An Introduction to Health Professionals’ Role in Addressing Human Trafficking
Riley Golby, Sian Hsiang-Te Tsuei, Alisha Zacharias
With approximately 2.4 million humans trafficked around the world annually, the United Nations General Assembly has adopted the Convention Against Transnational Organized Crime to tackle this profitable, illicit venture. Despite Canada’s efforts, it continues to be an origin, destination, and transit point for international and domestic human trafficking.[2,3] In Canada between 2012 and 2013 alone, 30 offenders were convicted, with many offences committed against children. These figures, however, may be drastic underestimates of the impact of this issue due to the relaxed legal framework and poor general public awareness.
Human trafficking is very complex and is closely linked to a trafficked individual’s life circumstances. Being recruited is often tied to predisposing social determinants of health; those trafficked are frequently females, from disadvantaged socioeconomic backgrounds, marginalized ethnicities, and rural areas.[5,6] The UN defines human trafficking as an act related to kidnapping, forcible confinement, debt-bondage, forced labour, cross-border exploitation, and the recruitment and harbouring of persons.[7,8] While some trafficked individuals may fall under this definition, its narrow scope does not account for the circumstances surrounding marginalized populations such as aboriginal women, youth and children, migrants, new immigrants, and teenaged runaways who constitute a significant portion of trafficked individuals in Canada. Therefore, it is more appropriate to state that human trafficking occurs when the conditions of someone’s history create a circumstance in which another individual is able to exploit by requiring that they perform labour that they cannot refuse or work in conditions that they have no control over.
Trafficked individuals are often subjected to physical, sexual, and psychological abuse during their exploitation.[10,11] It is estimated that 28% to 50% [12,13] of these individuals access health services during captivity, posing an urgent and unique opportunity for health professionals to identify, support, and refer them.[13,14] Despite experts’ call for incorporating relevant training for residents and medical students, a gap in training remains within most medical training.[15,16]
Outline of Current Interventional Strategies
Current interventions in Canada are three-pronged. The legal aspect focuses on policy advocacy and prosecution of perpetrators, mainly relying on the legislators and the police. Second, clinical support includes identification of the trafficked persons through in-person and telephone counseling or medical interviews, and the services may be provided by community organizations as well as primary care providers and forensic specialists. Finally, social support offers shelter and rehabilitative services, focusing on basic life skill development. Relevant organizations include government agencies, health services, and community organizations.
Not all organizations tackling this issue share the same perspective on the definition and approach to addressing human trafficking. For example, Supporting Women’s Alternative Network (SWAN), an organization dedicated to the safety and rights of sex workers, recently published an article outlining the harm of the current mainstream description of human trafficking . They assert that assuming immigrant sex workers are trafficked persons too hastily has only brought harm to the women assumed to be victims. They have shown that law enforcement agencies have mistakenly conducted raids into settings stereotyped to hold trafficked persons, such as massage parlors with migrant sex workers. SWAN asserts that this may psychologically traumatize those involved in the raids and preclude their future usage of government services.
It is therefore important to distinguish sex work from human trafficking. When a sex worker presents for medical care, physicians should not assume that the individual is trafficked without appropriate evidence. This is important as intensive forensic measures for presumed trafficked individuals may undermine the autonomy of and rapport with a voluntary sex worker. Since it is equally important not to miss the opportunity to correctly identify and support a trafficked individual, a balanced approach is for health professionals to consider trafficking as a ‘differential diagnosis’ – one to actively rule out. This is similar to how health care providers consider cancer amongst the differential diagnosis for fever and rule it out based on further history, physical exam, and possibly investigations.
Best practice guidelines are not yet available for the screens, interventions, and clinical considerations specific to assisting trafficked individuals. However, some guiding principles are noted periodically in the literature [19,20]. One resource available is the guide “Caring for Trafficked Persons: Guidance for Health Providers” which is both a good educational tool and is one way to begin equipping primary health care providers. It can help physicians distinguish voluntary sex workers from trafficked persons and bring awareness to clinical ‘red flags’ associated with trafficked persons. If red flags are detected in the family medicine setting, based on the guide’s recommended referral features, the individual may be transported via ambulance to emergency for more comprehensive assessment with forensic support if it exists at the local hospital level.
Moving Forward to Provide Better Care
Although experts are developing healthcare provider training and protocols, evidence-based approaches for assisting trafficked individuals are still lacking. Health authorities are currently using internal training modules to train healthcare providers to recognize and assist trafficked individuals,[17,23] which aims to introduce human trafficking as a differential diagnosis and possible management. While the training modules are a useful starting point, their effectiveness has yet to be verified. Secondly, these modules may portend self-selection biases as the individuals who are primarily interested in completing the training may already have explored some clinical strategies around the issue. They will help these individuals advance their understanding of their roles but do not necessarily educate the population not previously exposed to the issue. Targeting those who are not yet exposed is a crucial step to allow health care providers adequately address human trafficking.
Educating Canadian health care providers around the current landscape of trafficking in Canada will improve the recognition and assistance for trafficked individuals and influence clinical interventions. In addition, raising more awareness may generate more advocacy momentum for this often overlooked group of patients in the political, academic, and clinical arenas.
We believe that a multi-level approach including current health care students and physicians, medical faculties, and provincial and federal governments is required. We recommend that medical schools and educators: (1) dedicate plenary time to the complexity surrounding human trafficking; (2) create best practice health care protocols for trafficked individuals through appropriate partnerships with other health disciplines; and (3) ensure health care professionals are sensitized to trafficked individuals needs through training. We also recommend that federal and provincial governments: (1) address the health and public health issues surrounding trafficking; and (2) develop research programs to explore best practices for identifying, treating, and supporting trafficked persons.
There are necessary improvements to be made in order to assist today’s trafficked individuals, with medical students and physicians playing an essential role. They can become effective advocates for promoting fundamental social change, while properly identifying and aiding current trafficked persons. However, the lack of evidence-based practices will continue to divide approaches for healthcare providers seeking to make positive interventions. Trafficked individuals need advocacy. Education and awareness of this complex issue is the crucial piece in confronting this global issue. Informing students, educators, and lawmakers about the issues concerning human trafficking is the first and essential step in creating an acceptable and appropriate standard of care for trafficked persons.
- International Labour Organization. ILO action against trafficking in human beings [Internet]. Geneva: International Labour Organization; 2008 [cited 2014 Oct 10]. Available from: http://www.ilo.org/wcmsp5/groups/public/—ed_norm/—declaration/documents/publication/wcms_090356.pdf.
- Ministry of Justice. Human trafficking in BC [Internet]. [Cited 2014 Oct 3]. Available from: http://www.pssg.gov.bc.ca/octip/.
- Perrin, B. Invisible chains: Canada’s underground world of human trafficking. Toronto: Viking Canada; 2010.
- U.S. Department of State. Country narratives: A through C [Internet]. U.S. Department of State; 2014 [cited 2014 Oct 6]. Available from: http://www.state.gov/documents/organization/226845.pdf.
- Stewart, DE and Gajic-Veljanoski, O. Trafficking in women: the Canadian perspective. CMAJ 2005; 173(1): 25-26.
- Perry, KM and McEwing, L. How do social determinants affect human trafficking in Southeast Asia, and what can we do about it? A systematic review. Health and Human Rights 2013; 16(2).
- Sikka A. Trafficking of Aboriginal women and girls in Canada. Aboriginal Policy Research Series: Institute On Governance; 2009.
- 8. Gosnell-Myers G. Far from home: Experiences of sexually exploited Aboriginal youth in Vancouver. Findings from the B.C. Urban Aboriginal youth domestic trafficking in persons policy research report [Internet]. Prepared for the Office of the Federal Interlocutor for Métis and Non-Status Indians; 2012 June [cited 2014 Sept 28]. Available from: http://www.firstpeoplesgroup.com/mnsiurban/PDF/women_children_youth_families/Gosnell-Myers_G-Far_From_Home_SEY_%282012%29.pdf.
- Public Safety Canada. National Action Plan to Combat Human Trafficking. 2012 [cited 2014 Dec 5]. Available from: http://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/ntnl-ctn-pln-cmbt/index-eng.aspx
10. Rafferty Y. The impact of trafficking on children: Psychological and social policy perspectives. Child Development Perspectives, 2008; 2(1): 13-18.
11. Gajic-Veljanoski O, Stewart DE. Women Trafficked Into Prostitution: Determinants, Human Rights and Health Needs. Transcultural Psychiatry 2007; 44(3): 338-358.
- Family Violence Prevention Fund. Turning pain into power: Trafficking survivors’ perspectives on early intervention strategies [Internet]. San Francisco, CA: Family Violence Prevention Fund; 2005 [cited 2014 Oct 5]. Available from: http://www.childhood-usa.org/upl/files/4109.pdf.
- Baldwin SB, Eisenman DP, Sayles JN, Ryan G, Chuang KS. Identification of human trafficking victims in health care setting. Health and Human Rights Journal 2013; 16(2).
- Miller E, Decker MR, Silverman JG, Raj A. Migration, sexual exploitation, and women’s health: A case report from a community health center. Violence Against Women 2007; 13: 486–97.
- Barrows J, Finger R. Human trafficking and the healthcare professional. South Med J. 2008; 101: 521–524.Sabella D. The role of the nurse in combating human trafficking. Am J Nurs. 2011; 111(2): 28-37.
- Wong J, Hong J, Leung P, Yin P, Stewart D. Human trafficking: An evaluation of Canadian medical students’ awareness and attitudes. Education for Health, 2011; 24(1).
- Abdulla N. Fraser Health launches online learning module to help staff identify victims of human trafficking [Internet]. [cited 2014 Oct 6]. Available from: http://news.fraserhealth.ca/News/September-2014/Fraser-Health-launches-online-learning-module-to-h.aspx.
- Clancey A, Khushrushahi N, Ham J. Do evidence-based approaches alienate Canadian anti-trafficking funders? Anti-Trafficking Review 2014; (3): 87-108.
- Munoz, J. How to recognize, treat victims of sex trafficking [Internet]. [cited 2014 Dec 6]. Available from: http://www.acepnow.com/article/recognize-treat-victims-sex-trafficking/
- Stanford School of Medicine. Human trafficking [Internet]. [cited 2014 Dec 6]. Available from: http://humantraffickingmed.stanford.edu/.
- Zimmerman, C. & Borland, R. Caring for trafficked persons: Guidance for health providers [Internet]. International Organization for Migration, 2009. [cited 2014 Dec 6]. Available from: http://publications.iom.int/bookstore/free/CT_Handbook.pdf.
- Ahn R, Alpert EJ, Purcell G, Konstantopoulos WM, McGahan A, Cafferty E, et al. Human trafficking: Review of educational resources for health professionals. American Journal of Preventive Medicine 2013; 44(3): 283-289.
- Ministry of Justice. Online training [Internet]. [cited 2014 Oct 3]. Available from: http://www.pssg.gov.bc.ca/octip/training.htm.
- International Organization for Migration. Budapest declaration on public health and trafficking in human beings [Internet]. Budapest: Regional Conference on Public Health & Trafficking in Human Beings in Central, Eastern, and Southeast Europe; 2003 March [cited 2014 Oct 10]. Available from: http://www.iom.int/china_conf/files/organizers/iom/budapest_declaration.PDF,