Human Trafficking: The Role of Medicine in Interrupting the Cycle of Abuse and Violence.

Human trafficking is a modern form of slavery involving the appropriation, control, and exploitation of humans for profit. It is an egregious human rights violation, and under the Victims of Trafficking and Violence Protection Act of 2000 (1) and its subsequent reauthorizations (Table 1), it is also a federal crime in the United States. Of note, U.S. studies have found that up to 88% of trafficked persons seek medical care while being exploited (2). Internal medicine physicians knowledgeable about the clinical presentations of human trafficking can play a key role in mitigating its devastating effects. Table 1. Victims of Trafficking and Violence Protection Act of 2000* Although the clandestine nature of this crime precludes exact prevalence figures, the International Labor Organization estimated in 2012 that about 20 million persons worldwide are victims of forced labor and sexual exploitation; most are women and girls (55%), and more than one quarter are children younger than 18 years (26%) (3). Human trafficking generates an estimated $150 billion (in U.S. dollars) in annual profits globally, including those from U.S.-based criminal activity (4). Human trafficking has been reported in all 50 states and the District of Columbia (5). An analysis of U.S. cases investigated between 2008 and 2010 found that 95% of confirmed labor trafficking victims were either undocumented (67%) or legal (28%) immigrants, and nearly two thirds were aged 25 years or older (62%). In contrast, confirmed victims of sex trafficking were largely U.S. citizens (83%) and younger than 25 years (87%). Further, 90.7% of all confirmed victims were femalewomen and girls accounted for 68% and 94% of confirmed labor and sex trafficking victims, respectively (6). However, it is important to note that men and boys may be underreported because of gender norms and cultural constructs of the strong male, and transgender persons have not been adequately studied because gender is a dichotomous variable in most studies. Traffickers prey on vulnerable groups, such as adolescents and young adults with a history of child abuse; involvement in child protection and welfare systems; or homelessness; and those who identify as lesbian, gay, bisexual, transgender, or queer (717). Other at-risk populations include persons with disabilities; immigrants and migrant workers; and marginalized groups, such as racial and ethnic minorities and financially insecure persons with limited education or prospects for formal employment (7, 1012, 14, 1820). Health Outcomes Trafficking victims endure a wide range of physical, reproductive, and mental health problems (2, 1012, 14, 15, 17, 2032). Acute injuries, including accidental and intentional ones leading to death, may be related to the physical demands of manual labor, lack of personal protective equipment, hazardous working conditions, physical violence, and sexual abuse. Victims are at elevated risk for recurrent sexually transmitted infections, unintended pregnancies, and forced abortions. Chronic health conditions, dental disease, and communicable diseases related to unsanitary and crowded living and working conditions may progress untreated. Food and sleep deprivation, forced substance use, and blocked access to needed medications may also contribute to poor health outcomes. Severe psychological and emotional distress from repeated threats, isolation, debasing treatment, and denied agency may lead to posttraumatic stress disorder (PTSD), complex PTSD, psychosomatic pain syndromes, substance use disorders, self-injurious behaviors, suicidal ideation, and suicide. Table 2 offers examples of health-related problems for which victims and survivors may seek medical care. Table 2. Health Problems Associated With Human Trafficking* Population Health Implications Population health research provides a glimpse into the gravity of human trafficking, confirming that it is a public health concern. In an early study, Willis and Levi (28) estimated that each year 90% of sex-trafficked children (aged <18 years) develop substance use disorders, 12% have forced abortions, and 16% attempt suicide. Some studies (2931) suggest a strong link between sex trafficking and HIV transmission. One study (14) found that 94% of domestic sex-trafficked women reported addiction to alcohol or drugs, and 100% reported at least 1 mental health problem. The severity of PTSD among trafficked persons is higher than what is seen among those affected by intimate partner violence and war or mass violence (24). Indeed, the psychological effects of human trafficking have been equated to those seen in survivors of torture (32). Clearly, human trafficking has important health implications for the spread of HIV and communicable diseases, the rising epidemic of substance use disorders, and the crippling effects of serious mental illnessall of which reverberate beyond the individual to include society at large. Although further research is needed, key epidemiologic studies in the past decade have advanced human trafficking dialogue beyond the human rights and criminal justice perspectives to the problem-solving framework of public health. This critical paradigm shift has been instrumental in expanding research and the development of policies and programs that focus on wide-scale, multisector prevention and intervention strategies. Access to Health Care Survivors repeatedly report having received medical care while being exploited (2, 33). A study of female survivors aged 14 to 60 years found that 87.8% reported having been medically evaluated at least once while trafficked, yet none were identified as being trafficked by a provider (2). The emergency department was the most commonly cited health care access point63% of survivors reported having received care there. Other points of access included primary care offices (22.5%), urgent care centers (21.4%), community health clinics (19.4%), and other reproductive health care clinics (2). Trafficking victims are also admitted to inpatient hospital units as a result of their injuries and illnesses. Personal survivor stories suggest that trafficked persons may continue to live at home, attend school, and even maintain contact with their primary care physicians (34). Thus, the evidence overwhelmingly points to many missed opportunities to prevent or interrupt the cycle of abuse and violence. As the Patient Protection and Affordable Care Act expands health care access to traditionally underserved patient populations, health care providers should be prepared to safely and appropriately respond to trafficked persons. Current research has not yielded a highly sensitive or specific clinical feature for reliable detection of at-risk or trafficked persons in the health care setting. Nonetheless, the convergence of multiple indicators should prompt further screening. Although there are no validated screening tools for human trafficking in the health care setting, providers should engage in discussions about safety, coercive relationships, and trafficking in private or with the assistance of professional medical interpreters when necessary. Providers are strongly discouraged from using accompanying persons or family members as interpreters because traffickers can either be, or pose as, a parent or other family member. Patients should be reassured that screening is routine. They should be informed about their right not to answer any questions and about the limits of confidentiality. Providers should take cues from the patient, and the interview should proceed sensitively from general questions about working and living conditions, to those about general safety and coercion, and then to those specifically about trafficking (10, 23, 26, 35). Table 3 is a condensed list of human trafficking indicators and potential screening questions. Table 3. Indicators of Human Trafficking* Barriers to Identification, Disclosure, and Assistance Trafficked persons who need medical care may present to a health care facility either alone or with their trafficker or an associate. Such a visit represents a rare window of opportunity for a trafficked person, who would otherwise have little chance of engaging in a one-on-one discussion with a trusted authority figure. However, disclosures may be hindered by a general distrust of authority; guilt or shame because of a sense of complicity; fear of judgmental treatment; threats of physical harm by the trafficker; fear of retaliation against loved ones; fear of deportation; and, in the case of minors, fear of being reported and returned to an abusive home (7, 15, 17, 21, 33, 3638). Therefore, providers should focus on building trust and rapport with patients suspected of being trafficked instead of immediately trying to obtain a disclosure. Aggressive pursuit of victim disclosure can be harmful to the patient and damage the patientprovider relationship, which may diminish the likelihood of a future disclosure. Disclosure may also be hampered by a lack of privacy. Failure to interview the patient alone or reliance on accompanying persons to communicate with nonEnglish-speaking patients may prevent the patient from disclosing exploitation even when assistance is desired. A low level of awareness and lack of training about human trafficking often render clinicians ill-prepared to recognize its signs and symptoms, screen patients who exhibit red flags, and respond to those who disclose trafficking or for whom mandatory reporting to state authorities would be indicated based on reasonable suspicion (for example, minors) (15, 17, 3841). Even clinicians with specialized training may have difficulty assisting this population if demands on their time and attention interfere with their ability to foster trust and engender the feeling of safety that victims of trafficking need to request and accept assistance (15, 17, 38). Once trafficking is identified or disclosed, barriers to assistance may include a lack of policie