Human Trafficking: Guidance for Health Providers

1. Human Trafficking: Guidance for Health Providers I have wings, I can fly, Unshackle my chains and Watch me soar… (The song of a trafficked child) Sarah Kureshi, MD MPH

2. Learning Objectives The participant will be able to: • Define human trafficking. • Describe the causes and mechanisms of human trafficking. • List various approaches to combat human trafficking. • Explain the health consequences of human trafficking. • Identify tools for medical providers to use for victim identification and assessment.

3. What is Trafficking? “Trafficking in persons” is: • The action of recruitment, transportation, transfer, harboring, or receipt of persons • By means of the threat or use of force or other forms of coercion, of abduction or fraud, of deception, of the abuse of power of a position of vulnerability or of the giving of receiving of payment or benefits to achieve the consent of a person having control over another persons • For the purposes of exploitation From the United Nations Protocol to Prevent, Suppress, and Punish Trafficking in Persons, especially Women and Children, supplementing the United Nations Convention Against Transnational Organized Crime (Dec 2002)

4. The A-M-P Model

5. Forms of Trafficking • Forced Labor • Sex Trafficking • Bonded Labor/Debt Bondage • Involuntary Domestic Servitude • Forced Child Labor • Child Soldiers • Any child prostitution, even if child is “willing”

6. What is NOT Trafficking • Illegal adoptions • The trade in human organs • Child pornography • Adult prostitution

7. Human Trafficking by the Numbers • 49,105 trafficking victims reported worldwide (in 2009) • 5,606 trafficking prosecutions and 4,166 convictions worldwide (in 2009). The majority were sex trafficking cases. • 12.3 million adults and children in forced labor, bonded labor, and forced prostitution around the world • Prevalence of worldwide trafficking victims: 1.8 per 1,000 • Prevalence of trafficking victims in Asia: 3 per 1,000 • 1.2 million children being trafficked each year State Dept: Trafficking in Persons Report 2010

8. Scope of the Problem • Human trafficking has become the second fastest growing criminal industry — just behind drug trafficking (US Department of Justice, 2010) • Human trafficking is a $32 billion industry, with half coming from industrialized countries (National Human Trafficking Resource Center, 2011)

9. Risk Factors of Human Trafficking • Poverty • Social exclusion • Limited economic & educational opportunity • Poor governance • Lack of rule of law • Political conflict & war

10. Risk Factors of Human Trafficking • Natural disasters • Systematic devaluation of women and girls (from social systems including patriarchy) • Marginalization and discrimination based on ethnicity, race, disability, and religion

11. How are persons trafficked? • Deceit (false job promises) • Fraudulent marriages • Kidnapping • Local contacts • Direct sales (even by family members) • Debt bondage • Falsification of documents • Bribes

12. How traffickers keep victims enslaved? • Isolation from the public (limiting contact with outsiders) • Isolation from family members • Confiscation of passports, visas and identification documents • Use or threat of violence toward victims and families of victims • Threat of shaming by exposing the circumstances to their family • Telling victims they will be imprisoned/deported for immigration violations if they contact the authorities • Control of the victims’ money

13. Countries of origin vs Countries of destination

16. Example from U.S. U.S. vs Phan (in PA) • Two Vietnamese women trafficked into nail salons on fraudulent fiance visas • Worked 7 days/week, 11 hrs/day in salon for 8 yrs • Forced to cook and clean also • Not pain but charged $500/month for rent/utilities • Forbidden to talk to customers about themselves

17. Example from India “When I look back, nightmares keep coming back. I shudder to visit my memories. I was just ten and my aunt sold me to a red light area in Mumbai. The torture, the pain, all those beatings … can I ever forget them? Most of the time I had no idea what was happening. They made me drink and then the men came and came and came. How many years was I there? I don’t know – maybe five or six? … My body was weak, I was sick, and I wondered when will all this end?” -An Indian girl speaking of her experiences in the brothels Excerpt from “Me & Us” video documentary produced by Prajwala

18. Why Does Human Trafficking Continue? • Obvious reasons: • High demand for sex and for cheap labor • Corruption • Victim-blaming • Trafficking Networks • Police and Governments

19. Why Does Human Trafficking Continue? Trafficking Networks: • Are widespread, highly organized, and difficult to identify • Have numerous intermediaries, some villages and urban centers are central market points for illicit transactions, routes change frequently, often follow migration patterns    • Are particularly active during periods of economic hardships      • Are facilitated by technological advances Police and Government: • Not requiring passports or other forms of identification to pass through country borders (ex. Nepal to India) • Sometimes participating in the transactions themselves

20. Approaches to Combat Trafficking Must Take Into Account Several Factors

21. Recent Approaches Addressing Trafficking • Repressive measures to prevent migration, prostitution, and organized crime have dominated anti-trafficking initiatives • “3D” phenomenon of detention, deportation and disempowerment • Examples of the Enforcement Framing Methods: • United Nations Crime Commission’s treaty in 2000 – Palermo Protocol • United States Trafficking Victims Protection Act (TVPA) of 2000

22. U.N. Palermo Protocol • Protocol to prevent, suppress, and punish trafficking in persons, especially women and children • “3P” paradigm: prevention, criminal prosecution, and victim protection

23. Shortcomings of these Approaches • Minimal focus on pursuing and prosecuting traffickers, pimps, and the consumers of the commercial sex trade • Failure to address the causes that lead to victimization • Failure in addressing the public health implications of trafficking and providing health guidelines for treating victims • Failure to focus on rehabilitation and empowerment of rescued victims

24. Trafficking in Persons Report 2010 Tier Placements Map • http://www.state.gov/g/tip/rls/tiprpt/2010/138377.htm • 2010 report reflects upgrades for 23 countries in recognition of long overdue results and downgrades for 19 countries demonstrating sparse victim protections, desultory implementation, or inadequate legal structures

25. What Is Needed? • Political will and commitment of governments • Consensus on a definition of trafficking to clarify the legal status • Prevention – addressing the issue in terms of poverty, access to education, programs for sustainable livelihood • Promoting gender equality

26. What Is Needed? (cont.) • Awareness raising and advocacy (locally, nationally, and regionally) • Strengthening legislative framework, ratifying international conventions and ensuring implementation of legal provisions • Rehabilitation and reintegration of victims through healthcare, counseling, education, training, employment, and social integration

27. Consequences of Trafficking Physical health consequences • Headaches, fatigue, dizziness • Memory loss • Sexually transmitted infections (including HIV) • Physical assault and sexual assault injuries • Abdominal pain, back pain • Dental problems • Unsafe abortions, poor prenatal care, unwanted offspring • Higher maternal mortality risk

28. Consequences of Trafficking Mental health consequences • Depression • Post traumatic stress disorder • Suicidal thoughts • Community ostracism: isolation, discrimination • Psychological burdens of rape, slavery, and exploitation Other • Legal insecurity: having illegal status or doing illegal work may decrease willingness to access social and health services • Loss of honor and self esteem • Risk of alcohol and drug addiction

29. Role of the Healthcare Provider Front-line health-care providers may be the only outsider with the opportunity to speak with a victim • Victim identification • Victim assessment and evaluation ***28% of trafficked victims in a U.S. sample came into contact with a health care provider during captivity, but went unrecognized (Futures Without Violence, 2010)

30. When Do Victims Seek Medical Services • In an emergency • After an assault • For a gynecological exam • For prenatal or neonatal care • For routine checkups • For unrelated health issues

31. Barriers to Victim Self-Identification • Accompanied/monitored by exploiter • Fear of retribution by exploiter • Fear of being returned to family or placed with social services (for minors) • Distrust of authority & “learned loyalty” to exploiter • Language/social barriers • No personal ID/documents • Fear of arrest or deportation • Shame and/or hopelessness

32. Victim Identification – Red Flags • Inability to keep appointments or follow care instructions • Evidence of an inability to move or leave a job • Accompanied by a person who does not let the patient speak • Fear, anxiety, hyper-vigilance, paranoia, depression • Not speaking the language of the State • Recently arrived in the State from another part of the world or the country • Lack of passport, immigration or identification documentation • Addictive behaviors

33. Victim Identification – Red Flags • Hematoma or contusions • Lacerations or scarring • Dislocated limbs or fractures • Missing or broken teeth • Bald spots • Burns (cigarette burns)

34. Potential Health Indicators: Sex Trafficking • Persistent or untreated STIs or UTIs • Abnormally high number of sex partners • Trauma to vagina or rectum • Presence of cotton or debris in vagina • Repeated abortions or miscarriages • Unintended pregnancies or fertility problems • Tattoos with pimp’s name on various parts of body

35. Potential Health Indicators: Labor Trafficking • Dehydration, heat stroke • Sleep deprivation • Musculoskeletal and ergonomic injuries • Pesticide or chemical exposure • Water and sanitation related illness • Air quality and respiratory problems • Untreated skin infections/irritations • Evidence of sexual abuse

36. Trafficking Assessment: Screening Questions • Can you leave your job or situation if you want? • Can you come and go as you please? • Have you been threatened if you try to leave? • Have you been physically harmed in any way? • What are your working or living conditions like? • Where do you sleep and eat? • Do you sleep in a bed, on a cot or on the floor? • Have you ever been deprived of food, water, sleep or medical care?

37. Trafficking Assessment: Screening Questions • Do you have to ask permission to eat, sleep or go to the bathroom? • Are there locks on your doors and windows so you cannot get out? • Has anyone threatened your family? • Has your identification or documentation been taken from you? • Is anyone forcing you to do anything that you do not want to do? • Do you owe a debt to anyone?

38. Understanding the Victim The victim may: • Exhibit trauma bonding • Be accompanied by the exploiter • Not self-identify as a victim • Give conflicting stories or misinformation • Refuse services • Be distrustful

39. How to Interact with Trafficking Victims • Use a non-judgmental tone • Ask open-ended questions • Avoid secondary victimization by being careful with the language/vocabulary you use (do not refer to them as prostitutes or slaves, etc) • Take language and vocabulary cues from the victim • Do not make promises that you can’t keep • Make sure an interpreter is not known to the victim

40. Required Actions • Maintain confidentiality • Express objectivity and compassion • Do not express a ‘legal opinion’ but provide referral to legal counsel • Do not offer personal involvement or assistance • Consult with the trafficked victim before reporting a crime or seeking protection on their behalf

41. What to do next • Follow existing protocols for child abuse, sexual abuse, rape, domestic violence, etc • Explain reporting obligations to the patient • Provide options while keeping in mind the patient’s age and immigration status • Know the local organizations that help survivors of trafficking – governmental, non-governmental, international • In U.S., provide the National Human Trafficking Resource Center (NHRTC) hotline number: 1-888-3737-888 • If victim is a child then report to HHS foreign national child victims

42. National Human Trafficking Resource Center (NHRTC) hotline • Not a mandatory reporter • All hotline staff can help to: • Review trafficking indicators • Provide assessment questions • Assess safety and help establish safety plan • Provide resources and referrals

43. U.S. State Maps www.traffickingmap.org Click on your state in the map to access in-depth local information and resources