Promoting Human Rights by Attending to Human Trafficking
Psychiatrists, like other health care professionals, will encounter human trafficking victims, including sex trafficking victims. This article provides clinical and practical information to help psychiatrists identify victims and provide trauma-informed care.
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Human trafficking, or involuntary slavery, is a public health problem and human rights violation that affects 27.6 million people worldwide, according to the U.S. State Department, including about a million people in the United States. A 2021 White House fact sheet reported that the $150 billion industry ranks second to smuggling as the world’s largest criminal enterprise. Traffickers force millions of people to provide domestic, farm, hospitality, begging, construction, factory, salon, massage, landscaping, health care, sales, hacking, sexual (includes prostitution, mail order and child brides), military (child soldiers), care for children and persons with disabilities, and other services without compensation. Physicians who identify enslaved people can provide treatment, obtain services, and advocate for them. Although the focus of this article is on sex trafficking, many features overlap with other forms of human trafficking.
In the United States, trafficking victims come from various backgrounds and communities. In Ohio, for example, more than 55% of known trafficking victims are U.S. citizens or permanent residents, 91% are female, and 61% are minors. Traffickers view enslaved people as revenue-generating commodities who are most lucrative when they work constantly. They are moved around the country, based on demand, to provide services and generate revenue. Labor traffickers transport victims during harvest season or to meet seasonal labor demands in resort towns, recreational areas, factories, the construction industry, restaurants, etc. Victims of sex trafficking are relocated to towns that have sporting events, conventions, festivals, and other high-density events. Frequent relocation has two other benefits: It disorients victims, making it difficult for them to escape, and it obfuscates efforts of law enforcement to identify and assist victims and arrest their captors.
Risk Factors
Although there is no specific profile for trafficking victims, certain factors can increase the risk of being enslaved. Women, people who have mental disorders, members of sexual minorities, people who have experienced maltreatment, migrant workers, immigrants, impoverished individuals, those in the sex trade, and those with friends or family in the sex trade are at higher risk. Also, children in unstable homes, foster care, or gangs are more likely to be targeted by traffickers. One-third of youth who run away or are homeless are approached by a pimp in the first 24 hours.
Recruitment and Enslavement
A trafficker grooms individuals in person or on electronic media by showering praise on them and making them feel special. This may include providing “likes” or encouraging and flattering comments on social media. The predator may express love, provide gifts, or pose as a recruiter in the fashion or entertainment industry. Victims feel valued and develop a relationship with the trafficker and begin to disclose personal information.
Why Trafficking Victims Reject Help
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Fear of retaliation
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Confusion
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Distrust of advocates
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Self-blame
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Mental illness
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Unworthiness
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Fear of retraumatization
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Stigma
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Fear of rejection by family
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Not ready
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Fear of homelessness
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Fear of legal problems
The National Human Trafficking Hotline can be reached by phone (888-373-7888), text (23373), and chat (humantraffickinghotline.org/chat). Interpreters are available only by phone.
When trust is established, the trafficker begins to engage in interpersonal violence. The trafficker may berate, isolate, and harm or threaten to harm the victim, their friends, and their loved ones. Also, they deprive victims of necessities, including food, shelter, sleep, clothing, and bathing. Victims do not have access to money, electronic media, and sources of identification. Frequent relocation and illicit drugs are used to disorient and control the victim. Additionally, the trafficker may confuse victims by providing occasional rewards and privileges.
In time, victims may develop learned helplessness, blame themselves, believe they are unworthy of better treatment and healthier relationships, and identify with the trafficker/aggressor. Some victims may not realize they have been conned by a predator. They are emotionally withdrawn and can easily blend in and be overlooked by health professionals.
Human Trafficking and Medicine/Psychiatry
Multiple studies have found that up to 88% of trafficking victims have come into contact with the health care system. The professional’s familiarity with the presentation of trafficking victims is essential to providing evidence-based care, according to a 2022 report in PLOS One. Since 80% of health outcomes are not related to the patient-physician encounter, identifying and helping trafficking victims receive appropriate services can greatly influence their health and emotional wellness.
Psychiatrists can encounter enslaved individuals in urgent care clinics, emergency departments, mental health drop-in centers, substance use treatment programs, psychiatry outpatient programs, inpatient psychiatric units, and consultation-liaison services. Victims can be accompanied by someone who controls the narrative by providing the medical history. Victims are ordered to remain silent and not to talk or cooperate if they are separated. This prevents victims from disclosing that they are enslaved and asking for help. The medical history may be inconsistent with patients’ symptoms and the medical evaluation.
The psychiatrist should always conduct part of the patient interview when others are not present. If a patient requests a chaperone, then a hospital staff member who is familiar with privacy requirements should be asked to be present. Also, visitors should not be permitted to serve as interpreters. The service should be provided by an objective professional who is required to comply with health care privacy laws.
Trafficking victims who have been assigned aliases may struggle when disclosing their demographics. Those who have been relocated frequently may be geographically disoriented. They can present with evidence of chronic untreated physical and mental disorders, including chronic substance use and sexually transmitted infections. Many female sex trafficking victims have had one or more pregnancies and been forced to get abortions. Victims of labor trafficking, including children, may have serious injuries, such as fractures, lacerations, and crush injuries due to being overworked and other unsafe workplace practices. At times, tattoos or branding may also be indicators of involuntary servitude.
The psychiatrist may be asked to consult on medical patients who have mental status changes. Patients may be withdrawn, silent, in a daze, emotionally numb, or confused and fatigued. Or they may become agitated and hypervigilant if they have been traumatized by the physical examination. Also, the psychiatrist may be asked to assess or speak with the angry “family” of a patient who has a severe illness and insists on signing out of the hospital against medical advice. The trafficker wants the patient to leave the hospital before too many questions are asked. The goal is to avoid detection.
Trafficking and Minors
Trafficked latency-aged and preadolescent children also may present in health care settings. The child and adolescent psychiatrist may be consulted due to concerns about sexually precocious behavior, attachment problems, aggression, impulsivity, regressive behaviors (urinary and/or fecal incontinence, regressive language, thumb sucking), or other symptoms. Trafficked youth and adults are at risk for mood and anxiety disorders, posttraumatic stress disorder, substance use disorders, aggression, disruptive behavior disorders, and suicide spectrum behavior.
Intervention for Trafficking Victims
Psychiatrists should be familiar with resources that are available to victims. Some hospitals and agencies have an identified person or team that is trained to work with trafficking victims. Involving trained professionals is important since routine communication by health, law enforcement, and social service professionals may humiliate, frighten, or retraumatize victims.
Enslaved individuals may reject assistance. They may fear harm, stigmatization, humiliation, and/or retaliation. Victims have been conditioned to believe that they aren’t worthy of compassion, concern, or assistance. Also, victims may be ambivalent about returning to their former life because they anticipate judgment and rejection, and enslavement has affected their maturation, socialization, education, and health.
The therapeutic alliance and health outcomes can be improved for trafficking victims when physicians are culturally humble. Psychiatrists learn the tenets of cultural humility—engaging in critical self-reflection while being open-minded, curious, and nonjudgmental—during psychotherapy training.
What Should You Do?
The following case examples describe signs that suggest a patient is a victim of sex trafficking and suggestions on how to help the individual get to safety.
• Case: A woman with depression with psychotic features is admitted to the psychiatric hospital after a suicide attempt. You notice that she becomes emotionally distressed whenever she speaks with her boyfriend. When her mood improves, she says that she wants him to move out of her apartment, but she will face eviction if he does because she is underemployed and will not be paid for the time she spent in the hospital. After you explore options with her, she decides to let him stay because “it’s better than the shelter. He will help me earn the money to pay him back” by arranging for her to have sex with his friends.
Discussion: The patient is being trafficked in her home by her partner. The psychiatrist informs the patient that help is available. The patient is offered and reviews educational materials about trafficking. She agrees to meet with an advocate from the hospital’s trafficking intervention team as long as the psychiatrist will be present.
The following day, the patient says that she doesn’t want to meet with the advocate. Her partner/manager tells her that she needs to leave the hospital because she’s not mentally ill and they may lose their home because she hasn’t been working. He alleges that the treatment team has been brainwashing her and is trying to control her. The psychiatrist respects the patient’s decision, thanks her for taking time to review the written material, and informs her that help is available if she changes her mind.
• Case: The adolescent medicine team asks you to evaluate a 16-year-old cis-gender male who has been treated for sexually transmitted infections several times in the last six weeks. The team is concerned about his mental health and a drug screen that showed opioid metabolites. You introduce yourself to the youth and the uncle and explain your role. The youth is silent. The uncle says that he will provide the youth’s medical history since the youth is known to lie. Although the uncle says that he is the youth’s legal guardian, he lacks proof but says that he presented it during a previous visit. You leave the room and inform the clinic staff that the youth is not permitted to leave. While you are reviewing the youth’s legal status, he and the uncle try to leave.
Discussion: The record indicates that the youth’s mother has custody and when contacted, she reports that the youth ran away from home three months ago and that he doesn’t have an uncle. The psychiatrist contacts the police department and child protection services agency and provides the mother’s information.
• Case: An 11-year-old girl in the United States wants to join a chat group. She decides to join Omegele, an anonymous chat site, because it doesn’t require participants to identify themselves. She meets a guy who is posing as a minor. She enjoys chatting with him as he makes her feel special. He eventually convinces her to submit a nude photo of herself to him. After she does so, he tells her that she can go to jail for child pornography and become a registered sex offender. He says that he will keep her secret if she continues to send her photos. She is afraid and sends him photos for three years.
Discussion: In this true case, the girl was identified by her school uniform. The abuse stopped after Ryan Fordyce of Winnipeg, Manitoba, was arrested for child pornography involving seven minors. She and her parents sued, and Omegele was shut down.
This case illustrates the importance of exploring how children and adolescents use social media. This includes learning about how they obtain information, their favorite apps, their online friends, whether they have released personal information on the internet, and whether they have been bullied. It also is important to ask caretakers if they are monitoring how youth are using the internet and social media. In my practice, I encountered several minors who used Omegele before it was shut down.
Treatment efficacy studies are limited due to small sample sizes. A trauma-informed multidisciplinary, patient-centered approach is the preferred method for treatment. Cultural humility should be employed when engaging patients at their pace and allowing them to guide the course of treatment. Patients should know that their need for autonomy and safety, both physical and emotional, will inform where and when the interviews occur.
Patients should be shown and informed that the interviews are being held in a safe place. This should be communicated along with the process and objective of the evaluation. Patients should be told about the limits of confidentiality and privilege, including the conditions under which the psychiatrist must involve law enforcement, social services. or other agencies.
If the patient lacks the capacity to give informed consent, then a legal proxy should be consulted for consent. When this occurs, a developmentally informed explanation of the objective, process, and limitations of the interview should be provided to the patient.
The comprehensive treatment/rehabilitation plan can include physical, gynecological, and mental health care, along with social, housing, legal, and educational services; case management; employment coaching; and other resources if the victim can benefit from them and the victim or guardian/proxy chooses to accept them. Interpreters should be provided for all aspects of the rehabilitation program when it is appropriate to do so. The goal is to support the patients’ recovery while empowering them as they bolster their resilience. This can reduce the risk of re-traumatization.
Rehabilitation can be overwhelming for patients who struggle with trust and fear, traumatic stress, and/or mental illness. They may decline or undermine rehabilitation, including psychiatric care, due to having an external locus of control, believing they’re not worthy, not being ready to commit, and/or fear of relapse or not succeeding. Patients may be ambivalent about reunification and being judged by family and friends from their former life.
Patients may not be ready for drug rehabilitation and may have many fears, including retaliation, rejection, stigma, and failure. The risk for relapse is high—some patients may relapse up to 20 times before succeeding. The needs of patients who progress through rehabilitation change over time, and the comprehensive treatment plan should be modified periodically to reflect this.
Many agencies are working to increase awareness of human trafficking among health care professionals. Health professions boards have begun to require human trafficking education as part of the licensure-renewal process. Also, a growing number of health facilities require staff in-service training on human trafficking. Resources for human trafficking assessments and enslaved people should be easily accessed at health care facilities, especially those that provide urgent care emergency medicine and tertiary medical services.
Human trafficking should be discussed at every level of medical education, including lectures about pediatric, adolescent, women’s, immigrant, global, and correctional physical and mental health. Also, education about human trafficking should be included in teaching modules about LGBTQ+, child and adolescent, community, rural, and forensic psychiatry. Interdisciplinary collaboration and culturally informed messaging should be made available also. Psychiatrists who become adept at identifying trafficking victims can facilitate earlier intervention, reduce the degree of victim traumatization, and improve the odds of victim rehabilitation. ■
Resources
Biographies
Cheryl D. Wills, M.D., is a forensic psychiatrist and an associate professor of psychiatry at Case Western Reserve University. She is APA’s immediate past Area 4 trustee.
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Psychiatric News
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Published online: 24 June 2024
Published in print: July 1, 2024 – July 31, 2024
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