Erin Williamson, Nicole M. Dutch, and Heather J. Clawson
Caliber, an ICF International Company
|This Issue Brief presents an overview of the major topics discussed at the National Symposium on the Health Needs of Human Trafficking Victims sponsored by ASPE and held in Washington, DC, September 22-23, 2008. The brief focuses on the post-presentation discussions and suggestions of participants.В Most of the presentations themselves, along with the agenda, are available at: https://quickplace.icfconsulting.com/2008humantraffickinghealthsymposium.|
On September 22 - 23, 2008, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) within the U.S. Department of Health and Human Services (HHS) sponsored a national symposium focused on the health needs of human trafficking victims. This symposium developed from an exploratory study, funded by ASPE, examining how HHS programs are addressing the needs of victims of human trafficking. This symposium brought together health care workers and members of the anti-human trafficking community to discuss trafficking victims health needs, how best to identify victims in health care settings, and ways that the health care system can provide improved and effective health care services to this population.
More than 150 experts and professionals from a variety of fields attended the symposium. Attendees included directors of national medical associations; program directors of hospitals located in communities highly affected by human trafficking; medical personnel working in clinics and organizations serving victims of human trafficking; executive directors of anti-trafficking organizations; and government officials from HHS, U.S. Department of Justice, U.S. Department of Labor, U.S. Department of State, U.S. Department of Education, U.S. Agency for International Development, and U.S. Congress.
The symposium was organized in five major panel sessions, each of which ended with a discussion among attendees and panelists. Session 1, Introduction to Trafficking as a Health Issue, provided an overview of the issue including the role of various government agencies working to combat human trafficking, major cases prosecuted by the Department of Justice, certification of international victims by the Office of Refugee Resettlement within HHS, and the major health consequences of human trafficking. Session 2, Encountering Victims: Identification, Disclosure, and Other Issues, took a closer look at victims of human trafficking, challenges in identifying victims, key indicators to improve identification, how victims present themselves to health care settings, and how the Health Insurance Portability and Accountability Act might affect services to this population. Sessions 3 and 4 focused on Health Service Provision to Victims, examined the physical, emotional, and mental health issues affecting this population, public health concerns resulting from human trafficking, medical services currently available, and additional resources needed to improve service delivery. In Session 5, Lessons Learned and Promising Practices, agencies successfully treating the physical and mental health needs of human trafficking victims described their programs and promising practices.
This brief presents an overview of the major topic areas discussed during the National Symposium on the Health Needs of Human Trafficking Victims. The brief focuses primarily on the post-session discussions and suggestions to improve the delivery of health services to victims. Most of the presentations, as well as the symposium agenda, are available at https://quickplace.icfconsulting.com/2008humantraffickinghealthsymposium.
Understanding the Definition of Human Trafficking and its Relationship to Other Populations
The Trafficking Victims Protection Act of 2000 (TVPA) defines trafficking as the use of force, fraud, or coercion to compel labor and/or commercial sexual activity. Under this definition, human trafficking can present itself in multiple ways and numerous settings. While the TVPA legally defines human trafficking, symposium participants and anti-trafficking experts pointed out that this comprehensive definition is not often used in the public arena, and sometimes it is not even employed by anti-trafficking service providers and advocates, who might view human trafficking as confined to foreign-born women subjected to sex trafficking. These discussants cited the media and other public outlets as common sources providing a restricted view of human trafficking that applies only to female victims of sex trafficking. This narrow focus disregards the significant number of male and transgender victims, as well as the millions of victims of labor trafficking who may not have experienced sexual coercion as well. It also does not adequately recognize those U.S. citizens or legal permanent residents subjected to sex or labor trafficking who never cross any national boundaries (i.e., domestic victims). The relevant criteria establishing whether an individual is a trafficking victim is the presence of force, fraud, or coercion, not movement across geographical space or membership in any nationality group.
In addition, anti-trafficking representatives pointed out that victims are sometimes defined narrowly as coming from the same background or sub-population. For example, reports on child sexual exploitation often assert that a significant number of minor, domestic female victims of commercial sexual exploitation are runaways. While this may be true for some domestic victims, assuming this is the case for all such female minor victims of sex trafficking may result in practitioners maintaining false assumptions and/or obtaining incomplete and inaccurate histories; this can result in unanticipated and potentially hazardous treatment strategies and outcomes. For example, if a physician working with a juvenile patient assumes he or she is a runaway, the physician may infer that something at the patients home prompted him or her to run away. This assumption could hinder family reunification for victims who are not runaways, or for whom reunification may be preferable. Symposium attendees representing multiple constituencies emphasized the importance of understanding that victims of trafficking can come from a variety of backgrounds and experiences and exhibit a wide range of characteristics.
Symposium attendees concluded that discussions on human trafficking must take place at the practitioner and policy levels and incorporate a comprehensive definition of human trafficking in order to address the health issues facing this population and ensure proper care for all victims.
However, within this broad definition are several discrete categories of victims who often may need different types of services and support.
Sub-Populations of Human Trafficking that Require Specialized Attention
Domestic victims of human trafficking were a sub-population discussed frequently throughout the symposium. While the majority of human trafficking victims in the United States are U.S. citizens, law enforcement, medical practitioners, and social service providers all pointed out that the resources for domestic victims are not comparable to those available for international victims. They observed that shelter is one of the most inadequate resources for domestic victims. While advocates for victims of domestic violence have effectively demonstrated the need for and benefits of shelters, social service practitioners note these shelters typically do not have the necessary personnel or resources to support victims of human trafficking, especially victims of labor trafficking. In some cases, female victims of trafficking refer to pimps as boyfriends, thus confusing whether cases involve domestic violence or trafficking. Additionally, shelters tend to be for females and, therefore, unavailable for male and transgender victims of human trafficking. Law enforcement and community organizations report having a difficult time locating adequate short- and long-term housing for domestic victims who escape their trafficking situations. As a result, many domestic minor victims are housed in juvenile detention centers, which often do not recognize or treat these youth as victims of a crime, but rather as perpetrators. A number of attendees identified the need for additional resources to establish specialized short- and long-term housing options for domestic victims, particularly minors.
Social service providers also noted that accessing public benefits can be difficult for domestic victims of human trafficking. They report that while programs such as food stamps and Temporary Assistance for Needy Families (TANF) exist, they have eligibility requirements that may limit participation by domestic victims. For example, the Food Stamp program (now called the Supplemental Nutrition Assistance Program, or SNAP) generally requires applicants to have proof of address, a birth certificate, and a Social Security card, which most domestic victims do not have at the time they escape their trafficking situations. While victims can apply for various forms of identification, this process can be cumbersome and time-consuming, leaving victims at high risk for re-victimization and hindering attempts to receive public assistance. Additionally, prior arrests for solicitation or other offenses often result in ineligibility for food stamps and other programs. TANF requires individuals to be at least 18 years of age and have at least one child. As a result, social service providers report that minors with children and adults without children are generally ineligible for this program.
Adults and children with special needs are also likely to require particular attention and services. Social service providers and researchers report that individuals with special needs are disproportionately targeted by traffickers. They added that these victims may be more vulnerable due to mental impairments as well as their need for financial resources to pay for medical care. Very little is known about how best to treat and work with this sub-population in the short-term as well as what resources are needed for their long-term care.
Victims of labor trafficking may also require special attention. For example, they may suffer permanent and/or chronic medical conditions requiring intensive and lifelong treatment. For children, these medical conditions can severely affect their physical development. One example of this is children exposed to chemicals harming their respiratory system and hindering proper lung development. In addition, victims of labor trafficking may also have experienced sexual assault during their trafficking experience, putting them at risk for an increased number of associated health and mental heath issues. Since little research exists regarding labor trafficking, including the number of victims and their needs, as well as the health consequences of labor trafficking in the United States, more work is needed to ensure the health care needs of this sub-population are properly identified and met.
Attendees also pointed out that children of adult victims require specialized attention, especially children who are at heightened risk for trafficking as a result of their mothers being in prostitution. Social service providers report that more resources are needed to effectively identify and prevent these children from becoming victims themselves. Gay, lesbian, and transgender youth are also at elevated risk for trafficking according to victim service providers. When these children escape their trafficking situations, they often need specialized support and services to help them overcome significant identity issues that can result from their trafficking experiences. For example, social service providers report that domestic, female victims of trafficking often initially identify themselves as being lesbian then later identify as straight or bi-sexual. There is little known regarding the cause of this phenomenon or whether these identity issues existed prior to their trafficking experience; however, providers note that this issue of identity is one that many domestic female victims struggle with as part of their recovery. Children and adults can also experience re-victimization if their images have been posted online. Medical professionals serving victims of human trafficking cited online images as a major factor in computer aversion, which can significantly affect completing school or attaining gainful employment. Additionally, representatives of anti-trafficking organizations report that more attention is required for children who are trafficked into the United States for the purposes of adoption, as well as U.S. children trafficked abroad.
Physical and Mental Health Professionals Roles in Prevention
Mental health providers and researchers emphasize the importance of medical providers having a holistic understanding of human trafficking as well as an appreciation for sub-populations requiring specialized attention. They point out the unique role health care providers can fulfill in terms of screening for individuals at risk for human trafficking. Social service providers affirm that individuals can be at risk for human trafficking as a result of a history of abuse, runaway tendencies, and low income or poverty, in addition to a variety of other factors. They acknowledge that physical and mental health providers are often privy to information crucial to effective prevention. For example, doctors or nurses who are aware of a minors history of physical, emotional, or sexual abuse can incorporate screening questions into their sessions to identify indicators of potential trafficking at early stages. School nurses aware of families needing additional financial resources could alert youth in those families to labor trafficking and ways to identify safe employment options. Mental health providers also suggested examining those sub-populations who are at risk for trafficking yet were not victimized to better understand what factors might be critical to preventing human trafficking.
Factors Contributing to Identifying Victims and Providing Services
Social service providers and medical professionals confirm a number of contributing factors can complicate identifying victims of trafficking and providing services to them. A common reason victims of human trafficking are not identified, and therefore do not receive proper care, is because these cases are misclassified. For example, many cases of sex trafficking, especially those in which victims are romantically involved with their traffickers, are identified as sexual or domestic violence cases. Cases of human trafficking are sometimes even processed as domestic violence cases in the court system. Social service providers anecdotally report this is partly due to limited awareness among law enforcement personnel, community service providers, and medical professionals about the scope of the definition of human trafficking. They assert first responders should be adequately trained about this issue so they can properly identify and respond to victims they encounter, including domestic victims.
Symposium attendees described additional barriers to identifying and providing services to international victims of human trafficking. They reported that one of the largest barriers for this population is language. International victims often have limited or no understanding of English. Victims of labor and/or sex trafficking may have signed illegal contracts that they believe legitimize their circumstances. International victims seeking medical and social services usually require the assistance of a translator. Service providers indicate that in order to ensure international victims are properly identified and safe, independent, confidential translators must be available. However, medical and social service providers acknowledge this requirement can be extremely challenging, if not impossible, to meet. Even providers in New York City, which has many multi-lingual communities, noted difficulties in finding appropriate translators when non-English speaking clients present themselves. Additionally, language phone lines can be costly and uncomfortable for both clients and providers, and may not be able to provide translation for all client languages.
Lack of cultural competency by health care providers can also significantly hinder the effectiveness of medical care provided to international victims. Social service providers at the symposium emphasized that an important part of cultural competency is the understanding and use of alternative medicines. They report that international as well as some domestic victims of human trafficking often come from cultures in which folk healing, healing rituals, and secret societies are commonly accepted and used. For example, some African-based therapeutic systems subscribe to the idea that only practitioners belonging to secret societies are able to provide proper psychological treatment. Social service providers also note that cultural competency entails understanding the cultural and religious beliefs surrounding certain medical practices and procedures, such as consuming prescription drugs, using birth control, and undergoing abortions. Successfully working with and treating these clients calls for incorporating into treatment the medical techniques with which victims are familiar and comfortable. Social service providers describe this as being especially true for children who need a comfortable and supportive environment. They suggest that medical practitioners be able to make referrals to specialized providers if they are not familiar or comfortable with medical treatments used by certain populations.
Illiteracy, and specifically health illiteracy, often hinders victim identification and proper medical care. Organizations working with victims of human trafficking point out that many victims, both international and domestic, are illiterate. Therefore, they may be unable to read pamphlets, posters, or other written materials providing important medical information. Additionally, as our culture becomes more dependent on technology to communicate, increasing amounts of information about social services and medical care are being disseminated through the Internet. Individuals who are illiterate, have limited or no understanding of the English language, and/or have no access to the Internet have increasingly less access to crucial information.
The consequences of human trafficking on mental health cannot be overstated. Victims of human trafficking have experienced considerable trauma, some of which does not present itself until years later. According to mental health service providers working with this population, practitioners need to have specialized training to most effectively provide care to clients experiencing trauma. One of the unique aspects of human trafficking that can lead to significant trauma is the fact that these victims have been paid for the harm perpetrated against them. Monetary payment for forced labor and/or sexual services and the social normalization of prostitution often result in victims receiving conflicting and confusing messages regarding their experiences. Treating only physical symptoms without addressing the underlying trauma will not effectively help this population overcome their experiences. Attendees acknowledged that in order to address short- and long-term trauma, adequate health care coverage that includes mental health services is imperative for all victims.
Practitioners from a variety of fields indicated that coordinated service delivery is essential to preventing re-victimization. Victims often experience significant co-morbidity of physical and mental health problems, which cannot be treated as if they exist separately. Health providers and social service agencies recognize the need to develop relationships and systems to better coordinate service delivery, especially for helping victims move from emergency services to long-term rehabilitation and stability. Communities that have successfully developed integrated service delivery systems should be studied and their best practices should be shared.
Working with victims of human trafficking can be extremely draining on service providers. Mental health providers reported that compassion fatigue and vicarious trauma among service providers can dramatically affect services. Organizations and individual practitioners working with this population need to ensure they have the supports necessary to sustain their work on behalf of victims.
Re-traumatizing victims within ostensibly safe institutions is a serious concern. For example, providers working with victims in juvenile detention centers and other public systems pointed out that victims may be re-traumatized within those systems.
Similarly, social service providers reported that some international victims have been re-traumatized by systems that treated them as suspected terrorists. Mental health workers testified that the majority of victims within such public institutions have not had their trafficking experiences recognized as traumatic. They suggested training and education could help these systems learn how to work with victim populations in a way that is not re-traumatizing.
Mental health providers noted the role of resilience, not only in preventing human trafficking but also in helping victims of trafficking deal with and overcome their trafficking experiences. They cited dissociative disorders and other mental health conditions as coping mechanisms victims adopt to survive their trauma. While the importance of resilience in helping victims of human trafficking is anecdotally recognized, the variation in the treatment outcomes of victims indicates the need for further research to better understand its role in victims ability to overcome traumatic experiences.
Human Trafficking as a Public Health Issue
The symposium not only focused on the health care needs of individual victims of trafficking but also the public health consequences of human trafficking. The majority of research on human trafficking as a public health issue has focused on its effect on the prevalence of tuberculosis, HIV/AIDS, and Hepatitis B. Social service providers working with victims near the United States-Mexico border recognize the significant threat of cross-border contamination among the populations they serve. Government officials reported working on cross-cultural collaborations to examine and reduce cross-border contamination. But both government representatives and social and health service providers agreed that more work is needed in this area.
Training Physical and Mental Health Professionals
One of the major outcomes of the symposium was the recognition that training the medical field on the issue of human trafficking is imperative to improve identification of, and service delivery to, victims. Health care and social service providers also acknowledged that simply training first-responder medical personnel, such as emergency room physicians or emergency medical technicians, is not sufficient; all medical professionals, including those working in other public systems such as the justice system, need proper training. Participants also agreed that special efforts should be made to ensure medical professionals serving marginalized populations, such as nurses and physician assistants working with needle exchange programs, also receive training about human trafficking. Training would assist with identifying and treating victims and enhance prevention so health professionals could identify clientele at risk for trafficking.
An improved training strategy would integrate the issue of human trafficking into the general and continued education of medical professionals. A number of medical professionals suggested that various medical associations, such as the American Medical Association, American College of Obstetricians and Gynecologists, and American Academy of Pediatrics, should focus their attention and resources on the issue of human trafficking. Social service providers and medical professionals suggested incorporating human trafficking into continuing education courses with a focus on quality of care, safety issues, and potential malpractice. Others suggested incorporating the topic of human trafficking into the larger issue of patient experience with violence and abuse.
Social service agencies have had some success in working with associations. However, they understand medical associations took significant time to recognize domestic violence as an issue, and are committed to continuing work with associations to gain attention for human trafficking.
Social service providers and medical professionals also discussed adding human trafficking to the standard educational curricula of doctors, nurses, social workers, psychologists, and other health professionals. They suggested creating a comprehensive human trafficking curriculum that could be adapted and used by a variety of institutions and audiences. The curriculum could be augmented by more specialized, targeted curricula, for example curricula specifically for emergency room nurses. Attendees identified a variety of existing training tools for the medical field, but believed developing a standard human trafficking curriculum would be valuable.
Attendees discussed who would be best equipped to provide training on human trafficking to the medical field. Medical professionals and social service providers agreed the training should be conducted by a peer (e.g., a nurse would train other nurses). However, they also acknowledged that the demand for training of medical professionals is much greater than the number of qualified medical professional trainers. Social service agencies offered examples of how they have successfully trained medical professionals. They noted that social service providers can sometimes present a more comprehensive perspective on the array of issues trafficking victims face. Social service providers also suggested having victims participate in training, enabling health care professionals to learn first-hand about their experiences.
Educating the Public
In addition to educating health care professionals, symposium attendees discussed the importance of educating the broader public, including individuals in other professions who may encounter this population. Human trafficking has received greater media and public attention; however, attendees noted that the majority of people in the country remain unaware of this problem, especially as it relates to labor trafficking and domestic victims. Social service professionals reported coming into contact with people from all walks of life who may have witnessed instances of human trafficking but lacked the proper information or resources to recognize it. They expressed the need for further and ongoing public education and awareness building to successfully address human trafficking.
Research and Data
Ongoing research and comprehensive data regarding the health care needs of, and services available to, victims of human trafficking can help ensure services meet their health and mental health needs. Medical professionals, social service providers, and researchers in the anti-trafficking movement expressed concern that no data tracking systems exist to accurately evaluate current health service delivery systems for victims of human trafficking. They noted this deficiency at both the local and national levels. Social service providers agreed lack of data not only hindered assessment of services they provide, but also impeded funding to enhance services as government and non-government funders request data to demonstrate victims needs for services and agency needs for financial support. Yet they cannot obtain data without funding to build data infrastructure and conduct research. One health care provider working with this population suggested instituting a public health task force to assist with data collection for victims services.
Social service providers and researchers affiliated with universities reported working jointly on research projects to assess health needs and services for victims of human trafficking, but they agreed that an overall infrastructure for data collection is lacking in the anti-trafficking field. All attendees acknowledged that data collection is an enormous challenge given service providers limited time availability and lack of expertise in developing and implementing data collection systems.
In addition to data collection and evaluation of services, symposium attendees identified other areas in which further research is needed:
- Demand reduction programs
- Societal factors promoting solicitation of commercial sex
- Typologies of traffickers
- Typologies of the consumer or end user (e.g., johns, employers)
- Economic factors involved in trafficking
- Health consequences of labor trafficking in the United States
- Financial impact of human trafficking in terms of health and mental health services
- Public health impact of human trafficking in the United States
- Role of resiliency among victims
- Protective factors for vulnerable populations
- Best practices for treating victims of human trafficking
Attendees agreed that human trafficking is more likely to be eliminated or reduced if the motives of traffickers and other exploiters (e.g., johns, employers, relatives) can be understood and their activities prevented. They also cited the importance of integrating public awareness and corporate responsibility into preventing labor trafficking. Representatives of anti-trafficking organizations and service providers working with trafficking victims commented that they were not fully aware of best practices being implemented by other anti-trafficking organizations and recommended an improved infrastructure for sharing information. They suggested starting with a listserv that included symposium attendees to begin building a community of practice for information sharing.
Human Trafficking and Related Fields
While human trafficking has an extensive history, the Federal government only recently enacted the TVPA, which established new programs and services for victims of human trafficking. Accordingly, symposium attendees recognized that the anti-trafficking field can learn significant lessons by examining best practices and advances in similar fields, including domestic violence, child sexual abuse, victims of torture, and refugees. Medical providers observed that several best-practice models have been created and implemented in the United States and a number of suggestions presented at the symposium have been successful in other fields.
Social service providers and government representatives also encouraged building coalitions and partnerships between those in the anti-trafficking field and individuals and organizations in related fields in order to share information, ideas, and resources. Anti-trafficking service providers believed services currently are provided within distinct categories in which an individual is treated as a refugee, victim of torture, or victim of human trafficking, as opposed to an approach that is based on a more inclusive, multi-dimensional framework. Attendees felt an integrated, multi-dimensional approach was especially important for law enforcement and prosecutors whose mandates tended to encourage them to investigate and prosecute cases within strictly defined guidelines and parameters. Coalitions and stronger partnerships would assist in creating a multi-dimensional, victim-centered framework of service provision and would help reduce duplication of services. Anti-trafficking representatives from Florida noted they have begun implementing a multi-dimensional framework in their trainings, which has helped service providers from various backgrounds compare and contrast human trafficking needs and services across related fields.
Symposium participants recommended greater collaboration among service providers and agencies in various fields and encouraged improved and increased data collection among government agencies addressing human trafficking.
The National Symposium on the Health Needs of Human Trafficking Victims provided a unique opportunity for members of the anti-trafficking community and health care professionals to begin discussing ways to improve identifying and providing services to human trafficking victims in medical settings. Participants identified specific ideas, contacts, and next steps that could build on the relationships established and lessons learned at the symposium. As with efforts to provide effective services to victims of crime, violence, and abuse, participants recognized both the progress that has been made and the steps that still need to be taken.
Trafficking Victims Protection Act of 2000. Pub. L. No. 106-386, 8 U.S.C. § 1101, § 7101, 114 STAT 1464 (2000).
 There is ongoing discussion within the anti-trafficking field about the use of the terms victim and survivor to describe individuals currently in, or who have escaped from, a trafficking situation. This paper uses the term victim throughout to describe these individuals.
 To view the symposium documents please use the following username and password. Username: 2008symposium and Password: humantrafficking
To obtain a printed copy of this report, send the title and your mailing information to:Human Services Policy, Room 404E
Assistant Secretary for Planning and Evaluation
U.S. Department of Health and Human Services
200 Independence Ave, SW
Washington, DC 20201
Fax: (202) 690-6562