V. Jordan Greenbaum
Human trafficking violates the fundamental human rights of child and adult victims and impacts families, communities, and societies. Trafficked persons originate from countries worldwide and may belong to any racial, ethnic, religious, socioeconomic, or cultural group. They may be of any gender. According to the United Nations Protocol to Prevent, Suppress and Punish Trafficking in Persons , child trafficking refers to the “recruitment, transportation, transfer, harboring or receipt of a person” under 18 yr old for purposes of exploitation. Two major types of trafficking involve forced labor and sexual exploitation (Table 15.1 ). While adult sex trafficking requires demonstration of force, fraud, coercion, deception, or the abuse of power as a means of exploitation, these are not required for persons younger than 18 yr. Interpretation of the international protocol varies across the globe; U.S. law does not require movement of a victim to qualify as human trafficking. In addition, minors who “consent” to commercial sex in the absence of a third party (trafficker) are victims of commercial sexual exploitation, because their age precludes true informed consent.
The word victim is used in this chapter in the legal sense and refers to a person who has been harmed as a result of a crime or other event. It is not intended to imply any subjective interpretation of the person's feelings about his/her situation or imply any judgment about that person's resilience.
Child trafficking may occur within the confines of the child's home country (domestic trafficking) or may cross national borders (international , or transnational , trafficking). Globally, victims tend to be trafficked within their own country or to a country in the same region. In the United States, most identified child sex trafficking victims are U.S. citizens or legal residents; few statistical data exist on victims of child labor trafficking. Variations in definitions of terms, problems with data collection, and underrecognition of victims complicate estimates of the prevalence of human trafficking, but the International Labour Organization estimates that 5.5 million of the world's children are victims of forced labor (this includes human trafficking). In a study of 55,000 officially identified trafficking victims, the United Nations Office on Drugs and Crime estimated that approximately 17% were girls and 10% boys. However, laws that define sexual exploitation in terms of girls and women, as well as cultural views regarding gender roles, lead to underreporting of boys, especially as victims of sex trafficking, so their numbers may be higher than estimated.
Factors creating vulnerability to human trafficking exist at the individual, family, community, and societal levels (Table 15.2 ). Age is an important risk factor for adolescents since they are at a stage in their development at which they have limited life experience, a desire to demonstrate their independence from parental control, and a level of brain maturation that favors risk-taking and impulsive behaviors over careful situational analysis and other executive functions. They are also very interested in social media and are savvy at internet use, which render them susceptible to online recruitment and solicitation.
Recruitment of child victims for labor or sex trafficking often involves false promises of romance, job opportunities, or a better life. Children may remain in their exploitative situation for a number of reasons, including fear of violence to themselves or their loved ones should they attempt escape; guilt and shame for believing the fraudulent recruitment scheme or engaging in illegal and/or socially condemned activities; humiliation and fear of criticism by authorities; debt bondage (believing they owe the trafficker exorbitant amounts of money and cannot leave until the debt is paid), and fear of arrest and/or deportation. Many children do not recognize their victimization. Girls who believe their trafficker is a boyfriend may view their commercial sexual activities as demonstrations of their love; boys engaging in commercial sex to obtain shelter or food while living on the street may feel they are exploiting buyers rather than being victimized. Traffickers may use violence, economic manipulation, and psychological manipulation to control their victims.
Trafficked persons may seek medical care for any of the myriad physical and emotional consequences of exploitation. They may present with traumatic injuries inflicted by traffickers, buyers, or others or injuries related to unsafe working conditions. They may present with a history of sexual assault, or symptoms/signs of sexually transmitted infections (STIs) and infections related to overcrowded, unsanitary conditions. They may request testing for HIV or complain of signs/symptoms of HIV or infections endemic to the victim's home country (e.g., malaria, schistosomiasis, tuberculosis). Other clinical presentations may involve pregnancy and complications of pregnancy or abortion; malnutrition and/or dehydration; exhaustion; conditions related to exposure to toxins, chemicals, and dust; and signs and symptoms of posttraumatic stress disorder (PTSD), major depression, suicidality, behavioral problems with aggression, and somatization. Some children may have preexisting chronic medical conditions that have been inadequately treated before or during the exploitation (e.g., diabetes, seizure disorder, asthma). Trafficked persons may also seek care for medical issues related to their children.
Many of the same factors that keep victims trapped in their exploitative conditions also preclude them from disclosing their situation to others. Most victims presenting for medical care at clinics, hospitals, and emergency departments do not self-identify as trafficked persons. Consequently, it is incumbent on the medical professional to be aware of risk factors so that potential victims may be recognized and offered services. A trafficked child may present to a medical facility alone, in the company of a parent/guardian (who may or may not be aware of the trafficking situation), a friend or other person not involved in the trafficking, a person working for the trafficker (who may pose as a friend or relative), or the trafficker. Traffickers may be male or female, adult or juvenile, and they may be family members, acquaintances, friends, or strangers. On occasion, children are brought in by law enforcement or child protective services, as known or suspected victims. Table 15.3 lists possible indicators of labor or sex trafficking. In some cases, the best indicator is the chief complaint , which may be a condition frequently associated with trafficking (e.g., teen pregnancy, STI symptoms/signs (especially with history of prior STI), preventable work-related injury). The practitioner may become concerned about possible trafficking on recognizing the presence of 1 or more risk factors (runaway status; recent migration and current work in sector known for labor trafficking).
When interacting with a possible victim of trafficking, the medical provider should use a trauma-informed, human rights–based, culturally appropriate, and gender-sensitive approach (Table 15.4 ). This involves being aware that trauma experienced by children may influence their thoughts about themselves and others, their beliefs and perceptions of the world, and their behavior. Hostility, withdrawal, or distrust may be reactions to trauma and should be met with a sensitive, nonjudgmental, empathic response by the provider. Physical safety of the patient and staff are critical, and protocols should be in place to address security issues that may arise if the trafficker is on the premises. Psychological safety of the patient may be facilitated by separating them from any accompanying person when obtaining the medical history, conducting the visit in a warm, child-friendly environment, taking adequate time to build rapport and begin to establish trust, and ensuring that any interpreter used is not from the same community as the patient and is trained in human trafficking.
Respect for the patient's rights is essential, including the right to an explanation of the purpose of the questions being asked, and the reasons for, and elements of, the examination and diagnostic evaluation. Informed assent by the patient for all steps of the process should be obtained when possible. The limits of confidentiality should be explained in a way the child understands so that they are able to choose what information to disclose. A risk assessment should include a discussion with the patient of safety concerns (involving current risks and perceived risks after discharge). While many trafficked persons have committed crimes during their period of exploitation, it is critical to treat the child with respect and compassion, viewing the patient as a victim of exploitation rather than a criminal offender. Every attempt should be made to understand and respect cultural and religious influences that may affect the child's views of their bodies, their condition, and their desired treatment.
In some cases the provider may become concerned about the possibility of human trafficking only after speaking with the child and obtaining the medical history. Social or other vulnerability factors may come to light, prompting concern about exploitation. In such cases the provider may consider asking additional questions, if this can be done in a nontraumatizing manner. Such questions might include the following:
Such questions may open the door to a discussion of exploitation and facilitate the provider identifying appropriate resources and referrals.
All elements of the medical history and review of systems are important, but special attention should be paid to reproductive history (including sexual orientation and identity, prior history of sex partners, STIs, pregnancy/abortions, condom use); injury history; substance use/misuse; and mental health history and current symptoms. Rates of substance misuse, depression, PTSD, depression, and suicidality are very high, and questioning may highlight the need for emergency care or nonurgent referrals. It also provides an opportunity for anticipatory guidance aimed at harm reduction: a discussion of condom use, STIs, HIV/AIDS, and substance use may prove invaluable, since many victims lack accurate information on these topics. It is important to identify any chronic conditions, especially if untreated, and to assess vaccination status. Many trafficked persons have had very poor healthcare in the past and lack basic primary care. It is important to ask questions about signs/symptoms of infections endemic to the child's home country or to countries in which the child has been trafficked (e.g., tuberculosis, dengue, malaria; see Chapter 10 ).
A thorough physical examination allows the provider to assess and treat acute and chronic medical conditions, collect forensic evidence (as appropriate), assess nutritional and developmental status, and document recent and remote injuries. Diagnostic testing may identify pregnancy, STIs, HIV, non–sexually transmitted infections, vitamin and mineral deficiencies, anemia, toxic exposures, drugs, or alcohol. A sexual assault evidence kit may reveal trace evidence or DNA from offenders. Informed assent for the exam, assault kit, and diagnostic tests is important, as is careful explanation of each step during the process, and monitoring of the patient for signs of distress and anxiety. Those who have been sex-trafficked may experience particular distress during the anogenital examination, the oral exam, and when injuries are photographed. A trauma-trained chaperone is very helpful in providing comfort and support to the patient. The examination should be conducted outside the presence of anyone suspected of being involved in the trafficking situation. After the exam the provider should explain the results, ask the child if they have any questions about the exam, and give them the opportunity to discuss concerns about their bodies. Trafficked persons may harbor anxiety about a variety of issues, including possible infertility, future health, or possible permanent damage from work-related injuries and toxic conditions.
Providers may follow U.S. Centers for Disease Control and Prevention (CDC) guidelines on STI testing and prophylaxis. Additional resources on laboratory testing for sexually and non–sexually transmitted diseases may be obtained from the CDC (https://www.cdc.gov/ ) or World Health Organization (WHO) websites (http://www.who.int/en/ ). In general, STIs of greatest relevance include Neisseria gonorrhoeae , Chlamydia trachomatis , Trichomonas vaginalis , HIV, syphilis, and hepatitis B and C viruses. Methods of testing and decisions to treat (e.g., positive test results vs prophylaxis vs syndromic treatment) will depend on national guidelines as well as on medical resources, which may be limited in some countries or regions. However, consideration should be given to the high likelihood that the patient may be lost to follow-up after the visit, so the decision to delay treatment until test results are available may lead to lack of needed medication. Testing and treatment decisions need to be outlined in a protocol. Emergency contraception and other methods of birth control (especially long-acting reversible contraception) should be discussed with the patient as feasible.
Many child victims of trafficking (and children of trafficked adults) have experienced nutritional deprivation, lack of immunizations, and general poor health, especially if they are from low-resource countries or are born into the trafficking situation. Guidance on medical screening and care for immigrant children (see Chapter 10 ) may also be obtained from the CDC or American Academy of Pediatrics (AAP) Red Book or Immigrant Child Health Toolkit .* Consideration should be given to vaccine-preventable diseases (including tetanus if there are open wounds) and common diseases in the child's home country. Domestic or international victims may have iron deficiency, hemoglobinopathies, vitamin D deficiency, and undiagnosed vision or hearing problems. Crowded, unhygienic living conditions during the trafficking period raise the risks of tuberculosis, scabies, and diarrheal illnesses. Toxic levels of lead or chemicals may be present, and vitamin/mineral deficiencies should be considered. A developmental assessment is important, given the high likelihood of poor primary care in the past and possible harsh living conditions.
Documentation of health and injuries is extremely important and should be detailed and accurate. Body diagrams and photographs (if not traumatizing to the child) are helpful, as are written descriptions of injury location, type (e.g., contusion, laceration), size, shape, and color. All photographs should include patient identifiers and a measuring instrument when possible. Distance photographs to establish injury location may be supplemented with close-up photographs from various angles. Physical signs of untreated illness, malnutrition, and other conditions need to be documented carefully. When documenting the medical history, direct quotes should be used when possible (quotes of provider and of victim statements). Records, including written, video, audio, and photographic records, should be stored in a secure health information system, with limited access and password protection. Strict protocols for patient confidentiality and privacy should be established and followed.
Healthcare providers must comply with mandatory reporting laws in their state or country, but in doing so, should make every effort to avoid causing harm to the child or their family. In the event the parent is the trafficking victim rather than the child, care should be taken to make reports and referrals only with the victim's consent (unless child's safety/health are at risk). For those practicing within the United States, assistance on interpreting laws, working with suspected victims, making reports to authorities, and identifying local referral sources may be obtained by contacting the National Human Trafficking Resource Center (1-888-3737-888). The NHTRC has trained staff to assist victims and professionals alike, including interpreters for over 100 languages. Additional assistance may be obtained by contacting state or local law enforcement and antitrafficking task forces or local child advocacy centers. In some countries, “helplines” and “hotlines” may be used to seek assistance for suspected trafficking victims. It is important for the healthcare provider to be aware of local, state, and national resources for trafficking victims. Exploited persons have numerous needs that extend beyond the range of the healthcare provider's ability to respond. A multidisciplinary team approach is needed to ensure the child is provided with necessary food, shelter, crisis management, language interpretation, immigration assistance, mental health and medical care, educational needs, and other services. Such a team may include local victim service providers, shelter staff, behavioral health professionals, child protective services (CPS) workers, law enforcement, child advocacy center staff, sexual assault providers, and victim advocates. Table 15.5 lists potential health-related referrals.
Trafficked victims may face considerable social stigma and discrimination . They may be viewed as consenting participants, illegal immigrants who deserve maltreatment, or “bad kids” who are responsible for their own actions. In some countries, laws on sexual exploitation do not include boys, and cultural beliefs foster the attitude that males cannot be victimized. Variations in the age of consent may result in a child being considered an adult in one country and a child in another. For these reasons and others, it is important for the healthcare provider to advocate for the child's victim status when interacting with other professionals and emphasize the need for comprehensive, sustained, trauma-informed services.
Prior to discharge, the provider should ensure the patient understands the results of the evaluation and the treatment plan, has a safety plan, and is aware of options for future care. When referrals are being made, it is helpful for the provider to take steps to ensure services are actually obtained by following up with the referral staff, sending medical records (as appropriate and with victim consent), and assisting the victim with arrangements as feasible. It is also helpful to counsel the victim on their basic human rights, including their right to medical care. If responsible for long-term care of the child, the provider should consider that treatment needs change over time, so treatment plans must be reevaluated periodically. Continuity of care is important but can be challenging when the child is moved to another city, is transported back to the home country, or is re-trafficked. Communication and collaboration with external agencies and healthcare providers can be extremely helpful, along with assignment of a case manager to help ensure referrals are in place in destination towns or villages.