ABSTRACT: Human trafficking is a widespread problem with estimates ranging from 14,000 to 50,000 individuals trafficked into the United States annually. This hidden population involves the commercial sex industry, agriculture, factories, hotel and restaurant businesses, domestic workers, marriage brokers, and some adoption firms. Because 80% of trafficked individuals are women and girls, women's health care providers may better serve their diverse patient population by increasing their awareness of this problem. The exploitation of people of any race, gender, sexual orientation, or ethnicity is unacceptable at any time, in any place. The members of the American College of Obstetricians and Gynecologists should be aware of this problem and strive to recognize and assist their patients who are victims or who have been victims of human trafficking.
Human trafficking is defined as "the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery" (1). Largely unrecognized, annual trafficking estimates have ranged from 14,000 to 50,000 individuals in the United States (2). Many experts think current reported statistics vastly underestimate the scope of the problem. Although states that border Canada and Mexico and states with major ports are points of entry, the problem exists in all states because trafficking networks quickly move people across the country. Trafficked individuals have been reported in all states in the United States; however, accurate data are not available because of the difficulty in identifying trafficked individuals.
Trafficked individuals fear identification. In addition, the networks responsible for trafficking are adept at eluding law enforcement. Traffickers and those being trafficked have complex relationships with each other. In some cases those trafficked may be related to their captors, fear for their safety, or feel they would not survive without the assistance of the trafficker.
Federal legislation, passed in 2000 and reauthorized in 2003, 2005, and 2008, aimed to punish traffickers, protect and free victims, and eliminate human trafficking, is not well known or well enforced, and few trafficked individuals can afford legal representation (1, 3). From 2001 to 2009 only 2,076 foreign national victims of human trafficking have been certified by the Department of Health and Human Services (4). This significant lack of victim identification underscores the need to better educate the public and governmental officials about this ubiquitous problem.
Characteristics of Individuals Being Trafficked
Individuals who are trafficked have many faces. No racial or ethnic group is spared; however, vulnerable people, such as those of war-torn areas or economically poor areas are more commonly subjected to human trafficking. Some are unwittingly ensnared by human traffickers, whereas others are desperate to escape their circumstances and then find themselves enslaved in a worse situation. No community is immune to this problem. Eighty percent of trafficked individuals are female and 50% of victims are minors (2, 5). Many are paid little or nothing for their services and fear deportation because they often do not have any identification papers. Rates of sexually transmitted infections and human immunodeficiency virus (HIV) infection are prevalent among these victims (6).
One million children, most of whom are girls, are exploited in the global commercial sex trade every year (7). Many of these children are violated by sexual acts 100-1,500 times per year (8). The United States has federal laws against individuals engaging in sexual acts with individuals younger than 18 years, which are the Mann Act, the Child Sexual Abuse Prevention Act of 1994, and the PROTECT Act of 2003. States vary in their definition of underaged sex as well as their definition of a minor regarding prostitution laws. In addition, the Department of Homeland Security and U.S. Immigration and Customs Enforcement have a program called Operation Predator, which aims to identify and prevent child predators from traveling in and out of the United States. Refer to the Resources section for contact numbers to report Americans suspected of engaging in sex tourism and to report suspected cases of child sexual abuse.
Forms of Human Trafficking
Trafficking involves the commercial sex industry, agriculture, factories, hotel and restaurant businesses, domestic help, marriage brokers, and some adoption firms. Any form of human trafficking may be operated by organized crime, individuals, or both. Forced bondage involves placing the victim at the mercy of their employer as can be seen in migrant workers. Migrant workers are separated from their social support and their families at home who often are counting on their wages and are forced to tolerate inhumane working and living conditions, usually earning less than what was originally promised. Involuntary servitude poses a unique challenge because it is especially difficult to identify these cases, most of which occur in private homes. Many of these victims, mostly women, are abused physically, emotionally, and sexually (9).
Challenges of Human Trafficking
The most challenging aspect of addressing human trafficking is identifying the victims, which is problematic for several reasons. Victims may not perceive themselves as trafficked individuals. They may fear retaliation by the trafficker; lack knowledge of resources to help themselves; and face many cultural, social, and language barriers. Some of these aspects are analogous to the difficulties in identifying victims of domestic violence or prostitution. Identifying victims is the first step in an effective strategy to combat trafficking.
Although recognizing trafficked individuals is difficult, having some knowledge of its existence allows for the possibility of recognition. Many service providers and community members are on the frontline of contact with victims of human trafficking. Health clinics, hospitals, social welfare offices, and police frequently and unknowingly experience face-to-face contact with trafficked individuals. Obstetrician-gynecologists may be key to the identification of trafficked individuals. Because 80% of trafficked people are women and girls who may be at risk of gynecologic and obstetric issues due to their circumstances, they may go to practitioners' offices or emergency departments for their first medical contact. The Polaris Project, a national organization working to address human trafficking by advocating for stronger federal and state laws, operating the National Human Trafficking Resource Center hotline and providing services to help victims of human trafficking (see Resources), provides a set of general and health indicators that can alert a health care practitioner to the signs of a patient who is a possible victim of human trafficking. Following are some of these indicators:
- Lack of any official identification papers or cards (driver's license, passport, green card)
- Vague answers about their situation ("I'm just visiting" but has no passport)
- Many inconsistencies to their stories
- No eye contact
- No control of their money (someone else pays cash for their health care visit)
- Signs of physical abuse (bruises, burns, cuts, broken bones or teeth)
- Signs of depression or posttraumatic stress disorder
- Drug or alcohol addiction
Signs of being a victim of sex industry trafficking may include the following:
- Known age younger than 18 years (along with some combination of the following signs)
- Multiple sexual partners reported
- Multiple episodes of sexually transmitted infections
- Inappropriate attire for a health care visit (eg, lingerie)
- Tattoos or other types of branding for which the patient offers a vague explanation
- Evidence of sexual abuse or trauma
Asking open-ended questions of the patient regarding mental and physical health can sometimes reveal abusive situations. Being alert to an unusual dynamic between the patient and her partner often can lead a health care provider to suspect abuse. Finding a way to speak to the patient in the presence of a chaperone and away from the partner is extremely important. If the patient relates a history of abuse in addition to being the victim of human trafficking, the National Human Trafficking Resource Center Hotline (1-888-373-7888) can be contacted to help determine the next steps to help the victim. It is useful to have a list of local shelters, safe homes for abused women and children, and contact information ready to give to women in need. Literature such as posters, brochures, or small pocket cards (translated as necessary) can be left in bathrooms or waiting areas where women can more discreetly obtain information and resources. If a child is suspected of being involved in abuse, Child Protective Services should be contacted as well as the National Center for Missing and Exploited Children (see Resources).
If you think you have a victim of human trafficking in your office, the following is important:
- Be sensitive (every situation is different)
- Make sure you are not putting yourself or your staff in danger (10)
- Contact the police if you suspect immediate danger to the victim or yourself
- Offer assistance—Give the patient outreach information, hotline numbers, or both for local services (only when patient is alone)
- Give the patient the National Human Trafficking Resource Center (NHTRC) hotline number (only when the patient is alone): 1-888-373-7888
- Call the NHTRC to report the incident or to locate local victims' services: 1-888-373-7888
Only when enough victims are assured of safety can another great challenge be met: identifying and prosecuting the traffickers. Although organized crime is significantly involved in human trafficking, there are plenty of individuals, sometimes family members of the victims, and small groups running their own exploitation enterprises. Human traffickers are very adept at using modern technology to operate their enterprises—cell phones, web sites, and other electronic devices (eg, personal digital assistants and smartphones). It is often very difficult to keep track of the intended use of myriad web sites on the Internet.
Eliminating Human Trafficking
One solution to address human trafficking is eliminating the demand for trafficked individuals. Strategies in the United States to help achieve this goal include workplace regulation and increasing public awareness and consciousness (11). Legislation should focus on the individuals and agencies that condone the trafficking of human beings, rather than criminalizing the victims of such activities. More global goals include improving the livelihoods of communities where residents are targeted for trafficking, and eliminating warfare that causes tragic disruption and exposes large numbers of refugees to the risks of being trafficked. A unified approach from local, national, and global leadership can result in the changes necessary to decrease the exploitation of victims of human trafficking.
Costs of Human Trafficking
Human trafficking takes an immense toll on the quality of human life as well as costs to society. This includes degradation of human rights, poor public health, disrupted families and communities, decreased governance, and diminished social and economic development (3). Victims of human trafficking require rescue, rehabilitation, and reintegration into society.
Safety for Health Care Providers
Because traffickers may be involved in organized crime, local gangs, or other trafficking networks, protecting health care providers and staff working with victims is imperative. See the following suggestions for enhancing the safety practices of physicians, staff, and patients (10) (please note the following list includes some general safety measures along with measures that apply to health care providers who may frequently help victims of abuse or human trafficking):
- Establish a relationship with the local police force and other security personnel.
- Obtain a security audit of the office or institution.
- Review emergency plans periodically.
- Restrict after-hours access.
- Improve lighting at entrances and in parking areas.
- Install security cameras, mirrors, and panic buzzers.
- Install deadbolt or electronic locks.
- Restrict access to all doors except the main entrance.
- Preprogram 911 (emergency telephone number) into all telephones.
- Enclose and secure reception areas.
- Develop an emergency notification system.
The exploitation of people of any race, gender, sexual orientation, or ethnicity is unacceptable at any time, in any place. It is costly both to the people and the nation and will take the concerted efforts of government agencies, nongovernmental agencies, law enforcement, and the public to defeat this problem. Barriers to accurately assess the scope of the problem include the hidden nature of the problem, fear and cultural barriers, lack of awareness on the part of the public and public officials, the limited legal language related specifically to human trafficking, and the lack of adequate funding and training for those capable of identifying and assisting victims of human trafficking (3). As health care providers to women and girls, the members of the American College of Obstetricians and Gynecologists should be aware of this problem and strive to recognize and assist their patients who are victims or who have been victims of human trafficking. This Committee Opinion is not the definitive resource of information for identifying and helping trafficked women seek care, but is an important tool that should be used by obstetrician-gynecologists to start the dialogue with these patients.
Child Exploitation/Operation Predator
Coalition Against Trafficking in Women
Human Rights Watch
National Center for Missing and Exploited Children
National Human Trafficking Resource Center
Safe Horizon Anti-Trafficking Program and Hotline
The Rebecca Project
U.S. Department of Justice
U.S. Department of State: Office to Monitor and Combat Trafficking in Person
U.S. Immigration and Customs Enforcement
World Health Organization
- Office to Monitor and Combat Trafficking in Persons, US Department of State. Trafficking in persons report. 10th ed. Washington, DC: US Department of State; 2010. Available at: http://www.state.gov/documents/organization/142979.pdf. Retrieved March 14, 2011.
- Office of the Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services. Human trafficking into and within the United States: a review of the literature. Washington, DC: HHS; 2009. Available at: http://aspe.hhs.gov/hsp/07/HumanTrafficking/LitRev/index.pdf. Retrieved April 5, 2011.
- Jackson School of International Studies, University of Washington. Human trafficking: a spotlight on Washington State. 2006 Task Force on Human Trafficking. Seattle (WA): University of Washington; 2006. Available at: http://csde.washington.edu/~scurran/files/HumanTraffickingSpotlightonWashingtonState.pdf. Retrieved March 14, 2011.
- Office of the Attorney General, US Department of Justice. Attorney General's annual report to Congress and assessment of U.S. government activities to combat trafficking in persons: fiscal year 2009. Washington, DC: USDOJ; 2010. Available at: http://www.justice.gov/ag/annualreports/tr2009/agreporthumantrafficking2009.pdf. Retrieved April 5, 2011.
- Polaris Project. Human trafficking statistics. Washington, DC: Polaris Project; 2009. Available at: http://www.polarisproject.org/resources/resources-by-topic/human-trafficking. Retrieved April 5, 2011.
- Administration for Children and Families, US Department of Health and Human Services. Resources: common health issues seen in victims of human trafficking. Available at: http://www.acf.hhs.gov/trafficking/campaign_kits/tool_kit_health/health_problems.pdf. Retrieved April 5, 2011.
- Office to Monitor and Combat Trafficking in Persons, US Department of State. The facts about child sex tourism. Washington, DC: US Department of State; 2005. Available at: http://2001-2009.state.gov/documents/organization/51459.pdf. Retrieved April 5, 2011.
- Office to Monitor and Combat Trafficking in Persons, US Department of State. Trafficking in persons report. Washington, DC: US Department of State; 2008. Available at: http://www.state.gov/documents/organization/105501.pdf. Retrieved March 14, 2011.
- Human Rights Watch. Hidden in the home: abuse of domestic workers with special visas in the United States. New York (NY): HRW; 2001. Available at: http://www.hrw.org/legacy/reports/2001/usadom. Retrieved March 14, 2011.
- American College of Obstetricians and Gynecologists. Guidelines for women's health care: a resource manual. 3rd ed. Washington, DC: ACOG; 2007.
- Office to Monitor and Combat Trafficking in Persons, US Department of State. Assessment of U.S. government activities to combat trafficking in persons. Washington, DC: US Department of State; 2009. Available at: http://www.state.gov/documents/organization/126789.pdf. Retrieved March 14, 2011.