Human Trafficking Is a Health Care Issue

INTRODUCTION

Human trafficking is a devastating crime and a profound violation of human rights.¹ As a local, national, and global health problem, it is a $150 billion industry representing the second largest source of income for organized crime.¹ A 2022 report by the International Labour Organization found that 50 million people worldwide are victims of human trafficking.² Female victims continue to be disproportionately affected.³ For every 10 victims detected globally, 5 are adult women and 2 are girls. About one-third of detected victims are children, both girls and boys, while 20% are adult men.³

Even though victims are typically isolated, many will seek medical treatment. Studies have found that up to 88% of victims come into contact with the health care system while being trafficked.¹ The most frequented health care settings/professionals include emergency departments, primary care physicians, dentists, obstetrician-gynecologists, and women’s reproductive health care clinics (eg, Planned Parenthood).⁴ Despite interactions with the health care system, a study found that over 76% of patients were unidentified due to lack of inquiries by health care providers.⁴

Common concerns that prompt contact with the health care system include infectious diseases, injury from physical violence, sexual abuse, malnutrition, dental disease, posttraumatic stress disorder (PTSD), anxiety, depression, or substance use disorders.¹ Many of these concerns may lead to necessary medications and contact with a member of the pharmacy team. Pharmacists and pharmacy technicians must be equipped with the necessary training and knowledge to identify and respond to the needs of victims of human trafficking.

DEFINING HUMAN TRAFFICKING

The United Nations defines human trafficking as “the recruitment, transportation, transfer, harboring or receipt of people through force, fraud, or deception, with the aim of exploiting them for profit.”⁵ The crime of human trafficking consists of 3 core elements: the act, the means, and the purpose.⁶ All 3 elements are essential to constitute the crime of human trafficking.⁶ Figure 1 illustrates these elements.^6,7

Human trafficking can take place even if the victim initially consented to providing labor, services, or commercial sex acts.⁷ The definition of trafficking is focused on the trafficker’s conduct and not that of the victim. The trafficker’s exploitation of the victim is what matters.⁷

Types of Human Trafficking

The United States (US) recognizes 2 primary forms of trafficking in persons: labor and sex trafficking.⁷

Labor Trafficking

Labor trafficking, also referred to as forced labor, means “all work or service which is exacted from any person under the menace of any penalty and for which the said person has not offered himself voluntarily.”² Coercion may take place during the worker’s recruitment process to force them to accept the job or, once the person is working, to force them to do tasks that were not part of what was agreed to at the time of recruitment, or to prevent them from leaving the job.²

Traffickers can commit this crime in any sector including, but not limited to, agricultural fields, factories, restaurants, hotels, massage parlors, retail stores, fishing vessels, mines, private homes, or drug trafficking operations.⁷ Forced labor is a concern regardless of a country’s wealth with more than half of all forced labor occurring in either upper middle-income or high-income countries.²

Forced Child Labor

Although some children may legally engage in certain forms of work, forcing or coercing children to work is illegal.⁷ Some indicators of forced child labor include situations in which the child appears to be in the custody of a nonfamily member and the child’s work financially benefits someone outside the family; or the denial of food, rest, or schooling to a child who is working.⁷

Another manifestation of human trafficking occurs when government forces or any nonstate armed group (NSAG) unlawfully recruits or uses children through force, fraud, or coercion as soldiers or for labor in conflict situations.⁷ Children can become involved in direct combat roles; become cooks, cleaners, porters, intelligence gatherers, spies, sex slaves; or be used in acts of terror.⁸

Sex Trafficking

Sex trafficking occurs when a trafficker uses force, fraud, or coercion to compel another person to engage in a commercial sex act or causes a child to engage in a commercial sex act.⁷ In cases where an individual engages in any sex act with a child (under the age of 18 years), the means is irrelevant regardless of whether there is evidence of force, fraud, or coercion—the act is illegal. Sex trafficking can take place at many sites, including private homes, massage parlors, hotels, brothels, and on the internet.⁷

Forced Marriage

Forced marriage is a human rights violation and a harmful practice that leads to physical, mental, and/or sexual abuse.² The number of men, women, and children living in forced marriages continues to rise globally. Two in 5 of those forced to marry were children when the marriage took place. Among these children, 41% were forced to marry before the age of 16 years.²

Although forced marriage can occur in any person, it is a highly-gendered practice.² More than two-thirds of those forced to marry are female. It is often underpinned by patriarchal norms where a girl’s value is seen to lie in her future role as a mother and wife and, in turn, is perceived to hold little economic value. Once forced to marry, there is a greater risk of further exploitation including sexual abuse (forced sexual intercourse with someone other than the spouse may occur); forced child-bearing; forced to work outside of the home while surrendering wages to the family; and forced domestic labor over what is reasonable to maintain a home.²

RISK FACTORS

Certain risk factors exist among victims of human trafficking that are common in both sex and labor trafficking.⁹ These risk factors are displayed in Table 1.^9,10

It is important for pharmacists and pharmacy technicians to be able to identify the risk factors among adolescents for labor and sex trafficking, since they are among the most vulnerable populations (Table 2).¹¹

HEALTH CONSEQUENCES

Most individuals who are trafficked are exposed to health risks before, during, and after the period of exploitation.¹² Their prior and present victimization amounts to a wide range of health consequences that can extend throughout their lifetime,⁴ as they continue to experience extreme stress reactions that affect physical, sexual, psychological, and social functioning.¹² Table 3 summarizes some of the basic categories of health risks as well as their health consequences in both labor and sex trafficking.¹²

Health Consequences Specific to Sex Trafficking

Most evidence of the adverse health effects due to sex trafficking primarily applies to women and girls.¹²

The health consequences of sexual trafficking include¹²:

• Abdominal pain
• Back pain
• Dental problems
• Dizziness
• Eating disorders
• Fatigue
• Headaches (most prevalent and enduring physical symptom)
• Memory loss
• Sexually transmitted infections (STIs)
• Sleep disturbance/insomnia
• Weight loss.¹²

Health Consequences Specific to Labor Trafficking

Those who are victims of labor trafficking are usually in situations where health and safety standards are extremely low.¹²

The common health problems identified in this population include¹²:

• Accidental injuries (eg, broken bones, concussions)
• Dehydration
• Exhaustion
• Gastrointestinal (GI) infection (water- and food-related)
• Heatstroke/stress
• Hypothermia/frostbite
• Malnutrition
• Occupational skin diseases (eg, skin cancer, skin infections)
• Repetitive motion disorders (eg, tendonitis, bursitis)
• Respiratory problems (eg, lung cancer, asbestos contamination).¹²

Psychological Health Consequences

In the most extreme cases, the psychological reaction of trafficked victims can be compared to torture victims.¹²

Common posttrauma responses include¹²:

• Anxiety
• Depression
• Hostility
• Irritability
• PTSD
• Suicidal ideation/suicide attempts.¹²

BARRIERS TO DISCLOSURE

There are several factors that serve as barriers to disclosing trafficking to health care providers. These factors include⁴:

• Distrust (may be due to a previous negative experience in the health care system)
• Fear of law enforcement involvement
• Fear of traffickers’ retaliation
• Lack of competency/professionalism from health care providers (eg, lack of empathy, judgmental attitude, missing red flags)
• Lack of privacy during the visit
• Limited ability to speak English
• Shame
• Traffickers’ control of the visit (eg, dominating the conversation; threats to victim/family if disclosure occurs; waiting outside to prevent escape).⁴

Due to these barriers, pharmacy staff must have a low threshold of suspicion for indicators of human trafficking. Table 4 lists red flags that indicate human trafficking.¹³

TRAUMA-INFORMED CARE APPROACH

There is wide consensus among experts across the field of trauma and adult human trafficking that trauma-informed principles should be incorporated into the assessment of potential victims of human trafficking.¹⁴ This is especially critical to avoid retraumatization. Retraumatization is any situation or environment that resembles an individual’s trauma triggering feelings and reactions associated with the original trauma.¹⁵ An in-depth account of the trauma experience during an interview is not necessary to determine if resources are needed, and this may lead to victim retraumatization.¹⁴

Trauma-Informed Care follows the “Five Guiding Principles” that serve as a framework to reduce the likelihood of retraumatization.¹⁵ These are illustrated in Table 5.¹⁵

ASSESSMENT OF VICTIMS OF HUMAN TRAFFICKING

Interviewing a person who has been trafficked raises a number of ethical questions and safety concerns.¹⁶ The World Health Organization (WHO) has developed recommendations based on a set of 10 guiding principles for the ethical and safe conduct of interviews with women who have been trafficked (Table 6).¹⁶ Even though the recommendations are focused on female victims, they also apply to other victims of human trafficking.¹⁷

Conducting the Interview

WHO recommends 4 stages to the interview process.¹⁶ These stages are discussed below.

Stage 1: Making the initial contact. To avoid putting an individual at risk of exposure, the pharmacist may wish to say that the interview is on a more neutral subject, such as "health."¹⁶ Another helpful tip to get the individual alone is to tell the trafficker that store policy does not permit others in the consultation room or say the individual needs a procedure that must be conducted in private (eg, a medical exam, X-ray). Once alone, detailed information on the true nature of the interview must be provided as part of the informed consent procedure.¹⁶

Stage 2: Identify time and place. Interviews must be in a completely private setting.¹⁶ Before and throughout the interview, the victim should be free to reschedule or relocate the interview to a time or place that may be safer or more convenient. Clarify how much time the individual will have so as to not cause additional problems (ie, the trafficker may be upset by a delay).¹⁶

Stage 3: Conducting the interview. Begin the interview by explaining the precautions being taken to protect the victim’s identity and to keep personal details strictly confidential.¹⁶ Be sure informed consent is obtained before proceeding (see Table 6). Before any advice is offered or intervention put into action, a discussion must take place that includes how the victim sees the situation; the risks and benefits of various options; and the best time to make changes.¹⁶

During the interview, watch for behavioral indications that the respondent no longer feels at ease or wishes to terminate the discussion.¹⁶ Be prepared to change the subject; provide an emergency break; or close the interview if conditions become unsafe.¹⁶

Stage 4: Closing the interview. If possible, interviews should end in a positive manner.¹⁶ The pharmacist may remind the individual of how they coped in such difficult circumstances and how helpful they have been with providing information that can be used to help others. Referral information and resources should be offered at this point.¹⁶ Always ask the individual if they want a referral, as this allows them to have a sense of agency and choice.¹⁴ All victims should be granted time and space to make their own decisions.¹⁶ Not all victims will be ready to accept an intervention, in such cases pharmacists must respect their choices.¹⁶

When conducting the interview, the pharmacist should keep the following in mind¹⁶:

• Allow the respondent to control the direction of the interview
• Never push a distressed respondent to continue
• Be sensitive with questions relating to family/children as many have been forced to move away from their family and this subject may be upsetting
• Law enforcement should only be engaged with the consent of the individual unless that individual is a child, in which case the pharmacist is obligated to report abusive situations.¹⁶

Table 7 provides additional tips the pharmacist can use to help build a relationship with the individual being interviewed.¹⁴

If an individual declines the interview, provide them with written resources for partnering agencies/organizations and/or the contact information for the National Human Trafficking Hotline (discussed below).¹⁴ Pharmacy staff should familiarize themselves with location-specific resources such as social workers; specialty clinics to care for patients experiencing abuse; and local organizations who provide patients with additional social services.¹⁴

Adult Human Trafficking Screening Tool

The National Human Trafficking Training and Technical Assistance Center developed a screening tool with questions that include indicators often seen in both labor and sex trafficking.¹⁴ The tool contains 8 questions and can be administered with minimal training in a face-to-face interview. The use of closed-ended questions that require simple “yes” or “no” answers make lengthy dialogue and detailed disclosure of the trauma unnecessary, avoiding the potential of victim retraumatization.¹⁴

The tool contains the following 8 questions¹⁴:

1. Sometimes lies are used to trick people into accepting a job that doesn’t exist, and they get trapped in a job or situation they never wanted. Have you ever experienced this, or are you in a situation where you think this could happen?
2. Sometimes people make efforts to repay a person who provided them with transportation, a place to stay, money, or something else they needed. The person they owe money to may require them to do things if they have difficulty paying because of the debt. Have you ever experienced this, or are you in a situation where you think this could happen?
3. Sometimes people do unfair, unsafe, or even dangerous work or stay in dangerous situation because if they don't, someone might hurt them or someone they love. Have you ever experienced this, or are you in a situation where you think this could happen?
4. Sometimes people are not allowed to keep or hold on to their own identification or travel documents. Have you ever experienced this, or are you in a situation where you think this could happen?
5. Sometimes people work for someone or spend time with someone who does not let them contact their family, spend time with their friends, or go where they want when they want. Have you ever experienced this, or are you in a situation where you think this could happen?
6. Sometimes people live where they work or where the person in charge tells them to live, and they’re not allowed to live elsewhere. Have you ever experienced this, or are you in a situation where you think this could happen?
7. Sometimes people are told to lie about their situation, including the kind of work they do. Has anyone ever told you to lie about the kind of work you’re doing or will be doing?
8. Sometimes people are hurt or threatened, or threats are made to their family or loved ones, or they are forced to do things they do not want to do in order to make money for someone else or to pay off a debt to them. Have you ever experienced this, or are you in a situation where you think this could happen?¹⁴

If the respondent answered YES to any of the questions, this may indicate a risk for current, former, or future trafficking.¹⁴ For information about the recommended training to administer the Adult Human Trafficking Screening tool, contact the National Human Trafficking Training and Technical Assistance Center at info@nhttac.org or 844–648–8822.¹⁴

REPORTING HUMAN TRAFFICKING

To report information about a trafficking situation, the pharmacy staff should contact the National Human Trafficking Hotline. The hotline is a 24/7, multilingual resource for victims, survivors, and witnesses of human trafficking.¹⁸ The hotline provides assistance to individuals in crisis through safety planning, emotional support, and/or immediate connections to emergency services. The hotline facilitates reporting to specialized human trafficking task forces, federal authorities, local law enforcement, and service providers throughout the country.¹⁸

All communication with the hotline is strictly confidential to the extent permitted by law.¹⁸ A tip can be reported anonymously, in which case the Trafficking Hotline will protect anonymity when sharing information about a potential trafficking case with authorities. The hotline can be reached¹⁸:

• By phone: 1-888-373-7888 (toll-free)
• By email: help@humantraffickinghotline.org
• By text: text HELP to 233733 (BEFREE)
• Online chat:humantraffickinghotline.org

Pharmacists should be familiar with the laws related to the mandated reporting of human trafficking relevant to their state. Legal requirements for health care professionals reporting human trafficking can be found at: https://www.aha.org/system/files/media/file/2021/01/Introduction-to-Human-Trafficking-and-Health-Care-Providers-Legal-Requirements-for-Reporting-and-Education.pdf

RESOURCES AND REFERRALS

The following sections provides a list of resources for those who are impacted by human trafficking.

National Human Trafficking Online Referral Directory

The directory provides access to emergency, transitional, and long-term social services for victims and survivors of human trafficking. Frequently requested referrals include case management, shelter, transportation, legal services, and mental health care. The directory can be accessed at: https://humantraffickinghotline.org/en/find-local-services

Office on Trafficking in Persons

The Office on Trafficking in Persons provides a list of federal services available to help victims of trafficking. The site can be accessed at: https://www.acf.hhs.gov/otip/victim-assistance/services-available-victims-trafficking

Administration for Children and Families

This government agency provides mental health resources for those impacted by human trafficking, including resources for health care professionals. The site can be accessed at: https://www.acf.hhs.gov/blog/2021/10/mental-health-resources-human-trafficking-survivors-and-allies

US Citizenship and Immigration Services

This federal agency provides information and resources for immigrants who have been subjected to human trafficking, including how to apply for visas. The site can be reached at: https://www.uscis.gov/humanitarian/victims-of-human-trafficking-and-other-crimes

KNOW THE LINGO

Human trafficking has a dialect unique to traffickers and victims.¹⁰ Being familiar with trafficking vocabulary will help the pharmacy staff relate to and understand individuals who have been trafficked. Common trafficking lingo are listed in Table 8.¹⁰

HELPFUL COMMUNICATION MESSAGES

Communicating with victims of human trafficking can be intimidating for health care professionals. The US Department of Health and Human Services (HHS) created a resource called Messages for Communicating With Victims of Human Trafficking to assist health care providers in building a rapport with the victim and promoting a trusting environment.¹⁹ Gaining the trust of trafficking victims is an important first step in facilitating disclosure and providing assistance.¹⁹

Sample messages the pharmacy staff can use to help gain this trust include¹⁹:

• We are here to help you
• Our first priority is your safety
• We can find you a safe place to stay
• You have a right to live without being abused
• You deserve the chance to become self-sufficient and independent
• We can help get you what you need
• You can trust me
• We want to make sure what happened to you doesn’t happen to anyone else
• You have rights
• You are entitled to assistance. We can help you get assistance
• You can receive help to rebuild your life safely in this country.¹⁹

HUMAN TRAFFICKING MYTHS/MISPERCEPTIONS

Myths or misperceptions often lead to missed opportunities to identify victims.¹⁰ Being aware of these myths is essential for health care personnel. This is especially true for those who are at the first point-of-contact, as is the case with the pharmacy technician, who is often the first to greet the patient. It is important to be aware of the following myths/misperceptions^10,20:

• Trafficking is always a violent crime (many times psychological manipulation is used instead of violence)
• Trafficking in persons is a crime that occurs in a faraway place (it occurs in every state in the US)
• Only undocumented foreign nationals get trafficked in the US (many foreign victims are legally living and/or working in the US)
• Trafficking only occurs in big cities (it can occur anywhere, including rural areas/suburbs)
• Trafficking only happens in illegal or underground industries (it has been documented in restaurants, cleaning services, construction, factories, etc.)
• All human trafficking involves commercial sex (experts believe worldwide there are more situations of labor trafficking than of sex trafficking)
• Only women and girls can be victims of sex trafficking (males are at risk, including LGBTQ boys and young men, who are particularly vulnerable to trafficking)
• An individual who is free to come and go is not the victim of human trafficking (bonds can be psychological or physical threats)
• Human trafficking involves moving, traveling, or transporting a person across state or national borders (this is human smuggling—trafficking does not require movement)
• All commercial sex is human trafficking (involving a child yes; involving an adult it is considered trafficking only if it is being done against his/her will as a result of force, fraud, or coercion)
• If the trafficked person consented to the initial situation, then it cannot be human trafficking or against their will (initial consent prior to acts of force, fraud, or coercion is not relevant to the crime)
• People being trafficked are physically unable to leave their situation, locked in, or held against their will (manipulation, having no safe place to go, or fear/threats also occur; chains of trafficking can be invisible)
• Labor trafficking is only a problem in developing countries (it still occurs in the US and other developed countries)
• Traffickers target victims they do not know (traffickers can include romantic partners or family members)
• Individuals in the legal system are “just criminals” (taking this viewpoint may miss the individual who has been forced into illegal activities by a trafficker).^10,20

CONCLUSION

Understanding the issue of human trafficking and its complexities is extremely challenging for health care professionals. Caring for individuals who have been trafficked requires special attention to their health, safety, and long-term well-being. Practicing “Trauma-Informed Care” can help victims of trafficking regain a sense of safety, dignity, and control while empowering them to seek help. Pharmacists and pharmacy technicians can help foster feelings of security, self-esteem, and self-determination by adopting approaches to care that emphasize confidentiality, information-giving, informed consent, and respect for individual decision-making.

REFERENCES

1. McAmis NE, Mirabella AC, McCarthy EM, et al. Assessing healthcare provider knowledge of human trafficking. PLoS One. 2022;17(3):e0264338. doi:10.1371/journal.pone.0264338
2. Global Estimates of Modern Slavery: Forced Labour and Forced Marriage. International Labour Organization (ILO), Walk Free, and International Organization for Migration (IOM). September 2022. Accessed November 6, 2023. https://www.ilo.org/wcmsp5/groups/public/---ed_norm/---ipec/documents/publication/wcms_854733.pdf
3. Global Report on Trafficking in Persons 2020. United Nations Office on Drugs and Crime (UNODC). January 2021. Accessed November 6, 2023. https://www.unodc.org/documents/data-and-analysis/tip/2021/GLOTiP_2020_15jan_web.pdf
4. Richie-Zavaleta AC, Villanueva A, Martinez-Donate A, Turchi RM, Ataiants J, Rhodes SM. Sex trafficking victims at their junction with the healthcare setting—a mixed-methods inquiry. J Hum Traffick. 2020;6(1):1-29. doi:10.1080/23322705.2018.1501257
5. Human trafficking. UNODC. Accessed November 6, 2023. https://www.unodc.org/unodc/en/human-trafficking/human-trafficking.html
6. The crime. UNODC. Accessed November 6, 2023. Accessed November 7, 2023. https://www.unodc.org/unodc/en/human-trafficking/crime.html
7. Trafficking in Persons Report. US Department of State. June 2023. Accessed November 7, 2023. https://www.state.gov/wp-content/uploads/2023/09/Trafficking-in-Persons-Report-2023_Introduction-V3e.pdf
8. Child soldiers: what you need to know. World Vision. February 5, 2021. Accessed November 7, 2023. https://www.wvi.org/stories/child-protection/child-soldiers-facts-and-foundations
9. Clawson HJ, Dutch N, Solomon A, Goldblatt Grace L. Human Trafficking Into and Within the United States: A Review of the Literature. Office of the Assistant Secretary for Planning and Evaluation (ASPE). August 29, 2009. Accessed November 8, 2023. https://aspe.hhs.gov/reports/human-trafficking-within-united-states-review-literature-0
10. Toney-Butler TJ, Ladd M, Mittel O. Human trafficking. In: StatPearls [Internet]. StatPearls Publishing; 2023. Updated June 11, 2023. Accessed November 8, 2023. https://www.ncbi.nlm.nih.gov/books/NBK430910/
11. Human trafficking in America’s schools. National Center on Safe Supportive Learning Environments. Accessed November 8, 2023. https://safesupportivelearning.ed.gov/human-trafficking-americas-schools/risk-factors
12. Caring for Trafficked Persons: A Guidance for Health Care Providers. International Organization for Migration (IOM). November 6, 2015. Accessed November 8, 2023. https://publications.iom.int/books/caring-trafficked-persons-guidance-health-providers
13. “Red flags” that may indicate human trafficking. National Human Trafficking Training and Technical Assistance Center (NHTTAC). Accessed November 8, 2023. https://nhttac.acf.hhs.gov/system/files/2022-11/Red%20Flags_35533_Updating_SOAR_handouts_v02(c)_508.pdf
14. Adult Human Trafficking Screening Tool and Guide. NHTTAC. January 2018. Accessed November 9, 2023. https://nhttac.acf.hhs.gov/sites/default/files/2018-07/adult_human_trafficking_screening_tool_and_guide.pdf
15. What is Trauma-Informed Care? Buffalo Center for Social Research. Institute on Trauma and Trauma-Informed Care. Accessed November 9, 2023. https://socialwork.buffalo.edu/social-research/institutes-centers/institute-on-trauma-and-trauma-informed-care/what-is-trauma-informed-care.html
16. WHO Ethical and Safety Recommendations for Interviewing Trafficked Women. World Health Organization (WHO); 2003. Accessed November 8, 2023. https://iris.who.int/bitstream/handle/10665/42765/9241546255.pdf?sequence=1
17. Toolkit to Combat Trafficking in Persons. 2006. Accessed November 9, 2023. https://www.unodc.org/documents/human-trafficking/HT-toolkit-en.pdf
18. National Human Trafficking Hotline (NHTH). Office on Trafficking in Persons. Updated October 2019. Accessed November 9, 2023. https://www.acf.hhs.gov/otip/victim-assistance/national-human-trafficking-hotline
19. Resources: Messages for communicating with victims of human trafficking. US Department of Health and Human Services. Accessed November 10, 2023. https://www.acf.hhs.gov/sites/default/files/documents/orr/communicating_with_victims_of_human_trafficking.pdf
20. Myths & facts. NHTH/Polaris. 2023. Accessed November 10, 2023. https://humantraffickinghotline.org/en/human-trafficking/myths-facts

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