilizing symptoms of complex PTSD or substance use. These may lead to grossly disorganized behaviors and/or labile moods (1, 3, 4). Patients may require a variety of mental health services such as acute crisis management, inpatient hospitalization, medication 4 management, residential care, substance use treatment, and outpatient therapeutic interventions (5).

Mental health needs are typically unmet due to a dearth in accessible, available and/or appropriate services provided by professionals trained on HT survivor-centered and traumainformed approaches, and to these patients never being adequately identified as trafficked (4). Service delivery that does exist tends to involve a patchwork of uncoordinated and inadequate care (6). For example, residential facilities may lack policies, practices and sufficiently trained staff to assist survivors presenting with acute mental healthcare needs, including clients with serious comorbidities, such as substance use disorders (7). Consequently, survivors may cycle between emergency departments, sporadic healthcare access, and various treatment programs, thus remaining vulnerable to exploitation (8).

In light of these service gaps, the Mental Health Council of HEAL Trafficking (https://healtrafficking.org), a health-oriented network of professionals dedicated to ending HT and supporting survivors, invited network healthcare professionals, including survivors, to join a series of Round Table Discussions. Discussions were focused on better understanding the gaps. This commentary presents the results of our discussions. It is intended to catalyze further discussions and actions to better meet the needs of this underserved population.

Eight discussions took place via video conference, between August 2020 and April 2021. The workgroup discussed acute and chronic mental healthcare needs of adult survivors, service gaps, and promising practices. We focused on adults rather than children due to the differing care mechanisms available to minors.

Notes were taken during each meeting, out of which emerged themes and action items to increase client identification, access to resources, and improve survivor mental healthcare across the lifecourse. A subgroup conducted an informal review of the literature utilizing PubMed and key words such as ‘human trafficking’, ‘mental health services’, ‘health services’, “acute’, ‘emergency care’, ‘health services needs’ ‘demand’, and ‘gaps’.

Our informal literature review revealed limited articles specific to gaps in mental health care services for survivors, thereby reinforcing our discussion’s findings and call to action. Our identified gaps were organized into three distinct areas, each with unique findings and action items. The three areas are: Research, Capacity-Building, and Systems Change. These are discussed below, as are identified promising practices.

It is imperative to view the findings below in the context of additional social/structural vulnerabilities and discriminations often experienced by survivors (9). These include, but are not limited to, mental health disorders, identity-based discriminations, homelessness (4), substance use (7), and pregnancy and parenthood (10). Considering these social determinants is a critical factor in holistically addressing HT as a public health issue (9).

Need for Research:

Discussions highlighted the need for trauma-informed research on the healthcare response to survivors facing acute and chronic mental health needs, and related funding. The workgroup found that it is critical to identify risk factors and potential ‘red flags’ that may improve identification of adults at risk for, or experiencing HT. It is critical to identify the barriers survivors face when seeking services for acute mental health needs. We need to develop and evaluate tools for assessing survivor overall needs, especially for those with acute and chronic mental health needs.

We need to better understand the prevalence and presentation of mental illnesses in survivors. We must also develop and evaluate evidence-based, trauma-informed, and gender-sensitive treatment strategies across the continuum of culture-responsive care. Further, we need to gather outcome and impact data on these mental health interventions for this population.

Discussion findings indicated a lack of inclusivity in research regarding male and transgender survivors, and other underserved minority groups (11, 12, 13). Research on promising practices will help inform stakeholders on possible ways to close service gaps. Research collaboration among multidisciplinary professionals, community members (such as organizations serving transgender adults and other marginalized populations), and service users is critical.

Capacity Building:

Advocacy, case consultation, training and education, and resource development are vital in building the capacity of allied professionals to effectively work with survivors. Advocacy is needed to promote widespread adoption and safe usage of the new ICD-10/11 codes specific to 7 HT (14). This data can be used to: 1) better understand the mental health impact of HT, increase effective screening and identification, improve continuity of care, and support research initiatives on the effectiveness of treatment interventions; and 2) increase funding to support treatment outcome research and delivery of services to meet the acute mental health needs of survivors.

Building the workforce capacity entails enhancing effective engagement in outreach and mentoring services for professionals. The quality of services may be improved through individual case consultation, group peer review sessions (15), and development of a clinician network fostering the exchange of ideas and information. Coalitions and networks (5) of vetted professionals enable warm hand-offs for survivors, thus ensuring continuity of care.

Education and training on HT, trauma-informed and gender/culturally-sensitive care is essential for staff at emergency departments, crisis stabilization units, psychiatric hospitals and other mental health facilities. Community service providers require education regarding traumainformed care and the intersection of HT and acute mental illness. Those working at shelters and residential programs need training to recognize the symptoms of acute mental health issues, and be able to understand symptoms and trauma from the perspective of survivors. They urgently need the skills to employ proactive interventions that address subtle symptoms, before these escalate to high acuity.

As HT is on the extreme end of a trauma continuum, extant resources and tools created for populations with similar presenting issues (e.g. individuals with a history of sexual assault or interpersonal violence) do not always address the full breadth of care required for survivors. 8 Collaboration among trauma trained specialists with clinical expertise in HT will create an avenue for such resources to be developed. Once stabilized, survivors would benefit from receiving individualized resources when being discharged from hospitals, and connected to a HT support specialist. Systems Change: There is a need to develop survivor-informed evidence-based practices and systems of care that address survivors’ unique needs, acute mental health challenges, and transitions to longer-term mental health care. These may involve dedicated HT experts within healthcare systems, and trauma-informed, culturally and gender sensitive programs that address HT, other trauma, substance use, and severe mental illness.

Systems changes need to reduce barriers for survivors with acute mental illness to access in-patient hospital units and, when stabilized, enter, or return to, residential care. Established HT protocols can facilitate collaboration between community service providers, local psychiatric facilities and outpatient mental health providers. Promising Practices: A dearth of evidence-based practices exist for survivors. Promising practices and emerging resources were identified: Trauma-informed and culturally appropriate training resources (e.g., SOAR to Health & Wellness Training Program; Core Competencies for Human Trafficking Response in Healthcare and Behavioral Health Systems), and toolkits for the development of response protocols within healthcare facilities (e.g., HEAL Protocol Toolkit) were detailed. One screening tool for HT was identified and validated for healthcare setting (e.g., Rapid Appraisal 9 for Trafficking RAFT) (15). The use of emerging tools like HT psychoeducational films were also discussed.

Solutions focused on expanding education on human trafficking for healthcare professionals (16), alongside citywide healthcare consortium partnerships (17) to improve collaboration between health services and their law enforcement and NGO partners, have been effective in filling these gaps. In addition to education, trauma-informed specialists identify and respond to the complex biopsychosocial needs of trafficking survivors and collaborate with medical, surgical, social and legal services while prioritizing mental health first (5). Anti-trafficking social workers planted in hospitals act as linkage workers to community partners.

Conclusion

Findings from our discussions highlight the need for research, advocacy, capacity building of allied professionals and services, and survivor-informed strategic changes within systems of care. These will address major gaps in acute and chronic mental healthcare for survivors, reduce harm and improve health outcomes. Multi-disciplinary collaborative teams are essential in providing a holistic response to the needs of trafficked persons, and addressing vulnerabilities that may contribute to re-trafficking. Survivors such as Jorge, Ryan, Bella, Nodin, and others, urgently need access to reliable information and resources. They need evidence-based, survivorand trauma-informed and culturally/gender-responsive support services within acute mental healthcare and community settings.

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Authors: Katherine Hargitt, PsyD., Frances Recknor, Dr.P.H., M.S.W., Emily Taylor-Ginger, M.S.W., L.C.S.W., Nathan Earl, B.S., Elizabeth Schutz, M.A., L.P.C., Elizabeth K. Hopper, Ph.D., Jordan Greenbaum, M.D., and Mollie Gordon M.A., M.D.

Bios:

Dr. Katherine Hargitt, PsyD., is a Licensed Clinical Psychologist, specializing in traumatic stress, and working with the County of Sonoma Department of Health Services’ Crisis Stabilization Unit. She has been actively involved in the anti-human trafficking field for 22+ years, leading advocacy efforts and training for civil society, and providing consultancy for governments and NGOs. She has worked as a Consultant for the National Human Trafficking Training and Technical Assistance Center, as well as ECPAT International, a global network of civil society organizations dedicated to ending the sexual exploitation of children (SEC), and was their Lead Researcher in a multi-country field research project focusing on the care, recovery and (re)integration needs of SEC survivors in Nepal, Thailand, and the Philippines. In 2002, she conducted an independent field research project on the psychosocial rehabilitation of trafficking survivors in Cambodia, India, Nepal, Thailand and the Philippines. Dr. Hargitt has provided expertise to the UN Special Rapporteur on the sale of children, child prostitution and child pornography. She has served as a Board Member for HEAL Trafficking, a national network of health and public health professionals, as well as MISSSEY, an organization devoted to youth impacted by SEC. Dr. Hargitt has been the Co-chair of HEAL Trafficking’s Direct Services Committee and the Mental Health Council, and is the Lead for the workgroup on Addressing Gaps in Acute & Chronic Mental Health Care for Survivors of Human Trafficking: A Call to Action. She serves as a founding member of the Sonoma County Human Trafficking Task Force and is a Mental Health Advisor for Global Heath Promise, an NGO focused on serving mothers who are trafficked or in sex work and their children.

Dr. Frances Recknor, M.S.W., L.C.S.W., Dr.P.H., has been engaged in human trafficking research and scholarship since 2015. Originally from Texas, Dr. Recknor works remotely as a Clinical Assistant Professor with the Anti-Trafficking Program with Baylor College of Medicine in Houston, Texas, and in Toronto, Ontario, where she currently resides, is an Adjunct Lecturer at the Dalla Lana School of Public Health. Dr. Recknor has presented and published on the topic of health, public health, and human trafficking both in the States and Canada. Currently, she is writing a book chapter analyzing Canada’s fulfillment of its U. N. Trafficking Protocol obligations to address the health and mental health recovery of persons who are/have experienced trafficking.

Emily Taylor-Ginger, L.C.S.W., is a trauma therapist and founder of Collective Growth, a private practice specializing in treating individuals impacted by harm and violence within the commercial sex industry. With over a decade of dedicated work in the anti-trafficking field, she provides clinical consultation and training to mental health professionals who support this population. Emily’s experience includes individual, group, and family therapy with survivors aged 12 to 55 across the gender spectrum, as well as hospital-based assessments and resource-linking for trafficked patients. As the Impact Producer for Point of View Story, she consults on the creation of therapeutic short films and authors Film Therapy-based written materials for use in treatment with survivors of commercial sexual exploitation and sex trafficking. Her anti-trafficking work spans community education, coalitions, research, case management, advocacy, and program development. Emily is a collaborating author to the article Provider Challenges in Responding to Retrafficking of Juvenile Justice-Involved Domestic Minor Sex Trafficking Survivors, published in the peer-reviewed journal Child Abuse and Neglect. She is a member of anti-trafficking organizations such as the National Center for Missing and Exploited Children’s Family Advocacy Outreach Network, the Global Association of Human Trafficking Scholars, and serves on Safe House Project’s Certification Review Board.

Nathan Earl, B.S., is the Co-Director of Men’s Haven Health in New Haven, CT, and Principal Public Health Advisor at Giantslayer., LLC, where he advances research and public health strategies to address human trafficking and related violence through a syndemic lens. His work focuses on health equity for underserved male populations, including boys, men of color, and 2SLGBTQIA+ youth, offering critical insights to federal agencies, state programs, and NGOs. A champion of collective impact, Earl integrates evidence-based practices with innovative prevention strategies to dismantle systemic barriers impacting marginalized groups. Earl leads and consults on impactful initiatives, including the 2024 International Conference on Violence Against Men and Boys, where he co-developed a curriculum focused on syndemic-based public health interventions for violence prevention among vulnerable male communities. His collaborative work with organizations such as the National Center on Child Trafficking, National Center for Youth Law, Yale School of Public Health, Quinnipiac School of Law, U.S. Department of Health and Human Services, and HEAL Trafficking reflects his dedication to equity and inclusive approaches, helping these entities create safer, more responsive systems for male survivors. Earl’s recent publications and research, including studies on service access barriers and biases impacting trafficking survivors, as well as his focused work on risks and trajectories for the commercial sexual exploitation of males, contribute to critical policy and practice reforms. His findings help shape a more equitable landscape in anti-trafficking and public health, particularly for underserved male populations.

Elizabeth Schutz, M.A., L.P.C. Growing up in Los Angeles, Elizabeth was exposed to diverse populations and cultures but most impactful was her exposure to the homeless living on the streets of Skid Row. After an early career in elementary education Elizabeth moved to Texas, where she pursued her Master’s in Counseling at Dallas Theological Seminary. While in grad school she began working with survivors of sex trafficking at an area residential program. Seeing the barriers to and lack of appropriate clinical care, a fire was lit. After graduation she spent a year in private practice before having the opportunity to step into the role of Director of Clinical Services at Treasured Vessels Foundation. While there she developed a phase model of clinical treatment based off the work of Judith Herman. During their she also served on the Board of C7 a DFW coalition working to address the issue of human trafficking. In 2024 she launched her own private practice where is not only provides care to survivors but also to individuals who whether because of some limiting beliefs or complex trauma are not experiencing the life they were created to live. Elizabeth is building and equipping a team as her practice continues to grow. Elizabeth is an adjunct professor at King’s University where she teaches undergrad counseling students. Passionate about teaching and equipping, she supervises practicum students and enjoys speaking. She has been a speaker at TEA, Trauma Support Services and multiple anti-trafficking organizations.

Dr. Elizabeth Hopper, Ph.D., is a Licensed Clinical Psychologist with a focus on human trafficking and traumatic stress. She is Co-Director of the National Center on Child Trafficking (NCCT), a federally funded initiative focused on improving care for trafficked and commercially sexually exploited children and their families. She is also Clinical Director of Massachusetts Justice and Equity for Child Trauma, a program that provides evidence-based trauma interventions for marginalized children and families exposed to complex trauma. She has served as Co-Chair of the Mental Health Council for HEAL Trafficking, a national network of health and public health professionals. She led Project REACH, a national anti-trafficking direct services and training/ technical assistance program, and was Director of the New England Coalition Against Trafficking. She has consulted for NHTTAC, OVCTTAC, the Department of State’s Office to Monitor and Combat Trafficking in Persons, FBI, HSI, and numerous other multidisciplinary partners.

Dr. Jordan Greenbaum, M.D., is a physician specializing in the area of child protection. She is the senior vice president of survivor care at OUR Rescue, an international anti-trafficking NGO. She is a past medical director of the International Centre for Missing and Exploited Children, and of the Stephanie Blank Center for Safe and Healthy Children at Children’s Healthcare of Atlanta. Greenbaum is a board member of the International Society on the Prevention of Child Abuse and Neglect (ISPCAN). She has provided training and technical assistance to health and mental health professionals, as well as international school staff, social workers, law enforcement officers and prosecutors globally to improve the community response to child abuse, exploitation, and trafficking. She provides training and technical assistance regarding the trauma-informed, rights-based approach to interacting with children and families who have experienced trauma related to sexual, physical or community violence, and forced migration.

Dr. Mollie Gordon, M.A., M.D., is an Associate Professor in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Houston, Texas. She completed medical school and residency at Barnes Jewish Hospital at Washington University in St. Louis. She is clinical faculty, the Associate Director of the inpatient Psychiatric Unit at Ben Taub Hospital and supervises residents, medical students and a team of interdisciplinary providers. She cares for adults with acute exacerbations of chronic mental illness, many of whom are vulnerable and marginalized. Her research background is in pharmacokinetics of dopamine dependent disease pathways, and the trauma of individuals who suffer from these conditions. She has worked with survivors of the 9/11 terrorist attacks to reintegrate them back into the workplace. In 2016 she participated in the development of the first fellowship in the mental health impacts of human trafficking at an academic medical center where she is Medical Director of this program. She was a co-chair of the American Medical Women’s Association – Physicians against the Trafficking of Humans where she leads train the trainer workshops nationally. She is on the HEAL trafficking speaker’s bureau, has testified for the national advisory council for the office of trafficking in persons, and lectures at national meetings on human trafficking. Recently she founded BCM division of global mental health to treat survivors of torture, trafficking and mass violence atrocities. She has published numerous papers in the field, edited a book in the space, and won numerous awards for her work.

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MISC.

– Correspondence should be sent to Katherine Hargitt, Psy.D., (e-mail: drkhargitt@gmail.com)

– All of the authors were part of the HEAL Trafficking (Health, Education, Advocacy, Linkage) Trafficking Workgroup on Addressing Gaps in Acute & Chronic Mental Health Care for Survivors of Human Trafficking.

– The views expressed are those of the authors and not necessarily those of HEAL Trafficking

– The authors wish to thank: Kamrie Reed Ericson, L.I.C.S.W., Sommer M. Howser, D.S.W., L.M.S.W., Cassandra Ma, Psy.D., Krista MacNeil, M.S.W., R.S.W., Brett Murphy-Dawson, M.D., Rachel Niemiec, D.N.P., F.N.P.-C., and Mark Steenbarger, M.F.A. Film, for their participation in the Round Table Discussions and reading of an earlier draft of this manuscript. The authors thank Hanni Stoklosa, M.D., P.H. and Rachel Robitz, M.D. for reading a recent draft of this manuscript.

– Disclosures: Authors Frances Recknor, Dr.P.H., M.S.W., Emily Taylor-Ginger, M.S.W., L.C.S.W., Elizabeth Schutz, M.A., L.P.C., Elizabeth K. Hopper, Ph.D, and Jordan Greenbaum, M.D. report no competing interests. Katherine Hargitt, Psy.D. reports the following conflict of interest: Consultant for the National Human Trafficking Training and Technical Assistance Center (NHTTAC). Nathan Earl, B.S reports the following conflict of interest: HEAL Speakers Bureau. Mollie Gordon M.A., M.D. reports the following conflicts of interests: HEAL Speakers Bureau, AMWA PATH Trainer, and Expert Witness on mental health and human trafficking.