Health Consequences and the Role of Healthcare for Trafficked Persons                                      Updated September, 2020

Human trafficking in its many forms, including forced labor, sex trafficking, and debt bondage, results in many negative health consequences for those trafficked.  Persons who are subjected to human trafficking often have little or no access to medical care, have reduced freedom to make decisions about their bodies and their lives, and are subjected to abusive treatment – both mental and physical. Indeed, with human trafficking affecting over 40 million people worldwide each year, the adverse health effects of trafficking comprise a “public health problem of global magnitude.[1]

Complex Trauma

Individuals who are trafficked often suffer compound forms of trauma.  The trauma experienced while being trafficked is added to pre-existing trauma from a person’s life before they were trafficked.[2] While any person can be trafficked, people who have significant disruptions to their lives are at a higher risk.  This can include, for example, people who are displaced by armed conflict or other disaster, people who are migrating, people who are homeless or experiencing poverty, people from from physically or emotionally abusive families, and people who have experienced sexual abuse or drug or alcohol abuse.

Thus, the trauma from trafficking compounds previous trauma and a personal history lacking in supportive, trustworthy relationships.[3]  Additionally, a person who interacts with a healthcare worker may be experiencing ongoing threats or coercion against themselves or their families, adding further anxiety.[4] This complex mix of trauma, both past and present, can complicate survivors’ access to and their experience with the healthcare system.[5]

Health Effects

Trafficked persons commonly experience homelessness, a lack of sanitation, poor nutrition, physical and psychological abuse, dangerous workplace conditions, and a lack of quality health care.[6] The health effects for survivors are similarly wide-ranging. Many trafficking survivors experience depression and anxiety, post-traumatic stress disorder (PTSD), suicidal thoughts or actions, fatigue, memory problems, and dizziness.[7]  They may also experience high amounts of shame or stigma because of their trafficking experience.[8] Trafficking usually involves some form of mental coercion and humiliation that leaves survivors with a loss of self-esteem that adversely impacts their mental health.[9] Mental health concerns are a “dominant and persistent” health consequence of human trafficking.[10]

Survivors also commonly report headaches, back and abdominal pain, dental problems, skin conditions, and ignorance of their HIV status.[11] Survivors may experience cardiovascular, hearing, or respiratory problems from unsafe and unclean working conditions.[12] They may also suffer from preventable infectious disease, such as tuberculosis, or from undetected chronic disease such as diabetes or cancer.[13] They may experience infections or mutilations because of sub-standard attempts at “medical” care by individuals hired by the trafficker.[14]

Persons subjected to any form of human trafficking commonly experience ongoing physical and sexual abuse. Trafficked persons may have bruises, lacerations, or scars from physical abuse. They may experience sexual violence, both at the hands of the trafficker and others, with attendant ano-genital injuries or infections. Trafficked persons are also at higher risk for being murdered than the average population. Rates of violence against persons experiencing human trafficking are extremely high. 

Sex Trafficking

Sex trafficking tends to be the most frequently-detected form of human trafficking, and women and girls are more likely than others to be trafficked for sexual exploitation.[15]  Along with health concerns generally experienced by all trafficking survivors, those trafficked for sex experience health consequences such as unwanted pregnancies, sexually-transmitted infections such as HIV, syphilis, and hepatitis B, and pelvic pain.[16] Substance abuse – both as a coping mechanism, and forced by the trafficker – is also common among sex-trafficked persons.[17]

Sex trafficked individuals experience adverse mental-health outcomes at a very high rate. In one study of commercially sexually exploited youth, about 77% of participants had a diagnosis of “probable” PTSD and 55% suffered from depression.[18]  In another, 89% of female survivors of sex trafficking experienced depression, and 42% of them had attempted suicide while trafficked.[19]

Labor Trafficking

Labor trafficking survivors also experience adverse health consequences connected to the type of work they perform, their living conditions, and barriers to accessing health care. As compared with sex-trafficking, however, less research has focused on health concerns related to labor trafficking.[20]

In general, occupational hazards for individuals illegally trafficked into certain industries are greater than for legally-employed workers, with correspondingly higher rates of injury and death.[21] Thus, the injuries typical for a given industry also occur to trafficked workers, simply at higher rates because of the lack of legal protections.  Table 1 lists examples of occupational injuries that may lead trafficked persons to seek health care.[22]

Table 1

The Response of Health Care Professionals

The health care sector can be instrumental in the prevention and detection of, and response to, human trafficking.[23]  The Palermo protocol suggests, but does not mandate, that state parties consider implementing measures to provide for the health care and psychological needs of trafficking survivors.[24] Research indicates that many trafficked persons will interact with a medical provider while being trafficked because of the many negative health effects associated with labor and sexual exploitation.

Yet, survivors experience multiple barriers to quality medical care and services. These include language and cultural barriers, stigma and discrimination, a lack of safety, failure to involve survivors in making decisions, and inadequate information or training for providers.[25] If they seek healthcare, survivors may try to avoid detection by healthcare workers out of fear of their trafficker, or fear of police (for example, if they know police have an arrest warrant). Some survivors have identified that other barriers include feeling judged by medical providers and concerns that they will not be allowed to make their own decisions.[26] Other trafficked persons identify concerns about confidentiality – that the medical provider will inform their probation officer or group-home staff about sensitive medical information.[27]

In addition to these barriers to accessing healthcare, human trafficking survivors often do not readily identify themselves as “victims” in need of help. For all these reasons, healthcare facilities should take proactive measures to lower barriers and identify patients who are experiencing human trafficking. Some medical facilities use screening tools in this effort.  For example, a tool aimed at discovering sexually exploited youth may involve a series of questions such as the following:

• “Has anyone ever asked you to have sex in exchange for something you wanted or needed (money, food, shelter, or other items)?”
• “Has anyone ever asked you to have sex with another person?”
• “Has anyone ever taken sexual pictures of you or posted such pictures on the internet?”[28]

Additionally, the SAFE Center and the Maryland Hospital Association have published a comprehensive set of tools and protocols called, Human Trafficking; Guidelines for Healthcare Providers, “an internal and external roadmap for health care professionals to address a trafficked patient’s medical and psychosocial needs both inside and outside of the hospital.” Thus, there are many examples for health care professionals and others to use in developing their own policies to help and care for trafficking survivors.

Trauma-Informed Treatment

To provide effective medical care, health care practitioners should seek out training about trauma, its effect on individuals experiencing trafficking, and the appropriate response.  Trauma can affect the way a survivor reacts to well-meaning health care providers, so being trauma-informed is an important basis for an effective response.[29]

Some behavioral reactions one might anticipate from a human trafficking survivor are:

• Hostility
• Uncooperative silence
• Memory loss or lapses as to details of an event, blocking out traumatic events (dissociation), discrepancies in multiple descriptions of the same event
• Disorientation
• Anxiety symptoms (even after it appears the person is “safe”)
• Fatigue
• Needing time to reconstruct traumatic experiences[30]

Healthcare providers who may encounter survivors of human trafficking should seek out training about complex trauma, attachment and loss, and substance use.[31] They should learn best practices about providing trauma-informed care.  Such practices might include providing a secure location that traffickers cannot access, allowing time to pass before asking for accounts of the person’s experiences, allowing the patient to make choices about their health care and the setting and timing of interviews, and plans for what will happen after medical treatment is completed.[32]

Coordination of Care

Beyond the treatment of individual patients, it is important for healthcare institutions to review their capacity to provide holistic care to survivors of trafficking. The Palermo Protocol suggests that state parties coordinate with non-governmental organizations on behalf of survivors for the provision of housing, legal resources, medical and psychological care, and employment opportunities.[33]  Sometimes called making “a warm hand off” to a resource agency,[34] assuring that survivors have ready access to all available resources is a best-practice for health care.[35]

Meeting Survivors’ Specific Needs

Researchers are continuing to study the most promising practices in assisting persons wishing to leave a trafficking situation. Programs that provide for the medical and mental-health needs of survivors with a non-paternalistic point of view have had good results. For example, sexually exploited youth identified that sincere relationships with mentors were a valuable tool to helping them leave a trafficking situation.[36] Thus, programs that provide a long-term mentoring connection, including trauma-focused cognitive-behavioral therapy, are promising.[37]

As with any population, individual survivors of human trafficking are not all the same; they do not all have the same needs. Although there is significant overlap in health care effects of  different human trafficking sectors, each individual will experience unique medical and psychological needs.[38] The Palermo Protocol requires state parties to take into account the individual needs of the trafficking survivor in the provision of resources.[39]

For example, individuals identifying as transgendered women note that they are often not included in resources or research aimed at sex-trafficking survivors.[40] Programs that are aimed solely at cis-gendered women often fail to protect and assist transgendered women; they often receive the “punitive force” of the legal authorities without benefitting from the protections for victims.[41] Transgendered women are often marginalized by formal legal and medical systems that too narrowly define the “victim” experience. Instead, healthcare programs developed and lead by transgendered individuals with lived experience have a better chance of success.[42]

Similarly, programs that are culturally appropriate for some are not for others. In the United States, Native American women are sex trafficked at astonishing rates.[43] Yet, the healthcare and mental-health resources available to them are rarely appropriate for their cultural background.[44] This lack of cultural connection can leave any survivor feeling excluded and left with their needs unmet. This hampers long-term success and may result in survivors returning to the trafficking experience.  Any healthcare program seeking to assist human trafficking survivors must do so with an eye toward the specific needs of the person who has been trafficked. Indeed, more research is needed to inform the health care response – in particular, research with more accurate representation of the populations at risk for trafficking, and longer-term studies of the health consequences.[45]

Conclusion

Human trafficking impacts the survivor’s whole person, mentally and physically. Health care providers around the world have patients who are experiencing human trafficking, even if the provider is unaware of it. Providers and facilities should begin the process of training and preparation to best serve their patients’ needs for health care and for resources to leave the human-trafficking industry.