Written and published during Delta 8.7’s Phase I (2017-2019), this Thematic Overview was initially intended to contextualize relevant policy interventions for policymakers and those looking for more resources. As an update to this, we encourage you to download and review our Policy Guides:
|Rights Lab Evidence Review||Rights Lab Evidence Review||Rights Lab Evidence Review|
|Public Database of Evidence||Public Database of Evidence||Public Database of Evidence|
|CRISIS POLICY GUIDE||JUSTICE POLICY GUIDE||MARKETS POLICY GUIDE|
Until recently responding to human trafficking was considered the job of law enforcement. It is now recognized that the healthcare field has a critical role as well. Healthcare can have a large impact on preventing human trafficking, assisting victims to exit their trafficking situation, and treating survivors’ physical and mental health needs. Since this is a new arena for most healthcare organizations, extensive training is needed to give healthcare personnel the tools they need to intervene effectively. In addition, government and community services are needed to respond to the myriad needs of victims and help them on the road to full recovery and well-being.
Key takeaways about the role of healthcare in addressing and treating victims and survivors of forced labour, human trafficking include:
- People who have been trafficked experience high levels of violence and report significant levels of injuries, physical pain and illness.
- Healthcare settings are one of the few places where victims encounter a professional in a safe setting and could have an opportunity to consider options for leaving their trafficking situation.
- Patients in healthcare settings include vulnerable individuals who are at high risk of victimization, victims who are currently being trafficking and survivors.
- Healthcare personnel can identify victims, provide non-judgemental care and education, and link them with resources.
- Partnership with law enforcement, access to affordable healthcare and strong social services are important components for prevention and treatment.
- Survivors of trafficking need integrated physical and mental healthcare services that are responsive to the violence and trauma that they have suffered.
What are the health risks of trafficking
People who are trafficked are likely to experience multiple physical and mental health problems as a result of their trafficking experiences, and many suffer acute and long-term health problems. Studies indicate that trafficked women, men and children experience high levels of violence and report significant levels of injuries, physical pain and illness.
- Mental health disorders and/or symptoms such as anxiety, depression, PTSD, suicidal ideation, self-harm, somatic complaints, aggressive behavior, memory loss and cognitive problems;
- Poor physical health such as acute injuries, chronic physical pain, fatigue, exhaustion, poor nutrition, sexually transmitted infections and other sexual and reproductive health complications, including unwanted pregnancy;
- Substance use or misuse such as drug or alcohol addiction, overdose, self-harm, needle-introduced infection and sleep problems;
- Social health consequences such as feelings of isolation, loneliness, shame, guilt, social withdrawal and risk of re-trafficking;
- Finance-related problems such as the inability to afford basic hygiene, medical care, nutrition and housing;
- Legal and security problems such as long periods in immigration detention centres or prisons, denial of health treatment from public clinics and services, traumatic reactions to experiences, and risk of re-trafficking; and
- Occupational injuries and disease such as bacterial and other infections, chemical burns, injury, musculoskeletal injury, exhaustion and poor nutrition.
Hospital operating room. Unsplash/Piron Guillaume
How do human trafficking victims use healthcare services?
While trafficking is a complex and pervasive public health matter, human trafficking is largely undetected and underreported as victims are often unaware that the exploitation they suffer is a crime, and for those who consider reporting, many remain silent for fear of repercussions.
Healthcare is one of the few places where victims encounter a professional in a safe setting and could have an opportunity to consider options for leaving the trafficking situation. Studies in high-resource countries have found that up to 88 per cent of sex trafficking victims had some contact with healthcare while being exploited, largely in hospital emergency room settings. Yet surveys with survivors show that labour and sex trafficking victims who seek health care almost never receive information or resources about human trafficking from the healthcare provider.
Victims of human trafficking may present with injuries due to sexual and physical assault, sexually transmitted infections, drug and alcohol use disorder, and other behavioral health conditions. A study of providers found that without training on how to identify and treat these patients, less than 10 per cent of emergency department medical staff felt confident to identify and treat a trafficked patient. Yet with even brief training, that percentage increased to over half.
How can healthcare help to prevent human trafficking?
In caring for a patient’s health needs a physician can play a key role in reducing violence and preventing trafficking. Patients include people who are at high risk for victimization as well as those who may become perpetrators. Some physicians use the patient visit as an opportunity to work proactively and educate their adolescent patients about safe relationships and connect them to resources in the community that can help. Those at risk of labour trafficking need information on topics such as safe migration and the dangers of fee-based job recruitment.
In some countries healthcare debt is a key driver of human trafficking, so it is important to ensure access to affordable healthcare for vulnerable families. For example, when a family member falls sick or is injured and government healthcare services are not available, low-income families must turn to the private sector where they have to pay out-of-pocket for medical care. Often these costs are beyond what the family can afford and they are forced to take a high-risk, high-interest loan from the informal sector. They then become bonded labourers to the money-lender and work to pay back the debt, but the interest rate can be so high that it is impossible to repay. They become trapped in debt-bondage slavery and are not allowed to leave under threat of violence.
What roles does healthcare play in treating victims and survivors?
Since healthcare personnel are among the few professionals who may encounter victims while they are in trafficking situations, they are in a good position to identify victims and potentially help them find safe ways to leave the trafficking situation. Identification often depends on noticing warning signs or red flags, engaging with possible victims privately in a compassionate manner, and educating them.
Education is very important as many victims do not self-identify as victims. As a result of the manipulation used by the trafficker they may feel that the trafficking is their fault. Labour trafficking victims often feel that they owe the trafficker money and are obligated to continuing working to pay back the debt, even when that loan is illegal and exploitative. They may be emotionally attached to their trafficker or the trafficker may be the father of their children.
Drugs may also be a factor as some traffickers use drugs to control their victims or victims may use them as a coping mechanism. Healthcare personnel can educate patients on the violence and other tactics that traffickers use to manipulate victims and keep them under their control.
They can also suggest available resources and, upon the victim’s request, link individuals with local service providers who can provide support. Since many victims will have been exposed to various abuses and may be fearful of their trafficker, it is common for them to feel reluctant to disclose their circumstances and reach out for help. Assistance must be offered in a manner that ensures the possible victim feels informed, that they have a safe place to consider their options, and that their decisions are voluntary and respected.
Physicians and staff should be trained on the risks associated with trafficking, especially victims’ concerns for their well-being and safety, including any immigration concerns, and the safety of their family. Providers should be offered specifc training to help them provide trauma-informed and patient-centered care. In a trauma-informed care model all staff are educated about trauma and how trauma can affect their patients as well as how it can affect them as caregivers. Trauma-informed care means treating the whole person, taking into account past trauma and their individual coping mechanisms when attempting to provide care for each patient. In a healthcare setting this includes welcoming patients and ensuring that they feel supported, maintaining an environment that is quiet and inviting, and communicating in a way that is respectful and non-judgmental.
At the core of patient-centered care is finding ways to put the individual in control of the clinical encounter. For instance, the provider should discuss what the patient wants from the appointment; describe what the patient should expect from the present and future encounters; ask the patient’s permission prior to examination; offer use of aids to allow observation of procedures; offer opportunities to ask questions and validate concerns; include a support person in the exam room when desired; and make allowances for the patient’s comfort and cultural adaptations.
Because health care providers are often faced with time constraints in medical settings, it is important to partner with other healthcare personnel who can assist with this work, such as social worker or other support staff if available. The PEARR tool, jointly developed by Dignity Health, HEAL Trafficking and the Pacific Survivor Center, provides more detailed guidance on the steps.
What resources are available to victims?
Victims of human trafficking often require a range of support services, including:
- Shelter/safe house
- Restoration to victim’s family/home
- Long-term housing placement
- Job skills training and job placement
- Mental health services
- Substance abuse recovery services
In many countries resources for victims may be very limited, but common partners include government agencies or community organizations that provide services such as domestic violence shelters, youth homeless programmes and immigrant service organizations. In some countries a special anti-trafficking unit has been established within law enforcement, and access to resources is coordinated through them. Out of respect for the patient’s rights and wishes, law enforcement should be contacted only with the patient’s permission or as required by law or other regulations.
What are the healthcare needs of victims during recovery?
Another key area for healthcare providers to address in human trafficking is to provide appropriate long-term health care for survivors. Survivors of human trafficking need integrated healthcare to address their ongoing medical, dental and behavioral health needs. This can best be provided through a team that has received specialized training in trauma-informed care. Human trafficking victims often have multiple unaddressed healthcare needs and therefore require extended appointment times. Patients may also need assistance with transportation to the clinic, health literacy education and health insurance enrolment or other financial assistance.
A comprehensive exam should be done as soon as possible, but it may not be possible on the first visit due to safety concerns, mental health status or time constraints. The comprehensive exam includes special attention towards signs of mental and physical abuse and neglect as well as mental health and substance use issues. Common physical findings in the exam include: multiple bruises, whip marks, finger impressions and ligature marks; malnutrition; poor dental health; genital trauma; anal trauma; burns from cigarettes, hot irons and/or acid; new and old fractures; and signs of substance abuse such as repetitive yawning, rhinorrhea, impaired cognition, abnormal affect, fearful appearance and “track marks”. These signs must be carefully documented in the medical record, which will be important if a court case against the trafficker is being prosecuted. In addition, this information is critical for both physical and mental health treatment of the patients. Since severe trauma is sometimes encapsulated, victims may not always recall the suffering that they have experienced. Accurate findings of these issues can be a helpful tool in delivering appropriate mental health services.
The history of physical abuse and emotional torture of trafficking victims results in the need for trauma-informed mental health services to address their psychological wounds. Evidence shows that many trafficking survivors, especially women and girls, have suffered traumatic events and abuse prior to being trafficked, which will affect their health as well. Left untreated, these wounds will often infect other areas and lead to difficulty in coping with life’s stressors and can negatively impact relationships. Effective mental health treatment can address this, and help survivors move into greater psychological well-being, and this improvement in mental health status can also impact some physical health conditions.
It is also helpful to remember that healthcare providers see survivors weeks or even years past their victimization. The patient may or may not realize that what happened to them was a crime and that there are services available to help them. As with other forms of trauma, it is important to consider whether their continued health issues could have been caused by the trafficking situation.
Clinical services for survivors should include:
- Assessment and treatment for pain
- Mental health services
- Substance use disorder treatment
- Primary care
- Health screenings
- Dental care
- Complementary and alternative medicine/culturally specific traditional remedies
- Chronic disease prevention and treatment
- STD testing and treatment
- Preventive reproductive health care
- Newborn and pediatric care for children of victims
- HEAL Trafficking toolkit
- Dignity Health Shared Learnings manual
- Caring for Trafficked Persons: Guidance for Healthcare Providers
- Training Guide for Facilitators
- Responsible Sourcing (for supply chain)
- Safe Dates (prevention education)
- PEARR Tool
Delta 8.7 thanks Petra Stanton (Dignity Health) for her work in drafting the Thematic Overview and Cathy Zimmerman (London School of Hygiene and Tropical Medicine), Ligia Kiss (London School of Hygiene and Tropical Medicine), Holly Gibbs (Dignity Health), Susie Baldwin (Los Angeles County Department of Public Health and HEAL Trafficking) and Marti MacGibbon for their comments on earlier drafts.
This article has been prepared by Petra Stanton as a contribution 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 author and do not necessarily reflect those of UNU or its partners.