A Tool for Health Professionals to Gather Data on Forced Labour and Human Trafficking
Around the world, public health officials monitor the incidence and recurrence of diseases and other conditions impacting health by using a global classification and coding system, the International Classification of Diseases (ICD). This system provides an internationally unified method of tracking symptoms, diseases, and physical injuries for which persons seek medical care. The ICD, issued by the World Health Organization (WHO) also allows researchers to determine short- and long-term adverse effects of physical conditions and external events and helps clinicians assess the effectiveness of treatment strategies.
At present, the ICD-11, the newest iteration of the classification, does not include any diagnostic health codes relating to forced labour and human trafficking, preventing the use of the global public health system to identify incidence and improve the health of victimized persons. Yet research has demonstrated diverse medical and mental health complications associated with human trafficking, and forced labour of children and adults.
Persons may experience preventable work-related injuries, traumatic injury from sexual assault, gang rape, and physical assault; sexually and non-sexually transmitted infections; chronic untreated medical conditions; malnutrition; chronic pain syndromes; complications of substance abuse; and psychosomatic complaints. Symptoms of post-traumatic stress disorder, major depression, anxiety disorders and suicidality are common.Research on the health impact, risk factors for health complications, and the cost and effectiveness of treatment is critically important in ongoing efforts to protect trafficked persons.
However, the lack of a standard method of accessing de-identified medical information about exploited children and adults thwarts efforts to gather research data. At present, relatively little is known about the incidence and severity of adverse health effects experienced by victims of different age groups and geographic locations, or among those involved in differing types of exploitation. The impact and effectiveness of many treatment interventions remain unknown. With specific ICD codes for human trafficking and forced labour, these and other critical public health issues may be addressed.
Use of specific ICD codes for research on other types of violence supports the need for codes on human trafficking. For example, a search of large medical databases for patients with codes for ‘sexual abuse’ and HIV-related diagnoses reveals information about the association between violence and infection. Similar searches might allow investigation of associations between sexual assault and other sexually transmitted infections, pregnancy, major depression and suicidality. Searches for patients with codes for both ‘child physical abuse’ and ‘fracture’ help clinicians understand which types of injuries are more likely to be associated with inflicted trauma, and subsequent record review provides critical information about risk factors for abuse (e.g. age, disability, co-morbid conditions). Results from these investigations may be used to allocate health resources, inform early identification and intervention efforts and improve patient health and well-being.
The need for an international approach
Human trafficking and forced labour take many forms, with geographic variations in the epidemiology and types of exploitation. These variations may be associated with regional differences in health trends and treatment needs. Extraordinarily high rates of HIV seroconversion documented in sex-trafficked adolescent girls from Nepal are not matched in the U.S, for example. In the Greater Mekong Subregion, where labour exploitation in fisheries is common, patients may present with injuries unique to that occupational sector. In order to prevent, identify, control, and eradicate forced labour and human trafficking, a solid global base of epidemiologic and clinical data is needed. New ICD codes will allow access to critical knowledge that will drive global health efforts and prevention strategies to address these severe human rights violations.
In 2014, a proposal for new codes on forced labour and human trafficking was submitted to WHO by the International Centre for Missing and Exploited Children (ICMEC) and HEAL Trafficking, in preparation for the release of the new global ICD-11 coding system in 2018 (to be implemented in 2022). Codes for specific types of child and adult labour and sexual exploitation were proposed, with input from the Pediatric Topic Advisory Group of WHO, and the Luxembourg Interagency Working Group (an international task force convened to design a set of terminology guidelines for the protection of children from sexual exploitation and abuse). The proposal apparently was reviewed by WHO committee members and was rejected without specific feedback.
The Need for Thoughtful Implementation
Implementation of new codes may have unintended consequences and efforts should be made to anticipate and address them. Ultimately, minimizing unintended consequences of explicit ICD codes involves recognizing the paramount importance of patient privacy, confidentiality and respect.
Stigma and bias from healthcare staff regarding ‘prostitution’, sex trafficking or forced labour exploitation may be increased when exploitation status is highlighted with an ICD code in the patient record. Patients may experience shame, anxiety or fear if they see a specific ICD code indicating exploitation. They may be concerned that their trafficker will become aware of it, realize that healthcare staff know about the exploitation and retaliate against the trafficked person. Patients may not see themselves as ‘exploited’ or ‘trafficked’ and may become distressed if they see the ICD code in their records.
To address these challenges, healthcare professionals may learn from the strategies employed by those working with child maltreatment and domestic violence. Special procedures may be adopted to create ‘confidential’ areas of the medical record (such as the privacy process used for mental health records); ICD codes may be removed from discharge instructions and other materials given to patients and families. Perhaps most importantly, staff may be educated about human trafficking, cultural sensitivity and trauma-informed care. Open discussion of the need for, and use of general ICD codes (those related and unrelated to exploitation) with a patient may also help allay fears and anxiety.
Finally, the realization that staff concerns about exploitation will appear in the chart in areas beyond the list of ICD codes should be understood by patients, families and staff. That is, the presence of the codes is not the only documentation of these issues since clinicians will have included information about exploitation in their admission, consult and/or progress notes.
Healthcare providers may be among the few professionals who have contact with sex and labour trafficked persons. It is critical that they are able to obtain and track information about the health, safety and well-being of these patients. This information may also prove critical to global prevention and intervention efforts, and achieving Sustainable Development Goal 8.7. Adoption of ICD codes that address these issues will facilitate these outcomes.
Jordan Greenbaum, MD is a child abuse physician from the United States. She is the medical director of the Global Health and Well-being Initiative with the International Centre for Missing and Exploited Children and medical director of the Institute on Healthcare and Human Trafficking at the Stephanie Blank Center for Safe and Healthy Children at Children’s Healthcare of Atlanta.
This post is part of a series of posts on the Forum brokered by HEAL Trafficking. To see the most recent piece, click here.
This article has been prepared by Christina Sambor and Murphy Barney as contributors to Delta 8.7. As provided for in the Terms and Conditions of Use of Delta 8.7, the opinions expressed in this article are those of the authors and do not necessarily reflect those of UNU or its partners.
 See Buller AM, Vaca V, Stoklosa H, Borland R, Zimmerman C. (2015) Labour exploitation, trafficking and migrant health: Multi-country findings on the health risks and consequences of migrant and trafficked workers, IOM and London School of Hygiene and Tropical Medicine; Ottisova L, Hemmings S, Howard LM, Zimmerman C, Oram S. (2016) Prevalence and risk of violence and the mental, physical and sexual health problems associated wtih human trafficking: An updated systematic review, Epidemiology and Psychiatric Sciences; Turner-Moss E, Zimmerman C, Howard LM, Oram S. (2014) Labour exploitation and health: a case series of men and women seeking post-trafficking services, Journal of Immigrant and Minority Health; Kiss L, Yun K, Pocock N, Zimmerman C. (2015) Exploitation, violence, and suicide risk among child and adolescent survivors of human trafficking in the Greater Mekong subregion, JAMA Pediatrics.
 See Lederer L, Wetzel C. (2014) The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities, Annals of Health Law; Cole J, Sprang G, Lee R, Cohen J. (2016) The trauma of commercial sexual exploitation of youth: A comparison of CSE victims to sexual abuse victims in a clinical sample, Journal of Interpersonal Violence, 31: 122-46.; Hossain M, Zimmerman C, Abas M, Light M, Watts C. (2010) The relationship of trauma to mental disorders among trafficked and sexually exploited girls and women, American Journal of Public Health 100: 2442-9; Ottisova L, Smith P, Shetty H, Stahl D, Downs J, ORam S. (2018) Psychological consequences of child trafficking: An historical cohort study of trafficked children in contact with secondary mental health services. PLOS One.
 United Nations Office on Drugs and Crime (2018) Global report on trafficking in persons
 Silverman JG, Decker MR, Gupta J, Maheshwari A, Willis BM, Raj A. (2007) HIV prevalence and predictors of infection in sex-trafficked Nepalese girls and women. JAMA, 298(5):536-542.
 Pocock NS, Nguyen LH, Lucer-Prisno DE, Zimmerman C, Oram S. (2018) Occupational, physical, sexual and mental health and violence among migrant and trafficked commercial fishers and seafarers from the Greater Mekong Subregion: A systematic review, Global Health Research and Policy, 3:28-41.