Expanding and Coordinating Human Trafficking-Related Public Health Research, Evaluation, Education, and Prevention

Problem Statement

Human trafficking occurs in all 50 US states and the District of Columbia. It is defined by the United Nations as “the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, or 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 of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs.”[1]

It is important to emphasize that human trafficking is not limited to sex trafficking and includes other forms of trafficking, such as labor trafficking, debt bondage, and organ trafficking.[2,3^] Because of the illegal and hidden nature of human trafficking and the lack of sound statistical methodology, accurate and reliable statistics on the numbers of individuals affected annually and overall prevalence are difficult to capture. Still, estimates range from 14,000 to 50,000 people being trafficked into the United States every year.[4,5] This broad estimate does not account for individuals entering the United States for other reasons who become trafficked, persons already trafficked here in previous years, or US citizens and residents who are trafficked within US borders.[6] Despite media assertions and intensified law enforcement measures, there is no reproducible evidence that large sporting events cause increases in sex trafficking.[7^] There is, however, evidence indicating that labor trafficking increases in settings of natural disasters[8] and that unaccompanied and separated minors are vulnerable to trafficking in emergency settings.[9^]

Growing evidence suggests that victims encounter health care providers while they are being trafficked but remain unidentified.[10–13] Victims of human trafficking experience many adverse health outcomes as a consequence of their exploitation, including unintended pregnancies and sexually transmitted infections, physical pain and injury, a wide range of mental and behavioral health problems, and chronic diseases.[14,15] Given these negative health consequences, it makes sense that law enforcement officials and service providers report health care practitioners as a source of victim referrals; moreover, health care providers may be the only professionals victims encounter while they are under the control of traffickers.[15,16]

Before there were data indicating that providers are encountering this population, clinicians voiced a need for education in this area.[17] Professional educational curricula typically cover issues associated with intimate partner and domestic violence, child maltreatment, and abuse of elderly and vulnerable individuals; however, human trafficking is not yet a standard part of most training curricula.[17] While human trafficking falls within the spectrum of abuse and exploitation related to fear, coercion, and control, it is a more heterogeneous, complex problem. For example, perpetrators may be individuals or groups, or they may be strangers or trusted members of the family or kin network.[18^] The lessons learned in other types of abuse are not immediately applicable to trafficking. Survivor-centered interventions are necessarily more varied and include provision of immediate needs such as food, housing, protection, and extensive medical and mental health care. Health care providers report being poorly prepared to identify and care for trafficked persons and to address their complex situations, however, leading to missed opportunities to serve victims in meaningful ways.[17,19] Providers are willing to and want to be trained in this area, acknowledging their frontline role in mitigating the adverse health consequences associated with human trafficking in the United States.[20,21]

Children are a special population vulnerable to being trafficked, particularly those outside of the care of a supportive environment.[22–24] Trained health practitioners are uniquely positioned to identify children and youths at high risk, and thus they can potentially be key players in prevention of human trafficking. Minors identified as particularly at risk for trafficking include those who have escaped from or have a history of living in abusive households, those who are homeless, and those with experience in foster care or the juvenile or criminal justice system.[24] Also, those who identify as lesbian, gay, bisexual, or transgender are disproportionately represented among homeless and trafficked individuals and are therefore disproportionately at risk.[24–27] Not enough data are available, however, to determine the true extent to which these groups are represented among those trafficked or recognized among identified victims.[23] While poverty is not causally linked to abuse, it has been shown that living in poverty increases exposure to risky sexual behaviors and leads to earlier onset of sexual activity,[27] factors that place young people at risk of sexual exploitation.[24] Youths of color are more likely than their White peers to live in these disadvantaged conditions,[29] making this population further vulnerable to trafficking.

Evidence-Based Strategies to Address the Problem
Informed by research in domestic and youth violence prevention, migratory practices, and other related fields, several strategies to prevent domestic trafficking have been proposed. However, the vast majority of trafficking interventions employed have no published evaluations of effectiveness, highlighting the need for more data in this area.

At the individual level, life skill training, including education on problem solving, effective communication, negotiation, decision making, conflict resolution, interpersonal relationship navigation, self-awareness, empathy, and stress management, may be useful in decreasing people’s vulnerability to trafficking.[30–32] In addition, migrants should be educated on how to safely move to a new country, acquire a living wage, and ascertain the authenticity of job offers.[33,34] One study showed improved precaution-taking behavior among those who received such educational interventions.[34] Mandatory education among those arrested for the purchase of exploited people’s services may help prevent the demand for trafficked persons.[35] An evaluation of a first-offender program concluded that completion of such programs reduced recidivism among men arrested for soliciting prostitution.[36] Still, the value of outreach programs remains debated,[37] and more data are needed on the true impact of such efforts to eliminate trafficking. Given the apparent overrepresentation of women, girls, and transgender individuals among those trafficked, many innovative initiatives have been challenging cultural and social norms regarding gender equity in an effort to decrease the vulnerability of these populations.[38] Still, no methodologically rigorous evaluations have been published in this area of trafficking prevention.[39]

Screening tools have been developed with disparate results. In the case of intimate partner violence, for example, screening tools have been deemed useful in identifying abuse and risk of abuse and in decreasing harm; however, such tools do not show comparable utility with respect to elder abuse.[40] Given the complexity of human trafficking, equivalent parallels to other forms of abuse and exploitation should not be assumed. Although screening tools for identifying victims of trafficking exist,[41] there are no validated tools specifically for use in health care settings.

Health care providers and first responders also need training on how to intervene when trafficking is recognized, and attitudinal biases among health workers must be eliminated to improve care for this patient population.[8,42] While there are numerous educational guidelines for providers, none have been strenuously evaluated in terms of patient-oriented outcomes.[43] Imperative to progress in combating human trafficking is a concerted multidisciplinary public health effort—one that is culturally and linguistically appropriate,[44] survivor centered, and trauma informed[45]—to design, implement, and evaluate empirically based interventions.

Opposing Arguments/Evidence

Critics have argued that there are no reliable statistics on the true scope of human trafficking and that the prevalence of trafficking has been overestimated.[46,47] While, as noted, the State Department’s estimate of the number of foreign nationals trafficked into the United States each year has ranged from 14,000 to 50,000,[4,5] no government agency has published an estimate of the number of trafficked domestic youths. A lack of precise figures has led detractors to contend that there is “unwarranted moral panic” about trafficking and to question whether an aggressive response is necessary.[46] Others assert that human trafficking is a criminal justice issue rather than a public health issue and suggest aggressive prosecution to serve as a deterrent and to protect the rights of survivors.

While it is true that reliable figures are somewhat lacking, trafficking is a brutal crime and entails egregious human rights violations. Given the nature of the crime and the harmful effects on individuals and communities, trafficking at any level is an issue that warrants urgent attention. The Bureau of Justice Assistance within the US Department of Justice states that human trafficking is the fastest-growing criminal activity and that it preys on the most vulnerable.[48] Trafficking affects the US health and health care system and requires a multipronged approach, as application of criminal prosecution in itself has proven insufficient to curb the problem.[18] There is currently no methodologically sound way to truly measure the financial burden of human trafficking on the health care system; in 2013, however, $84.9 billion was spent on uncompensated care in the United States.[49] Trafficking victims are among those who, by the nature of the illegal exploitation they have endured, do not have health insurance and are more likely to present for acute care or to delay care,[16] both of which are more costly than preventative and early care.

That only estimates are available argues for a concerted effort to train health care professionals who can not only identify and intervene on the part of victims but also facilitate data collection. That this criminal enterprise has costly public health implications argues for a public health response. Increased funding from private, state, and federal sources is needed to underwrite the cost of conducting more responsible research on the incidence and prevalence of human trafficking, examining the health outcomes associated with trafficking, and evaluating prevention efforts at various levels of the social-ecological framework. Because victims of trafficking are an “invisible” population, such efforts may not be straightforward and will rely on more responsible application of common methods[50^] as well as use of innovative methods such as respondent-driven[51] and capture-recapture[52] sampling.

Some may refute as premature calls that professional certifying bodies require all licensed health care practitioners to receive trafficking training. However, if health care providers are unaware of the existence of human trafficking among their patient populations, victims of trafficking will continue to slip through our health systems undetected. In the same way that health providers have learned to identify victims of intimate partner violence and child abuse and to intervene in the cycle of violence, they must be equipped with the clinical skills to detect, care for, and safely refer victims of trafficking. Untreated physical and mental illnesses pose a threat to victims, and untreated contagious infections are a danger to both individuals and the health of the broader community. The fiscal costs to societies in the forms of increased utilization of resources, increased emergency department use, and increased caseloads for child welfare systems have yet to be studied.

Moreover, governmentally legislated training of health care providers is a trend that has already begun across the United States. Many states have already enacted education laws related to human trafficking, some of which require, and others of which encourage, training. In the states that require training of health care professionals, various approaches are used as the mechanism for achieving the mandate, such as requiring training as a prerequisite for licensing and relicensing or requiring completion of continuing education courses.[53] States in which training for health care professionals is optional mandate state development of educational programs but do not require attendance on the part of professionals.[53] 

More research is needed on the best ways to implement universal provider awareness, but the need for education is critical. Urging certifying bodies to take up this issue will expedite and make standard the training of health care professionals. This widespread training is imperative, as clinicians have a critical role to play in intervening on behalf of victims as well as collecting urgently needed data that will underpin the development of best practices for addressing human trafficking on a multitude of fronts.

Action Steps

1. Federal, state, and private resources should be devoted to evaluating health provider human trafficking training programs and trafficking prevention programs.  
2. All health professional schools, societies, and certifying bodies should incorporate the topic of human trafficking (including labor and sex trafficking) in their curricula, integrating it into existing training on intimate partner, domestic, and sexual violence; child and elder abuse; mandated reporting; and trauma-informed approaches to care. 
3. All health societies and certifying bodies should have policies in place indicating the necessary involvement of health care professionals in the identification and referral of trafficked persons encountered in clinical settings.
4. Governmental agencies’ efforts to improve provider recognition of trafficking and intervention should include all states and the District of Columbia; should be coordinated across multiple sectors, including law enforcement and social services; and should be collaborative endeavors with community service agencies. 
5. State and federal governments and private organizations should fund quality research on the incidence and prevalence of human trafficking in its various forms. 
6. State governments, the federal government, and private organizations should fund rigorous research on and evaluation of the best methods of trafficking prevention and how providers can best identify and care for this patient population.
7. State governments, the federal government, and private organizations should fund quality research on the physical and mental health effects of the various types of human trafficking and on the diverse populations affected by trafficking, including women, girls, men, boys, people with transgender or gender-nonconforming experiences, lesbians, gays, bisexuals, men who have sex with men, unaccompanied and separated minors, and youths in child protective services.
8. State governments, the federal government, and private organizations should fund research on public health interventions that addresses trafficking at each level of the social-ecological framework and focuses on strategies that seek to prevent victimization and perpetration.
9. Professional societies and certifying and funding bodies should ensure that training of health professionals, human trafficking public health research, and anti-trafficking community projects incorporate the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care and involve the full partnership of survivor advisors to allow the development of a survivor-centered and trauma-informed model of care.

References

1. United Nations. Protocol to Prevent, Suppress, and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention against Transnational Organized Crime. Available at: https://treaties.un.org/Pages/ViewDetails.aspx?src=IND&mtdsg_no=XVIII-12-a&chapter=18&lang=en. Accessed January 22, 2016.

2. Walsh J. Human trafficking: it’s not just about sexual exploitation. Available at: http://www.hrw.org/news/2014/11/06/human-trafficking-it-s-not-just-about-sexual-exploitation. Accessed January 22, 2016.

3. United Nations Office on Drugs and Crime. Human trafficking: people for sale. Available at: http://www.unodc.org/toc/en/crimes/human-trafficking.html. Accessed January 22, 2016.

4. US Department of State. Trafficking in Persons Report, 2006. Available at: http://www.state.gov/j/tip/rls/tiprpt/2006/index.htm. Accessed January 22, 2016.

5. US Department of State. Trafficking in persons: a guide for nongovernmental organizations. Available at: http://www.dol.gov/wb/media/reports/trafficking.htm. Accessed January 22, 2016.

6. US Department of State. Trafficking in Persons Report, 2014. Available at: http://www.state.gov/documents/organization/226849.pdf. Accessed January 22, 2016.

7. Global Alliance Against Traffic in Women. What’s the cost of a rumor? A guide to sorting out the myths and the facts about sporting events and trafficking. Available at: http://www.gaatw.org/publications/WhatstheCostofaRumour.11.15.2011.pdf. Accessed January 22, 2016.

8. Allen ED, Strait PB. Natural disasters as a magnet for forced labor: the United States and Japan case studies. Glob Stud J. 2013;5:115–126.

9. Verma V. Sampling Elusive Populations of Labouring Children. Geneva, Switzerland: International Labour Organisation; 2013.

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13. Chisolm-Straker M, Richardson LD, Baldwin S, Gaïgbé-Togbé B, Ndukwe N, Johnson P. Poster presented at: Stolen Lives: An Interprofessional Response to Human Trafficking Conference, May 2014, Quinnipiac, CT.

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18. President’s Interagency Task Force to Monitor and Combat Trafficking in Persons. Federal Strategic Action Plan on Service for Victims of Human Trafficking in the United States, 2013–2017. Available at: http://www.ovc.gov/pubs/FederalHumanTraffickingStrategicPlan.pdf. Accessed January 22, 2016.

19. Reinhard A, Whitacre I, Hervey AM, Berg GM. Knowledge and attitudes of physicians in Kansas regarding domestic minor sex trafficking. Kans J Med. 2012;5:142–153.

20. Wong JC. Human trafficking: an evaluation of Canadian medical students’ awareness and attitudes. Educ Health. 2011;24:2059–2071.

21. Grace AM, Lippert S, Collins K, et al. Educating health care professionals on human trafficking. Pediatr Emerg Care. 2014;30:856–861.

22. Estes RJ, Weiner N. The Commercial Sexual Exploitation of Children in the U.S., Canada, and Mexico. Philadelphia, PA: University of Pennsylvania, School of Social Work; 2001.

23. Greenbaum VJ. Commercial sexual exploitation and sex trafficking of children in the United States. Curr Probl Pediatr Adolesc Health Care. 2014;44:245–269.

24. Institute of Medicine and National Research Council. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: National Academies Press; 2013.

25. Ray NC, Berger S, Boyle M, et al. Lesbian, Gay, Bisexual and Transgender Youth: An Epidemic of Homelessness. Washington, DC: National Gay and Lesbian Task Force; 2006.

26. Centers for Disease Control and Prevention. Sexual identity, sex of sexual contacts, and health-risk behaviors among students in grades 9–12—youth risk behavior surveillance, selected sites, United States, 2001–2009. MMWR Surveill Summ. 2011;60:1–133.

27. Polaris. Breaking barriers: improving services for LGBTQ human trafficking victims. Available at: https://polarisproject.org/resources/breaking-barriers-improving-services-lgbtq-human-trafficking-victims. Accessed January 22, 2016.

28. Leventhal T, Dupéré V, Brooks-Gunn J. Neighborhood influences on adolescent development. In: Handbook of Adolescent Psychology. New York, NY: John Wiley & Sons Inc; 2009.

29. National Poverty Center. The colors of poverty: why racial and ethnic disparities persist. Available at: http://www.npc.umich.edu/publications/policy_briefs/brief16/PolicyBrief16.pdf. Accessed January 22, 2016.

30. Dottridge M. Child Trafficking for Sexual Purposes. Rio de Janeiro, Brazil: EC-PAT International; 2008.

31. Violence Prevention: The Evidence—Preventing Violence by Developing Life Skills in Children and Adolescents. Geneva, Switzerland: World Health Organization; 2009.

32. Guzun I, ed. Life Skills Education for Prevention of Trafficking in Human Beings. Chisinau, Moldova: Child Rights Information Center Moldova; 2004.

33. Van de Glind H. Migration and Child Labour: Exploring Child Migrant Vulnerabilities and Those of Children Left Behind. Geneva, Switzerland: International Labour Office, International Programme on the Elimination of Child Labour; 2010.

34. Boak A, Boldoser A, Biu O, eds. Smooth flight: a guide to preventing youth trafficking. Available at: http://www.childtrafficking.com/Docs/ppat_2003_smooth_flight_guide_prevent_youth_trafficking.pdf. Accessed January 22, 2016.

35. Yen I. Of vice and men: a new approach to eradicating sex trafficking by reducing male demand through educational programs and abolitionist legislation. J Crim Law Criminol. 2008;98:653–686.

36. Shively M, Jalbert SK, Kling R, et al. Final Report on the Evaluation of the First Offender Prostitution Program. Washington, DC: Abt Associates; 2008.

37. Fisanick C, ed. Human Trafficking. Detroit, MI: Greenhaven Press; 2010.

38. Violence Prevention: The Evidence—Promoting Gender Equality to Prevent Violence Against Women. Geneva, Switzerland; World Health Organization; 2009.

39. Ricardo C, Eads M, Barker G. Engaging Boys and Young Men in the Prevention of Sexual Violence: A Systematic and Global Review of Evaluated Interventions. Washington, DC: Promundo-US; 2011.

40. US Preventive Services Task Force. Intimate partner violence and abuse of elderly and vulnerable adults. Available at: http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening. Accessed January 22, 2016.

41. Simich L, Goyen L, Powell A, Mallozzi, K. Improving Human Trafficking Victim Identification—Validation and Dissemination of a Screening Tool. New York, NY: Vera Institute of Justice; 2014.

42. Konstantopoulos M, Ahn R, Alpert EJ, et al. An international comparative public health analysis of sex trafficking of women and girls in eight cities: achieving a more effective health sector response. J Urban Health. 2013;90:1194–1204.

43. Ahn R, Alpert EJ, Purcell G, et al. Human trafficking: review of educational resources for health professionals. Am J Prev Med. 2013;44:283–289.

44. National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice. Washington, DC: Office of Minority Health, US Department of Health and Human Services; 2013.

45. De Chesnay M, ed. Sex Trafficking: A Clinical Guide for Nurses. New York, NY: Springer; 2013.

46. Weitzer R. The growing moral panic over prostitution and trafficking. Criminologist. 2005;30:1–5.

47. Somin A. Is there an unwarranted moral panic over sex trafficking? Available at: http://www.newamericancivilrightsproject.org/2014/10/21/is-there-an-unwarranted-moral-panic-over-sex-trafficking/. Accessed January 22, 2016.

48. Bureau of Justice Assistance, US Department of Justice. Anti-Human Trafficking Task Force Initiative: overview. Available at: https://www.bja.gov/ProgramDetails.aspx?Program_ID=51. Accessed January 22, 2016.

49. Coughlin TA, Holahan J, Caswell K, McGrath M. Uncompensated Care for the Uninsured in 2013: A Detailed Examination. Washington, DC: Henry J. Kaiser Family Foundation; 2014.

50. Brunovskis A, Surtees R. Untold stories: biases and selection effects in research with victims of trafficking for sexual exploitation. Int Migr. 2010;48:1–37.

51. Petersen RD, Valdez A. Using snowball-based methods in hidden populations to generate a randomized community sample of gang-affiliated adolescents. Youth Violence Juv Justice. 2005;3:151–167.

52. Gurgel RQ, da Fonseca JD, Neyra-Castañeda D, Gill GV, Cuevas LE. Capture-recapture to estimate the number of street children in a city in Brazil. Arch Dis Child. 2004;89:222–224.

53. Atkinson HG, Curnin KJ, Hanson NC. US state laws to assist trafficking victims: education of and mandatory reporting by physicians and others. Forthcoming.