CommitteeOpinion2017
Number 787
(Replaces Committee Opinion Number 507, September 2011)


Committee on Health Care for Underserved Women

This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women in collaboration with committee members Veronica Gillispie, MD, Jennefer A. Russo, MD, MPH, and Kavita Shah Arora, MD, MBE, MS.


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Human Trafficking

ABSTRACT: Human trafficking, or modern-day slavery, is a global problem with broad reach that is often underrecognized in the United States. Victims of trafficking have been found in a wide range of legal and illegal business settings, and this frequently hidden population is most often exploited in the commercial sex industry, agriculture, factories, hotels, restaurants, as domestic workers, and by marriage brokers and some adoption firms. Human trafficking disproportionately affects underserved women and children, with more than 70% of trafficking cases involving women and girls and more than 90% of victims trafficked into the sex industry. Obstetrician–gynecologists and other women’s health care providers are well-situated to identify and assist victims of human trafficking. Many trafficked individuals present to outpatient obstetrics and gynecology clinics, community health centers, family planning clinics, urgent care centers, and adolescent medicine clinics, and one half of all female victims of sex trafficking have visited the emergency department while involved in sex trafficking. Obstetrician–gynecologists and other women’s health care providers should be aware of human trafficking, recognize signs of human trafficking, and be prepared to assist patients who are victims or who have been victims of human trafficking. This Committee Opinion has been updated to include screening questions and indicators to identify victims of human trafficking, additional information regarding reporting obligations for suspected human trafficking, and additional resources for survivors of human trafficking.

Recommendations

The American College of Obstetricians and Gynecologists makes the following recommendations to improve awareness of the signs of human trafficking and to prepare obstetrician-gynecologists and other women’s health care providers to take action:

  • Recognize indicators of human trafficking, such as patients with signs of abuse or neglect or those accompanied by an individual who does not let the patient speak for themselves, refuses to allow for privacy, or insists on interpreting for them in place of a professional.
  • Become well-informed about common health care issues faced by victims of human trafficking, including sexually transmitted infections, substance use disorders, mental health problems, and physical trauma.
  • Evaluate a patient’s medical and nonmedical needs while recognizing the importance of providing a safe and comfortable environment for the patient, using appropriate methods of communication, and acknowledging the dynamics involved in evaluating a patient who is subject to human trafficking.
  • Be aware of the laws in your jurisdiction regarding reporting obligations for suspected human trafficking, with specific attention to mandatory reporting requirements for child abuse.
  • Provide resources for survivors of human trafficking, including brochures, pamphlets, and pocket cards displayed in examination rooms, waiting rooms, or, more discretely, in bathrooms in addition to contact information for organizations and resources that can support survivors.

Background

Human trafficking, or modern-day slavery, is a global problem with broad reach that is often underrecognized in the United States. The International Labor Organization estimates that 25 million individuals around the world are victims of modern slavery in the form of forced labor and sex trafficking (1). The United States is not immune, and the Global Slavery Index estimates that on any given day, more than 400,000 individuals in the United States are living in conditions of modern slavery, a prevalence of 1.3 per 1,000 individuals (2). Human trafficking disproportionately affects underserved women and children, with more than 70% of trafficking cases involving women and girls and more than 90% of victims trafficked into the sex industry (1). Human trafficking is estimated to be a $150 billion per year industry (3). The profit gained from human trafficking and the ability to evade law enforcement make human trafficking a difficult problem to address. It is important to note that these estimates for global and domestic human trafficking have been criticized and questioned, and that data regarding illegal activity is difficult to collect (4-5). However, these estimates are widely used by government agencies and others to quantify the prevalence and effect of human trafficking (4-5). This Committee Opinion has been updated to include screening questions and indicators to identify victims of human trafficking, additional information regarding reporting obligations for suspected human trafficking, and additional resources for survivors of human trafficking.

What Is 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” (6). It takes the form of forced labor, bonded labor, debt bondage among migrant workers, involuntary domestic servitude, and sex trafficking. Victims of trafficking have been found in a wide range of legal and illegal business settings, and this frequently hidden population is most often exploited in the commercial sex industry, agriculture, factories, hotels, restaurants, as domestic workers, and by marriage brokers and some adoption firms (7). Sex trafficking is a form of human trafficking in which a commercial sex act is induced by force, fraud, or coercion. Minors engaged in the commercial sex industry (eg, online and street prostitution, pornography, stripping, escort services) are considered victims of human trafficking regardless of the use of force, fraud, or coercion (6). Trafficking of children most commonly takes the form of forced child labor, child soldiers, and child sex trafficking.

Human trafficking and human smuggling are not the same and often are confused. Trafficking is based on exploitation of an individual whereas smuggling is the importation of individuals with deliberate evasion of immigration laws (8). However, individuals smuggled into the country are at risk of becoming victims of human trafficking because fear of deportation, economic hardship, and limited language proficiency can be used to exploit them.

box 1 for human trafficking

Who Is at Risk of Human Trafficking?

Individuals who are trafficked are diverse. No racial or ethnic group is spared, nor is any community immune to this problem. Vulnerable individuals, including those from politically or geographically unstable areas abroad or economically disadvantaged areas globally and within the United States, are at greater risk. Migrants, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and gender nonconforming individuals, those who are isolated from support networks, and survivors of violence and trauma are also at increased risk (2). Trafficking may be perpetrated by organized crime, individuals, or both.

Traffickers in the United States and abroad manipulate and exploit those who are vulnerable. Traffickers may make physical threats against the trafficked individual and their family, may pose as a loved one to gain initial trust, and may take away passports and other essential documentation from victims. As in other cases of abuse, it becomes very difficult to come forward and to escape trafficking once involved in this abusive relationship. Victims often experience self-blame and shame that prevent them from seeking help. Traffickers manipulate and reinforce these feelings. Isolation and internalized propaganda often make victims distrust law enforcement and other authorities (9).

Understanding force, fraud, and coercion as management tools used by traffickers will help health care providers understand why so few victims escape, why they are difficult to identify, and why it is challenging to find evidence of force, fraud, or coercion. Methods of power and control include both abusive and threatening behavior. Used constantly and unexpectedly, the goal is to violate personhood and render the trafficked person powerless. See the National Human Trafficking Resource Center’s Human Trafficking Power and Control Wheel at https://humantraffickinghotline.org/resources/human-trafficking-power-and-control-wheel.

Human Trafficking of Children and Adolescents

Children and adolescents at particular risk for human trafficking have a history of sexual abuse, are homeless or runaways, are in foster care, or have been in the juvenile justice system (10). One in three adolescents living on the street is recruited for sexual exploitation within 48 hours of becoming homeless (11). Children are typically targeted at arcades, malls, or bus stations (12).

Several barriers prevent the identification of children and adolescents involved in human and sex trafficking. They are less likely to understand that exploitation is abnormal, and may believe their victimization is their own fault. Children and adolescents separated from families because of trafficking or who are being trafficked by family members experience psychologic distress. All victims, particularly children, have difficulty explaining and describing their experience to law enforcement. Reporting child abuse is mandatory. The American College of Obstetricians and Gynecologists encourages individuals to contact the National Center for Missing and Exploited Children at http://www.missingkids.org/gethelpnow/cybertipline if child or adolescent human trafficking, sex trafficking, or abuse is suspected.

Women's Health Care Providers and Human Trafficking

Obstetrician–gynecologists and other women’s health care providers should be aware of human trafficking, recognize signs of human trafficking, and be prepared to assist patients who are victims or who have been victims of human trafficking. Obstetrician–gynecologists and other women’s health care providers are well-situated to identify and assist victims of human trafficking. One study reports 28% of trafficked individuals sought health care at least once during their imprisonment (13). Many trafficked individuals present to outpatient obstetrics and gynecology clinics, community health centers, family planning clinics, urgent care centers, and adolescent medicine clinics, and one half of all female victims of sex trafficking have visited the emergency department while involved in sex trafficking (14-16). These visits to health care providers may be one of few opportunities for a victim of human trafficking to speak to outsiders and are an important chance to intervene. The International Classification of Diseases, Tenth Revision codes on human trafficking released in 2018 help clinicians think about trafficking during clinical encounters, and they indicate that trafficking is a concrete medical diagnosis (17).

Recognition is the first step in helping victims. Obstetrician–gynecologists and other women’s health care providers should become well-informed about common health care issues faced by victims of human trafficking, including sexually transmitted infections, substance use disorders, mental health problems, and physical trauma (18). Organizations knowledgeable about human trafficking have gathered indicators to help health care providers recognize possible victims of human trafficking (see Box 1). Obstetrician–gynecologists and other women’s health care providers should recognize indicators of human trafficking, such as patients with signs of abuse or neglect or those accompanied by an individual who does not let the patient speak for themselves, refuses to allow for privacy, or insists on interpreting for them in place of a professional. Also, obstetrician–gynecologists and other women’s health care providers should be suspicious if patients are accompanied by someone who is controlling and insists on answering questions for them. Visible signs of physical abuse should lead to follow-up questions regarding the patient’s safety. These questions should be asked when the patient is alone, and suspicions should not be raised when attempting to isolate the victim from her potential abuser. Suggested questions that help identify suspected human trafficking are listed in Box 2.

box 2 for Human Trafficking

In addition to awareness of potential signs of trafficking, interviewing possible victims in private, maintaining cultural sensitivity, and building trust are all key in identification and counseling of victims. Obstetrician-gynecologists and other women’s health care providers should evaluate the patient’s medical and nonmedical needs while recognizing the importance of providing a safe and comfortable environment for the patient, using appropriate methods of communication, and acknowledging the dynamics involved in evaluating a patient who is subject to human trafficking. When assessing a child, adolescent, or woman as a potential victim of human trafficking, it is important to conduct the assessment in a safe, calm, and comfortable environment using the following techniques (19, 20):

  • Demonstrate approachable, relaxed body language.
  • Use empathetic listening techniques and maintain eye contact.
  • Be an engaged listener and resist the urge to take notes instead of listening.
  • Be clear about what services you can offer.
  • Build trust.

Health care providers may be uncomfortable asking patients about trafficking because they are not sure how to help. They can offer victims the necessary support, referrals, and resources to escape their situation (see the For More Information section). Obstetrician–gynecologists and other women’s health care providers should be aware of the resources available, both local and national, to assist in identifying patient needs, and provide referrals for support services (20). They should never directly confront a trafficker or otherwise put themselves or staff in danger. Obstetrician–gynecologists and other health care providers should provide resources for survivors of human trafficking, including brochures, pamphlets, and pocket cards displayed in examination rooms, waiting rooms, or, more discretely, in bathrooms in addition to contact information for organizations and resources that can support survivors.

Health care providers who suspect a competent adult is a victim of human trafficking must not involve law enforcement or social service providers without the patient’s express consent, unless the situation requires mandatory reporting (21). Laws on mandatory reporting vary by jurisdiction. Be aware of the laws in your jurisdiction regarding reporting obligations for suspected human trafficking, with specific attention to mandatory reporting requirements for child abuse. Information regarding suspected trafficking can be reported to the National Human Trafficking Hotline (1-888-373-7888); however, reporting to the hotline is in addition to, not in lieu of, other reporting required by law. This hotline also receives crisis calls from victims of trafficking in need of immediate assistance, provides referrals to local support services, and offers a directory of social service agencies, legal services, and volunteer and training opportunities addressing human trafficking (see the For More Information section).

For More Information

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at https://www.acog.org/More-Info/HumanTrafficking.

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s website, or the content of the resource. The resources may change without notice.

References

  1. International Labour Organization. Global estimates of modern slavery: forced labour and forced marriage. Geneva, 2017. Geneva: ILO; 2017. Available at: https://www.ilo.org/wcmsp5/groups/public/@dgreports/@dcomm/documents/publication/wcms_575479.pdf. Retrieved February 22, 2019.
  2. Walk Free Foundation. Global slavery index: United States. Available at: https://www.globalslaveryindex.org/2018/findings/country-studies/united-states/. Retrieved February 22, 2019.
  3. International Labour Organization. Profits and poverty: the economics of forced labour. Geneva: ILO; 2014. Available at: https://www.ilo.org/wcmsp5/groups/public/---ed_norm/---declaration/documents/publication/wcms_243391.pdf. Retrieved February 22, 2019.
  4. Weitzer R. New directions in research on human trafficking. Ann Am Acad Pol Soc Sci 2014;653:6–24.
  5. Richmond JC. Human trafficking: understanding the law and deconstructing myths. St Louis Univ Law J 2015;60(1):1-42.
  6. U.S. Department of State. Trafficking in persons report 2018. Available at: https://www.state.gov/j/tip/rls/tiprpt/2018/index.htm. Retrieved February 25, 2019.
  7. Anthony B, Kimball Penrose J, Jakiel S. The typology of modern slavery: defining sex and labor trafficking in the United States. Washington, DC: Polaris Project; 2017. Available at: https://polarisproject.org/sites/default/files/Polaris-Typology-of-Modern-Slavery.pdf. Retrieved February 22, 2109.
  8. Clawson HJ, Dutch N, Solomon A, Goldblatt Grace L. Human trafficking into and within the United States: a review of the literature. Washington, DC: U.S. Department of Health and Human Services; 2009. Available at: https://aspe.hhs.gov/report/human-trafficking-and-within-united-states-review-literature. Retrieved February 22, 2019.
  9. Polaris Project. In their shoes: understanding victims’ mindsets and common barriers to victim identification. Washington, DC: Polaris Project; 2009. Available at: http://humantraffickingsearch.org/wp-content/uploads/2017/06/Understanding-Victims-Mindsets.pdf. Retrieved February 22, 2019.
  10. English A. Sexual exploitation and trafficking of the young and vulnerable: reflections on a legal, ethical, and human rights disgrace. Adolesc Med State Art Rev 2011;22:312–20, xi.
  11. U.S. Department of Health and Human Services. Bought and sold: helping young people escape from commercial sexual exploitation. Available at: http://ncfy.acf.hhs.gov/sites/default/files/bought_and_sold.pdf. Retrieved February 8, 2019.
  12. Albanese J. Commercial sexual exploitation of children: what do we know and what do we do about it? NIJ special report. Washington, DC: U.S. Department of Justice; 2007. Available at: https://www.ncjrs.gov/pdffiles1/nij/215733.pdf. Retrieved February 7, 2019.
  13. Family Violence Prevention Fund. Turning pain into power: trafficking survivors’ perspectives on early intervention strategies. San Francisco (CA): FVPF; 2005. Available at: http://www.futureswithoutviolence.org/userfiles/file/ImmigrantWomen/Turning%20Pain%20intoPower.pdf. Retrieved February 22, 2019.
  14. Raymond JG, Hughes DM. Sex trafficking of women in the United States: international and domestic trends. Washington, DC: U.S. Department of Justice; 2001. Available at: https://www.ncjrs.gov/pdffiles1/nij/grants/187774.pdf. Retrieved February 22, 2019.
  15. Cohen SA. Ominous convergence: sex trafficking, prostitution and international family planning. New York (NY): Guttmacher Institute; 2005. Available at: https://www.guttmacher.org/gpr/2005/02/ominous-convergence-sex-trafficking-prostitution-and-international-family-planning. Retrieved February 22, 2019.
  16. Institute of Medicine, National Research Council. Confronting commercial sexual exploitation and sex trafficking of minors in the United States: a guide for the legal sector. Washington, DC: National Academies Press; 2014.
  17. American Hospital Association. ICD-10-CM coding for human trafficking. Chicago (IL): AHA; 2018. Available at: https://www.aha.org/system/files/2018-09/icd-10-code-human-trafficking.pdf. Retrieved February 8, 2019.
  18. Barrows J, Finger R. Human trafficking and the healthcare professional. South Med J 2008;101:521-4.
  19. National Human Trafficking Resource Center. Comprehensive human trafficking assessment tool. Washington, DC: NHTRC; 2011. Available at: https://humantraffickinghotline.org/sites/default/files/Comprehensive%20Trafficking%20Assessment.pdf. Retrieved February 22, 2019.
  20. Hemmings S, Jakobowitz S, Abas M, Bick D, Howard LM, Stanley N, et al. Responding to the health needs of survivors of human trafficking: a systematic review. BMC Health Serv Res 2016;16:320.
  21. Alpert EJ, Ahn R, Albright E, Purcell G, Burke TF, Macias-Konstantopoulos W. Human trafficking: guidebook on identification, assessment, and response in the health care setting. Boston (MA): Massachusetts General Hospital; Waltham (MA): Massachusetts Medical Society; 2014. Available at: http://www.massmed.org/Patient-Care/Health-Topics/Violence-Prevention-and-Intervention/Human-Trafficking-(pdf)/. Retrieved February 8, 2019.

Published online on August 22, 2019.

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Human trafficking. ACOG Committee Opinion No. 787. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;134:e90-5.

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