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Sex work and HIV/AIDS in Vietnam : addressing mental and emotional needs of trafficking victims Luu, Man Ky 2017

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  SEX WORK AND HIV/AIDS IN VIETNAM: ADDRESSING MENTAL AND  EMOTIONAL NEEDS OF TRAFFICKING VICTIMS   by   Man Ky Luu    B. A., University of Calgary, 2014      A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE DEGREE OF    MASTER OF ARTS    in   THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES   (Asia Pacific Policy Studies)      THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver)   April 2017   © Man Ky Luu, 2017     ii Abstract Poor mental health is a critical factor that can significantly impede reintegration success for many trafficked returnees. Sex trafficking is a highly traumatizing experience, and many victims of the sex trade describe feeling physically, psychologically and emotion-ally unwell at some stage of their post trafficking lives. These issues often develop dur-ing the period of exploitation, and intensify as they struggle to recover and reintegrate back into the society, mainly due to the stigma attached to their record as sex workers. In addition, their mental health worsens if they carry a sexually-transmitted disease, es-pecially HIV/AIDS, which further heightens their distress and prevents successful rein-tegration efforts. Nonetheless, ensuring psychological support and counselling is not the norm in Vietnam due to the lack of trained professionals, and also cultural prejudice to-wards people with mental illnesses. Thus, in the absence of formal mechanisms of as-sistance and counselling, alternative instruments to help victims cope with psychological stress, anxiety, depression, and even suicidal ideation should be promoted and sup-ported. This study seeks to explore religion and spirituality as an alternative instrument to address psychological and emotional needs of HIV-positive victims of sex trafficking in Vietnam.        iii Preface  This thesis is an original work by Kylie (Man Ky) Luu. No part of this thesis has been previously published.                  iv Table of Contents  Abstract .......................................................................................................................... ii Preface .......................................................................................................................... iii Table of Contents ......................................................................................................... iv Acknowledgments......................................................................................................... v Dedication ..................................................................................................................... vi Chapter I: Introduction .................................................................................................. 1 1.1 Background Information ......................................................................................... 1 1.2 Trafficking in Persons: Definitions .......................................................................... 2 1.3 Trafficking in Persons: Scope of the Problem ........................................................ 5 Chapter II: The Double Stigma, Discrimination, and Poor Mental Health ................. 9 2.1 Double Stigma and Discrimination ......................................................................... 9 2.2 How Does the “Double Stigma” and Discrimination Contribute to Poor Mental Health ......................................................................................................................... 13 2.3 Why is Mental and Emotional Health Important to Reintegration ......................... 15 Chapter III: Informal and Alternative Tools: Religion ............................................... 20 3.1 Buddhism as a Source of Spiritual Support .......................................................... 20 3.2 Buddhism as a Source of Social Support ............................................................. 27 3.3 Buddhism as a Tool to Fight Stigma and Discrimination ...................................... 29 Chapter IV: Discussion and Recommendations ....................................................... 32 4.1 To Buddhist Temples and Local Organizations .................................................... 33 3.2 To the Government of Vietnam ............................................................................ 39 3.3 Conclusion ........................................................................................................... 43 Bibliography ................................................................................................................ 45     v Acknowledgements   Above all, I would like to express my gratitude to my supervisor and mentor, Dr. Kai Ostwald, for his expertise, patience, and faith in my abilities since the day I arrived at the University of British Columbia. Thank you for always making time to listen to all of my questions and concerns, for guiding me through difficult times, and for reminding me - constantly - that I was just as bright and capable as others. Besides my advisor, I would also like to thank Dr. Tsering Shakya for his knowledge, calmness, and guidance throughout my writing process. I have deep respect for both of you.     I would like to thank the entire Regional Management Office of the United Na-tions Cooperation for Action against Trafficking in Persons (UN-ACT) for allowing me to be a part of their team. My five-month internship with UN-ACT was an eye-opening and inspiring experience. I am grateful for their assistance with my academic and career de-velopment journey.     Special thanks to Suhan Shim and Greg Legault, my fellow MAAPPS classmates who also double as my very good friends outside of class. Thank you for always being there for me any time I need your support and sound advice, and thank you for always believing in me, even when I did not believe in myself.     I would also like to thank my two greatest best friends in the entire world, Munguntulga Mandakhbayar and Paul Ingle. Through opposite time zones, distance, and changing seasons, I would not have made it this far without your support and un-wavering faith in me.     Most importantly, I would like to thank my family: my parents, my grandmother, uncle and auntie Wong, my big brother Hans, and my little sister Gia, for their uncondi-tional love and support. Thank you for inspiring me everyday, for not letting me give up on my dreams, and for supporting me and all of my crazy ideas and adventures. Thank you for everything. I love you all endlessly.   Lastly, to Jon Brasnett, my rock, my love, the most magical person to ever exist: I am forever grateful for the endless amount of love, kindness, and inspiration you have given me since the day we met. I am truly the luckiest girl in the world.           vi        This thesis is dedicated to my Ba and Mẹ, who have sacrificed so much to give me a life full of hopes and opportunities. To honour them, I also dedicate this thesis to millions of girls and women around the world; whose dreams are denied, and whose rights, free-dom, and bodily integrity continue to be violated.                    1 CHAPTER I: INTRODUCTION  1.1 Background information  According to the 2016 Trafficking in Persons Report, the Socialist Republic of Vi-etnam is primarily a source country that provides the human supplies for the cross-border as well as domestic sex trade. It is also, to a lesser extent, a destination for sex trafficking and forced labour.1 Sex trafficking is an attractive business for traffickers and organized crime networks because the profits are substantially high yet the risks are low. However, the business rarely profits the girls and women whose bodies are sold, used, and frequently abused. Sex trafficking is a traumatizing experience that does not only inflict long-lasting physical injuries on the victims, but also serious psychological scars. The majority of sex trafficking victims show symptoms of anxiety and major de-pressive disorders, which often develop during the period of exploitation and intensify as they struggle to recover and reintegrate back into the society, mainly due to the stigma attached to their record as sex workers. In addition, the stigma worsens if they carry a sexually transmitted disease, especially HIV/AIDS. Sexually transmitted diseases and sex trafficking are closely interlinked due to the victims’ frequent exposure to sexual abuse and other high-risk activities such as unprotected sexual encounters, multiple sexual partners, and intravenous drug use.   The shame factor of having worked in the sex industry, accompanied by an HIV-positive status can lead to feelings of anxiety, hopelessness, depression, and even sui-cidal ideation. As a result, poor mental health is very common amongst trafficking vic-                                                 1 U. S. Department of State, 2016 Trafficking in Persons Report, p. 398 (Washington, D.C.: U.S. Depart-ment of State, 2016), accessed April 12, 2017, https://www.state.gov/documents/organization/258876.pdf.  2 tims living with HIV/AIDS, which can seriously impede successful reintegration. None-theless, psychological support and counselling is currently not the norm in Vietnam due to the lack of resources and trained professionals, and also cultural prejudice towards people with mental illnesses. Thus, in the absence of formal mechanisms of assistance and counselling, alternative and traditional instruments, such as religion and spirituality, may be promoted to help strengthen the spirit and psychological resiliency of the vic-tims. Strong mental and emotional support will allow the victims to be able to reintegrate back into their home community, and empower them to live a healthy and productive lifestyle. In this paper, I suggest that Buddhist temples and related associations, and Buddhist monks, nuns, and laypersons may be given more incentives and responsibili-ties to help improve victims’ mental health. When people are mentally and emotionally healthy, they are better able to enjoy their lives and the people who are involved in their lives. For female victims of sex trafficking, especially those who live with a chronic ill-ness, such as HIV/AIDS, mental and emotional well-being allows them to take care of their own physical health, their loved ones, and also the communities that they live in.  1.2 Trafficking in Persons: Definitions  On November 15, 2000, the United Nations General Assembly adopted the Con-vention Against Transnational Organized Crime, the Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children (also known as the UN Trafficking Protocol) with the aim of promoting transnational cooperation in tackling or-ganized human trafficking networks. According to Article 3 of the UN Trafficking Proto-col, “trafficking in persons” is used to describe:   3 (a) “The recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs;  (b) The consent of a victim of trafficking in persons to the intended exploitation set forth in subparagraph (a) of this article shall be irrelevant where any of the means set forth in subparagraph (a) have been used.”2  According to this definition, trafficking is considered coerced if any of the means listed are employed and any consent used as a defence becomes irrelevant. While the Trafficking Protocol has established some agreement at the international level, the defi-nition of trafficking presented in the Protocol fails to mention the diversity of trafficking incidents experienced by the victims. More specifically, the definition presented in the Protocol focuses on the movement of people through threats, coercion, force, and de-ception. However, it ignores the growing trend of labour migration for the purposes of sex work. In short, while some women may be kidnapped, threatened, forced, and/or sold into the sex industry, other women choose to migrate and engage in sex work will-                                                 2 United Nations, Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially in Women and Children, Supplementing the United Nations Convention against Transnational Organized Crime (New York: United Nations General Assembly, 2000), accessed April 17, 2017, http://www.osce.org/odihr/19223?download=true.   4 ingly to be able to send remittances home.3 In many instances, sex trafficking in Vi-etnam conforms to the latter scenario, and the increase in the number of migrant girls and women has been found to correspond with the increase in exploitation of female Vietnamese migrant workers at their destination. Female labour migrants may choose to migrate within Vietnam or to another country. Job opportunities for young female mi-grants have increased in both urban formal and informal sector. While the formal sector includes textile, footwear, and garment factory jobs, the informal sector includes domes-tic housekeepers, street traders, restaurant employees, and karaoke bar workers.4 Jobs in the informal sector are often unregulated, and thus invisible, as workers tend to be excluded from national labour laws and regulations, high-level discussions, and social and legal protection. As a result of their invisibility, women in these sectors often find themselves in exploitative situation that amounts to trafficking.5 Female victims, under these circumstances, are also more likely to accept their conditions, and even blame themselves for their shortcomings. As explained later in this paper, self-blame also con-tributes to the deterioration of victims’ mental and emotional wellbeing.  The term “trafficking victim” refers to those who qualify as victims of trafficking in persons in accordance to Article 3 of the UN Protocol, or a country’s national trafficking legislation. However, the term “victim” has generated much debate in that it tends to im-ply powerlessness, rather than strength and resiliency. However, in a human rights framework, “victim” highlights the abuse and injustice forced on these individuals by                                                  3 Ramona Vijeyarasa, “The State, the Family and Language of ‘Social Evils’: Re-stigmatising Victims of Trafficking in Vietnam,” Culture, Health & Sexuality 12, no. 1 (2010), p. 91. 4 Le Thi Kim Anh, Lan Hoang Vu, Bassirou Bonfoh and Esther Schelling, “An Analysis of Interprovincial Migration in Vietnam from 1989 to 2009,” in Global Health Action 5 (2012), p. 7. 5 Thi Tue Phuong Hoang, “Protection for Trafficked Persons in Viet Nam: Another National Security Dis-course?” International Migration 53, no. 4 (2015), p. 26.  5 their perpetrators. Similarly, in the context of mental and emotional health aimed at the empowerment of individuals for successful reintegration, the term “victim” implies the victims’ right to mental health services and protection, as well as the responsibilities of the government and civil society to carry our these services. Thus, the term “victim” in this study describes someone who has been a victim of a crime and does not refer to any other characteristics.  1.3 Trafficking in Persons: Scope of the Problem  Vietnam has been ranked on Tier 2 of the Trafficking in Persons (TIP) Report. The TIP Report is an annual report issues by the United States Department of State to monitor and combat human trafficking around the world. This report ranks governments based on their observed efforts to recognize, acknowledge, and tackle human traffick-ing. The report thus divides countries into “tiers” based on their compliance with the minimum standards outlined in the Trafficking Victims Protection Act (TVPA), which sig-nify the following points:  (1) “The government of the country should prohibit severe forms of trafficking in persons and punish acts of such trafficking.  (2) For the knowing commission of any act of sex trafficking involving force, fraud, coercion, or in which the victim of sex trafficking is a child incapable of giving meaningful consent, or of trafficking which includes rape or kidnapping or which causes a death, the government of the country should prescribe punishment commensurate with that for grave crimes, such as forcible sexual assault.  6 (3) For the knowing commission of any act of a severe form of trafficking in per-sons, the government of the country should prescribe punishment that is suf-ficiently stringent to deter and that adequately reflects the heinous nature of the offence. (4) The government of the country should make serious and sustained efforts to eliminate severe forms of trafficking in persons.”6  Thus, according to these points, Tier 1 countries of the TIP Report are countries whose governments fully comply with the listed minimum standards while Tier 3, the lowest tier in the report, consists of countries whose governments do not fully comply with the minimum standards and are not making the efforts to do so.7   The “middle” tiers are “Tier 2” and “Tier 2 Watch List.” Both tiers consist of coun-tries whose national governments do not fully comply with the TVPA’s minimum stand-ards, but they are making significant efforts to bring themselves into compliance with those standards. However, countries on the Tier 2 Watch List are facing a surge in the number of trafficking victims but at the same time, their governments are failing to “pro-vide evidence of increasing efforts” to combat human trafficking. As a Tier 2 country, it means that even though the Vietnamese government is making significant efforts to not let the number of trafficked persons increase, Vietnam can easily fall into the Tier 2 Watch List or even Tier 3 if the government fails to protect the victims and increase its anti-trafficking efforts.                                                   6 U. S. Department of State, 2016 Trafficking in Persons Report, p. 46 (Washington, D.C.: U.S. Depart-ment of State, 2016), accessed April 12, 2017, https://www.state.gov/documents/organization/258876.pdf. 7 Ibid., p. 39.  7  Due to inconsistent methods of data collection and the clandestine nature of sex trafficking, it is nearly impossible to obtain exact data on sex trafficking in Vietnam. However, according to a study conducted by the Child Exploitation and Online Protec-tion Centre in 2011, between 2005 and 2009, approximately 6,000 women and children were identified as being trafficked from Vietnam. The majority of these women and chil-dren were trafficked to China for the purpose of forced marriage, or to be sexually ex-ploited in brothels. Other victims were trafficked to Cambodia, Thailand, Malaysia, and onwards to the rest of the world.8  Nonetheless, these figures do not accurately reflect the actual scale of the problem. First of all, sex trafficking is considered a sensitive issue in Vietnam and official gov-ernment data regarding sex trafficking, sexual exploitation and sex work are undis-closed. Most available and accessible figures are provided by non-governmental organ-izations, which tend to fluctuate due to different collecting methods. Second, most vic-tims of sex trafficking tend to abstain from reporting their experiences due to fear of re-taliation by their traffickers, sex work-related stigma within society, and the lack of trust in service providers and law enforcement. There is a lack of understanding and ade-quate research on the issue of sex trafficking, which is often associated with voluntary sex work and prostitution. In countries where sex work has not been legalized, reporting their experiences or being caught as sex workers can lead to fines, imprisonment, and even deportation. Vietnam’s anti-trafficking law continues to associate trafficking with the “social vices,” including prostitution, drug use, and HIV/AIDS. The public’s deep-                                                 8 Child Exploitation and Online Protection Centre, The Trafficking of Women and Children from Vietnam (United Kingdom: Child Exploitation and Online Protection Centre), p. 4, accessed May 3, 2015, https://ceop.police.uk/Documents/ceopdocs/NPM_CEOP_FCO_report_-_trafficking_of_Vietnamese_women_and_children.pdf.  8 rooted perception of trafficking as a social vice (or social evil) raises concerns about the fate of victims trafficked for the purposes of prostitution and sexual exploitation, who are often classified and targeted as sex workers by police and law enforcement officers.9   The government’s efforts to combat the social evils, especially sex work, are more punitive than protective, thus promoting dangerous misconceptions and criminaliz-ing victims of sex trafficking instead of protecting them. According to Thanh Nien News, a prominent newspaper in Vietnam, the Government abolished compulsory rehabilita-tion of sex workers in 2013, but imposing fines on them instead. Sex workers may be fined VND300,000 (approximately $15) for their first offence, and up to VND5 million for repeated offences.10 This approach continues to isolate victims, forcing them to retreat further into the hidden population out of fear of being caught, criminalized, and stigma-tized by the law as well as the society. As a result, victims of sex trafficking and sexual exploitation often choose to stay silent or remain in the sex industry to avoid post-trafficking threats associated with their legal, social and gender marginalization. Those who end up leaving the industry risk facing stigma, discrimination, abuse, and social iso-lation; which can further diminish their already fragile mental health and general well-being. Poor emotional and mental health, in turn, can significantly impede their recov-ery, reintegration, and productivity for many years to come.                                                    9 Charles Tucker, Kari Kammel, Heather Lehman, and Elisabeth Ward, “An Analysis of Human Trafficking for Sexual Exploitation in Vietnam and a Comprehensive Approach to Combating the Problem,” Interna-tional Law & Policy 16, no. 2 (2009), p. 475. 10 Thanh Nien News, “The Naked Truth About Prostitution in Vietnam,” Thanh Nien News, July 14, 2013, accessed April 12, 2017, http://www.thanhniennews.com/society/the-naked-truth-about-prostitution-in-vietnam-1883.html.  9 CHAPTER II: THE DOUBLE STIGMA, DISCRIMINATION, AND POOR MENTAL HEALTH 2.1 Double Stigma and Discrimination  Poor mental health among victims of sex trafficking, trafficked returnees, and sex workers is very common, partly due to the highly abusive work conditions that they en-dure throughout the trafficking process. In addition, the “double stigma” that these indi-viduals experience in the post-trafficking stage also generates a serious and negative impact on their already fragile mental and emotional well-being. I create the term “dou-ble stigma” because it encompasses both sex work-related stigma and HIV-related stigma; it can greatly compromise the victims’ mental and emotional well-being, and challenge their recovery and reintegration efforts.  Sex work-related stigma in Vietnam is a result of the culture of patriarchy, which has been heavily influenced by the teachings of Confucius. Historically, Confucianism instructed that a woman should show “good morality” by remaining a virgin until mar-riage and avoiding adultery, divorce, and abortion. In the contemporary society, espe-cially in rural areas, where the majority of trafficking victims come from,11 Confucian precepts like “men and women should remain physically distant” are still being taken into serious consideration as building principles for appropriate female behaviours. Thus, female sexuality is often met with moral restrictions, which indicates that that sex-uality is and has always been considered a dangerous and immoral force that needs to be controlled.12 This belief, over time, has been carried on to the contemporary society,                                                  11 Tucker et al., p. 443. 12 Helle Rydstrøm, “Sexual Desires and ‘Social Evils’: Young Women in Rural Vietnam,” Gender, Place & Culture 13, no. 3 (2006), p. 284.  10 where sexual desires and practices become subjects of government control and are as-sociated with the officially recognized category of social evils.13 The language of social evils has prompted the implementation of stringent laws and measures in dealing with sexual exploitation, which is constantly associated with voluntary sex work.  The stigma is further exacerbated when sex workers and trafficked returnees are found to be HIV-positive. HIV/AIDS is the most common and dangerous health risk amongst female sex workers in Vietnam. Once women and girls enter the sex trade, they are routinely exposed to “myriad forms of physical and psychological abuse throughout the trafficking process,” which make them extremely vulnerable to practices that can result in an HIV infection.14 Victims are required to accommodate multiple cli-ents on a daily basis, physically beaten to force them into having sex, and raped as a psychological tactic to intimidate them into future submission. However, sexual inter-course between male perpetrators and their female sex workers are often unprotected. Furthermore, most victims of sex trafficking are also exposed to illegal recreational drugs to help them cope with the physical and psychological trauma. Sharing syringes is a high-risk behaviour that exposes users to the risk of an HIV infection. Approximately ten percent of female sex workers throughout Vietnam are HIV-positive with even higher rates of infection found in cities such as Ha Noi and Ho Chi Minh City, where sex work and drug use are prevalent.15                                                  13 Ibid., p. 284. 14 Tucker et al., p. 454.  15 Ministry of Health - Viet Nam Administration of HIV/AIDS Control, Vietnam HIV/AIDS Estimates and Projections: 2007-2012 (Hanoi: Ministry of Health), p. 56, accessed July 10, 2016, http://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/documents/legaldocument/wcms_174609.pdf.  11  The double stigma enables discrimination to take place. Discrimination is de-scribed as “,,,the actions or treatment based on the stigma and directed towards the stigmatized.”16 The stigmatized thus often find themselves ostracized, rejected and shunned, and may experience sanctions, harassment, scapegoating and even violence based on their infection or association with HIV/AIDS. Discrimination often involves visi-ble actions and can be more easily identified. In this context, sex workers and victims of sexual exploitation, who are already a socially marginalized group, experience unfair and even abusive treatment for their association with HIV/AIDS. Discrimination tends to fall into two categories: legislative forms of discrimination, which reflect stigma enacted in law or policy; and community-level form, in which the marginalized experience dis-crimination in less formal contexts, often those related to family and other structures of the society.17  In the context of legislative discrimination, the Government of Vietnam opposes sex work, and considers it a social evil and the root of all crimes. Those who are caught up in these activities are regarded as immoral and are criminalized. Such formulation of the laws and the language of social evils surrounding sex work and sexual exploitation have negatively affected public attitudes towards individuals in the sex industry, which largely includes trafficking victims, thus stigmatizing their experience as victims of the sex trade. As a result, public empathy towards women in the sex industry is extremely low. At the same time, due to the high prevalence of HIV infections amongst female sex workers, animosity against these individual is even more inflated. The legal framework,                                                  16 Sheila M. Bunting, “Sources of Stigma Associated with Women and HIV,” Advanced Nursing Science 19, no. 2 (1996), p. 67. 17 J. R. Busza, “Promoting the Positive: Responses to Stigma and Discrimination in Southeast Asia,” AIDS Care 13, no. 4 (2001), p. 442.  12 together with the social and cultural beliefs, link people with HIV/AIDS to behaviours considered improper and immoral such as sex work, thus deepening the double-stigma and discrimination against HIV-positive sex workers and trafficking victims.   In addition, besides being associated with the “social evils,” fears of HIV trans-mission also perpetuate serious HIV/AIDS-related stigma in Vietnam, adding to the so-cial alienation already experienced by sex workers and trafficking victims. A lack of un-derstanding about the modes of HIV transmission has certainly inflated the stigma sur-rounding the illness. This is due to the inadequacy of sex education at schools and also sexual and reproductive health programs in the communities. Today, thanks to numer-ous studies and scientific advances made by the medical community, it is recognized that HIV is not easy to transmit. However, the fear of transmission and infection still lin-gers, including infection through casual contact.18 In some instances, people avoid eat-ing fruits or meals if an HIV-positive person has cut the fruits or prepared the food, and they also refuse to share eating utensils. Some even suggest that people living with HIV should live in segregated areas to reduce the risk of spreading the illness.19 Thus, in many countries such as Vietnam, HIV-related stigma and discrimination can be as dev-astating as the illness itself. A positive diagnosis can lead to social exclusion and shun-ning, abandonment by loved ones, loss of jobs and income, verbal harassment, and even physical violence.                                                  18 “Fuelling the Epidemic: HIV-Related Stigma and Discrimination,” Interagency Coalition on AIDS and Development, accessed April 10, 2017, http://www.icad-cisd.com/pdf/Fueling_the_Epidemic_HIV-Related_Stigma_and_Discrimination_Info_Sheet_EN.pdf.  19 Alice Gaudine, Lan Gien, Tran T. Thuan, and Do V. Dung, “Perspectives of HIV-Related Stigma in a Community in Vietnam: A Qualitative Study,” International Journal of Nursing Studies 47, no. 1 (2010), p. 44.  13 2.2 How Does the “Double Stigma” and Discrimination Contribute to Poor Mental Health?   In a country where sex work is already heavily stigmatized, associating sex work with HIV/AIDS infection exacerbates the stigma experienced by sex workers and traf-ficked returnees who are living with the illness. The projected stigma removes these in-dividuals from their families and friends, isolates them from their home communities, and creates a sense of self-hatred and internalized self-stigma amongst HIV-positive individuals, particularly sex workers and trafficking victims. Thus, a large number of these individuals often report low self-esteem and self-worth, and high level of depres-sion and even suicidal thoughts.   In a study conducted in China, researchers found that sex workers experienced very poor mental health. In this study, a total of 310 female sex workers in Liuzhou City of Guangxi agreed to participate, provided written informed consent, and completed a self-administered questionnaire. China and Vietnam share similar cultural values and legal framework regarding sexual exploitation and sex work. Furthermore, Guangxi is located in southwest China, bordering Vietnam, and Vietnamese female trafficking vic-tims and sex workers are very regularly found in the Chinese border regions. The re-search demonstrates that 30 percent of surveyed sex workers showed elevated depres-sive symptoms, 18 percent showed suicidal ideation, and 9 percent had attempted sui-cide in the past 6 months. Researchers of this study also concluded that female sex workers’ mental health was “positively associated with the level of perceived stigma.”20                                                  20 Yan Hong, Xiaoyi Fang, Xiaoming Li, Yang Liu, Mingquiang Li, and Tom Tai-Seale, “Self-Perceived Stigma, Depressive Symptoms, and Suicidal Behaviours Among Female Sex Workers in China,” Journal of Transcultural Nursing 21, no. 1 (2010), p. 33.  14 There are virtually no findings and studies on mental and emotional health challenges amongst female sex workers in Vietnam, and very limited studies on this issue in China due to the sensitive and illegal nature of the occupation. Thus, this particular study con-ducted in China is used to support the issue.   Besides HIV-related stigma and discrimination, people who are living with HIV/AIDS also report the feeling of “uncertainty,” which only intensifies the level of stress and anxiety they are already experiencing, and further undermines their mental well-being. It is important to note that despite the availability of antiretroviral therapy, these aggressive treatment regimens can only suppress the replication and progression of the virus. In short, HIV/AIDS cannot be completely cured, only managed. Thus, the feelings of uncertainty and anxiety stem from the obscure future caused by this illness and fear of death and dying.21 Furthermore, successful suppression of HIV viral replica-tion demands strict adherence to antiretroviral therapy. Therefore, long-term commit-ment to antiretroviral therapy can become financially draining, and emotionally and psy-chologically damaging, with the knowledge that discontinuation can lead to complica-tions and drug resistance, which can result in death.  The issue of financing HIV/AIDS treatment should be briefly discussed to better understand the struggles of the afflicted peoples. HIV/AIDS patients in Vietnam current-ly have free access to treatment.22 Nonetheless, the national program, which includes testing and medication, are operated by international donors, while financial support                                                  21 Tarik Tuncay, “Spirituality in Coping with HIV/AIDS,” HIV & AIDS Review 6, no. 3 (2007), p. 12. 22 Long Thanh Nguyen, Bach Xuan Tran, Cuong Tuan Tran, Huong Thi Le and Son Van Tran, “The Cost of Antiretroviral Treatment Service for Patients with HIV/AIDS in a Central Outpatient Clinic in Vietnam,” ClinicoEconomics and Outcomes Research 6 (2014), p.106.  15 from the Vietnam National Program for HIV/AIDS is insufficient.23 Due to their depend-ence on international funding, HIV/AIDS programs in Vietnam will encounter financial challenges in the near future when there is a reduction in external funding, meaning that patients will have to start paying for the treatment themselves. In addition, other finan-cial burdens and non-medical costs of HIV/AIDS treatment should also be taken into consideration. These costs include travel expenses and accommodation if patients have to travel to other places for treatment, meals, opportunity costs, loss of work time, and other medications.24   Confronting an infectious, highly stigmatized, and potentially life-threatening chronic illness is perhaps the most stressful life experience an individual can face. As a result, individuals with HIV/AIDS, especially those who have been involved in the sex industry and forced sexual exploitation, tend to suffer from serious psychiatric disorders such as depression, anxiety, substance abuse, and other mental disorders due to the stigma associated with their status as sex workers and their HIV-positive status. Afflict-ed individuals face the burden of their medical conditions as well as severe societal hos-tility at a time when they are most in need of social support. These stressors can critical-ly affect the mental and emotional well-being of sex trafficking victims, and further in-duce symptoms of severe depressive disorders and even suicidal ideation, which also contribute to the deterioration of their overall well-being and productivity.  2.3 Why is mental and emotional health important to reintegration?   Successful recovery and reintegration is the ultimate goal of trafficking victims and organizations that work with them. According to After Trafficking: Experiences and                                                  23 Ibid., 102. 24 Ibid., p. 106.  16 Challenges in the (Re)integration of Trafficked Persons in the Greater Mekong Sub-region by Rebecca Surtees, a central aspect of reintegration is the empowerment of trafficking victims, and giving them the support to develop skills toward independence and self-sufficiency, and to be actively involved in their recovery.25 Caring for the vic-tims’ mental and emotional health is an increasingly necessary step towards successful reintegration.   When people are mentally and emotionally healthy, they are better able to enjoy their lives and the company of people who are involved in their lives. They can love, ex-press themselves creatively, and learn new things without fear or limits. Individuals with strong mental and emotional health are better prepared to cope with difficulties, disap-pointments, and stress.26 For female victims of sex trafficking, especially those who live with a chronic illness, such as HIV/AIDS, resulting from their trafficking experience, mental and emotional well-being allows them to take care of their own physical health, their loved ones, and also those in their communities.  Their physical health will be taken care of by their adherence to their medica-tions. It is expected that mentally and emotionally healthy individuals will remember to take their HIV medications as prescribed, get tested often, exercise, see their doctors frequently, practice safer sex and if they use drugs, will take precautions to prevent transmission of diseases. Furthermore, as their mental, emotional and physical well-being improves, they will also be able to take care of their children and loved ones, and                                                  25 Rebecca Surtees, After Trafficking: Experiences and Challenges in the (Re)integration of Trafficked Persons in the Greater Mekong Sub-region (Bangkok: Bangkok: United Nations Inter-agency Project on Human Trafficking, 2013), p. 4. 26 “HIV and Emotional Wellness,” CATIE: Canada’s Source for HIV and Hepatitis C Information, accessed July 20, 2016, http://www.catie.ca/sites/default/files/emobro-en-2013.pdf.   17 contribute meaningfully to their families and the communities that they live in. They will be able to express themselves and communicate effectively with the people around them, go back to work, volunteer, create, advocate, and carry out their interests without fear or limits.  At the same time, trafficking victims who feel mentally and emotionally unwell lack the resiliency, coping mechanisms, and determination to live meaningfully. Without adequate support, their trafficking experience, HIV-positive status, and also the stigma and discrimination associated with their experience can worsen their mental and emo-tional well-being, and prevent them from living their lives to the fullest. They may ignore their physical well-being, engage in self-destructive behaviours and criminal activities, and neglect their loved ones. Many unassisted women and girls choose to go back to the sex industry due to the inability to recover from their experiences and reintegrate back into their communities. Others may choose to engage in criminal activities such as violence, robbery, drug trafficking, and even human trafficking. In extreme cases, traf-ficking victims may even choose to end their lives to escape their mental and physical sufferings. Thus, mental and emotional well-being is an extremely important and neces-sary component of the recovery, empowerment, and successful reintegration of sex traf-ficking victims.   Nonetheless, mental and emotional support services are not sufficient to support female sex trafficking victims in Vietnam, who often require special forms of support.27 Short-term facilities in Vietnam are only able to provide accommodation, basic necessi-                                                 27 Coordinated Mekong Ministerial Initiative Against Trafficking, (Re)Integration: Perspectives of Victim Service Agencies on Successes & Challenges in Trafficking Victim (Re)Integration in the Greater Mekong Sub-region (Bangkok: United Nations Inter-agency Project on Human Trafficking, 2012), p. 14.  18 ties, healthcare and initial counselling for up to 15 days. Long-term centres provide more extensive services that include mainstream education, vocational training, legal assistance, healthcare and counselling, depending on the results of a needs assess-ment. Long-term care centres are run by local Vietnamese government agencies, but receive technical and financial support from international non-governmental organiza-tions (NGOs).28 Due to the fluctuating nature of financial contributions, on top of the overall shortages of trained professionals in mental healthcare and counselling, traffick-ing victims have very limited access to professional psychological support in these cen-tres.  Therefore, in the absence of a formal counselling and support system, some ser-vice providers offer other informal types of emotional support. Some respondents de-scribe these forms of informal support as “listening to their problems” and “encouraging them.” Thus, in some shelter programs, trafficked persons are “counselled” by shelter staff and teachers. In the community, “counselling” is often conducted by volunteers and religious laypersons who work with service organizations.29 Although this type of infor-mal support and encouragement is very different from the formal services provided by trained professionals, and should never replace professional counselling and care, it can play a very important role in helping the female victims of sex trafficking. Thus, in-formal and alternative tools for coping with psychological stress, anxiety, depression and trauma should be promoted and supported in both shelter programs and also within the community. The latter is to address trafficking victims who opt out, or have left the shelter programs. These informal and alternative tools shall include religion and spiritu-                                                 28 Ibid., p. 5. 29 Surtees, After Trafficking, p. 133.  19 ality to help trafficking victims cope with their experiences and the above-mentioned double stigma that has severely undermined their mental and emotional well-being. In Vietnam, Buddhist temples, leaders, and laypersons may be encouraged to participate in the shelter program, rehabilitation centres, and community services to support the mental and emotional empowerment, recovery, and successful reintegration of the fe-male victims of forced sexual exploitation. This suggestion will be developed and dis-cussed further in the next two sections.                   20 CHAPTER III: INFORMAL AND ALTERNATIVE TOOLS: RELIGION 3.1 Buddhism as a source of spiritual support  Various studies have demonstrated that religious and spiritual inclination in-crease when individuals confront intensive emotional distress, somatic illness, or death. In these traumatic events, religion appears as a coping strategy. Coping is defined as “the prevailing cognitive and behavioural endeavour to meet certain external and/or in-ternal demands,” caused mostly by psychological and emotional pressures.30 HIV/AIDS is an illness that comes with great financial, physical, psychological and emotional pres-sures, especially for those who have been in the sex industry due to the double stigma towards sex work and HIV/AIDS, the physical and emotional abuse they have endured, and also the feelings of uncertainty and fear of the uncertain future. Nonetheless, when individuals confront the limit of their ability to control the outcome, religion may act as a source of comfort and hope, which can maximize a patient’s psychological adjustment to a severe diagnosis and sustain his/her life.3132 A number of afflicted individuals, thus, seek out religion and spirituality for psychological strength and a sense of control to ease the emotional burden of their sex work experience and HIV status, to reduce self-blame, and ultimately come to terms with their illness and identity post-trafficking. In ad-dition, most people rely on religion to alleviate the fear of suffering, death, and the un-certainty of what may happen after death through a belief in an afterlife. Religion can also act as a system of social support that offers a welcoming environment and creates                                                  30 Richard S. Lazarus, “Coping Theory and Research: Past, Present, and Future,” Psychosomatic Medi-cine 55 (1993), p. 237. 31 Stephen G. Post, “Ethic, Religion, and Mental Health,” in Handbook of Religion and Mental Health, ed-ited by Harold G. Koenig (San Diego: Academic Press, 1998), p. 23. 32 Verna Carson, Karen L. Soeken, Joyce Shanty, and Lillian Terry, “Hope and Spiritual Well-Being: Es-sentials for Living with AIDS,” Perspectives in Psychiatric Care 26, no. 2 (1990), p. 30.  21 a sense of belonging.33 Lastly, religious institutions can also act as informal educational institutions that disseminate information about human trafficking and exploitation of girls and women to community members. Education is an essential tool to combat the sex trade and forced sexual exploitation of girls and women, and also reduces the stigma and discrimination directed at sex trafficking victims and persons living with HIV/AIDS.   Many trafficked persons find comfort in religion and spirituality. According to the study After Trafficking, a number of victims described being taken to the temples by so-cial workers upon their return to their communities. Many of them talked about the tem-ple being a place that they visited often when feeling overwhelmed and upset. Others reported studying Buddhist philosophy, scriptures and lessons offered at the shelter. Trafficking victims interviewed in Surtees’ report generally spoke about religion as a source of assistance that helped alleviate the emotional costs of their trafficking experi-ences and help to resolve the challenges they faced in their post-trafficking lives.34  Buddhism is one of the major religions in Vietnam. Similarly to other majority Buddhist countries in Southeast Asia, the temple is not only the center of the communi-ty, but it also serves as an informal centre where people come to seek spiritual and emotional support in times of crisis. In addition to the shortages of trained professionals in counselling and mental health care, the Vietnamese people are also often reluctant to seek services from formal health settings, especially HIV/AIDS and mental health ser-vices, and thus frequently seek help from informal systems, especially Buddhism-                                                 33 Karolynn Siegel and Eric W. Schrimshaw, “The Perceived Benefits of Religious and Spiritual Coping Among Older Adults Living with HIV/AIDS,” Journal for the Scientific Study of Religion 41, no. 1 (2002) p. 91. 34 Surtees, After Trafficking, p. 135.  22 related organizations.35 Buddhist temples, especially in rural areas, are very active and engaged in local life; Buddhist leaders and monks are looked upon as the spiritual lead-ers and moral support of the community. Therefore, temples, monks, laypersons and lay Buddhist groups, and Buddhist-related organizations in Vietnam may be encouraged and given incentives to collaborate with local organizations to carry out mental health services and social programs to improve the well-being of HIV-positive sex trafficking victims.   It should be noted that religious conservatism towards sex work may reinforce stigma against sex workers and trafficking victims. Nonetheless, social programs and services offered by Buddhist temples and related organizations to help women from the sex trade tend to be, and should be voluntary. As mentioned, religious institutions and Buddhist-related organizations in Vietnam should be encouraged, not coerced, to de-velop and carry out these services. Voluntary participation will ensure a more compas-sionate attitude towards trafficking victims and sex workers.  According to Dr. Huong Nguyen, she found that in some Buddhist temples in Vi-etnam offer three groups of activities; all of them are offered voluntarily and free of charge on the principle of Buddhist compassion. Names of the temples were not provid-ed in her research, presumably to avoid public attention. The first group of includes di-rect therapy and healing for people showing various symptoms of severe mental illness, believed to be result of being “possessed” or “tortured” by spirits, ghosts, or devils.36 The second group of activities offered by Buddhist temples involves direct services to                                                  35 Huong Nguyen, “Linking Social Work with Buddhist Temples: Developing a Model of Mental Health Service Delivery and Treatment in Vietnam,” British Journal of Social Work 45, no. 4 (2015), p. 1243. 36 Ibid., p. 1248.  23 individuals and families going through disruptions or changes in life, such as death, ill-ness, divorce, bankruptcy, or unemployment. The last group includes activities that aim at alleviating stress, anxiety, fear or grievances of the local community or the whole so-ciety when faced with disasters, war, or social chaos.37 Treatment and counselling activ-ities offered by Buddhist temples are grounded in complex Buddhist philosophy. One central philosophy, known as the Four Noble Truths, is most frequently cited to address mental and emotional suffering. Thich Nhat Hanh, a prominent Vietnamese Buddhist monk, strongly advocates for the practice of applying the Four Noble Truths to reduce tension, stress, and unhappiness.38  The First Noble Truth is dukkha, which translates to “ill-being” or “suffering.” Suf-fering is an inevitable occurrence of life. Traditional Buddhist leaders have spoken of the First Noble Truth in this way: birth is suffering, aging is suffering, sickness is suffering, separation from loved ones is suffering, and death is suffering. In the contemporary world, however, suffering also describes tension, stress, depression, anxiety, fear, vio-lence, broken families, suicide, and other psychological turmoil.39 Thus, based on the First Noble Truth, sex trafficking victims are already suffering significantly; from abuse, separation, a potentially fatal illness, social alienation, and mental health issues. The Second Noble Truth, samudaya, states that suffering is caused by selfish attachment in the form of attraction and/or repulsion for objects, beings, ideas, events, and/or anything that we exclusively associate with “me” or “mine” because we tend to forget that we live                                                  37 Ibid., p. 1248. 38 Thich Nhat Hanh, “History of Engaged Buddhism: A Dharma Talk by Thich Nhat Hanh,” Human Archi-tecture: Journal of the Sociology of Self Knowledge VI, no. 3 (2008), p. 33. 39 Ibid., p. 31.  24 in an impermanent world and our lives are temporary.40 We are often unhappy and re-pelled by our current experience, and so we seek to end or avoid it, which only increas-es our suffering.41 In this case, trafficking victims are devastated and repelled by their past experiences and their HIV status, and so they cling to and stress over their health because they worry it may soon end, or they choose suicide as an easy way out. The Third Noble Truth, nirodha, or cessation of suffering, is possible if we learn to stop cling-ing to our worldly objects and circumstances. According to the third truth, the cessation of suffering is possible for trafficking victims if they stop clinging to their past experienc-es, their HIV diagnosis, and the double stigma and discrimination imposed upon them by the society as well as their own self. Lastly, the Fourth Noble Truth, marga, explains that we must follow the “Noble Eightfold Path” to liberate our suffering. The eight com-ponents of the Path include correct understanding about reality, correct intention and thoughts, correct speech, correct action, correct livelihood, correct effort, correct mind-fulness, and correct concentration and meditation.42   In short, most human suffering is caused by a person’s disillusionment and stub-born attachment to the self, and the thoughts and emotions that emerge from that self. An individual suffering from mental and emotional distress is someone who mistakenly equates their stress, fears, feelings, and emotions with their concrete self. Thus, this in-dividual will suffer even more tensions, exhaustion, depression, and psychological cri-ses caused by the endless, self-imposing waves of emotions. Therefore, based on this                                                  40 Darla Y. Schumm and Michael Stoltzfus, “Chronic Illness and Disability,” Journal of Religion, Disability & Health 11, no. 3 (2007), p. 11. 41 Bruce W. Scotton, “Treating Buddhist Patients,” in Handbook of Religion and Mental Health, edited by Harold G. Koenig (San Diego: Academic Press, 1998), p. 263. 42 Ibid., p. 264.  25 philosophy, according to Dr. Nguyen, a few Buddhist temples in Vietnam have estab-lished programs and activities to help mental health patients deal with their problems effectively, alleviate emotional trauma and suffering, and rid themselves of mental and emotional distress. These activities include meditation, physical exercises, counselling, learning the Buddhist sutras, fasting and retreat. The activities aim at reflecting the No-ble Eightfold Paths and eventually at freeing a person of “their illusions of and attach-ment to the self.”43 In some temples, Buddhist monks also perform an array of activities that aim to cleanse people of their feelings of guilt, shame, and fear.44 Praying, meditat-ing, and learning the Buddhist sutras are reasonably inexpensive activities. Nonethe-less, funding for these activities comes almost exclusively from donations of temple-goers and almost never from the Vietnamese government.45 Thus, even though some Buddhist temples are able to help local individuals and their families cope with some is-sues related to mental and emotional distress, they do not have the sufficient resources to help with more serious, large-scale social problems such as human trafficking and HIV-related mental heath issues, and HIV prevention and care.  In other countries in the region, such as Thailand and Cambodia, several Bud-dhist organizations and projects have been established by monks, backed by their na-tional governments, international organizations, and advocacy groups in response to the needs for Buddhist leaders to have a more active role in the empowerment, develop-ment, and protection of vulnerable individuals. Some projects also provide care for HIV                                                  43 Nguyen, “Linking Social Work with Buddhist Temples,” p. 1249. 44 Ibid., p. 1249. 45 Ibid., p. 1249.  26 patients, advocate for HIV prevention, and carry out services for patients with depres-sion and/or mental health issues.  The European Institute of Applied Buddhism, established and directed by Thich Nhat Hanh, offers retreat programs and courses for mental, cancer and HIV/AIDS pa-tients so that they can learn how to cope and accept their conditions based on the Four Noble Truths. According to Thich Nhat Hanh, acceptance is a practice that can help pa-tients prolong their lives by twenty or thirty more years.46   In Southeast Asia, the Sangha Metta Project (SMP) is probably the most well-known spiritual project that engages religious leaders in HIV prevention and care. The SMP was established in 1998 to educate and engage Thai monks in HIV/AIDS care, prevention, and education. By 2003, the SMP had educated more than 1,500 monks and nuns in HIV/AIDS prevention and care.47 Sangha Metta training covers the delivery of spiritual and emotional services to individuals and family members affected by HIV/AIDS; awareness-raising; prevention education; participatory social management skills and tools; and encouraging tolerance and compassion for afflicted persons in the community. Through UNICEF, the project has managed to provide training and advice for monks and nuns in Cambodia, China, Lao PDR, Myanmar, and Vietnam.48  Nonetheless, the SMP was not as popular in Vietnam as it was in the neighbour-ing countries, possibly due to the complex relationship between the Vietnamese gov-ernment and religious associations. The project was initially met with some apprehen-                                                 46 Thich Nhat Hanh, “History of Engaged Buddhism,” p. 36. 47 Tomoko Kubotani and David Engstrom, “The Roles of Buddhist Temples in the Treatment of HIV/AIDS in Thailand,” Journal of Sociology and Social Welfare 32, no. 4 (2005), p. 8. 48 United Nations Children’s Fund (UNICEF), The Buddhist Leadership Initiative (Thailand: UNICEF East Asia Regional Office, 2003), p. 12, accessed April 10, 2017, http://www.hivpolicy.org/Library/HPP001156.pdf.  27 sion on the part of the government as to whether it was appropriate and relevant for an HIV/AIDS project to involve Buddhist monks. However, the government eventually “warmed up” to the initiative. A study tour to Thailand was organized and training pro-grams were provided throughout 2003. In the same year, there were discussions on four possible pilot projects for the South, North, Central, and South-West regions of the country.49 Nonetheless, no official report on the progress or cancellation of the Sangha Metta Project has been provided since its launch in Vietnam. 3.2 Buddhism as a source of social support  Aside from providing spiritual support, religion can also be a source of social support for these individuals. It has been proven that the loss of social support, or social alienation, increases the rate of suicide.50 Ties to social groups - including families, friends, neighbours, voluntary organization, and religious organizations - give an indi-vidual multiple roles to play; as spouse, parent, sibling, friend, etc. These social roles provide feedback, self-esteem, and social recognition; all of which provide a sense of stability, well-being as well as material and emotional support when they are needed.51 Thus, the loss of close relationships and all the benefits they provide can be a trauma-tizing event. In this situation, religion does not only provide a system of beliefs and ritu-als to help individuals through difficult times, but it also establishes a community that can help people find meaning and hope in the context of their difficult experiences, and seek social support and guidance. In Vietnam, Buddhist temples are often situated in the heart of local communities, which allows them to be actively involved in the lives of                                                  49 UNICEF, The Buddhist Leadership Initiative, p. 12. 50 Ellen Idler, “Religion: The Invisible Social Determinant,” in Religion as a Social Determinant of Public Health, edited by Ellen L. Idler (Oxford, UK: Oxford University Press, 2014), p. 4. 51 Ibid., p. 33.  28 local people and the activities of the community. In a calm and non-threatening envi-ronment, the Buddhist temples can be a safe place for sex trafficking victims to come together, socialize, and re-build their ties with society. Nonetheless, there is a risk of backlash from conservative temple-goers as certain individuals may need more time to overcome the intolerance. In this case, Buddhist monks and nuns shall include mes-sages of forgiveness and compassion when explaining the Buddhist scriptures to tem-ple-goers. This form of advocacy work, through spiritual guidance, will be discussed fur-ther in the paper.   After Trafficking found that many of the surveyed trafficking victims received sup-port in talking to others with similar experiences. In some settings, there were opportuni-ties for organized group meetings and discussions, which some trafficking victims found extremely helpful.52 These groups met regularly and functioned as self-help groups that provided not only social and emotional support to one another, but also served as a safe space for information exchanges and trainings. Sex trafficking victims attended regular meetings with former sex workers and trafficked persons where they could safe-ly discuss their experiences throughout the trafficking process, the challenges they faced in their post-trafficking lives, and lessons learned. Many trafficking victims found this form of group support very helpful in making them feel not so alone, which helped them put their trafficking experiences behind them. In After Trafficking, trafficked per-sons who participated in these groups talked about having improved self-confidence and self-esteem, and being able to overcome their fears and sense of inferiority.53                                                   52 Surtees, “After Trafficking,” p. 135. 53 Ibid., p. 135.  29  In Thailand, at a Buddhist temple that offers medical, mental and emotional care for people living with HIV/AIDS, patients reported that being able to share one’s thoughts and feelings with other individuals who carried the illness was a major reason for their decision to come to the temple. Many subjects in this research described great challenges while living in their community because of the stigma and discrimination, which led to them being isolated or treated as the “different” ones. Thus, they noted that being the “same” as others helped them live comfortably, free of shame and worry. Most of the subjects developed close friendships with others who came to the temple, and confirmed that having friends in the same situation helped them process their compli-cated feelings. The volunteer doctors at this temple in Thailand expressed how amazing it was to witness individuals with HIV/AIDS help one another and cheer each other up in the face of hardships.54 It becomes clear that Buddhist temples in Thailand are able to act as a place where people living with HIV/AIDS can form informal support groups among themselves. The ability to live with others; the ability to share one’s thoughts and feelings - without fears of judgment and discrimination - with people who have been through similar experiences, and who are in the same situation, are crucial components that can help establish a safe support system for trafficking victims and those who are living with HIV/AIDS.  3.3 Buddhism as a tool to fight stigma and discrimination  Although providing spiritual, mental and emotional support to HIV-positive traf-ficking victims is a crucial step that can greatly influence successful reintegration; it is equally as important to tackle the sources that cause mental and emotional distress                                                  54 Kubotani and Engstrom, “The Roles of Buddhist Temples in the Treatment of HIV/AIDS in Thailand,” p. 15.  30 among afflicted individuals. It is clear that stigma and discrimination are major factors that contribute to mental and emotional health issues. Thus, measures need to be taken to help eliminate the negative effects of stigma and discriminatory acts against sex traf-ficking victims and persons living with HIV/AIDS. Providing education and training on HIV/AIDS, human trafficking, and exploitation is especially important since the Vietnam-ese society lacks proper knowledge about these issues and thus, the people also lack compassion towards sex trafficking victims and sex workers. As described, sex traffick-ing victims, sex workers, and HIV persons are perceived as the immoral ones, and thus, they are often treated with disdain and hostility by the society.    In this situation, Buddhist leaders, monks, nuns, and laypersons can provide sig-nificant support to the fight against stigma and discrimination. In Vietnam, a Buddhist monk is highly respected and admired, not only as a religious figure, but also as a teacher, an advisor, a leader, a healer, and a counsellor. When Buddhist monks show compassion towards sex trafficking victims, former sex workers, and persons living with HIV/AIDS, and demonstrate relevant skills and the recognition that these individuals are humans who have suffered enough, and their illness cannot be transmitted by interact-ing and caring for these individuals, people believe them and begin to follow their lead.   Employing the Buddhist faith to reach out and educate community members is a strategic move. In Cambodia, a similar initiative was carried out through the Kien Kes Health Education Network (KKHEN), which operated out of a Buddhist temple in Bat-tambang, an impoverished town in Cambodia with high HIV prevalence in the early 2000s. The Network was supported by USAID’s IMPACT (Implementing AIDS Preven-tion and Care Project) and managed by Family Health International (FHI). The FHI held  31 numerous trainings to help the monks better understand HIV/AIDS and how to mobilize community response. The monks learned about the history of the illness, self-care, be-haviour change communication, problem-solving, and project management. After the monks received training, they began to train teams of volunteers and laypersons. The trained volunteers spent 10 days per month teaching the community they lived in about HIV prevention, and assisting with home-based care. These volunteers were further “shadowed” by other volunteers, who continued to learn HIV care and prevention skills from them.55 The Network created a widespread and sustainable support system, and institutionalized these interventions and then replicated them in nearby temples. The monks helped to create a network at 30 other temples in 23 villages, trained volunteers and laypersons, and instructed members on how to disseminate their skills and knowledge on HIV prevention and care in their communities.56 Through a network of volunteers and effective community mobilization, KKHEN provided care and support to people living with HIV/AIDS, and also disseminated HIV/AIDS knowledge to the entire community and beyond. The Network and its branches helped de-stigmatize the HIV disease, raise awareness and generate public compassion towards afflicted individuals.                                                       55 Nora Rosenberg, The Kien Kas Health and Education Network: How One FBO Mobilized Community Compassion with Few Resources (Arlington: Family Health International Institute for HIV/AIDS, 2004), p. 3, accessed June 20, 2016, http://pdf.usaid.gov/pdf_docs/Pnadb363.pdf.  56 Ibid., p. 1-3.  32 CHAPTER IV: DISCUSSION AND RECOMMENDATIONS  The above discussion suggests that there is an increasing need for mental health and emotional support for victims of sex trafficking who are also living with HIV/AIDS in Vietnam. Confronting a highly stigmatized, infectious, and potentially fatal chronic illness is perhaps the most distressful life experience a person could face. In addition, the shame factor of having been trafficked into the sex industry can further lead to feelings of panic, anxiety, hopelessness, and depression. HIV-positive sex workers tend to suffer from serious psychiatric disorders such as depression, anxiety, substance abuse, and other mental disorders due to the burden of societal hostility at a time when they are most in need of social support. These stressors can severely affect the mental and emotional well-being of these individuals, which may contribute to the deterioration of their general well-being and productivity.   As mentioned, psychological support that aims at improving the mental and emo-tional well-being of trafficking victims is not sufficient to help girls and women who have been sexually exploited. Their access to psychological support is limited due to lack of financial resources and shortages of trained professionals. Nonetheless, mental and emotional support is extremely important to the overall well-being of victims of sex traf-ficking, and can influence the success of their recovery and reintegration. Thus, in the absence of formal systems of assistance and counselling, alternative tools for coping with depression, psychological stress, trauma, and anxiety should be fostered and uti-lized. In Vietnam, Buddhist temples, leaders, monks, nuns, and laypersons can be the alternative sources of support for victims of sex trafficking and persons living with HIV/AIDS. Buddhist temples in Vietnam are often situated in local communities and they  33 are also deeply engaged in the daily life of these communities, while Buddhist leaders and monks are respectfully perceived as spiritual leaders, teachers, and counsellors. Thus, Buddhist temples, monks, and nuns should be encouraged and given more incen-tives to help victims of sex trafficking and persons living with HIV/AIDS, and the connec-tion between Buddhist temples and local organizations working with the victims should also be fostered to deliver appropriate services to afflicted girls and women. It should be noted that my recommendations are inspired by Dr. Huong Nguyen’s study, “Linking Social Work with Buddhist Temples: Developing a Model of Mental Health Service De-livery and Treatment in Vietnam,” published in the British Journal of Social Work in De-cember 2013. 4.1 To Buddhist Temples and Local Organizations  First, Buddhist temples and local organizations can work together closely to refer individuals to available mental and emotional health services. For example, if a victim of sex trafficking comes to the temple for solace and some brief counselling, but has not been informed about the available victim service providers in her community, Buddhist monks and nuns can refer her to these service providers and organizations. Similarly, if service providers and local organizations determine that some of their members are ex-periencing spiritual, mental, and emotional difficulties, and can benefit from counselling with Buddhist monks, they can refer these individuals to local Buddhist temples that col-laborate with these organizations. At the temples, Buddhist monks can provide spiritual guidance to victims of trafficking by offering group counselling so that the women can talk to the religious leaders about their issues, giving them lessons on Buddhist scrip-tures and philosophy, praying together, and helping them develop skills and confidence  34 to deal with their mental and emotional issues. The Buddhist temple is able to provide a safe, calm, and spiritual environment for the victims to learn how to cope with their past experiences and health conditions, forgive those who have hurt them, free their mind, and ultimately alleviate their suffering. Providing spiritual guidance through the teaching of Buddhist scriptures and philosophy is already one of the many responsibilities of the temples. Thus, activities that help to improve trafficking victims’ mental, emotional and spiritual well-being such as meditation, prayers, and learning the Buddhist sutras should not interfere with the mandates of the temples, since such activities also take place quite regularly.  Second, the Buddhist temple is a non-threatening and empowering place for vic-tims of trafficking to seek social and emotional support. Many trafficking victims highlight the importance of being able to talk about their experiences with others who are, or have been, in similar situations, and receive mutual encouragement and support. Thus, aside from offering spiritual one-on-one and/or group counselling sessions for victims, Buddhist leaders, monks, and volunteers can collaborate with local organizations and service providers to organize frequent group meetings and discussions, where victims can come together and talk about their experiences in a non-judgmental environment.   It should be noted that if a local temple does not possess the capacity to hold large groups of people, meetings and discussions can take place at another community centre, preferably after regular working hours to prevent public attention, which can make participants feel uncomfortable. At the community centre where meetings take place, service providers, Buddhist monks and laypersons may attend and partake in the  35 discussions. The presence of a spiritual leader can bring about a calm and compas-sionate environment for the participants.   Being surrounded by people who have been through the same troubles is helpful in making trafficking victims feel less alone, and allowing them to put their experiences behind them. Furthermore, being able to talk about their experiences and struggles openly and confidently, without fears of being judged and isolated, can also improve the victims’ self-esteem and self-confidence. Former sex workers and sex trafficking victims who have successfully recovered and reintegrated should also be invited to these group meetings to share their stories and lessons learned, and should be encouraged to offer advice to help recent victims. The temple is a safe place for trafficking victims to seek mutual understanding, compassion, guidance, and success stories to move forward with their recovery. It is a place where trafficking victims can form empowering and long-lasting friendships, re-build social ties, and regain their sense of belonging. Nonethe-less, participants should be encouraged to join the meetings, but not forced. This model may not be suitable for all victims of sex trafficking, as some may feel uncomfortable sharing their stories and reliving their trafficking experiences, and some may feel un-comfortable disclosing their HIV status to others. Thus, although informal and alterna-tive sources of support such as Buddhist temples can fill an organizational gap in men-tal health and emotional support services, they cannot and should not replace formal mental healthcare facilities. Professional psychologists and counsellors cannot be re-placed by religious institutions as some victims may feel more comfortable seeking one-on-one help from trained specialists.   36  In addition, Buddhist temples and associated organizations can offer services to the community and family members of the victims, who also often need spiritual, mental and emotional support to come to terms with their loved ones’ experiences. In some sit-uations, family members may feel guilty for directly or indirectly causing the trafficking situation of their loved ones. In other cases, family and community members may expe-rience difficulties accepting their loved ones’ experiences, and may need counselling to come to terms with the events. With the victims’ consent, Buddhist temples are encour-aged to invite family and community members to the victims’ group meetings, and facili-tate discussions so that the victims can share their stories in a safe, respectful, and spir-itual environment. Buddhist monks can also offer lessons on Buddhist philosophy and compassion to community and family members to help them understand and accept what the victims have gone through. As mentioned, giving lessons on Buddhist philoso-phy and compassion to followers and community members is already a responsibility of the Buddhist temples. Thus, it should not be costly for Buddhist temples to provide these informal counselling services. Effective community and family counselling can re-sult in awareness, understanding, and compassion towards the victims. Subsequently, family and social ties may be re-established and strengthened, which may significantly improve the victims’ mental and emotional well-being, and positively affect their recov-ery process and reintegration.   Lastly, the temples can be a place for education and advocacy, which are crucial elements in the fight against stigma and discrimination towards sex workers, sex traf-ficking victims, and persons living with HIV/AIDS. As previously described, the double stigma, which encompasses sex work and HIV-related stigma, is a major factor that  37 contributes to the poor mental and emotional health of victims of sex trafficking. There-fore, as well-respected and influential figures of the society, Buddhist monks should be encouraged to use their position to educate community members on the consequences of stigma and discrimination; and also on the issues of human trafficking, sexual exploi-tation of girls and women, and HIV/AIDS, and advocate for the appropriate treatment of afflicted individuals. They may incorporate messages of compassion in their lecture on Buddhist scriptures and philosophy. When respected religious figures express knowledge about these sensitive issues, and demonstrate compassion towards the marginalized peoples, the general public will mirror their actions.  This particular activity is important since the Vietnamese society lacks knowledge on these issues, and thus compassionate towards trafficking victims and sex workers. Buddhist monks and local organizations can collaborate to display and distribute mate-rials on human trafficking, abuse and exploitation of girls and women, and HIV trans-mission. Booklets and pamphlets on human trafficking and HIV/AIDS may be revised to leave out sensitive information to avoid backlash from conservative temple-goers. In addition, the KKHEN model can be fostered and utilized to mobilize the community. First, local organizations, medical professionals, and trained counsellors can collaborate with Buddhist temples to educate and advance the monks’ and nuns’ knowledge on human trafficking and HIV/AIDS. It is not absolutely imperative to train every single monk and nun in a temple, as the ones who volunteer to participate in the training can pass on their knowledge at a later time. Buddhist monks and nuns are encouraged to participate in the training, but never coerced. Voluntary participation inspires a more en-thusiastic attitude to learn, and a more compassionate attitude towards trafficking vic- 38 tims and sex workers, and also does not take away the time and responsibilities of other monks and nuns in the temple. Training can include the identification of various trends and aspects of human trafficking, sexual exploitation, victim identification, victim as-sessment, HIV/AIDS prevention and care, self-care, and behaviour change communica-tion. After training is finished, the monks and nuns will utilize their knowledge to train laypersons and volunteers. The volunteers can then bring their knowledge back to their communities and educate the locals on the multiple features of human trafficking, the vulnerabilities of girls and women, sexual exploitation, and HIV transmission, prevention and care. The dissemination of knowledge related to human trafficking, sexual exploita-tion and HIV/AIDS can certainly help de-stigmatize the victims of sex trafficking, their HIV status and their experiences. In this area of education, advocacy and community development, Buddhist temples can play a crucial role in raising awareness, shaping public compassion, and strengthening social networks; which can improve, not only the mental and emotional well-being of afflicted individuals, but also the overall well-being of all community members.  Nevertheless, even if a few temples have the capacity to run these programs, it does not mean that all temples in Vietnam have the same capacity. Small temples in poor, rural areas are inadequately equipped to organize and host group meetings, par-ticipate in training, and educate the communities in which they are located. The least costly form of assistance they can provide is informal counselling services, which are already part of the mandates of the temples. As mentioned, these services include pray-ing, meditating, chanting, and learning the Buddhist scriptures and philosophy. This  39 form of mental, emotional and spiritual support, though modest and insufficient, is still more helpful to trafficking victims than not having any kind of support at all. 4.2 To the Government of Vietnam   The above recommendations to Buddhist temples and local organizations can be implemented effectively only if they have the support of the Government of Vietnam. Thus, there are specific actions that the government can initiate to ensure that alterna-tive mental and emotional health services can be carried out to support sex trafficking victims and those living with HIV/AIDS.  First, the Vietnamese government can provide financial aid directly to selected Buddhist temples so that they have sufficient resources to provide informal counselling; and spiritual, mental, and emotional support to afflicted individuals. Funding can be used to organize group meetings and discussions, and/or counselling sessions. If the first option is not viable, the government can provide funding for local organizations and service providers that have connections with Buddhist temples, so they can collaborate with monks and nuns, and deliver such activities and services at the temples. Additional funding for local organizations will allow social workers and trained counsellors to pro-vide training for Buddhist monks and nuns; which can include education on human traf-ficking issues, exploitation of girls and women, HIV prevention and care, and mental and emotional health support to victims of sex trafficking. In addition, it is important that the Government of Vietnam must ensure that both Buddhist monks and service provid-ers receive basic training in victim identification and victim assessment so they can refer afflicted individuals to appropriate health and other services.    40  The Government of Vietnam may encourage Buddhist institutions, colleges and universities to incorporate courses on social issues into their curricula. These courses shall cover topics related to basic development issues and challenges in Vietnam such as human trafficking, gender norms, violence against women, HIV/AIDS, and other is-sues. When equipped with knowledge on these issues, Buddhist monks and nuns are more capable of advocating for the marginalized groups, fighting the stigma and dis-crimination against these groups and certain outdated beliefs, and educating communi-ties on these issues. As trusted and influential figures of the society, the knowledge and actions of Buddhist monks can greatly influence the perceptions and behaviours of the general public towards sex trafficking victims, former sex workers, and persons living with HIV/AIDS. Thus, it is crucial that Buddhist monks are educated, not only on Bud-dhist scriptures and philosophy, but also on basic social issues and development chal-lenges affecting the Vietnamese society.  The Government of Vietnam can also develop a program that helps connect local organizations and service providers to local Buddhist temples. A strong collaboration between local organizations and Buddhist temples is crucial to the delivery of support services to afflicted individuals, and also the effectiveness of the services. Nonetheless, it is difficult for local organizations and Buddhist temples to find each other and connect without a foundation. This government platform can inform local organizations and ser-vice providers of available local Buddhist temples that are also interested in helping, or are already offering some mental health services to community members. Then, local organizations can approach Buddhist temples to initiate collaboration. Local organiza-tions and service providers may have certain infrastructure, resources, and qualifica- 41 tions to carry out programs that can benefit victims of sex trafficking such as victim iden-tification, victim assessment, legal support, vocational training, amongst others. Howev-er, Buddhist temples carry certain strengths that may put them in a better position to de-liver services such as mental and emotional support, as well as informal education and advocacy work. Buddhist temples, just like grassroots organizations and local non-governmental organizations, are close to the local communities and people. Thus, a strong collaboration between local organizations and Buddhist temples will lead to the development and implementation of activities and programs that are best suited to the characteristics, cultures, conditions, and specific needs of the local people.    Nonetheless, we should bring into consideration the complex relationship be-tween the Government of Vietnam and organized religions. In Buddhist countries like Thailand, Cambodia, and Myanmar, it could make sense for a program like this to re-ceive state endorsement. In Vietnam, however, there has been tension in the past, be-tween the government and religious institutions that still exists today. Organized reli-gions are often perceived as a threat to the control and legitimacy of the government. But in this paper, I would like to reason that the relationship does not have to be so complex, especially in allowing Buddhist institutions to provide certain social programs, such as mental, emotional and spiritual support to the marginalized population such as victims of sex trafficking and sexual exploitation. Drawing from a research conducted in China by Dr. André Laliberté in 2012, a country with a political system and perception of organized religions similar to that of Vietnam, relations between the Chinese govern-ment and religious institutions are becoming more complementary in recent years. Bud-dhist institutions have developed into important providers of social services and  42 healthcare. He argues that Buddhist associations in China contribute to nurturing high levels of civility by expressing a preference for stability and social harmony, rather than pressuring the Chinese government to engage in political reforms.57   In the area of helping sex trafficking victims and educating the public on these challenges, Buddhist associations and other religious institutions can act as substitute to compensate for the country’s lack of capacity in financial and human resources. In Vietnam, it is the lack of formal mental and emotional health support that can provide a space for Buddhist institutions to step in. As previously mentioned, counselling and mental health services are not the norm in Vietnam. Thus, there are very few profes-sionals trained in this field, and access to formal mental health services is limited. Sex trafficking victims and former sex workers, especially those living with HIV/AIDS, are in desperate need of mental and emotional health assistance to help them recover from their experiences, trauma and diagnoses, which will help them reintegrate back into their communities. Without any support for their mental and emotional health, victims of trafficking suffer from serious psychological conditions. In addition, without sufficient ed-ucation on human trafficking, sexual exploitation and HIV/AIDS, the general public, es-pecially the home communities of the victims, continue to carry a distorted view of their experiences. Thus, besides the deterioration of their mental health, victims are also al-ienated and trivialized. As a result, many choose to go back to the sex trade due to the inability to reintegrate back to their home communities. Others may engage in other illic-it and criminal activities such as drug trafficking and sometimes even human trafficking. These are social tensions that can be reduced if the government collaborates with reli-                                                 57 André Laliberté, “Buddhist Charities and China’s Social Policy: An Opportunity for Alternate Civility?” Archives the sciences sociales des religions 158 (2012), p. 96-110.  43 gious associations, giving them support and limited responsibilities to carry out social services to help victims of sex trafficking. Moreover, a strong collaboration between the government and religious organizations tend to strengthen the resilience of the current regime, rather than undermine it with demands.58  4.3 Conclusion  In this paper, I have briefly reviewed the human trafficking situation in Vietnam, and provided a more extensive picture of the lives of sex trafficking victims after they leave the sex industry. A lot of girls and women forced into the sex industry are also liv-ing with HIV/AIDS due to the frequent exposure to sexual abuse and harmful practices that lead to the transmission. The abuse continues in their post-trafficking lives due to the stigma that surrounds their sex work experience, and also their HIV-positive status. This double stigma can sometimes lead to major depressive disorders and suicidal ideation, which also contributes to the deterioration of their overall well-being and productivity. Mental and emotional support is extremely important to the recovery and reintegration of victims of trafficking. Without sufficient mental and emotional support, victims may neglect their overall well-being, their lives, engage in self-destructive be-haviours, and even commit suicide to escape their sufferings. Many unassisted women and girls choose to go back to the sex industry due to the inability to recover from their experiences and reintegrate back to their communities.   Local organizations and service providers working with human trafficking victims lack the financial and human resources to meet the mental and emotional needs of sex trafficking victims. Counselling and mental health services are not the norm in Vietnam.                                                  58 Ibid., p. 114.  44 Thus, there are very few professionals trained in this field, and access to formal mental health services is limited. In the absence of formal counselling and support system, some service providers offer informal and alternative types of mental and emotional health support. In Vietnam, Buddhist temples are in a powerful position to help improve the mental and emotional well-being of victims of sex trafficking and persons living with HIV/AIDS. Buddhist monks are highly respected and perceived as the spiritual leaders and moral support of the community. Buddhist temples are also located in local com-munities and thus, they have a very close relationship with community members, who also place great trust in the temples. Thus, my paper argues that Buddhist temples and monks should be encouraged and given more incentives and responsibilities to play a larger role in improving the mental and emotional well-being of victims of sex trafficking. The Vietnamese government can provide financial aid directly to Buddhist temples to carry out these services. If this option is not viable, the government can provide aid to local organizations that have connections with Buddhist temples so they can collaborate in the areas of: (i) spiritual support; (ii) social support; and (iii) community education and advocacy. In order for the collaboration to be effective and meaningful, the Vietnamese government must establish a program that connects local organizations to local Bud-dhist temples that are interested in helping. 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