When most people think of human trafficking, they think of forced prostitution, child labor, or something similar. Slavery is often thought of as a blight in US history, something very far in the past. Yet, human trafficking is very well alive today in the US, and many of us in healthcare have probably encountered a victim. Human trafficking is much more than you may think. According to the FBI, human trafficking is, in fact, the third (or possibly the second depending on the source) largest crime across the globe. The bureau classifies human trafficking as:
  • Forced labor: Persons are coerced to work in some service or industry.
  • Domestic sex trafficking of adults. Persons are forced into prostitution through fraud, force, or coercion.
  • Sex trafficking of international adults and children. International adults or children are forced, coerced, or swindled into commercial sexual acts with a link to the US.
  • Domestic servitude. Domestic or international persons are forced or coerced into domestic servitude for families or households.
Around the world, it is estimated that there are over 12 million victims of human trafficking, although less than 1% have been identified. Another source estimates that there are 27 million adults and 13 million children who are victims. Clearly, human trafficking is a well-hidden crime, and accurate statistics are difficult to ascertain. In the US, victims have been found across the nation, with the highest rates identified in California. Other states with the highest incidence rates include Texas, New York, and Florida. Of all victims, almost 80% are used for commercial sex and 19% for labor exploitation. It has additionally been estimated that over 50% of victims are children. Countries that appear most valued as destination countries of trafficked persons include Germany, Greece, Israel, Japan, Turkey, Thailand, the Netherlands, and the US. The recruiter is known to the victim in approximately 46% of cases. According to FBI estimates, 100,000 women and children are currently trafficked every year in the US with an average age of 11 years old. Victims of human trafficking are kept in servitude in various ways. Many are lured by false promises of good jobs and better lives. Women are more vulnerable, as they are seen as inferior in status and have less opportunities in many places around the world. Many victims experience physical and psychological abuse. This can include beatings and sexual abuse. Food and sleep deprivation is often utilized, as well as threats against the victim and their  family members. Victims are typically kept in isolation from others, and their freedom of movement is taken away. Sectors where trafficked persons are commonly utilized include domestic help, construction, sweatshops, pornography/sex, ranch/farm work, restaurants, janitorial services, and nail salons. As medical professionals, it is important to note that approximately 87% of trafficking victims have accessed the healthcare system during their captivity. What is truly frightening is that only approximately 10% of physicians recognize a human trafficking victim, and less than 3% of emergency room doctors receive any training in recognizing them. In one estimation, there are 1 million adult and 400,000 child trafficking victims living in the US. When doctors suspect human trafficking, the laws are not clear what to do next as due to variance between states. Also, by reporting, a doctor could potentially be placing a patient in more danger. Victims of human trafficking come from all socioeconomic classes and all educational levels. However, risks factors for victimization have been identified. Homeless and runaway children are at high risk of victimization. Foreign nationals are also highly susceptible. Recruiters from their home countries make them financially indebted to them. Additionally, these victims are exploited by their lack of understanding in the culture and limited English skills. They don’t know their rights or the laws or even how to navigate their surroundings. Past victims of violence and trauma, such as domestic violence or sexual assault, are also more vulnerable and often targeted by traffickers. As medical professionals, we need to be aware of human trafficking and that many of the victims may come to us for medical care. They cannot speak out, so it is imperative that we learn the warning signs:
  • Patient does not have freedom of movement. They are often accompanied by their abuser to their medical appointments and are not free to come alone. The trafficker may speak for the patient and/or the patient may looks to the before speaking.
  • Patient works long hours with no breaks and low pay. As part of a medical visit, we were taught to always take a work history. A patient who is working more than 10 hours per day, 7 days per week is definitely one we should pay special attention to.
  • Patient appears unduly anxious or fearful.
  • Patient avoids eye contact.
  • Patient becomes overly fearful when law enforcement is mentioned.
  • Patient appears malnourished.
  • Patient shows signs of physical and/or sexual abuse, physical restraint, torture, or confinement.
  • Patient shows signs of no medical/dental care.
  • Multiple sexually transmitted diseases.
  • Unusual tattoos. Some traffickers like to brand their victims.
  • Few or no personal possessions.
  • Has no control over their own finances.
  • Unable to vocalize why they are there.
  • Confused as to what city or location they are in.
  • Loss of time sense.
  • Variations in their story.
  • Employer is holding the patient’s passport or other identifying documents.
  • Answers appear scripted or rehearsed.
  • Under 18 and involved in prostitution.
Other signs include patients who pay cash and do not give insurance information, substance abuse, symptoms of withdrawal, lies about age/name/personal information, and no address given. If you suspect that someone may possibly be a victim of human trafficking, some important questions to ask include:
  • Do you have your passport or other identification documents? If not, who does?
  • Are you in debt to your employer?
  • Are you allowed to leave your job if you don’t like it?
  • Can you come and go wherever you want?
  • Have you or your family been threatened?
  • Do you live with your employer? What are your living arrangements?
  • Where do you eat and sleep?
  • Is anyone hurting you?
  • Do you feel safe?
If a victim is a child, it is mandatory that doctors report this. However, the same is not so clear with adult victims, and the laws vary across states. How do you evaluate/treat a possible human trafficking victim?
  • Speak to the patient alone.
  • Conduct a complete examination, including STD screening and pregnancy test where indicated.
  • Evaluate and treat injuries.
  • Provide prophylaxis against STDs.
  • Ensure follow-up care is established.
  • Take steps to ensure patient safety.
  • Contact law enforcement.
  • Give community referrals for safe housing, etc.
  • Call the national human trafficking hotline: 888-373-7888.
Outside the obvious trauma, victims of human trafficking suffer many physical, social, and emotional harms. They are often alone and kept isolated on purpose. Imagine, for example, coming to a foreign country because you want to make a better life for your children. You are given promises that this will happen, and you are given hope, despite the poverty you are surrounded with. And then you come to the country where you don’t know the language or culture or even where you are. Your employer takes your passport and places a huge financial debt on your head that you will never be able to pay off. You are forced to work long hours, you may sometimes get paid or maybe not. You may need medical care, but you are denied. Your boss takes over ever aspect of your life, and you are no longer free, even to just go for a walk outside your home. You are abused and neglected. You and your family are threatened. You cannot go to the police, because you don’t know the laws in the country and may in fact view the police as the enemy. In order to control you, the boss keeps you isolated, away from all other people. You came with your dreams and instead found your nightmares. No one is going to help. Imagine that, and realize there are numerous victims in the US, many of whom come to us for medical care. We may be their only hope; their last chance. Are we going to fail them too? Are we going to be part of the silence that allows slavery to exist and flourish in the 21st century? I think it has gone on long enough. We are doctors and need to educate ourselves so that we do not harm our patients by ignoring their suffering. It is time to step up and help end lives destroyed and lost so others make billions of dollars of profits every year. It is so easy to look the other way and not follow our suspicions. But those who do are part of the problem. Note: The statistics found researching this article varied greatly depending on the source.
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