1. Identification and Management of Victims of Human Trafficking – Advice for the Family Physician
Ranit Mishori, MD, MHS, FAAFP
Georgetown University Department of Family Medicine
Washington, DC
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2. Learning Objectives Define human trafficking.
Describe the risks factors of human trafficking.
Understand the scope of human trafficking.
Explain the health consequences
Identify screening tools and procedures
Consider protocol development
Identify resources
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3. The illegal trade of humans against their will for purposes of sexual exploitation, forced labor, or modern-day slavery
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4. Action (recruit, harbor, transport, provide, obtain) by
Means (force, fraud, coercion)
for
Purpose (sexual exploitation; Labor 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)
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5. Types
Sexual
Labor
Transnational
Domestic
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6. #AAFPGlobal

7. #AAFPGlobal

8. Labor Restaurants Agriculture Private homes Nail salons Panhandling
Sweatshops
Hotels
Factories
Landscaping
Fishing industry
Construction
Shipping ports
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9. Sex Trafficking Private Homes Internet Strip Clubs Hotels
Massage Parlors
Topless Bars
Street corners
Casinos
Cantina Bars
Truck stops
Escort Services
Major Sporting Events (?)

10. #AAFPGlobal

11. Forms of Trafficking Forced Child Labor Child Soldiers
Any “child prostitution”, even if child is “willing”
CSEC = Commercial Sex Exploitation of Children
= Sex abuse
The proliferation of sex trafficking is encouraged by the growing demands of the sex industry in both the East and West.
Forms of Forced Labor Include:
Agriculture
 Mining
 Logging
 Construction
 Fishery
 Sweatshop factory (e.g. garments, packaging, food processing)
 Domestic Servitude
 Begging
 Drug dealing
 Janitorial
 Food services
 Other service industry, etc.
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12. N National center for victims of crime http://victimsofcrime.org/
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13. World Stats: Human Trafficking
State Dept: Trafficking in Persons Report 2010
There are really no completely reliable statistics, but these are some that we have (the numbers are likely much much higher). Make a note that trafficking is truly a global phenomenon … it also occurs in the US.
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14. It’s a business
Human trafficking has become the second fastest growing criminal industry — just behind drug trafficking (US Dept of Justice)
Human trafficking is a $32 billion industry, with half coming from industrialized countries (National Human Trafficking Resource Center)
See polaris handout
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15. Countries of origin vs. Countries of destination
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16. Note the multiple international trafficking routes
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17. Note: Often people think of trafficking as an issue in the developing world, but the US is not immune to human trafficking
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18. Risk Factors (International)
Poverty
Social exclusion
Limited economic
& educational opportunity
Poor governance
Lack of rule of law
Political conflict & war
Note: ANYONE can be a trafficking victim
Poor women and children are the key target group, because of their marginalization, limited economic resources and predominance in the "invisible" informal sector.      
Persons from impoverished households in rural areas and urban slums, poor women migrants to urban areas seeking jobs, those engaged in marginal economic activities and in other low status work and services.      
Women and girls who are unmarried, divorced, separated or widowed.      
Ethnic minorities, "scheduled castes" or "other backward classes," indigenous people, hilltribes, refugees, and illegal migrants.      
Person with low levels of education, some primary school education, or the illiterate.      
Young children running away from home, girls and women from communities in which commercial sex work is a legitimized practice, children from disrupted families, and those financially supporting their families.      
Persons who lack awareness of their legal rights, their exploited situation, and have no channel for seeking redress.      
Women and children of varying ages, ranging from babies to women in their seventies.

19. Risk Factors Natural disasters Status of women
Marginalization, discrimination
based on ethnicity, race,
disability, and religion
US: Victims of child abuse
Runaway and homeless youth;
LGBT; Ethnic minorities; disabled
Poor women and children are the key target group, because of their marginalization, limited economic resources and predominance in the "invisible" informal sector.      
Persons from impoverished households in rural areas and urban slums, poor women migrants to urban areas seeking jobs, those engaged in marginal economic activities and in other low status work and services.      
Women and girls who are unmarried, divorced, separated or widowed.      
Ethnic minorities, "scheduled castes" or "other backward classes," indigenous people, hilltribes, refugees, and illegal migrants.      
Person with low levels of education, some primary school education, or the illiterate.      
Young children running away from home, girls and women from communities in which commercial sex work is a legitimized practice, children from disrupted families, and those financially supporting their families.      
Persons who lack awareness of their legal rights, their exploited situation, and have no channel for seeking redress.      
Women and children of varying ages, ranging from babies to women in their seventies.

20. 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
Deceit: Unscrupulous agents deceive parents, lure women and girls with false promises of well-paid work in cities or marriages to rich partners.   
Kidnap: Criminal gangs or middlemen kidnap women and children, force them to work against their will, and often sell them to brothels.
Local contacts: Traffickers enlist the help of local persons and villagers to identify vulnerable families. Traffickers operate in an organize network having their agents make contacts with unsuspecting women and children around bus and train stations.  
Direct Sales: Women and children are sold to traffickers by parents or other family members. Traffickers sell young girls to brokers across borders in Asian countries for one to two thousand dollars (per child or young woman) or more 
Debt Bondage: Economic incentives to parents and arrangements which bond children and young women into sex-slavery or other exploitative forms of labor, though details of these debt terms are ill defined    
Falsification of Documents: False documents and passports make it difficult to identify and trace trafficked persons    
Bribes: Commonly paid to various officials or police to procure false documents, or at border crossings
In some countries, poor families will sell a daughter to a trafficker or a pimp, who either buys the girl outright or provides a loan called a "debt bond" to the family that the girl must then pay off through prostitution. It usually takes years for the girl to earn enough money to buy her freedom, and by then, she may be infected with AIDS or another disease.
                                       
How are women and girls trafficked?
Traffickers recruit women and girls through deceptive, sometimes coercive, means such as falsified employment advertisements for domestic workers or waitresses that prey on the economic vulnerability of impoverished women and families. Women may also be lured with false promises of marriage, and girls may be bartered by families who believe their daughters will have the opportunity to earn legitimate income for the family as a domestic or factory worker. Women facing violence in their homes may seek to leave their communities, even if by risky means. Traffickers often work as part of highly sophisticated networks of organized crime, yet may gain credibility with their targets by speaking the local language and living in the same village. Modern communications technology allows large networks of suppliers and consumers of sex services to develop.
Once in the hands of brothel owners and pimps, the girls are subjected to a tortuous “break in period” that often includes multiple gang rapes, beatings, deprivation of food, and being burned by acid or cigarettes. The abuse can continue for weeks or until the girl complies with the wishes of the brothel.

21. Who are the traffickers?
Organized Crime
Corporations
Diplomats/Governments
Gangs
Pimps
Family Members (36%)
Friends/Neighbors
Small Businesses

22. Covenant House Survey Immediate Family 36% Boyfriends 27%
Employers 14%
Friends of Family 14%
Strangers 9%

23. How traffickers keep victims enslaved?
• Isolation (from public, family)
• Confiscation of documents
• Use/Threat of violence
• Threat of shaming
• Threat of imprisonment or
deportation, return to family
• Control of victims’ money
The goal is to instill fear in the victims

24. Case 57 year old woman from SE Asia
Set up: Outpatient clinic, affluent DC
CC: Persistent HA, knee pain, knee bruising
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25. Role of the Healthcare Provider
28% of trafficked victims in one U.S. sample came into contact with a health care provider during captivity, but went unrecognized
50% foreign nationals
87.8% domestic sex trafficking
Baldwin et al Lederer & Wetzel Family Violence Prevention Fund.
The cost of this missed opportunity is incalculable! Healthcare providers play a KEY role!
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26. Who did they see Pediatricians 3% Traditional/alternative 5%
Dentist 17%
Ob-Gyn 17%
Primary Care 29%
ED 39%
Chisholm-Straker et al 2014
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27. Barriers Victim: Exhibit trauma bonding
Be accompanied by the exploiter
Not self-identify as a victim
Give conflicting stories or misinformation
Refuse services
Be distrustful
Fear of arrest/deportation
Health Professional:
Lack of knowledge
Misclassification (domestic violence)
Cultural assumptions
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28. What to do
SOAR:
Stop
Observe
Act
Respond
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29. Observe: Red Flags
Doesn’t keep appointments or follow care instructions
Unable to move or leave a job
Accompanied by a person that doesn’t let the patient speak
Behaviors: Fear, anxiety, hyper-vigilance, paranoia, depression
Not speaking the language of the State
Recently arrived, consider country of origin
No papers
Certain jobs
Substance abuse
These all involve coercion and control
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30. Red Flags – Physical Signs
Hematoma or contusions
Lacerations or scarring
Dislocated limbs or fractures
Missing or broken teeth
Bald spots
Burns (cigarette burns)
These all involve force & abuse
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31. Red Flags Persistent, untreated STIs/UTIs High number of sex partners
Trauma to vagina or rectum
Presence of debris in vagina
Repeated abortions, miscarriages
Unintended pregnancies or fertility problems
Tattoos with pimp’s name
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32. 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
Suspected sexual abuse
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33. Psychological Substance abuse Affective symptoms Depressions/anxiety
PTSD
Emotional Blunting
Sleep problems
Somatization
Hostility
Low self esteem
Suicidal ideation
Disassociation
Excessive guilt
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34. Health Professional Role
Separate
Interview
Report
Refer
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35. Act: Required Actions Separation (protocols, labs, imaging)
Confidentiality
Objectivity and compassion
No ‘legal opinion’ -- provide referral
Do not offer personal involvement or assistance
Informed Consent (“nothing about us without us”)
Ask permission before reporting or seeking protection on their behalf
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36. Screening
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37. Trafficking Assessment: Screening
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?
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38. Trafficking Assessment: Screening
• 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?
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39. Interacting with Suspected Trafficking Victims
Non-judgmental tone
Open-ended questions
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
Secondary victimization: Secondary victimisation (also known as post crime victimisation[2] or double victimisation[3]) relates to further victimisation following on from the original victimisation.[2] For example, victim blaming, inappropriate post-assault behaviour or language by medical personnel or other organisations with which the victim has contact may further add to the victim's suffering.
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40. Protocol Development
Separation procedures (who, how, where, safety, security)
Interview procedures (who, when, interpretation, what tools)
Reporting Procedures (informed consent, state laws, documentation, HIPPA, federal/immigration)
Safety protocols (victim, staff, scenarios)
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41. Respond: What to do next
Follow local/state protocols for child abuse, sexual abuse, rape, domestic violence, etc
Call hotline: (NHRTC)
Text BeFree (233733)
Online reporting form:
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42. Referrals Healthcare NGO Federal Law Enforcement Local Law enforcement
Social Services
Legal Services
Substance abuse services
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43. Additional Resources
Human Trafficking – National Human Trafficking Resource Center (NHTRC) 
24 hour Hotline:
Domestic Violence – National Domestic Violence Hotline
24 hour Hotline: SAFE (7233)
Sexual Abuse – Rape, Abuse and Incest National Network (RAINN)
24 hour Hotline:
Suicidal Thoughts – National Suicide Prevention Lifeline
24 hour Hotline: TALK (8255)
Dating Violence – National Dating Abuse Helpline
24 hour Hotline:
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44. U.S. State Maps www.traffickingmap.org
Click on your state in the map to access in-depth local information and resources
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45.
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46. https://healtrafficking.org/ http://slaveryfootprint.org/
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48. What the AAFP is doing
Add topic to CME Curricular Framework Address as a ‘hot topic’ at 2016 FMX
Commission on Health of the Public and Science (CHPS) is developing a position paper for approval by the Board of Directors
Action by local chapters (NYAFP ) support for NYS legislature bill A8650-B / S6835-B
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52. Acknowledgement
This presentation was made possible, in part, by a President’s Grant from the Josiah Macy Jr. Foundation
For questions:

53. Questions?