1 A Description of Services Provided by U.S. Rehabilitation Centers for Domestic Sex Trafficking Survivors BY NAOMI MAE TWIGG B.S.N, Millersville University, 2004 M.S., University of Illinois at Chicago, 2008 THESIS Submitted as partial fulfillment of the requirements for the degree of Doctor of Philosophy in Nursing Sciences in the Graduate College of the University of Illinois at Chicago, 2012 Chicago, Illinois Defense Committee: Dr. Barbara Dancy, Chair and Advisor Dr. Agatha Gallo Dr. Cheryl Schraeder Dr. Marsha Snyder Dr. Lola Prince, University of St. Francis
2 I dedicate this dissertation to my Lord and Savior, Jesus Christ. By surrendering daily to his plan, he has made the completion of this dissertation possible. A special dedication to my beloved, family and friends for their unfailing support, guidance, patience, and love. ii
3 ACKNOWLEDGEMENTS I would like to thank my dissertation committee, Dr. Barbara Dancy, Dr. Agatha Gallo, Dr. Cheryl Schraeder, Dr. Lola Prince, and Dr. Marsha Snyder, for their unwavering support and assistance. They provided guidance throughout all phases of my dissertation leading me to accomplish my research goals. I would like to thank the participants of this study for their valuable contributions. I am inspired by their work and devotion to restoring the lives of domestic minors of sex trafficking and eradicating the commercial sexual exploitation of children. NMT iii
4 TABLE OF CONTENTS CHAPTER PAGE I. SPECIFIC AIMS 1 II. LITERATURE REVIEW 5 A. Significance.. 5 B. Conceptual Framework.. 5 C. Innovation. 7 III. RESEARCH METHODOLOGY.. 8 A. Design 8 B. Setting and Sample. 8 C. Measures.. 10 D. Procedure. 11 E. Data Analysis IV. RESULTS.. 14 A. Demographics of Rehabilitation Centers. 14 B. Population Demographics at Rehabilitation Centers. 15 C. Description of Other Characteristics of Rehabilitation Centers 16 D. Description of Services at Rehabilitation Centers Immediate needs Ongoing needs Long-term needs 25 E. Frequency of Core Services at Rehabilitation Centers. 26 F. Common Practices Across Rehabilitation Centers. 28 V. DISCUSSION 29 A. Common Practices Across Rehabilitation Centers Organizational structure Staffing Daily operations Services to meet DMST survivors needs. 37 B. Framework 39 C. Limitations. 41 D. Implications Practice Research.. 43 E. Conclusion. 45 CITED LITERATURE 47 APPENDICES 52 APPENDIX A.. 52 APPENDIX B.. 53 APPENDIX C.. 54 APPENDIX D.. 58 APPENDIX E.. 60 iv
5 TABLE OF CONTENTS (continued) CHAPTER PAGE VITA v
6 LIST OF TABLES TABLE PAGE I. SUMMARY OF TARGETED SAMPLE... 9 II. DEMOGRAPHICS OF REHABILITATION CENTERS.. 14 III. POPULATION DEMOGRAPHICS AT REHABILITATION CENTERS 16 IV. OTHER CHARACTERISTICS OF THE FIVE REHABILITATION CENTERS.. 17 V. EIGHT CORE SERVICES TO ADDRESS DMST SURVIVORS NEEDS. 27 VI. COMMON CHARACTERISTICS ACROSS REHABILITATION CENTERS.. 28 vi
7 LIST OF ABBREVIATIONS AIDS CPS CSEC DMST ECPAT Acquired Immune Deficiency Syndrome Child Protective Services Commercial Sexual Exploitation of Children Domestic Minors of Sex Trafficking End Child Prostitution, Child Pornography and the Trafficking of Children for Sexual Purposes FBI GED HIV NGO PTSD SAMHSA STD TIP TVPA U.S. Federal Bureau of Investigation General Educational Development Human Immunodeficiency Virus Non-governmental Organization Posttraumatic Stress Disorder Substance Abuse and Mental Health Services Administration Sexually Transmitted Disease Trafficking in Persons Trafficking Victims Protection Act United States vii
8 SUMMARY Sex trafficking is often referred to as modern day slavery. In the Trafficking in Persons Report 2012, there are 20.9 million worldwide trafficking victims. There are estimated to be 244,000 U.S. children and youth at risk for domestic minor sex trafficking (DMST) and 100,000 to 300,000 DMST victims in the U.S. The detrimental effects of DMST include an array of psychological, behavioral and physical health conditions. An evident gap exists between the staggering number of youth trafficked in comparison to the limited number of U.S. rehabilitation centers for trafficking survivors. The purpose of this qualitative, descriptive research study was to provide a comprehensive description of services offered at rehabilitation centers for DMST survivors. An integrated model of Bronfenbrenner s ecological theory and Macy and Johns s framework for aftercare services to address sex trafficking survivors needs was used to guide this research study. Using a semi-structured interview guide, five telephone interviews were conducted with two founders, two directors of social services, and one program manager. This study provided a fuller understanding of the range of services offered across these rehabilitation centers and identified how these services were addressing the immediate, ongoing and long-term needs of DMST survivors. Ultimately, this study has advanced science by laying the foundation for future studies to develop best practice guidelines and an integrated care management model for DMST survivors. viii
9 I. SPECIFIC AIMS The long-term goal of my research is to develop a comprehensive service delivery model for rehabilitation centers offering services to domestic minors of sex trafficking (DMST). Due to the underground nature of sex trafficking, the incidence and prevalence of DMST in America is grossly skewed. Clawson, Layne, and Small (2006) estimated that 397,502 females (0.227% of the total population of females in the United States) are at risk for sex trafficking in the United States. Females between the ages of years old are at the greatest risk. Estes and Weiner (2001) found that the number of American children and youth at risk for DMST are estimated to be 244,000. The total population of females trafficked for sex in the United States was 29,876 (0.021% of the total population of females in the United States) with the highest percentage of females between the ages of 15 to 19 years old (Clawson, Layne, & Small, 2006). End Child Prostitution, Child Pornography, and the Trafficking of Children for Sexual Purposes (ECPAT, 1996) estimated that there are 100,000 to 300,000 DMST victims in the U.S. Trafficking Victims Protection Act (TVPA) of 2000 defined sex trafficking as a commercial sex act induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age. DMST is defined as the commercial sexual abuse of children (under the age of 18) through buying, selling, or trading their sexual services (Shared Hope International, 2007). Sex trafficking is often referred to as modern day slavery because of the involuntary servitude, peonage and other forms of forced labor that are associated with trafficking (Danailova-Trainor & Laczko, 2010; Trafficking Victims Protection Act [TVPA], 2000). The average age of entry into sex trafficking for females is years old (with some girls as young as nine) and the average age of entry for males is years old (Estes & Weiner, 2001; Omrod & Finkelhor, 2004). To date, eight states throughout the country have passed Safe Harbor laws to protect the rights of minors by clearing their records of prostitution convictions that may have accrued while they were trafficked and referred them to aftercare services (N. Marquez, personal 1
10 2 communication, April 30, 2012). The purpose of these new laws is to increase the identification of trafficking victims and to appropriately refer them to social services. Ultimately, this will result in more referrals to rehabilitation centers and an increase in prosecution of traffickers (Illinois Safe Children Act, 2011). Despite the extent of victimization and the change in laws, research on rehabilitation services for this population is limited. Research on sex trafficking has focused on the risk factors of DMST, the lived experience of DMST survivors and the complex needs of DMST survivors (Miller, Decker, Silverman, & Raj, 2007; Rafferty, 2008; Shigekane, 2007; Willis & Levy, 2002; Zimmerman et al., 2008). DMST survivors suffer from a combination of physical, behavioral and psychological conditions including, but not limited to, low self-esteem, posttraumatic stress disorder (PTSD), substance abuse, and/or sexually transmitted diseases (STDs) (Rafferty, 2008; Zimmerman et al., 2008). To the best of the researcher s knowledge, there are 14 rehabilitation centers providing services to DMST survivors in the U.S. This is an insufficient number of rehabilitation centers compared to the estimated number of minors at risk of being trafficked and those actually trafficked (Danailova-Trainor & Laczko, 2010; Smith, Vardaman, & Snow, 2009). Disturbingly, the lack of rehabilitation centers and services for DMST survivors has contributed to re-victimization and criminalization (Smith et al., 2009). Macy and Johns (2011) conducted a systematic literature review to identify services recommended for DMST survivors. Based on their review, they developed a framework for services to address sex trafficking survivors needs. Within their framework, they identified seven core services: basic necessities (e.g., food, water); secure, safe shelter and housing; physical health care; mental health care; legal and immigration advocacy; substance abuse services, and; job and life skills training (Macy & Johns, 2011). They categorized these core services into three domains including immediate, ongoing and long-term needs (Macy & Johns, 2011). See Appendix A for a model of Macy and Johns s (2011) framework for aftercare services to address sex trafficking survivors needs. Clawson and Goldblatt-Grace (2007)
11 3 identified similar services (basic needs, mental health counseling/treatment, medical screening/routine care, life skills, and job training) supportive of Macy and Johns s (2011) seven core services. However, little is known about the services offered and the frequencies of the services offered across rehabilitation centers. Guided by an integrated model of Bronfenbrenner s (1979) ecological theory and Macy and Johns s (2011) framework for continuum of aftercare services to address sex trafficking survivors needs, this study assessed the services provided across 14 U.S. rehabilitation centers. A comprehensive literature review was conducted on this topic using the following databases: CINAHL, PubMed, JSTOR, Embase, PsycInfo, Social Service Abstracts, Sociological Abstracts, and Criminal Justice Abstracts. After reviewing an array of published articles and governmental reports, this was the first study of its kind to provide a comprehensive description of the services offered across rehabilitation centers for DMST survivors in the U.S. This study was the first step in reaching my long-term goal of developing a comprehensive service delivery model for rehabilitation centers offering services to DMST survivors. The purpose of this qualitative, descriptive research study was to provide a comprehensive description of services offered at rehabilitation centers for DMST survivors. This study provided a fuller understanding of the range of services offered across these centers and identified if these services addressed the immediate, ongoing and long-term needs of DMST survivors (Smith et al., 2009). Data was collected through individual interviews with administrators at rehabilitation centers for DMST survivors. The specific aims were to: (1) Describe services offered at rehabilitation centers for DMST survivors to address survivors immediate, ongoing and long-term needs; (2) Provide the frequency of the seven core services across the rehabilitation centers; (3) Propose essentials and best practices for program directors and founders of rehabilitation centers for DMST survivors.
12 4 Increasing our knowledge of services provided at rehabilitation centers for DMST survivors will assist in defining core services critical for the protection and restoration of the health of sex trafficking survivors (Macy & Johns, 2011; Smith et al., 2009).
13 II. LITERATURE REVIEW A. Significance The psychological and behavioral outcomes of DMST survivors include lower selfesteem, loss of self-confidence, anxiety, panic attacks, depression, hopelessness, PTSD, substance abuse disorders, suicidal ideations, attachment disorders, mistrust of adults, antisocial behaviors, difficulty relating to others, developmental delays, language and cognitive difficulties, deficits in verbal and memory skills, poor academic performance, and grade retention (ECPAT, 2006; Rafferty, 2008; Raymond, Hughes, & Gomez, 2001; Shigekane, 2007; Twill, Green, & Traylor, 2010; Williamson, 2006; Zimmerman et al., 2008). The physical outcomes of DMST include complications from high-risk pregnancies and unsafe abortions, headaches, fatigue, dizziness, pain (e.g., back, stomach, pelvic), STDs, HIV/AIDS, and gynecological infections (Rafferty, 2008; Williamson, 2006; Zimmerman et al., 2008). Raphael and Shapiro (2002) found that girls trafficked before the age of 15 were found to have more health problems as adults than girls involved in the sex industry after the age of 15. Additionally, girls who were involved in the sex industry before the age of 18 were more likely to report having an STD and no HIV testing (Martin, Hearst, & Widome, 2010). These findings demonstrated a clear and present need for rehabilitative services for survivors exiting DMST situations (Family Violence Prevention Fund, 2005; Hotaling, Miller, & Trudeau, 2006; Kotrla, 2010). B. Conceptual Framework Collaborative and coordinated service delivery models are recommended to address the numerous, significant needs of DMST survivors (Caliber, 2007). Macy and Johns s (2011) framework for a continuum of aftercare services to address sex trafficking survivors changing needs incorporated seven core services within three domains: immediate, ongoing and longterm needs. This aftercare service delivery framework was selected because it was the first framework developed for rehabilitation centers offering services to sex trafficking survivors. 5
14 6 The seven core services included: basic necessities; secure, safe shelter and housing; physical health care; mental health care; legal and immigration advocacy; substance abuse services, and; job and life skills training. This framework was used to assess the level of services provided at U.S. rehabilitation centers for DMST survivors. Two of the seven core services (basic necessities; secure, safe shelter and housing) can be found within the domain of immediate needs (Macy & Johns, 2011). Once immediate needs are addressed and survivors become stabilized in a safe environment, establishing services to address their ongoing needs becomes a priority (Macy & Johns, 2011). Four of the seven core services (physical health care; mental health care; legal and immigration advocacy; substance abuse services) were found within the domain of ongoing needs (Macy & Johns, 2011). The last core services (job and life skills training) were found within the domain of long-term needs (Macy & Johns, 2011). A goal for all service providers is to move DMST survivors to a level of independence. Macy and Johns s (2011) framework was integrated with Bronfenbrenner s (1979) ecological theory. See Appendix B for an integrated model of Macy and Johns s (2011) framework for aftercare services to address sex trafficking survivors needs and Bronfenbrenner s (1979) ecological theory. Bronfenbrenner s (1979) theoretical framework was used in this study because it emphasized the relationship between individuals and their environment (Rafferty, 2008). Bronfenbrenner (1979) identified five environmental systems including mircosystem, mesosystem, exosystem, macrosystem, and chronosystem. The microsystem was represented by settings in which the individual lives including family, peers, church, or school (Bronfenbrenner, 1979). In this study, Macy and Johns s (2011) framework represented the microsystem including their peers and staff at the rehabilitation center. The mesosystem characterizes the relationship between the various agents in the microsystem (Bronfenbrenner, 1979). The exosystem refers to the broader community in which the DMST survivor lives. In this study, the exosystem included extended family, school, mass media, and neighborhoods (Bronfenbrenner, 1979). Macrosystem was the cultural context in which the
15 7 individual lived including social conditions, laws, history, culture, and economic systems (Bronfenbrenner, 1979). In this study, the macrosystem included recent changes to laws on DMST, an increase in social awareness of DMST and a decrease in funding related to the depressed economy. Chronosystem referred to patterns of environmental and transition across an individual s lifespan (Bronfenbrenner, 1979). These environmental systems were known to shape the development of individuals (Bronfenbrenner, 1979). More research on service delivery models for rehabilitation centers are needed (Clawson & Goldblatt-Grace, 2007; Fong & Cardoso, 2010; Shigekane, 2007). The contribution of this study increased the knowledge and understanding of services offered to DMST survivors at rehabilitation centers allowing us to determine if survivors were receiving appropriate rehabilitative services to reintegrate back into society. Another contribution of this study was the expansion of core services offered at rehabilitation centers, which led to adaptations of a comprehensive service delivery model for rehabilitation centers serving DMST survivors. C. Innovation This was the first study to integrate Bronfenbrenner s (1979) ecological theory and Macy and Johns s (2011) framework for aftercare services for sex trafficking survivors. Secondly, this research study was one of the first studies to provide a comprehensive description of services at rehabilitation centers for DMST survivors in the U.S.
16 III. RESEARCH METHODOLOGY A. Design A qualitative description, nonexperimental research approach, was used to fulfill the purpose of this research study. The main purpose of this study was to describe services offered at U.S. rehabilitation centers for DMST survivors. Qualitative description fulfilled the aims of this study since it is considered the method of choice when straight descriptions of a phenomenon are desired (Sandelowski, 2000). Qualitative description allows the researcher to obtain a fuller description capturing all the elements of an event by targeting information-rich participants. It allowed the identification of Macy and Johns s (2011) seven core services across rehabilitation centers and the development of a descriptive summary of services provided at rehabilitation centers for DMST survivors. Therefore, contributing to the development of a more comprehensive database of best practices for the delivery of aftercare services. B. Setting and Sample The setting for this study included the 50 states within the U.S. Purposeful, convenience sampling of founders, program directors and/or program managers of rehabilitation centers for DMST survivors was appropriate for this research study because of the importance of recruiting information-rich participants to provide detailed and insightful information about services offered at rehabilitation centers (Patton, 2002). These accounts assisted the researcher in obtaining a better understanding of this phenomenon. The inclusion criteria for rehabilitation centers included: a) provided services exclusively to DMST survivors; b) actively housed DMST survivors; and, c) provided services to males, females, and transgender DMST survivors aged 11 or older. The exclusion criteria for rehabilitation centers included: a) runaway shelter for minors (DMST survivors housed with other non-dmst survivors); and, b) social service agency who provided services to DMST survivors without on-site housing. The rationale for excluding runaway shelters for minors and social service agencies without on-site housing was because trafficking survivors require 8
17 9 housing with a higher level of security and require more time-consuming and lengthy support compared to refugee and domestic violence survivors (Shigekane, 2007). The inclusion criteria for interviewees included: a) held the job title of founder, program director and/or program manager of a rehabilitation center; b) 21 or older; and, c) spoke English. The exclusion criteria for interviewees included: a) did not hold the job title of founder, program director or program manager of a rehabilitation center; b) 20 or younger; and, c) did not speak English. All participants of this study met the inclusion criteria. A comprehensive, web-based search was conducted in August 2011 by the researcher resulting in the identification of 14 rehabilitation centers in the U.S. that appeared to meet the selection criterion for this study. Table I is a summary of the targeted sample in relation to how they met the inclusion and exclusion criteria for this study. TABLE I SUMMARY OF TARGETED SAMPLE Inclusion Exclusion n Agreed Refused No response* No center Adults only Other** Original Additions Total * Rehabilitation center met criteria, but no response to recruitment efforts. ** Rehabilitation center failed to respond to recruitment efforts; researcher unsure if these centers met the inclusion criteria. Of the 14 rehabilitation centers contacted, eight rehabilitation centers met the selection sample criterion, but only four agreed to participate, one declined to be interviewed, and three failed to respond. Of the remaining six rehabilitation centers contacted: four were found to have
18 10 no rehabilitation center related to a recent closure or delay in opening; one center only provided services to adults, and; one participant never responded. More information was later provided to the researcher from a participant, which led the researcher to contact an additional 10 rehabilitation centers. From this 10, two rehabilitation centers met the selection criterion; one participated in the study and the other one failed to respond. Of the remaining eight rehabilitation centers contacted: one offered only crisis housing and one housed DMST survivors with domestic violence survivors and runaway youth; five provided services to adults only, and; one failed to respond. Altogether 24 rehabilitation centers were contacted, 10 met the selection criterion; five participated in this study, four failed to respond, and one declined to be interviewed. C. Measures A semi-structured interview guide developed by the researcher was used to interview the founder, program director or program manager of a rehabilitation center for DMST survivors. See Appendix C for the interview guide. The interview guide was based on an integrated model of Bronfenbrenner s (1979) ecological theory and Macy and Johns s (2011) framework for a continuum of aftercare services to address sex trafficking survivors changing needs. The interview guide consisted of 39 questions. Two questions elicited information on demographics of the DMST survivors at the rehabilitation center and the origin of referrals to the rehabilitation center. Ten questions were related to the rehabilitation center, specifically its mission, vision, and philosophy; treatment model; board of directors; funding sources; geographic location; safety protocols; bed assignments; challenges and achievements, and; a question about neighborhood perception. Nine questions sought information about employees and staff development at the rehabilitation center including: quantity and type of employees; employee demographics; description and length of new employee orientation; description and frequency of ongoing staff development training; employee counseling services; employee turnover, and; employee satisfaction. Five questions addressed the immediate needs of DMST survivors, six
19 11 questions addressed the ongoing needs of DMST survivors, and three questions addressed the long-term needs of DMST survivors. Three questions elicited information on participants followup after exiting their rehabilitation center. The final question on the interview guide asked if the participant had any additional information he/she would like to share about their rehabilitation center for DMST survivors. D. Procedure First, an updated web-based search was conducted to ensure rehabilitation centers still met the inclusion criteria for this study. This revised search was completed in collaboration with the Polaris Project, a national organization on human trafficking, to confirm the existence of rehabilitation centers for DMST survivors. After receiving approval from the University of Illinois at Chicago Institutional Review Board, an employee from each rehabilitation center holding the job title as founder, program director or program manager was approached via to seek his/her interest for participating in this study. A cover letter along with a copy of the informed consent was included in the sent to potential participants. If the potential participant responded with interest of participating in the study, then a date, time and interview method were arranged via for the interview. For rehabilitation centers located outside the Midwest region of the U.S., web-based interviewing, Nefsis, was the first interview approach offered. This latter method required participants to have Internet access, a microphone and a webcam. If participants were located outside the Midwest and lacked technical capabilities for a web-based interview, then a telephone interview was offered. Web-based and telephone interviewing were selected as practical options related to the widespread, geographic locations of rehabilitation centers across the U.S. Telephone interviews were found to be as effective as face-to-face interviews in qualitative research (Hamilton & Bowers, 2006). For rehabilitation centers located in the Midwest, a face-to-face interview was the first interview approach offered followed by either a web-based or telephone interview. If two weeks passed after the original recruitment
20 12 was sent, then the researcher called potential participants to determine their interest in participating in this study. All of the participants preferred to be interviewed via the telephone because of its convenience and their previous unsuccessful attempts with web-based software. At the beginning of the interview, the researcher obtained undocumented informed consent from participants to participate in this study. During the interviews, the researcher requested documentation (e.g., annual report, training manuals, curricula) from participants, but only one participant provided requested documentation. Interviews were all digitally recorded; the shortest interview lasted one hour and nine minutes and the longest interview lasted one hour and fifty-two minutes. After the completion of the interview, a $50 online donation was made through PayPal to the rehabilitation center for the participants participation in the study. E. Data Analysis Creswell s (2009) criteria for qualitative data analysis were used. Creswell s (2009) six steps to qualitative data analysis included: 1) organizing and preparing data for analysis; 2) reading through all the data; 3) coding the data; 4) generating themes/categories for analysis; 5) providing representation of description/themes in the qualitative narrative; and, 6) interpreting the data. These six steps are considered both structured and flexible (Ulin, Robinson, & Tolley, 2005). The researcher was fully immersed in the data prior to the completion of data collection (Ulin et al., 2005). Glaser and Strauss s (1967) approach was selected as the preferred method to code data, which resulted in the development of a code list after data collection. The advantage of developing a code list after data collection included molding codes to fit the data collected, being more open-minded and being context-sensitive going into the analysis (Miles & Huberman, 1994). The original code list consisted of 28 codes. The code list was originally developed from the first interview, but later evolved as more data was collected and after receiving input from a committee member and a peer reviewer. The code list underwent six revisions with a final code list consisting of 27 codes. See Appendix D for a final version of the
21 13 code list. The transcripts from the interviews were uploaded to Atlas.ti, qualitative data analysis software, and coded accordingly. During data analysis, the researcher merged two codes together (challenges merged with barriers, success merged with outcomes, and retention strategies dissolved into two existing codes, staffing and program resources). Additionally, across-case analysis was conducted to identify the frequency of core services across the rehabilitation centers (Ayres, Kavanaugh, & Knafl, 2003). The researcher developed five matrices: a table of findings organized using the code list; a table of immediate, ongoing, and long-term needs organized by each rehabilitation center; a frequency table of Macy and Johns s seven core services organized by each rehabilitation center; a table of population demographics of those served at the rehabilitation center organized by each rehabilitation center, and; a table of demographics of the rehabilitation centers organized by each rehabilitation center. The researcher reviewed the matrices with two qualitative researchers. All data was stored as password-protected documents on an encrypted computer; data was also saved on an external hard drive as a back-up and stored in a fireproof, locked safe. All participants were assigned an identification number; these numbers were used to code all documents. Documentation retrieved from the rehabilitation centers was stored in a fireproof, locked safe. Data will be kept up to five years from the date it was collected, January and February Lincoln and Guba s (1985) evaluative criteria for trustworthiness was used to establish credibility, dependability, confirmability, and transferability. Multiple independent coders, analysis by independent investigators, and inclusion of information about the researcher s background and professional training were all used to increase the dependability of qualitative findings (Ulin et al., 2005). Furthermore, an audit trail was maintained to ensure confirmability and thick, rich descriptions were provided to convey transferability of findings (Ulin et al., 2005).