Human Trafficking and Exploitation
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
Today, some label human trafficking as a form of "modern day slavery," and frequently, human trafficking has been linked to sex work and prostitution, although there are other forms of trafficking, such as forced labor and domestic work. Human trafficking can involve women, men, and children. Human trafficking is one of the worst abuses of human rights. The United States State Department in its June 2013 annual Trafficking In Persons Report estimates that 27 million people worldwide are victims or survivors of human trafficking today. Moreover, trafficking of persons is believed to be the fastest growing criminal industry in the world and is estimated to be a $32 billion business annually, second only to illicit drugs. Today, some label human trafficking as a form of "modern day slavery," and frequently, human trafficking has been linked to sex work and prostitution, although there are other forms of trafficking, such as forced labor and domestic work. Human trafficking can involve women, men, and children. Its victims experience a host of psychological problems, including post-traumatic stress, helplessness, and depression, due to the physical, sexual, and psychological abuse they have experienced. As human trafficking becomes an increasingly more common problem in the United States, healthcare and mental health professionals will require knowledge of human trafficking patterns, the health and mental health needs of human trafficking victims, and successful interventions for victims.
The purpose of this course is to increase the level of awareness and knowledge about human trafficking and exploitation so health and mental health professionals can identify and intervene in cases of exploitation. This information is presented with the intention of educating health care providers on the long-term medical needs of survivors and on how they can establish a healthcare clinic in their communities. This document is developed to encompass a basic overview of human trafficking. This will attempt to provide practitioners with a glimpse of the realities of human trafficking victims' lives and the physical, psychological, social, and sexual abuse they experience. Specific interventions and responses are discussed, including mental health, social services, educational, prevention, and legal efforts. Finally, for practitioners who do work with human trafficking victims, the emotional toll that it takes upon practitioners is discussed.
Learning Objectives: Upon completion of this course, you should be able to: Define human trafficking; Identify the forms of human trafficking; Identify economic, political, social, and cultural factors that contribute to human trafficking; Describe methodological and research barriers to the study of human trafficking; Compare the different perspectives that have been used to frame the problem of human trafficking; Analyze the trafficking experience, including how traffickers recruit and the financial implications of trafficking; Explain the psychological, health, and social consequences of human trafficking; Utilize interviewing strategies to assess and identify victims and promote the ethical treatment of trafficking victims; Describe various educational, prevention, mental health, legal, and social services interventions and responses targeted to human trafficking victims and Discuss the political counter-transference and secondary traumatization practitioners experience when working with victims of human trafficking and the importance of self care.
Human trafficking is not a new social problem; it has always existed. In the United States, it has historically been referred to as "white slavery," although it involves people of all races and ethnicities (1). Even in the last three decades, human trafficking has continued to be an issue. In the 1970s, there were an increased number of foreign-born sex workers in Europe, with a large percentage originating from Southeast Asia. By the 1980s, more women from Africa and South America were entering into the sex work trade in Europe (1). However, it was not until the 1990s that human trafficking gained global media attention, particularly as it related to women from Eastern Europe and the former Soviet Union. One reason it is believed the public embraced this social problem at that time was because the victims were depicted as white and innocent, women whose lack of education and socioeconomic advantages made them prey to human traffickers. Portrayed in this manner, there was public sympathy and outcry to provide assistance. Fears of "white slavery" in the 19th century stemmed from anxieties about outside intrusion. Today, human trafficking, a modern-day slavery, evokes fear stemming from multiculturalism. For those in developing countries, it symbolizes the encroachment of Western values (2). It is estimated that 21-27 million individuals are trafficked at any given time worldwide with up to 17,500 individuals trafficked to the United States annually (2).
Trafficking refers to the exploitation of a person for goods or services, and the term can be applied to situations of forced labor as well as sexual servitude or any combination of the two. Roughly one-fourth (22%) of the victims are involved in sexual trafficking and the majority of victims of trafficking are women and girls (3). Although human trafficking has always existed, it has begun to garner increased attention as a result of awareness and outreach efforts. All social problems compete for attention, and various groups will make compelling claims about social problems using persuasive rhetoric and dramatic statistics (3). Attention will be drawn from the media, politicians, organizations, and public, all of whom will respond to the gravity of the condition. It is through this process of claims-making and counter claims-making that "conditions" that may not necessarily have initially attracted attention can develop into a recognized social problem (3). How the problem is described or constructed will influence public opinion, which will then ultimately facilitate action from governmental agencies, social service organizations, and international agencies.
The United Nations defines human trafficking as (4): The recruitment, transportation, transfer, harboring or receipt of persons, by means of threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation or the prostitution or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude or the removal of organs.
The United Nations Office on Drugs and Crime divides the definition of human trafficking into three sections: the act, means, and purpose (5). The act, or what is done, generally refers to activities such as recruitment, transportation, transfer, harboring, or receipt of persons. The means of trafficking consists of threats or use of force, coercion, abduction, fraud, deception, abuse of power or vulnerability, or giving payments or benefits to a person in control of the victim. Finally, these acts are carried out for the purpose of exploitation, which includes prostitution, sexual exploitation, forced labor, slavery or forced servitude, and the removal of organs http://www.netce.com/coursecontent.php?courseid=771&works=true - bibl.workscited.7 (4),(5). It is important to remember that human trafficking is not human smuggling. Human smuggling involves an individual being brought into a country through illegal means and is voluntary. The individual has provided some remuneration to another individual or party to accomplish this goal (5).
Scope of Human Trafficking:
As the issue of human trafficking is so complex, it is difficult to determine the scope of the problem. Many scholars and researchers believe that published estimates are just educated guesses. On a global level, the United Nations estimates that 4 million people are trafficked every year (5)(6). The U.S. Department of State has stated that approximately 600,000 to 800,000 men, women, and children are trafficked across international borders on an annual basis (7). It is estimated that 80% of victims are women and girls and 50% are minors. The estimates for the United States are equally unclear, but some approximate that 14,500 to 17,000 individuals are illegally transported to the United States every year for the purpose of exploitation. This analysis about human trafficking found that human trafficking is portrayed as an epidemic, growing at alarming rates, with some government reports estimating 40,000 to 50,000 individuals trafficked in the U.S. each year (8). It has been suggested that many of the reports have overestimated the scope of the problem and points out that the estimates fluctuate drastically year to year (6). In many cases, women and children are considered the typical victims of human trafficking. Women are more vulnerable to trafficking due to the lack of social safety nets in many developing countries. Coupled with women's subordinate social statuses in many cultures, this leads to the "feminization of poverty." Although the social conditions may make women and children more vulnerable to human trafficking, the reality is that men are also victims of human trafficking.
Factors that contribute to human trafficking are: globalization, poverty, corruption, digital technology, racial sexual stereotypes and culture. Several perspectives have been employed to understand human trafficking and exploitation, including feminist, criminal justice/criminology, migration and labor, human rights, and labor rights perspectives. Each offers insight into how the problem is viewed and presented. Victims of trafficking experience a host of psychological, mental health, and emotional distress. Post-traumatic stress disorder (PTSD) is common given the trauma many victims experience, including physical and/or sexual violence and abuse; victims forced into prostitution experience continual daily sexual assault. Researchers have identified a host of aversive health, sexual, and reproductive consequences common among victims of human trafficking: head traumas, concussions, and lacerations; fatigue; poor nutrition, malnutrition, starvation, and dehydration; Muscle, nerve, sensory, and dental damage; human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS); sexually transmitted infections; negative outcomes of (multiple) abortions performed in unsafe and unhealthy conditions; urinary tract infections and pelvic inflammatory disease; and death.
FORMS OF TRAFFICKING
The Victims of Trafficking and Violence Protection Act (VTVPA) of 2000 (PL 106-386) is a United States federal statute passed by Congress to address the issue of human trafficking and offers protection for human trafficking victims. This statute defines sex trafficking as, "the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act" (9). A commercial sex act is, "any sex act on account of which anything of value is given to or received by any person" (9). In other words, it involves the illegal transport of humans into another country to be exploited in a sexual manner for financial gains. Victims of sex trafficking could be forced into prostitution, stripping, pornography, escort services, and other sexual services. Victims may be adult women or men or children, although there is a higher prevalence of women and girls. The term "domestic minor sex trafficking" has become a popular term used to connote the buying, selling, and/or trading children for sexual services within the country, not internationally. In the United States, the children most vulnerable to domestic minor sex trafficking are those who are homeless, abused, runaways, and/or in child protective services (10). Although highly controversial, it is said that sex trafficking victims differ from prostitutes in that sex trafficking victims are forced to involuntarily perform sexual services and are often not paid for their "work." On the other hand, individuals involved in prostitution make a decision to provide sex services for a fee. This does not necessarily mean prostitution is a choice these individuals would have made if other options were available or that they have a choice in selecting their sexual partners and/or sexual activities.
Bonded Labor / Forced Labor
The United Nations has defined debt bondage as: The status or condition arising from a pledge by a debtor of his personal services or of those of a person under his control as security for a debt, if the value of those services as reasonably assessed is not applied towards the liquidation of the debt or the length and nature of those services are not respectively limited and defined (11). Essentially, because the individual does not have money as collateral for the debt owed, the individual pledges his/her labor or, in some cases, the labor of a child or another individual for an unspecified amount of time. These individuals may be transported or trafficked into another country for the purpose of forced labor.
In many cases of bonded labor, the initial loan may be welcomed by the individual. However, the victims do not realize that with the low wages, unspoken high interest rates and other continually accruing fees, and the owner's manipulation of the "accounts," laborers can never repay the loans. Some families find themselves in a cycle of poverty as the debt cannot be paid off and is passed down from generation to generation. Bonded labor can involve laborers in brick kilns, mines, stone quarries, looming factories, agricultural farms, and other manufacturing factories. In the United States, individuals may be trafficked to work long hours in garment factories, restaurants, and other manufacturing sectors. Frequently, the employer/captor will take away victims' identifications, monitor their movements, socially isolate them, and/or threaten deportation if they do not comply (12).
In the United States, forced labor is predominantly found in five sectors (12):
- Prostitution and sex industry (46%)
- Domestic servitude (27%)
- Agriculture (10%)
- Sweatshops and factories (5%)
- Restaurant and hotel work (4%)
It is speculated that most of the forced labor occurs in California, Florida, New York, and Texas, all major routes for international travel (13). Domestic servitude refers to a category of domestic workers (usually female) who work as servants, housekeepers, maids, and/or caregivers, often in private homes. In some cases, young women are lured with the promise of a good education and work, and when they arrive in the United States, they are exploited economically, physically, and/or sexually. Their passports or identification papers are taken away, and they are told they have to pay off the debt incurred for their travel, processing fees, and any other bogus expenses. Because they do not speak English, they find they have no other recourse but to endure exploitive working conditions. Unfortunately, as in many sectors of forced labor, there are no regulations to monitor the conditions under which domestic servants operate.
Child labor can be viewed as a specific form of bonded labor or forced labor. However, not all child laborers have been trafficked. Child labor is defined by International Labour Organization (ILO) as economic labor performed by a child younger than 15 years of age. Child labor is deeply rooted in poverty and the infrastructure and political stability of the country as well as market forces (14). The ILO estimates that there are 215 million child laborers in the world (14). Between 2004 and 2008, there was a 15% decrease in the number of girls in child labor and a 24% decrease in the number of girls performing hazardous work. However, these numbers increased for boys in the same time period.
The definition of child labor is controversial because the definitions for "work" and "childhood" are ambiguous and often culturally defined (15). On a conceptual level, work may be beneficial for the socialization and educational processes of children. So, it is important to differentiate between child work and child labor. Child work has been defined as activities that are supervised by an adult and that promote the development and growth of the child, while child labor does not benefit the child. Many definitions of child labor create a dichotomy whereby child work is considered not harmful while child labor has negative emotional, intellectual, and social consequences (16). Work that is exploitive for children has been defined as working long hours at a young age, work that is poorly compensated, and work that produces physical, social, and psychological stress that will hamper development, access to education, and self-esteem.
In some cases of trafficking, children are kidnapped and trafficked to serve as soldiers. It is estimated that at any one time, around 300,000 children younger than 18 years of age are currently serving as child soldiers (17). Traffickers prefer to recruit children to serve as soldiers because they are inexpensive and more easily molded and shaped to comply and obey without question. They are also more likely to kill fearlessly and recklessly. Child soldiers are treated as adults, without any regard to how the physical and psychological rigors of war will affect them psychologically and developmentally. In Uganda, where children are kidnapped or recruited as child soldiers relatively often, the Lord's Resistance Army has been known to initiate new child soldiers in brutal ritualized killings of others so as to terrorize them into submission and annihilate any moral conscience they may have about killing (18).
It can be difficult to comprehend the atrocities that these children witness and experience. Bayer, Klasen, and Adam conducted a study involving 169 former Ugandan and Congolese child soldiers who were an average of 15.3 years of age (19). Almost all (92.9%) reported having witnessed a shooting, 89% witnessed someone wounded, and 84% witnessed someone seriously beaten. A total of 54.4% reported having killed someone, and 27.8% reported that they were forced to engage in sexual activity (19). In another study, the researchers found that the experience of conscription among children produced significant emotional and psychological traumas and a host of cognitive and behavioral problems (19). In this study of 19 child soldiers, 18 had volunteered to join the army and one had been abducted. Although most of the children volunteered into the army, their participation became involuntary. Some tried to run away or disobey, which resulted in beatings and imprisonment. If captured, they were told to commit suicide.
Assessment and Identification:
Because human trafficking is often a hidden problem, identifying human trafficking victims can be difficult. The Administration for Children and Families recommends the key is to inquire beyond what is on the surface. They suggest practitioners observe for and inquire more in-depth about the following key points (20):
- What evidence is there that the individual is being controlled? Human trafficking victims are controlled in every aspect of their lives by the perpetrators. They are socially isolated from family, friends, and almost any form of human interaction;
- What country did the individual emigrate from and how long they have been in the U.S.? Many victims of human trafficking have recently been trafficked from other countries. As discussed, common sending countries/regions include Eastern Europe, Asia, Latin America, Africa, India, and Russia;
- What physical evidence of abuse is apparent (e.g., bruises, lacerations, scars)? What psychological symptoms are present (e.g., fear, anxiety, depression, sense of helplessness)? How does the individual explain these symptoms?
- Is the victim accompanied by someone who is not necessarily a family member? Why? Probe for detailed information on the relationship;
- Who does most of the talking? Particularly for victims who are trafficked from another country, their English can be limited. Why? Probe for information;
- What explanations does the individual give for not having legal documents, such as a driver's license, social security number, passport, or visa? To control victims' movements, traffickers often take away passports and any legal identification documents;
- What is the individual's home and work situation? Basic questions about what they eat, where they live, where they sleep, and who they live with could be telling. For example, practitioners may ask individuals what specific type of work they do, if they can leave the job if they wanted to and if they can come and go with ease.
If practitioners are suspicious that they have come in contact with an individual who is experiencing human trafficking, they should contact the National Human Trafficking Resource Center at 1-888-373-7888 or the Trafficking in Persons and Worker Exploitation Task Force Complaint Line at 1-888-428-7581. Under the child abuse laws, practitioners who are mandated reporters who are suspicious that a minor is being abused should immediately report the abuse. For more information regarding specific states' reporting requirements, please visit http://www.childwelfare.gov/systemwide/laws_policies/state/index.cfm
Education and Prevention:
Education is believed to be a key ingredient in the prevention of human trafficking. Raising awareness through advertisements, campaigns, and other creative vehicles regarding recruitment threats, the various deception techniques employed, the different forms of human trafficking, and the consequences of human trafficking can decrease the incidence. Because the general public often believes human trafficking is a problem that only occurs in developing countries, there is a clear need for public education about trafficking and safety for young children and women in and outside the United States. Education about human trafficking has become a higher international priority. Innovative and creative approaches are being implemented to disseminate information about human trafficking. For example, groups have used street plays to educate communities about child labor dangers in India (21).
Mental Health and Social Services:
As discussed, human trafficking victims experience an array of mental health and psychological issues. Mental health counseling is vital, but it is important to remember that the concept of counseling may be foreign to victims from non-western cultures. The expression of emotions may be in opposition to cultural values of emotional restraint, which can be intensified by feelings of shame and guilt resulting from experiences with sexual and physical assault. Beyond the paramount importance of the practitioner gaining the patient's trust, practitioners may educate patients about the counseling process and explore their patients' expectations about counseling, healing, and recovery (22).Given differing cultural beliefs about healing, it is crucial that practitioners explore with patients the use of traditional healing methods. There are many indigenous healing interventions victims may be using, including cultural rituals, faith healing, therapeutic touch, herbal remedies, and spiritual practices. These interventions are multi-layered, taking into account the physical, psychological, communal, and spiritual (23). These healing methods are historically rooted in specific cultures, and therefore, practitioners should become familiar with traditional healing methods and how they can be integrated with Western counseling techniques. For example, given many cultural groups' beliefs that unmarried girls are defiled if raped, a cultural cleansing ritual may be needed as a first step to help a community accept a returning victim who was sexually assaulted during her trafficking experience. After this ritual is performed, it is possible that both the patient and her family may be more open to counseling and other services. Physicians, social workers, nurses, therapists, and counselors must be familiar with legal, educational, case management, educational, job and life skills training, and housing services in the community. Human trafficking victims are not only unfamiliar with navigating the social service system, but many are also not proficient in English. Therefore, practitioners will serve as coordinators and advocates, linking necessary services. Furthermore, because many community organizations and agencies are not familiar with human trafficking, practitioners must take a primary role in educating colleagues about the complex dynamics of human trafficking.
Physicians, social workers, nurses, allied health professionals, counselors, and psychologists will find themselves in multiple roles when working with victims of human trafficking. Advocacy is one of these roles and involves the practitioner being an agent for change. This consists of engaging in activities that alter the social conditions at the individual, family, community, and institutional levels (24). One way to advocate on behalf of human trafficking victims is by signing petitions or joining credible organizations concerned with changing the circumstances that lead to human trafficking. Many organizations have petitions established on their websites for individuals to persuade policymakers, legislators, and government officials to advocate for the protection of human trafficking victims, create greater awareness of the problem, and prosecute traffickers.
LAWS AND POLICIES
Victims of Trafficking and Violence Protection Act (VTVPA):
A wide range of laws have been established to protect human trafficking victims and to prosecute perpetrators. A general knowledge of these laws is helpful when caring for victims and seeking appropriate social services. The VTVPA was enacted in 2000 and reauthorized in 2003 and 2005 by the Trafficking Victims Protection Reauthorization Acts (25). Because victims of trafficking are often viewed as criminals, this law states that victims of severe trafficking should not be penalized for any illegal behaviors or acts they engaged in as a result of being trafficked, including entering the United States with false documents or no documentation or working without appropriate paperwork. This law also allows T Nonimmigrant Status (T visas) to be granted to victims of trafficking so they may remain in the United States with the purpose of collaborating with the federal authorities to prosecute the perpetrators. During this time, victims are offered a range of benefits and services, including access to the Witness Protection Program (25). After three years, victims can apply for permanent resident status. One of the criticisms of the Act is that it places the burden of demonstrating innocence and coercion on the victim. The Act also fails to recognize the complex dynamics of human trafficking. Many victims have been abused and terrorized by the perpetrators, who they must now provide information and evidence against to stay in the country. Victims are continually fearful that they will be deported. Victims who are of minor age are eligible for Unaccompanied Refugee Minors programs, the Children's Health Insurance program, and Temporary Assistance to Needy Families. Furthermore, victims between 16 and 24 years of age are eligible for work permits and can apply for the Job Corps program (21). However, it is important to remember that the key to this law is that the victim must have experienced a "severe form" of trafficking and the victim must be willing to assist in the apprehension and prosecution of the perpetrator to receive services.
William Wilberforce Trafficking Victims Protection Reauthorization Act:
The William Wilberforce Trafficking Victims Protection Reauthorization Act was introduced and signed into law in 2008. It allocated $5 million in 2009, $7 million in 2010, and $7 million in 2011 to provide services to victims and to prevent human trafficking (25). It amends the VTVPA and assists foreign governments to implement programs to prevent human trafficking. Victims of human trafficking in other countries are also eligible for assistance through organizations that have grants from the U.S. government. Greater monitoring of trafficking trends through databases will also be implemented. This Act also includes the Child Soldiers Prevention Act of 2008, which promotes the establishment of criteria and policies to end human rights abuses, greater support and rehabilitative services for child soldiers, and collaboration with foreign countries to eradicate the use of child soldiers (26).
The Prosecutorial Remedies and Other Tools to End the Exploitation of Children Today Act:
The Prosecutorial Remedies and Other Tools to End the Exploitation of Children Today Act was enacted in 2003. This law maintains that all sexual activity with minors, within or outside the United States, is illegal. American citizens who engage in sex with minors in any country and who are caught will be prosecuted in the United States (27).
Counter-transference, Secondary Traumatization, and Self Care International and Political Counter-transference
International and political counter-transference can occur when practitioners work with patients from other countries and cultural groups. This is manifested on several levels. First, practitioners may assume that what works in the United States can be applied to immigrants and refugees. This ethno-centric view presupposes that Western paradigms about healing and well-being are universal to all cultures. Second, the Western construct of the healthcare or social service provider as an expert may promote unequal power relationships. These attitudes can be quickly picked up by victims of human trafficking, which can negatively impact the rapport and trust building phases of the therapeutic relationship.
Practitioners may be, consciously or unconsciously, affected by media depictions of particular cultural groups and the social problem of human trafficking. Media portrayals can mold social norms and beliefs, which can then translate into ethnocentric, imperialist, or negative reactions and responses toward the victim. For example, human sex trafficking and prostitution are often linked by the media, and the practitioner's beliefs about prostitution can affect his or her relationship with the victim. A common instinctive reaction to prostitution is to remove the individual from the situation, with force if necessary. Similarly, the media often shows young female human trafficking victims being collected by police officers. This may cause practitioners to believe on some level that victims of human trafficking are criminals. In many cases, the media perpetuates radicalized and colonizing views of women of color who are victims of sex trafficking (28). The colonizing depictions reinforce the myth that women from developing countries are helpless and powerless, deserving of our protection and worthy of being saved (28). To what extent have these messages been internalized and how might these messages ultimately affect practitioners' attitudes and beliefs systems about human trafficking victims?
The terms "secondary traumatization," "secondary traumatic stress," "secondary victimization," "vicarious traumatization," and "compassion fatigue" refer to the psychological impact of being in close contact with those who are directly affected by trauma and helping or wanting to help the victim. Figley has defined secondary traumatic stress as, "the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other". Vicarious traumatization consists of a "transformation of the inner experience of the therapist that comes about as a result of empathic engagement with patients' trauma material". Vicarious traumatization can include emotional and cognitive arousal symptoms such as increased emotional sensitivity, lack of well-being, intrusive thoughts, and difficulty concentrating. According to the Registered Nurses' Association of Ontario, organizations should develop policies and structures related to peer debriefing following exposure to traumatic events or stories. Policies should be developed to support staff and minimize vicarious trauma (29).
Secondary trauma can affect practitioners' beliefs about the world, others, and self (30). For example, humans have beliefs about safety, trust, sense of control, intimacy, and sense of esteem and competence (30). But trauma, even indirect trauma, can disturb these beliefs. Trauma that is caused by another human (e.g., abuse) may be more difficult for practitioners to cope with because it is related to the issue of human evilness. Human trafficking certainly raises questions about how one human can inflict such terror upon another. Ultimately, this profoundly affects existing beliefs, more so than trauma caused by natural events (e.g., natural disasters).
PRACTITIONER SELF CARE
In a study of clinicians who work with sexual abuse survivors, clinicians were asked what parts of their work were enjoyable. They indicated that they enjoyed being part of the journey and process of patients' growing, healing, and changing. Witnessing patients' resilience and strength also spurs clinicians' own personal growth. However, one cannot ignore that when practitioners who work with victims of trauma, including human trafficking, they enter the world of victimization, horror, and abuse through their patients' detailed and graphic stories. As a result of building a rapport and relationship with their patients, practitioners share their emotional burden. This can affect clinicians socially, psychologically, spiritually, and/or interpersonally. Self care is integral to the prevention of negative symptoms such as burnout, secondary traumatization, and compassion fatigue. Practitioners' education, training, and licenses do not necessarily provide effective shields to these types of stressors (31). To some extent, practitioners might be more vulnerable to neglecting self care because rigorous academic studies and early professional training may have overlooked this aspect of professional life.
Self care can consist of an array activities that touch on the following domains: physical (e.g., exercise, nutrition, sleep), recreational (e.g., play activities, vacation time, hobbies), social support (e.g., interaction with friends, family members), and spiritual/religious (e.g., prayer, meditation). Self-care activities exist along a continuum, with proactive planning and reactive intervention on either end. Practitioners should determine where along this continuum they will implement self-care activities. To be most effective, self care should be viewed as proactive rather than reactive when a specific stressor occurs. Practitioners should spend some time asking themselves about the specific behaviors they are currently engaging. For example, what type of exercise regimen is the practitioner currently engaged in? How frequently? How often does the practitioner interact with friends (with whom specifically)? A self-care plan might also include cognitive and stress management techniques, such as biofeedback, hypnosis, and other cognitive strategies (32). The monitoring of self care is as important as establishing a plan. Self-care check-ins can be established, whereby practitioners are assigned to peers so they can hold each other accountable to their self-care plans. Or if a practitioner is comfortable, a supervisor can incorporate this monitoring into his/her regular supervision.
When providing education and interventions to practitioners about self care and secondary traumatization, a message of "blaming the victim (practitioner)" can inadvertently be conveyed (33). Practitioners may feel that they are perceived as weak because they are encouraged to take care of themselves. Along the same lines, organizations should determine if their culture and climate may implicitly convey a message that hinders practitioners from engaging in self-care activities. For example, is taking vacation time implicitly associated with a lack of commitment or dedication? If practitioners do not work overtime, do they feel they will be perceived as less motivated than their colleagues who are working overtime (34)? Is there space in the work environment for practitioners to relax? Ensuring that there is a designated space for practitioners to take breaks after emotionally difficult meetings with patients and their families can encourage self-care behaviors (34).
CREATING INTERDISCIPLINARY MEDICAL SERVICES FOR SURVIORS OF HUMAN TRAFFICKING
Addressing the medical needs of survivors of human trafficking is challenging. Trafficking is a brutal cycle of exploitation that involves psychological, physical and sexual abuse. It leaves victims vulnerable to a variety of medical conditions including chronic pain, malnutrition, sexually transmitted diseases, unintended pregnancy, physical and traumatic injuries, dental disease, posttraumatic stress disorder, depression, and anxiety. In addition, patients are often fearful and distrusting of medical providers as a result of their history of abuse and may be resistant to attempts to evaluate them. Guidelines for working with victims of trafficking emphasize the importance of maintaining confidentiality and safety and avoiding re-traumatizing the patients when collecting a history or performing a physical examination. As a result of the wide scope of needs that will be encountered by service providers when working with survivors of trafficking, care is ideally provided through a multidisciplinary, collaborative unit of professionals who have been trained on human trafficking (35). Many elements of collaborative clinic model are present in major cities and medical research centers in United States of America. These resources should be used to counteract the ravages of exploitation on the health of an alarming number of victims both in the United States and abroad. We encourage healthcare providers across the globe to evaluate local trafficking populations care needs and attempt to provide trauma-informed care to these patients. For individuals who are interested in creating such services in their community, a list of 10 steps to guide this process is provided below.
Elements of the Hope through Health Clinic with Community Care:
- Providers: Comprising bilingual obstetrician-gynecologists and family practice physicians, medical assistants, nurses, mental health nurse practitioners, and behavioral therapists.
- Social workers: Multiple bilingual social workers from both community care and refugee services should be present to evaluate the patients' non-medical needs.
- Ancillary clinical support: Comprising the financial screener, telephone interpreting service, and laboratory and imaging technicians; these individuals will be informed of a patient's history of trafficking only if it is relevant to the service being provided.
- Clinic coordinator: The clinic coordinator position should be created to allow for better continuity with patients and to facilitate referrals from refugee services, in most areas a single point of contact for trafficking reports; this position should be staffed by a case manager from refugee services who is familiar with the victims' social situations and most pressing needs. The clinic coordinator schedules patient visits and referral services and oversees clinic flow.
- Human trafficking training: A training course is provided by refugee services to inform volunteers and staff of the local prevalence of human trafficking and to describe the effect of trafficking on patients; participants are taught aspects of trauma-informed care and how to screen for trafficking.
- Funding: The majority of patients at the clinics in USA are eligible for country- or state-funded medical assistance program; patients who are ineligible for these options are offered a sliding-scale fee for services, and, if this is beyond what a patient can afford, the clinic will cover costs from a designated fund; this fund comprises donations from the community and is intended to cover the cost of medical services and clinic programs that are not covered elsewhere.
- Clinic location: The clinic is held at a community care clinic site that was found to be most convenient for the majority of patients; it has multiple examination rooms as well as a room for group activities and meals. A security guard is present while the clinic is in operation; the clinic is located on main routes of public transportation.
- Health education modules: Based on feedback from patients, a curriculum was created to address health-related topics, including nutrition and cooking, safe sex practices, parenting skills, self-defense, and relaxation techniques. Skilled professionals have been recruited from the community to deliver presentations and organize activities related to the topics; these professionals volunteer their time and are screened and trained by refugee services.
- Communal meals: Patients are offered a meal after they have been seen by the medical provider; these meals are attended by staff, volunteers, and fellow patients and are meant to foster a sense of community and support among the patients.
- Research: We recognize the need for research on the unique health needs of survivors of trafficking as well as on the optimal manner for providing comprehensive care to these patients; we currently are involved in an interdisciplinary research project to address these question.
- Community research: Interested individuals or groups can support the clinic by fundraising or providing meals to the clinic; patient identification and clinic location is not revealed to the general public.
Suggested Steps for Organizing a Multidisciplinary Medical Clinic for Human Trafficking Survivors
- Assess the existing human trafficking support systems in the area as well as the prevalence of human trafficking.
- Approach the agencies currently working with survivors of trafficking and discuss medical needs for this population; determine existing gaps in care and whether elements of trauma-informed care are present.
- Identify funding source(s) for medical services that exists for these patients; engage local health care systems that would be willing to accommodate the formation of a specialty clinic to meet the needs of trafficking survivors.
- Identify interested medical personnel and social workers and train them on how to provide trauma-informed care for this population (35).
- Reach out to groups in the community that might be interested in fundraising, leading health education activities, or providing other services such as clothing and food drives for the clinic.
- Create a need assessment to identify the medical and social needs of the population as well as a method to ensure that these needs are being addressed through the clinic.
- Offer the option of attending the clinic to potential patients; attendance should never be coerced or required to receive other services.
- Hold frequent meeting with collaborative partners to reiterate goals of the clinic, reflect on successes and weakness of the project, and address ways to improve delivery of care.
- Educate other health care providers in the community about the importance of screening for human trafficking during patient encounters.
- Engage potential referral sources from the community, including the police department, the department of public health, hospital and clinic systems, and social service programs, among others.
Although many questions can be used to elicit a history of human trafficking, a validated screening tool that healthcare providers can use in typical encounters should be developed (36). There is also a great need to research the long-term health effect of trafficking on patients and to determine whether the proposed trauma-informed medical clinic improves health outcomes.
Human trafficking is a severe human rights violation. Because the roots of human trafficking are multifaceted, no one solution exists to eliminate this problem. Unfortunately, as the problem grows, practitioners will be confronted with the issue in their patient populations. Practitioners should be committed to the collaboration amongst disciplines to address poverty, racism, discrimination, and oppression in order to reduce the vulnerable positions of human trafficking victims and their families. Because of the social justice component in the codes of ethics of professionals such as physicians, nurses, social workers, psychologists, and counselors, all practitioners can play a key role in the individual, community, and systemic levels to help address this gross abuse of power. One way to begin is to educate oneself and one's respective disciplines about the global nature of human trafficking and the complex dynamics of the problem.
A growing number of patients are affected by human trafficking. In the course of creating medical clinic for the victims, it is important for the clinic to not open prematurely, before clinic system and services are sufficiently organized, so that patients do not feel neglected or misled. Identifying and encouraging one another's capacity to address these human rights atrocity is the core of our global initiative. While human trafficking flourishes in an environment of isolation and shame, we strive as a group of health care providers to restore community and empower our patients. We hope these efforts can be repeated everywhere to help these patients with very special needs.
FUNDING: Special thanks to, WHEC Global Health Initiative, for providing the funding and support for the research and development for this series of articles. We invite our partners to join us in eliminating this global human rights atrocity.
- World Health Organization (WHO)
- National Institutes of Health (NIH)
Human Trafficking: The Role of Health Care Provider
- Centers for Disease Control and Prevention (CDC)
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