Human trafficking, a form of modern slavery, is an egregious violation of human rights with profound personal and public health implications. It includes forced labor and sexual exploitation of both U.S. and non-U.S. citizens and has been reported in all 50 states. Victims of human trafficking are currently among the most abused and disenfranchised persons in society, and they face a wide range of negative health outcomes resulting from their subjugation and exploitation.
Medicine has an important role to play in mitigating the devastating effects of human trafficking on individuals and society. Victims are cared for in emergency departments, primary care offices, urgent care centers, community health clinics, and reproductive health clinics. In addition, they are unknowingly being treated in hospital inpatient units. Injuries and illnesses requiring medical attention thus represent unique windows of opportunity for trafficked persons to receive assistance from trusted health care professionals.
With education and training, health care providers can recognize signs and symptoms of trafficking, provide trauma-informed care to this vulnerable population, and respond to exploited persons who are interested and ready to receive assistance. Multidisciplinary response protocols, research, and policy advocacy can enhance the impact of antitrafficking health care efforts to interrupt the cycle of abuse and violence for these victims.
References
- 1. Victims of Trafficking and Violence Protection Act of 2000, Pub. L. No. 106-386, 114 Stat. 1470 (2000). Google Scholar
- 2.
Lederer LJ ,Wetzel CA . The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law. 2014;23:61-91. Google Scholar - 3.
International Labour Organization . ILO Global Estimate of Forced Labor: Results and Methodology. Geneva: International Labour Office; 2012. Google Scholar - 4.
International Labour Organization . Profits and Poverty: The Economics of Forced Labour. Geneva: International Labour Office; 2014. Google Scholar - 5. National Human Trafficking Resource Center. 2015 NHTRC annual report. February 2016. Accessed at http://traffickingresourcecenter.org/resources/2015-nhtrc-annual-report on 15 April 2016. Google Scholar
- 6. Banks D, Kyckelhahn T. Special report: characteristics of suspected human trafficking incidents, 2008-2010. U.S. Department of Justice. April 2011. Accessed at www.bjs.gov/content/pub/pdf/cshti0810.pdf on 15 April 2016. Google Scholar
- 7.
Estes RJ ,Weiner NA . The Commercial Sexual Exploitation of Children in the U.S., Canada and Mexico. Philadelphia: Univ Pennsylvania; 2001. Google Scholar - 8.
Tyler KA ,Hoyt DR ,Whitbeck LB ,Cauce AM . The impact of childhood sexual abuse on later sexual victimization among runaway youth. J Res Adolesc. 2001;11:151-76. CrossrefGoogle Scholar - 9.
Whitbeck LB ,Chen X ,Hoyt DR ,Tyler KA ,Johnson KD . Mental disorder, subsistence strategies, and victimization among gay, lesbian, and bisexual homeless and runaway adolescents. J Sex Res. 2004;41:329-42. [PMID:15765273 ] CrossrefMedlineGoogle Scholar - 10.
Barrows J ,Finger R . Human trafficking and the healthcare professional. South Med J. 2008;101:521-4. [PMID:18414161 ] doi:10.1097/SMJ.0b013e31816c017d CrossrefMedlineGoogle Scholar - 11. Williamson E, Dutch NM, Clawson HJ. National symposium on the health needs of human trafficking victims: post-symposium brief. U.S. Department of Health and Human Services. July 2009. Accessed at https://aspe.hhs.gov/basic-report/national-symposium-health-needs-human-trafficking-victims-post-symposium-brief on 15 April 2016. Google Scholar
- 12.
Gwadz MV ,Gostnell K ,Smolenski C ,Willis B ,Nish D ,Nolan TC ,et al . The initiation of homeless youth into the street economy. J Adolesc. 2009;32:357-77. [PMID:18760466 ] doi:10.1016/j.adolescence.2008.01.004 CrossrefMedlineGoogle Scholar - 13.
Ahrens KR ,Katon W ,McCarty C ,Richardson LP ,Courtney ME . Association between childhood sexual abuse and transactional sex in youth aging out of foster care. Child Abuse Negl. 2012;36:75-80. [PMID:22265906 ] doi:10.1016/j.chiabu.2011.07.009 CrossrefMedlineGoogle Scholar - 14.
Muftic LR ,Finn MA . Health outcomes among women trafficked for sex in the United States: a closer look. J Interpers Violence. 2013;28:1859-85. [PMID:23295378 ] doi:10.1177/0886260512469102 CrossrefMedlineGoogle Scholar - 15.
Macias Konstantopoulos W ,Ahn R ,Alpert EJ ,Cafferty E ,McGahan A ,Williams TP ,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;90:1194-204. [PMID:24151086 ] doi:10.1007/s11524-013-9837-4 CrossrefMedlineGoogle Scholar - 16.
Dank M ,Yahner J ,Madden K ,Banuelos I ,Yu L ,Ritchie A ,et al . Surviving the Streets of New York: Experiences of LGBTQ Youth, YMSM, and YWSW Engaged in Survival Sex. Washington, DC: Urban Institute; 2015. Google Scholar - 17.
Macias-Konstantopoulos ,Munroe D ,Purcell G ,Tester K ,Burke TF ,Ahn R . The commercial sexual exploitation and sex trafficking of minors in the Boston metropolitan area: experiences and challenges faced by front-line providers and other stakeholders. J Appl Res Child. 2015;6:4. Google Scholar - 18.
Chettiar J ,Shannon K ,Wood E ,Zhang R ,Kerr T . Survival sex work involvement among street-involved youth who use drugs in a Canadian setting. J Public Health (Oxf). 2010;32:322-7. [PMID:20061578 ] doi:10.1093/pubmed/fdp126 CrossrefMedlineGoogle Scholar - 19.
Organization for Security and Co-operation in Europe Office of the Special Representative and Co-ordinator for Combating Trafficking in Human Beings . Unprotected Work, Invisible Exploitation: Trafficking for the Purpose of Domestic Servitude. Vienna, Austria: Organization for Security and Co-operation in Europe; 2010. Google Scholar - 20.
Turner-Moss E ,Zimmerman C ,Howard LM ,Oram S . Labour exploitation and health: a case series of men and women seeking post-trafficking services. J Immigr Minor Health. 2014;16:473-80. [PMID:23649665 ] doi:10.1007/s10903-013-9832-6 CrossrefMedlineGoogle Scholar - 21.
Zimmerman C ,Yun K ,Shvab I ,Watts C ,Trappolin L ,Trepete M ,et al . The Health Risks and Consequences of Trafficking in Women and Adolescents: Findings from a European Study. London: London School of Hygiene and Tropical Medicine; 2003. Google Scholar - 22.
Tsutsumi A ,Izutsu T ,Poudyal AK ,Kato S ,Marui E . Mental health of female survivors of human trafficking in Nepal. Soc Sci Med. 2008;66:1841-7. [PMID:18276050 ] doi:10.1016/j.socscimed.2007.12.025 CrossrefMedlineGoogle Scholar - 23.
International Organization for Migration; United National Global Initiative to Fight Human Trafficking; London School of Hygiene and Tropical Medicine . Caring for Trafficked Persons: Guidance for Health Providers. Geneva: International Organization for Migration; 2009. Google Scholar - 24.
Hossain M ,Zimmerman C ,Abas M ,Light M ,Watts C . The relationship of trauma to mental disorders among trafficked and sexually exploited girls and women. Am J Public Health. 2010;100:2442-9. [PMID:20966379 ] doi:10.2105/AJPH.2009.173229 CrossrefMedlineGoogle Scholar - 25.
Oram S ,Stöckl H ,Busza J ,Howard LM ,Zimmerman C . Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: systematic review. PLoS Med. 2012;9:e1001224. [PMID:22666182 ] doi:10.1371/journal.pmed.1001224 CrossrefMedlineGoogle Scholar - 26.
Alpert EJ ,Ahn R ,Albright E ,Purcell G ,Burke TF ,Macias-Konstantopoulos WL . Human Trafficking: Guidebook on Identification, Assessment, and Response in the Health Care Setting. Waltham, MA: Massachusetts General Hospital and Massachusetts Medical Society; 2014. Google Scholar - 27.
Kiss L ,Pocock NS ,Naisanguansri V ,Suos S ,Dickson B ,Thuy D ,et al . Health of men, women, and children in post-trafficking services in Cambodia, Thailand, and Vietnam: an observational cross-sectional study. Lancet Glob Health. 2015;3:e154-61. [PMID:25701993 ] doi:10.1016/S2214-109X(15)70016-1 CrossrefMedlineGoogle Scholar - 28.
Willis BM ,Levy BS . Child prostitution: global health burden, research needs, and interventions. Lancet. 2002;359:1417-22. [PMID:11978356 ] CrossrefMedlineGoogle Scholar - 29.
Silverman JG ,Decker MR ,Gupta J ,Maheshwari A ,Patel V ,Raj A . HIV prevalence and predictors among rescued sex-trafficked women and girls in Mumbai, India. J Acquir Immune Defic Syndr. 2006;43:588-93. [PMID:17019369 ] CrossrefMedlineGoogle Scholar - 30.
Silverman JG ,Decker MR ,Gupta J ,Maheshwari A ,Willis BM ,Raj A . HIV prevalence and predictors of infection in sex-trafficked Nepalese girls and women. JAMA. 2007;298:536-42. [PMID:17666674 ] CrossrefMedlineGoogle Scholar - 31.
Dharmadhikari AS ,Gupta J ,Decker MR ,Raj A ,Silverman JG . Tuberculosis and HIV: a global menace exacerbated via sex trafficking. Int J Infect Dis. 2009;13:543-6. [PMID:19153056 ] doi:10.1016/j.ijid.2008.11.010 CrossrefMedlineGoogle Scholar - 32.
Organization for Security and Co-operation in Europe . Trafficking in Human Beings Amounting to Torture and Other Forms of Ill-Treatment. Vienna, Austria: Organization for Security and Co-operation in Europe; 2013. Google Scholar - 33.
Baldwin SB ,Eisenman DP ,Sayles JN ,Ryan G ,Chuang KS . Identification of human trafficking victims in health care settings. Health Hum Rights. 2011;13:E36-49. [PMID:22772961 ] MedlineGoogle Scholar - 34.
Flores TL . The Slave Across the Street: The True Story of How an American Teen Survived the World of Human Trafficking. Boise, ID: Ampelon; 2010. Google Scholar - 35. National Human Trafficking Resource Center. Comprehensive human trafficking assessment. 2011. Accessed at http://traffickingresourcecenter.org/sites/default/files/Comprehensive%20Trafficking%20Assessment.pdf on 15 April 2016. Google Scholar
- 36.
Williams TP ,Alpert EJ ,Ahn R ,Cafferty E ,Konstantopoulos WM ,Wolferstan N ,et al . Sex trafficking and health care in Metro Manila: identifying social determinants to inform an effective health system response. Health Hum Rights. 2010;12:135-47. [PMID:21178195 ] MedlineGoogle Scholar - 37.
Greenbaum VJ . Commercial sexual exploitation and sex trafficking of children in the United States. Curr Probl Pediatr Adolesc Health Care. 2014;44:245-69. [PMID:25131563 ] doi:10.1016/j.cppeds.2014.07.001 CrossrefMedlineGoogle Scholar - 38.
Macias-Konstantopoulos W ,Bar-Halpern M . Commercially sexually exploited and trafficked minors: our hidden and forgotten children.. In: Parekh R, Childs EW, eds. Stigma and Prejudice: Touchstones in Understanding Diversity in Healthcare. Current Clinical Psychiatry. Cham, Switzerland: Springer Publishing; 2016:183-202. Google Scholar - 39.
Clawson HJ ,Small KV ,Go ES ,Bradley WM . Needs Assessment for Service Providers and Trafficking Victims. Washington, DC: U.S. Department of Justice; 2003. Google Scholar - 40.
Chisolm-Straker M ,Richardson LD ,Cossio T . Combating slavery in the 21st century: the role of emergency medicine. J Health Care Poor Underserved. 2012;23:980-7. [PMID:24212151 ] doi:10.1353/hpu.2012.0091 CrossrefMedlineGoogle Scholar - 41.
Ahn R ,Alpert EJ ,Purcell G ,Konstantopoulos WM ,McGahan A ,Cafferty E ,et al . Human trafficking: review of educational resources for health professionals. Am J Prev Med. 2013;44:283-9. [PMID:23415126 ] doi:10.1016/j.amepre.2012.10.025 CrossrefMedlineGoogle Scholar - 42.
Isaac R ,Solak J ,Giardino AP . Health care providers' training needs related to human trafficking: maximizing the opportunity to effectively screen and intervene. J Appl Res Child. 2011;2:8. Google Scholar - 43.
Grace AM ,Ahn R ,MaciasKonstantopoulos W . Integrating curricula on human trafficking into medical education and residency training. JAMA Pediatr. 2014;168:793-4. [PMID:25048726 ] doi:10.1001/jamapediatrics.2014.999 CrossrefMedlineGoogle Scholar - 44.
Massachusetts Medical Society . Massachusetts Medical Society adopts resolutions on physician education, substance use disorder, human trafficking, and weight stigma [press release]. Waltham, MA: Massachusetts Medical Society; 7 May 2016. Google Scholar - 45. Harrison SL, Atkinson HG, Newman CB, Leavell Y, Miller D, Brown CM, et al. American Medical Women's Association position paper on the sex trafficking of women and girls in the United States. American Medical Women's Association. May 2014. Accessed at www.amwa-doc.org/wp-content/uploads/2013/12/AMWA-Position-Paper-on-Human-Sex-Trafficking_May-20141.pdf on 15 April 2016. Google Scholar
- 46.
U.S. Department of Justice .U.S. Department of Health and Human Services .Department of Homeland Security; President's Interagency Task Force to Monitor and Combat Trafficking in Persons . Coordination, Collaboration, Capacity: Federal Strategic Action Plan on Services for Victims of Human Trafficking in the United States, 2013-2017. Washington, DC: US Gov Pr Office; 2014. Google Scholar - 47. U.S. Department of Health and Human Services; Administration for Children and Families; Office on Trafficking in Persons. SOAR to health and wellness training. 23 May 2016. Accessed at www.acf.hhs.gov/programs/endtrafficking/initiatives/soar on 15 April 2016. Google Scholar
- 48.
Substance Abuse and Mental Health Services Administration .U.S. Department of Health and Human Services . Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol Series 57. Publication no. (SMA) 14-4816. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014. Google Scholar - 49.
Elliott DE ,Bjelajac P ,Fallot RD ,Markoff LS ,Reed BG . Trauma-informed or trauma-denied: principles and implementation of trauma-informed services for women. J Community Psychol. 2005;33:461-77. CrossrefGoogle Scholar - 50.
Early TJ ,GlenMaye LF . Valuing families: social work practice with families from a strengths perspective. Soc Work. 2000;45:118-30. [PMID:10710985 ] CrossrefMedlineGoogle Scholar
Author, Article and Disclosure Information
From Massachusetts General Hospital Freedom Clinic, Boston, Massachusetts.
Acknowledgment: The author thanks colleagues at the Massachusetts General Hospital (MGH) and external collaborators in antitrafficking work for their ongoing support.
Grant Support: By the Partnership for Freedom 2014 Reimagine Opportunity Innovations Challenge Award (for Dr. Macias-Konstantopoulos' work with the MGH Freedom Clinic and the MGH Human Trafficking Initiative [Boston, Massachusetts]). Led by Humanity United (San Francisco, California) and the U.S. Departments of Justice, Health and Human Services, Housing and Urban Development, State, and Labor (Washington, DC), the Partnership for Freedom is a public–private partnership dedicated to promoting innovative solutions to end modern-day slavery.
Disclosures: Dr. Macias-Konstantopoulos reports grants from the Partnership for Freedom Reimagine Opportunity Innovations Challenge outside the submitted work. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-0094.
Corresponding Author: Wendy Macias-Konstantopoulos, MD, MPH, Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 910, Boston, MA 02114; e-mail, [email protected]
Author Contributions: Conception and design: W. Macias-Konstantopoulos.
Drafting of the article: W. Macias-Konstantopoulos.
Critical revision of the article for important intellectual content: W. Macias-Konstantopoulos.
Final approval of the article: W. Macias-Konstantopoulos.
Collection and assembly of data: W. Macias-Konstantopoulos.
This article was published at www.annals.org on 9 August 2016.

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