Challenges to Supporting Domestically Sex Trafficked Persons: In-Depth Interviews with Service Providers

ABSTRACT

Domestic sex trafficking is an emergent area of study with problematic gaps in our understanding of the challenges that inhibit client recovery. As social service providers are often on the frontlines of care provision, in this study, we explored the challenges they experienced when serving domestically sex trafficked adolescents and adults. Semi-structured interviews were conducted with 15 providers in Ontario, Canada’s largest province, and thematically analyzed. Our study found that providers faced systemic-, provider-, and client-related challenges, including insufficient funding, a dearth of (appropriate) shelter and/or housing, problems with healthcare and health professionals, entrenched biases within law enforcement, the weight of emotional work, fear for themselves and their clients, survivors’ misgivings about the systems established to assist them, and their unresolved concurrent mental health issues. By exploring intersections among various challenges facing service providers with the goal of improving services for domestically sex trafficked persons in Canada, we contribute to discourses informing research, policy, and practice considerations in various jurisdictions, working toward achieving UN Sustainable Development Goals 5 and 16 (specifically targets 5.2, 16.1, and 16.2).

KEYWORDS:

• barriers to care
• Canada
• domestic
• Ontario
• sex trafficking
• service providers
• social services

Introduction

Human trafficking, a crime and human rights violation, has serious health consequences (Recknor et al., 2022). In Canada, human trafficking is defined as “recruiting, transporting, receiving, holding, concealing, or harboring a person … for the purpose of exploiting them” (Public Safety Canada, 2019). Sex trafficking, more specifically, is defined as exploitation that is sexual in nature, and is considered “domestic” when exclusively occurring within a country’s borders (Public Safety Canada, 2019). The overwhelming majority of identified sex trafficked persons are women and girls, who may experience high rates of physical injury and concurrent physical health problems, mental illness, and/or drug use and may, as a result, frequently present at emergency departments and clinical treatment facilities (Conroy & Sutton, 2022; Lederer & Wetzel, 2014; Simkhada et al., 2018).

Due to the nature of domestic sex trafficking and the vulnerabilities trafficked persons may experience prior to, during, and after sexual exploitation, a variety of social services are generally required to comprehensively address their needs (Macy & Graham, 2012). Providers are in unique positions to assist these individuals, but such complex challenges can pose difficulties (Duncan & DeHart, 2019). However, little is known about social service providers’ perceptions of providing the requisite supports for domestic sex trafficked persons. While a growing number of American studies have made meaningful contributions to this nascent research landscape, profound gaps in Canada can have equally profound consequences (Hodgins et al., 2022).

Challenges to Meeting Client Needs

Sex trafficked persons can present with multiple and complex needs when seeking assistance, which can range from basic – food, water, shelter, and crisis services – to recondite, such as case management, longer-term and/or transitional housing, mental healthcare, substance use treatment, and legal and education/employment assistance (Duncan & DeHart, 2019; Koegler et al., 2021). Indeed, due to the extent of the psychological, physical, and/or sexual violence and subsequent trauma sex trafficked persons may have endured, their needs have been described as extensive, entrenched, and time intensive (Duncan & DeHart, 2019).

Research to date has suggested that different types of agencies and disciplines are necessary to respond to trafficked persons as this brings varied perspectives to care while increasing providers’ ability to leverage resources and provide the client-centered, trauma-informed, and culturally sensitive services recommended for all trafficked individuals (Busch-Armendariz et al., 2014; Okech et al., 2018; Richie-Zavaleta et al., 2021). Such services should be well-coordinated and holistic, providing wrap-around care that utilizes a strengths-based approach (Okech et al., 2018). Trafficked persons whose needs have not been adequately and comprehensively addressed are at high risk for re-trafficking, cycling in and out of treatment, and further exploitation (Gordon et al., 2018a; Hodge, 2014; Koegler et al., 2021).

Despite the clear imperative for comprehensive services, most sex trafficked persons experience numerous barriers to care and support, as has been identified in the United States. An individual’s sense of shame, fear of judgment and repercussions related to disclosure of sex trafficking, and/or generalized mistrust of, for example, law enforcement and human service providers, can inhibit them from seeking or benefitting from assistance (Duncan & DeHart, 2019; Haney et al., 2020). Further, a lack of shelter and/or available housing and the absence of needed services in one centralized location pose further challenges. For example, service providers in Missouri identified shelter as a critical need for 93% of their clients; however, only 27% were able to access these services (Koegler et al., 2021). In addition, some organizations refuse to admit substance-using individuals, thereby limiting access to accommodations as substance use may be common among persons trafficked for sex (Gerassi, 2018; Koegler et al., 2022).

Social service practices are commonly rooted in social justice values, champion the concerns of oppressed persons, and are guided by the broader contexts in which clients are situated. Social service providers are, therefore, uniquely qualified to aid sex trafficked clients with their recovery (Okech et al., 2018). However, an earlier study of service providers noted that they may not be receiving the specialized training required to address the complexities with which clients present (Jacobson et al., 2023). Additional challenges to the care of sextrafficked persons, as noted by sex trafficking scholars studying the American context, include a lack of funding and resources devoted specifically to this population and, where general human trafficking response programs do exist, services have tended to be fragmented and inaccessible (Gibbs et al., 2015; Koegler et al., 2021; Powell et al., 2018).

Canadian Context

A recent scoping review of sex trafficking studies in Canada yielded only 14 scholarly articles, seven of which involved Ontario (Hodgins et al., 2022). Of these Ontario studies, three were not exclusively focused on domestic sex trafficking (McDonald & Timoshkina, 2004, 2007; Pashang, 2019). Of the other four, two did not examine challenges to service provision (Baird et al., 2020; De Shalit et al., 2021). While the remaining two studies discussed barriers to care, they focused on a subset of sex trafficked persons and/or the data from service providers was not disaggregated from persons with lived experience (Nagy et al., 2020; Olson-Pitawanakwat & Baskin, 2021). Such scant information in the Ontario context could be particularly problematic given the province has been acknowledged as a hub for domestic sex trafficking (Vernile et al., 2015).

The Present Study

This study aims to fill the critical gaps in knowledge related to barriers in caring for and meeting the needs of domestically sex trafficked adolescents and adults in Ontario, Canada. Knowledge gleaned from this research could begin to inform improvements in policies and practices, ultimately enhancing the overall health and well-being of those most affected in Canada and worldwide. This study is part of a larger research project aimed at understanding social service providers’ knowledge, attitudes, and practices surrounding care provision for sex trafficked persons in Canada (Jacobson et al., 2023). Studies examining this specific geographical location may deepen our understanding of domestic sex trafficking in new contexts, expanding the relevance of existing work on this topic.

Method

Conceptual Framework

Critical social theory as described by Denzin (2017) framed the larger program of research. Inherently committed to social justice and anti-oppressive policies, this theory makes visible daily inequities and institutional practices that disadvantage certain people (Denzin, 2017). A qualitative research design, appropriate for exploratory studies of stakeholders’ perspectives, was employed (Rendle et al., 2019).

Recruitment

Recruitment began January 12, 2022 and ended February 17, 2022. Purposive sampling was used to recruit diverse providers working within social service settings in one of Ontario’s seven regions (southwest, southeast, northwest, northeast, central, central east, and central west). Emails describing the study were sent to organizations for distribution to staff working in these regions. Recruitment flyers were tweeted and posted within the Ontario Social Workers and Social Service Workers Facebook group. Sociodemographic questionnaires and consent forms delineating anonymous and confidential participation, the study purpose, potential risks and benefits, and the freedom to withdraw from the study at any time and without consequence, were sent to those indicating interest, signed, and returned.

Interview Guide

Our semi-structured interview guide was developed based on a review of the literature, items adapted from Cunningham and DeMarni Cromer’s (2016) Human Trafficking Myths Scale, and team expertise in sex trafficking, sexual violence, and conducting sensitive research with a critical orientation. Questions explored social service provider knowledge, attitudes, and practices with clients domestically trafficked for sex. For example, questions such as: “How do you think individuals come to be sex trafficked?” and “In your own words, what is (domestic) sex trafficking,” queried provider knowledge; “Why might people who are sex trafficked remain in sex trafficking,” queried attitudes; and “How would you identify someone who is sex trafficked,” queried support practices. Questions probing perceived challenges to providing support to domestically sex trafficked persons included, “What challenges stand in the way of you being able to provide the client with appropriate support?” and “Is there anything that would make it easier to provide clients with the support they express needing/you think they need?”

Data Collection

Interviews of one-to-two hours were conducted on Zoom between January 28, 2022 and February 17, 2022. Participants gave verbal consent to start audio and video recording and were reminded that they could stop the interview at any time without consequence. To protect privacy, pseudonyms were used throughout this research process and any associated publications. After each interview, notes with observations and initial thoughts were written. On completion of 15 interviews, no new information was revealed and interviews were discontinued (Guest et al., 2006). Following each interview, the generated transcript and audio file were saved to a secure online directory accessible only to team members and deleted from Zoom. Participants received a $25 CAD gift card as a gesture of appreciation.

Participant Characteristics

Of the 15 providers who consented to participate in the study, 12 worked in urban areas and three in suburban. Two identified as “Canadian,” seven as white or Caucasian, five as Black, and one as South Asian. Ages ranged from 26 to 55 years. Three identified as men and 12 as women. Participants included managers/supervisors (5), social workers (2), case workers (2), and one each of: child and youth care practitioner, child welfare worker, harm reduction counselor, addictions worker and support worker. One did not report. Thirteen had a Master’s or undergraduate degree. Seven had worked in social services for 0–5 years, three for 6–10 years, five for more than 10 years, and three of whom indicated 30 years or more. Participants reported providing services to various number of sex trafficked clients per year: more than 10 (2), between six and ten (2), between one and five (5), and none (3). Three did not know (see Jacobson et al., 2023).

Data Analysis

Several steps were taken to ensure dependability and trustworthiness of the analysis. Reflexive journals were kept to document insights, trace concepts of interest and their inter-relatedness, and contribute to an audit trail. The latter was also aided by taking notes at meetings to track discussions and decisions made (Nowell et al., 2017). Frequent team meetings and debriefings with the senior researchers experienced in gender-based and qualitative research allowed the opportunity to critically discuss ideas, observations and lessons learned, and to question how implicit biases could affect data interpretation (Bergen & Labonté, 2020; Nowell et al., 2017; Shenton, 2004).

Analysis occurred between February 2022 and May 2022. Transcripts were de-identified, checked for accuracy, and imported into Dedoose Management Software (Version 9.0.46., 2022). Data were analyzed utilizing Braun and Clarke’s (2006) six-phase approach.

In the first phase, two authors immersed themselves in the transcripts, looking for patterns and meanings as they familiarized and re-familiarized themselves with the data; one author repeatedly listened to audio recordings of the interviews. In the second phase, two authors independently coded the first transcript and engaged with other team members to generate initial codes and discuss similarities and differences between coders; there was minimal dissension on assignment of codes. Analytic memos were used to document coding-related decisions. Two additional transcripts were reviewed in this manner with no new codes identified and an initial code book was formed. The process of independent coding of data continued for five additional transcripts at which point the code book was finalized. In phase three, the remaining transcripts were coded by one author and the search for themes intensified. The team met regularly to discuss and consider emergent themes. In phase four, codes were distilled and themes were refined. Phase five involved naming the final themes and sub-themes (Nowell et al., 2017). Phase six involved the final analysis, selection, and extraction of illustrative quotes for the themes and article drafting (Jacobson et al., 2023; Nowell et al., 2017).

In this article, we focus on one prominent theme that emerged from the data analysis: “Challenges in Supporting Sex Trafficked Clients.” Other themes are reported elsewhere (Elliott et al., 2023; Jacobson et al., 2023 Recknor et al., 2023). Table 1 presents the most salient associated sub-themes and codes.

Table 1. Theme: Challenges in Supporting Sex Trafficked Clients.

Sub-themes	Codes
Insufficient Funding for Resources and Support Services	Lack of specialized care
	Unmet training needs
	Additional (specialized) staff needed
	Overworked staff
	Lack of needed time for clients
	Long waitlists
Dearth in (Appropriate) Shelter and/or Housing	Time and resources to acquire supports
	Unattainable admission requirements
	Problematic and short-term referrals
Problems at the Interface with Healthcare and Health Professionals	Institutional overload
	Insufficient knowledge
	Ineffective communication
	Judgmental attitudes
	Frictional collaborative relationships
Entrenched Biases within Law Enforcement	Reluctance to report
	Avoidance of interaction
	Failing marginalized communities
Weight of Emotional Work	Fear, frustration
	Shock, triggering/trauma
	Upset, worried
Client Misgivings	Fear of stigma
	Distrust of providers
	Mistrust of systems
	Generalized wariness
	Interpersonal disconnections
	Resistance to being labeled sex trafficked
Clients’ Unresolved Issues	Readiness to accept/facilitate care
	Co-occurring addiction and poor mental health
	Experiences of trauma

Results

“Challenges in Supporting Sex Trafficked Clients” is comprised of participants’ rich and nuanced perceptions regarding challenges of serving sex trafficked clients. Quotations are used to illustrate each sub-theme below.

Insufficient Funding for Resources and Support Services

Participants cited funding as one of the greatest challenges to providing appropriate, safe, and accessible resources and services to sex trafficked clients. Without sufficient funding, providers were limited in the support they could provide despite their desire to assist clients. Kit (unknown number of sex trafficked clients/year, 6–10 years of experience)  said, “So, that’s where the frustration comes. … What do you want me to do with them if you’re not going to give me money?” Faced with sex trafficked clients in extenuating circumstances, Phoenix (6–10 sex trafficked clients/year, 1–5 years of experience)  and Kit had both given their own money to clients (e.g., for food or therapy). Further, Stevie (1–5 sex trafficked clients/year, >10 years of experience) noted that the lack of funding dedicated to training and hiring additional social service providers specialized in working with sex trafficked clients resulted in overworked staff with excessively high caseloads, less time for clients, and ultimately reduced quality of care.

Insufficient funding limited the availability of specialized services needed by sex trafficked persons, which often left these individuals attempting admission to programs designed for populations with less complex needs and with eligibility requirements sex trafficked persons often could not meet (e.g., sobriety requirements. There was also a lack of accessibility to the full range of services needed to facilitate recovery. This was particularly true with regard to mental health and/or substance use services, within which a dearth of clinicians specially trained to work with sex trafficked persons was described. These deficits impacted providers’ ability to work with clients not yet stabilized. Alex (6–10 sex trafficked clients/year, >10 years of experience) reported that limited funding devoted to emergency, transitional, and/or safe and affordable long-term housing resulted in excessively long waitlists.

Dearth in (Appropriate) Shelter and/or Housing

Participants reported that connecting clients with safe and appropriate shelter was one of the most difficult facets of their job. This work required excessive amounts of time and, due to the lack of housing specifically designed for their clients’ needs, often resulted in inappropriate and/or failed placements, ultimately necessitating alternate arrangements.

Finding appropriate housing in emergencies was described as particularly challenging. Alex said, “That was always my fear. … I need to know what to do if at four o’clock on Friday, somebody … is saying, ‘I don’t want to go back.’” Although Alex’s agency could secure funding for a hotel room – sometimes for up to two weeks – this was only a temporary measure, as the provider would then need to find another placement for the client.

Participants also expressed concern about the lack of shelters and transitional housing specifically for sex trafficked persons. In the absence of these and/or in the case of an emergency, providers sometimes placed clients in domestic violence shelters. However, this option was limited, as many of these shelters did not accept sex trafficked persons and those that did had rules that were often incompatible with sex trafficked clients’ needs. Alex stated the following:

They’re expected to do things like contribute to chores and go to groups and talk and stuff. … [But] when a victim of human trafficking first leaves, they might need to sleep for a week and be on their own, right? … [It] just doesn’t work.

Several participants reported that securing shelter for substance using clients was similarly problematic. Providers stated that programs often had sobriety requirements. Given the pervasiveness of substance use amongst sex trafficked clients and the lengthy waitlists for treatment programs and/or detox facilities, finding housing in the interim was difficult. Alex described what often occurs:

The challenge … is … getting them to where they need to be in the short-term, … until that bed is available. … We had one girl, we felt like we were doing a patchwork quilt … put her here for a couple of days, and then this one opens up … but she can only be there for this long, and then … we have to move her. … That sort of shuffling happens. And so often you see someone who wants … help. They want to work on their addictions and start to heal and there’s nowhere for them to go or there’s a big waitlist, right?

Problems at the Interface with Healthcare and Health Professionals

Participants reported that their ability to assist clients in obtaining quality healthcare was hindered by existing strains on the healthcare system that resulted in long waits in emergency rooms, a lack of beds and institutional capacity, and overburdened healthcare professionals. Alex also attributed social service providers’ difficulties in supporting clients needing healthcare to an overall lack of healthcare professionals’ knowledge of and ability to identify and respond to sex trafficking. “[T]hey don’t know what to look for, they don’t know what to do with it if they see the signs, like who to call – that sort of thing,” Alex opined, noting that healthcare professionals often spoke to clients “on the go,” and did not seem to “have the capacity to sit with a person and have a conversation” or understand how trauma could impact a person’s ability to retain information.

Healthcare professionals’ judgmental attitudes were also identified as problematic and impacted clients’ decisions to disclose their status as sex trafficked during a medical visit. This was a particular concern for those using substances, with mental health issues, or perceived to be sex workers. Riley (unknown number of sex trafficked clients/year, 1–5 years of experience) reported clients saying, “‘they’re already treating me like I’m not human and they don’t know what I’ve been through.’” As a result of these and institutional challenges noted earlier, it was not uncommon for clients to refuse to go to the hospital or stay at a facility to receive care; participants then had to locate alternate facilities.

The relationship between healthcare workers and social service providers was also strained, according to participants, who noted the need for better collaboration. According to Avery (>10 sex trafficked clients/year, >10 years of experience), collaborations were challenging for two reasons: healthcare professionals’ lack of understanding of the role of social service providers and devaluation of “the input of anyone outside of the medical field.” Storm (1–5 sex trafficked clients/year, 6–10 years of experience) agreed, suggesting that incorporating the input of social service providers, such as shelter workers who are with clients 24/7, could inform a strong collaborative social/medical care plan. However, as providers were frequently unable to accompany clients to their healthcare visits, clients were often left uncertain about what they were supposed to do.

Entrenched Biases within Law Enforcement

Several participants described the involvement, or potential involvement, of police in client cases as a challenge to their ability to establish trust with clients and reported on the ways in which they navigated this barrier. Storm expressed awareness that many sex trafficked clients were from communities that had historically experienced – and to this day experience – discriminatory behaviors entrenched in the very institutions to which they must turn for assistance, including the police. As such, Storm recognized how damaging filing a report to the police could be to clients’ trust, yet under certain circumstances a report was required (e.g., the person is a harm to themselves or someone else). In the early stages of interactions with clients, Storm communicated this information and assured them that if a report was needed, they would be advised.

Kit was unsure about calling the police, commenting that police “only benefited white girls,” and their involvement could bring about more harm than good:

So, what will usually happen is if the police catch you engaging in sex work, or something like that, they’ll … pressure … you to give up the pimp. And, if you don’t … they’ll charge you because now you’ve pissed them off.

Morgan (>10 sex trafficked clients/year, 1–5 years of experience) actively took steps to avoid interacting with the police or filing a report and ensured clients were aware of this. Emphasizing this, in Morgan’s opinion, helped to build trust with clients: “And I always preface [discussions] with like, I have absolutely no need to report anything to the police ever, unless you want me to. [It helps them feel like you] are on their team.”

Weight of Emotional Work

Participants described some of the emotional challenges they experienced in their roles that increased the difficulty of their work. They commonly reported feeling “upset,” “worried,” or “traumatized,” and experiencing fear for their clients and selves. For example, several expressed frustration at the limitations they faced in their jobs, frequently related to the lack of funding or available resources with which to assist clients, while at the same time wanting and being asked to support them. Jaime (1–5 sex trafficked clients/year, 1–5 years of experience)  reported worrying about clients: “There were many nights where I would cry … thinking ‘Oh my God. Is tonight the night where she’s dead?’” Avery remarked, “[The work] can be triggering and traumatic. … You have to be able to be with people in really dark places.” Alex said, “I get emotional sometimes talking about this, because it really hurts my heart.” When a “pimp” was outside a client’s home during a home visit, Quinn (1–5 sex trafficked clients/year, >10 years of experience)  described feeling personal fear and fear for the client:

[My client] kept looking out the window. … [She said] “I’m scared he’s going to kill me.” … And I kind of just sat there. … I asked, “You want me to call the police?” … I remember leaving and not trying to look at the [pimp’s] car. … My car was … right in front of his. I’m like, “Oh my God, don’t shoot me.” And then I left. Nothing happened to her that I knew of. … I never saw her again.

Client Misgivings

Participants reported that trust was central to a sex trafficked client’s healing process, but their tendency not to trust impeded the provider’s ability to care. Storm commented on clients’ general mistrust of systems: “The medical system, social services, [the] police … are systems people maybe don’t trust, for really valid reasons. And so, accessing support can be really challenging and difficult and like, perhaps not safe for them.” Client mistrust was thought to be due to psychologically abusive treatment by traffickers, fear of stigma, and generalized mistrust of institutions and anyone associated with them. Alex commented on traffickers’ “investment in breaking clients down psychologically,” so that by the time they presented to providers, they were already distrustful. Jaime described the time intensity of attempting to foster that trust with one client: “She was scared. … During the first days she really didn’t want to talk. Others can go for two weeks or [longer]. You have to be patient and … take it easy on them.”

Participants also noted that clients often did not trust providers because they were afraid of the stigma that could come with the label of being “trafficked.” According to Robin (0 sex trafficked clients/year, 1–5 years of experience), “[They’re afraid] the information will leak … and it will spread that she is a prostitute.” Avery described it as having a “fear of judgment and … of being held accountable or blamed for what happened to them.” Consequently, clients did not always disclose their circumstances to the provider.

Differences in social identities and experiences between clients and providers further impacted working relationships, as reported by Riley and Stevie. According to Riley, “It doesn’t work out well … because clients … they’re like, ‘you don’t know me, you can’t relate.’” Stevie elaborated:

You have to be sensitive to … someone’s background … the level of trust they have in any kind of government institution, and [one] that has a male offering the supports. … There would be cases where they don’t want to hear it from [a male]. … But … a female present[ing] the information … [would help] the client accept the information.

Clients’ Unresolved Issues

Participants reported that clients were not only dealing with the challenges inherent to their experience of being trafficking but often faced concurrent issues such as trauma, mental health, and/or addiction, and frequently associated homelessness. Participants delineated some of these intersecting issues and, in some instances, attempts to serve clients that faced them. Avery, for example, described a client who was experiencing addiction and mental health issues and the difficulty in knowing how to assist her:

One thing that was difficult was her complex mental health. … There was a lot of delusion … alternative beliefs … hearing voices. So, sometimes it was kind of difficult to figure out what was actually happening. … She also used alcohol. … That made things difficult too.

Other participants described experiences serving clients with unresolved trauma and its complicating effects on care provision. Jordan (unknown number of sex trafficked clients/year, >10 years of experience) described a client who did not want to receive any funding for which she qualified. Rather, the client wanted to work and put the experience behind her “like a bad dream.” However, when this client began working in a restaurant “the manager yelled at her and then she was crying, or a customer made her feel uncomfortable.” Jordan worked with this client to help her refocus her attention from job searching to first taking care of herself. Avery noted that without added staff and specialized training, clients’ intersecting addiction, mental health, and/or trauma needs would not receive the adequate care required for a full recovery.

Further obstacles included clients’ own understanding of sex trafficking. Participants described clients who did not believe that “trafficking” described their situation – despite violence characterizing many of their circumstances– and depicted some of their clients as “not ready” to leave. Avery observed, “a lot of girls [see him as her boyfriend]. … She feels like she’s doing it by choice … not realizing that you really can’t consent under coercion or manipulation.” Kit described the need to navigate the provider–client relationship with particular care in this context; if the client became offended, they may “share with the guy, and the guy catches on to what you’re doing and moves them,” obstructing any further efforts to help.

Discussion

This study begins to address the paucity of research focused on examining barriers facing social service providers when delivering care and supports to domestically sex trafficked persons. Understanding challenges particular to providers, who are at the forefront of support and care provision, is critical to building practices that can more comprehensively address the extent and depth of sex trafficked persons’ needs. As such, the information learned from the diverse providers who participated in this study – representing a variety of ethno-racial backgrounds, ages, years and roles within social services, and geographically and culturally distinct regions of Ontario – has the potential to inform improvements in care and supports for this marginalized population in Canada and elsewhere.

Critical social theory obliges researchers to scrutinize existing structures to identify sites for change, challenge systems of oppression, and center the needs of those most oppressed (Denzin, 2017). Framing the current study through this lens compelled a critical examination of inadequacies in the systems of support available to domestically sex trafficked persons in Ontario and provided insight into the challenges facing social service providers working within these systems. As sex trafficked persons wield little power or means to ameliorate the systemic factors that shape their experiences, critical social theory dictates that it is incumbent upon those with relative privilege to examine deficits in support that perpetuate such imbalances. On the whole, study sub-themes reflected systemic-, provider-, and client-related challenges to care delivery for individuals trafficked for sex, many of which intersected to reflect broader structural inadequacies. Understanding these barriers can be a starting point for redressing inequitable systems.

One of the greatest challenges social service providers cited as inhibiting the provision of appropriate, safe, and accessible care for domestically sex trafficked clients – inadequate funding – is a systemic issue that appears to be consistent across contexts and regions and has been documented as a barrier for providers serving trafficked persons in Canada as early as 2005 (Duncan & DeHart, 2019; Gibbs et al., 2015; Koegler et al., 2021; Oxman-Martinez et al., 2005; Powell et al., 2018). Though funding specific to combating human trafficking is sometimes available, its allocation can also be problematic with criminal justice responses often being prioritized (Hodgins et al., 2022). Additional systemic challenges were a lack of available appropriate and safe shelter; inadequate access to specialized addiction, mental health, and trauma services; and negative interactions with law enforcement that laid bare the imbalance between those who design and those who interact with such structures (Duncan & DeHart, 2019; Gerassi, 2018; Gibbs et al., 2015; Koegler et al., 2021; Powell et al., 2018).

If support systems are not designed to meet the needs of individuals who are domestically trafficked for sex, these structures will continue to fail them. Without appropriate funding, for example, there are significant limitations to social service providers’ work and services remain fragmented, hampering the delivery of care (Powell et al., 2018). The practice of placing sex trafficked clients in any available shelter or housing program alongside other service populations in the absence of specialized housing options is not uncommon, yet perpetuates some of the numerous challenges that sex trafficked individuals face (Duncan & DeHart, 2019). Similar to Gerassi (2018), we found that clients simultaneously seeking shelter, substance use treatment, and/or a detox facility face enormous hurdles given sobriety requirements at most shelters, excessively long wait lists for treatment and/or detox, and the scarcity of qualified providers. At times, these individuals are forced to choose between detoxing alone in a hotel, detoxing on the streets, or remaining with the trafficker, who will likely keep them supplied with drugs.

An overburdened healthcare system was also described as largely ill-equipped to effectively respond to the needs of sex trafficked persons presenting for care. This, in combination with healthcare professionals’ judgmental attitudes and lack of knowledge, precluded sex trafficked persons from disclosing their own circumstances, an unsurprising finding given existing literature that has demonstrated the impact of provider biases on interactions with persons trafficked for sex (Lederer & Wetzel, 2014; Macias-Konstantopoulos et al., 2013; Rajaram & Tidball, 2018; Richie-Zavaleta et al., 2020). Such biases may arise out of a lack of formal education on the subject; human trafficking education generally is lacking among healthcare providers, which is connected to deficits in knowledge and tools needed to effectively work with trafficked persons (Coughlin et al., 2020; McAmis et al., 2022; Ross et al., 2015; Shin et al., 2022). Specific to Canada, Mason et al. (2018) found in a sample of social service providers working in child protective services and those in mental healthcare that targeted education and training may facilitate better understanding and valuing of one another’s roles and work.

Social service providers emphasized that the current system of policing reinforced the barriers that domestic sex trafficking persons otherwise faced; their need to navigate clients’ worry about law enforcement involvement in their case could interfere with care provision. Providers remarked that when clients were aware that they had an obligation to make a police report under certain circumstances, the client/provider trust that they knew to be essential to the healing process was undermined. Providers had unique methods of managing this with clients and, at times, such strategies were shaped by their own negative perceptions of police. While the perspectives on policing held by providers working with sex trafficked clients are under-researched, our findings echo one study examining client perspectives which noted that clients’ fear of providers calling police undermines trust and willingness to disclose (Richie-Zavaleta et al., 2020).

Provider-related challenges that emerged in this study appear to intersect with the structures under which they work. For example, limitations associated with scarce resources were a source of significant frustration, interfering with what providers wished to accomplish and impacting client care, a finding consistent with Gerassi et al. (2017) previous work. Further, fear for themselves and clients, and the emotional responses invoked by bearing witness to clients’ difficult circumstances suggests the potential for vicarious trauma, a phenomenon identified among service providers working with trafficked and otherwise traumatized populations (Gordon et al., 2018a; Ramirez et al., 2020). Vicarious trauma is both harmful to the providers and the clients with whom they work, as the quality of care may suffer as a result (Gordon, et al., 2018a; Ramirez et al., 2020).

Social service providers also reported challenges to service delivery associated with their domestically sex trafficked clients; these were at times driven by inadequacies in the systems designed to serve them. For instance, clients’ lack of trust in these systems and the providers working within them, often based on prior negative experiences, can impede disclosure. This, in turn, interferes with attempts to understand a client’s circumstances, address their needs, and build the healing client/provider relationship considered necessary for recovery (Busch-Armendariz et al., 2014). One particularly potent source of client distrust that emerged in this study – related to the fear of being stigmatized and treated poorly by providers – is consistent with results of other studies of trafficked persons (Rajaram & Tidball, 2018; Recknor et al., 2018). Trafficked persons can experience a “multiplicity of stigma” as they are often members of several stigmatized social groups about which providers may hold biases (Fukushima et al., 2020, p. 125). When stigma is embedded in practice, providers risk perpetuating the problems their services are intended to address, which may manifest as poor client/provider relations and negatively impact client outcomes (Fukushima et al., 2020; Recknor et al., 2018). Moreover, content within provider sex trafficking training can perpetuate negative stereotypes about sex trafficked persons, which can reinforce providers’ own biases (Jacobson et al., 2023).

Social service providers also identified that domestically sex trafficked clients contended with unresolved issues of addiction, mental health, and trauma, which is unsurprising in light of a lack of available specialized services. This finding supports existing scholarship indicating that these issues can decrease clients’ investment in recovery, while complicating treatment and providers’ ability to secure resources for their clients (Duncan & DeHart, 2019; Gordon et al., 2018a; Powell et al., 2018). Trauma, mental health, and addiction issues are well documented as sequelae often associated with sex trafficking, though knowledge on how to best treat them is still emerging (Gordon et al., 2018b). What is clear is that a lack of support for such services – financial or otherwise – has cumulative effects for sex trafficked clients who may have multiple intersecting vulnerabilities, which often requires a full cohort of services to address. However, the co-occurrence of such problems poses barriers to access as services most commonly treat each issue independently (Gordon et al., 2018b; Okech et al., 2018).

While the findings of this study may not be generalizable, they may be transferable and of use to policymakers and service providers working in similar contexts in Canada and beyond, seeking to understand and improve upon existing services for those who are domestically sex trafficked (Nowell et al., 2017). In addition, this study solely examined the perspectives of social service providers who may, through the course of their work, encounter clients trafficked for sex. Future studies could examine the perspectives of other providers, such as those working in healthcare, and/or center the voices of sex trafficked persons to more fully illuminate their recovery needs.

Informed decision-making relating to service improvement and funding allocation are difficult in light of sparse research on domestic sex trafficking. Our study was an initial step to advance the knowledge to inform change. Continual evidence generation is needed through activities such as community needs assessments, evaluations of existing services and systems of delivery, and assessments of client outcomes (Koegler et al., 2021). The proliferation of such future studies, which should be a topic of interest to funding agencies in both the health and social science fields, as well as others, holds the potential to drive positive change and promote the well-being of clients who have experienced sex trafficking while decreasing their likelihood of re-victimization (Koegler et al., 2021).

Despite the limitations inherent to the design of our study and need for a wider array of studies on domestic sex trafficking, our findings can further inform an underdeveloped but much-needed dialogue on addressing systemic-, provider-, and client-related factors that pose challenges to meeting sex trafficked individuals’ needs. Indeed, critical social theory compels researchers to examine the ways in which these issues interconnect to reflect broader norms and practices and drive change in response to any inequities or power imbalances perpetuated by existing systems (Denzin, 2017). Moreover, by contributing to global discourses that could inform research, policy, and practice considerations in the context of domestic sex trafficking of adolescents and adults, the current study aligns with United Nations Sustainable Development Goals 5 (“Achieve gender equality and empower all women and girls”) and 16 (“Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels”; United Nations General Assembly, n.d.). In particular, this research can shape the response to this largely gendered form of violence and exploitation, thereby contributing to targets 5.2 (“Eliminat[ing] all forms of violence against all women and girls in the public and private spheres, including trafficking and sexual and other types of exploitation”), 16.1 (“Significantly reduc[ing] all forms of violence and related death rates everywhere”), and 16.2 (“End[ing] abuse, exploitation, trafficking and all forms of violence against and torture of children”) in Ontario and other regions (United Nations General Assembly, n.d., pp. 18–25). To this end, several suggestions to remediate challenges to service provision in the domestic sex trafficking context follow.

First, it is critical to ensure that appropriate services are available for domestically sex trafficked persons, whose extensive and time intensive needs demand responsive approaches (Duncan & DeHart, 2019). The absence of appropriate services is cited by social service providers not only as a systemic issue but also a source of frustration that compounds clients’ ongoing challenges related to mental health, addiction, trauma, and trust. In particular, our findings suggest the need to explore shelter options with programming tailored for or conducive to sex trafficked persons’ needs, and invest in addiction and mental healthcare services and clinicians (Gerassi, 2018; Koegler et al., 2021; Oxman-Martinez et al., 2005; Powell et al., 2018). Given the centrality of these issues to client recovery and the lack of evidence-based interventions, it is essential that funding for these endeavors and research into “best practices” for serving sex trafficked clients continues (Gordon et al., 2018b, p. 83). Expert consensus thus far, within and outside of the social service sector, points to the utility of holistic, multidisciplinary, collaborative, and integrated models of wrap-around care and support that are preferably co-located (Edwards & Mika, 2017; Gordon et al., 2018b; Richie-Zavaleta et al., 2021). If these follow a strengths-based approach and are client-centered, culturally sensitive, and trauma-informed (taking into account a client’s history of trauma and adapting service delivery in a way so as not to retraumatize), clients’ ability to trust may follow (Edwards & Mika, 2017; Okech et al., 2018; Richie-Zavaleta et al., 2020). As these principles are implemented in practice, clients’ fears of being stigmatized may be reduced, positively impacting their perceptions of extant support systems and ultimately contributing to improved client outcomes.

Training for social service providers, too, can incorporate these approaches to ensure informed, consistent service delivery and professional support while minimizing opportunity to perpetuate systemic problems. Sex trafficking education that proactively addresses these issues has previously been documented in Canada as lacking, which is problematic in light of providers’ varying and sometimes erroneous knowledge of domestic sex trafficking (Jacobson et al., 2023). Providers may benefit from education on the barriers that sex trafficked clients might face – or anticipate facing – when accessing their and other social services, how this could manifest in poor client/provider relations, and creative strategies to recognize and address systemic and personal bias. In particular, training and curricula for all providers serving sex trafficked clients should encourage the examination of internalized biases and support self-reflection (Fukushima et al., 2020; Recknor et al., 2018). Providers’ challenges with healthcare professionals, as well as inconsistent approaches to managing contact with law enforcement and informing their clients of the circumstances that necessitated a police report, may warrant, at a minimum, strengthened guidance to navigate these interactions in a manner that preserves client/provider trust.

Agencies assisting sex trafficked clients might also consider proactively implementing strategies to mitigate the effects of vicarious trauma on staff. Activities could include training to enhance understanding of this phenomenon, monitoring provider wellbeing, and organizational support to encourage reflection on stressors inherent to working with trafficked clients (Ramirez et al., 2020). This work requires specialized knowledge and additional time to address clients’ multifaceted needs, which may warrant hiring, training, and specifically dedicating providers and/or teams to this population while assigning lighter caseloads and increasing time per client. By providing social service workers with the resources to adequately serve this client population, provider–client challenges could be mitigated (Koegler et al., 2021; Jacobson et al., 2023; Koegler et al., 2021).

Conclusion

Findings of our research begin to highlight the key systemic-, provider-, and client-related challenges impeding providers’ ability to facilitate their clients’ recovery and healing as well as the ways in which we may begin to respond to this pernicious human rights and health issue. Future research could build on this information, incorporating the perspectives of other key stakeholders and employing additional methodologies to develop a robust evidence base from which policy and institutional decisions can be made. The resulting improvements in service delivery that could eventually arise from this work can address some of the structural imbalances that inhibit provision of the appropriate care and support for sex trafficked persons both in Canada and globally. To this end, we contribute to the furtherment of United Nations Sustainable Development Goals 5 and 16.

Author Contributions

Conceptualization – JDM, FR, and RM; data curation – DJ; formal analysis – DJ, FM, and FR; funding acquisition – JDM and RM; interpretation – CEK, JDM, FR, RM; methodology – DJ, JDM, RB, and RM; project administration – JDM, FM, and RM; supervision – JDM and RM; writing (original and revised drafts) – CEK, JDM, FR; critical review of drafts – all authors.

Ethical Approval

The Women’s College Hospital Research Ethics Board approved the research project in December 2021 (REB# 2021–0133-E).

Informed Consent from Participants

Prior to participating in an interview, participants provided signed consent following their review of forms delineating anonymous and confidential participation, the study purpose, potential risks and benefits of participation, and the freedom to withdraw from the study at any time and without consequence. Prior to commencing interviews, participants gave verbal consent to start audio and video recording and were reminded that they could stop the interview at any time without consequence.

Acknowledgments

The research team wishes to thank the social service providers who participated in our study, without whom, the study would not have been possible. We also express gratitude for the funding support given to us by the HART Foundation.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Data Availability Statement

The transcripts cannot be shared due concerns of participant confidentiality; however, the data supporting the conclusions of this study are included in the manuscript.

Additional information

Funding

This research was funded by the HART Foundation. The views expressed in this article are solely those of the authors and do not necessarily reflect those of the funder.