A girl I grew up with became dependent on heroin after suffering sexual abuse at the hands of a family friend. She went to drug rehabilitation centers many times, but the numbing effects of the heroin kept pulling her back. Human traffickers found her at a party and put her on a plane with other girls to sell her for sex. She got her hands on a cell phone, contacted her father, and was eventually rescued by the FBI. She was lucky.
Human trafficking is one of the world’s fastest growing crimes, according to the US Department of Justice . Labor and sex trafficking has been reported in every US state, in both cities and rural areas . Gathering reliable data is challenging, but there are an estimated 21 million trafficking victims worldwide , and approximately half of all transnational trafficking victims are minors . Many victims are vulnerable to traffickers because of their histories of physical or sexual abuse, neglect, homelessness, poverty, or—in the case of minors—running away .
Many situations involving human trafficking are ethically complex, including victims’ interactions with health care professionals. It is believed that 30-88 percent of US trafficking victims visit a health care professional at least once during their captivity . The goal of this issue of the AMA Journal of Ethics® is to identify issues and challenges that health care professionals, policymakers, and advocates—drawing upon their professional authority and experiences—can use to build evidence-based practices and to motivate effective legislative and organizational policies to fight human trafficking globally.
Addressing human trafficking in medical education will be an important step forward. Within the past three years, at least 11 US medical and nursing professional associations have issued anti-trafficking statements and recommended education on human trafficking . Standard medical training covers intimate partner violence, elder abuse, and child abuse, but not human trafficking . In one survey, most medical students, resident physicians, and attending physicians reported that they lacked knowledge about the extent of trafficking and how to refer trafficking victims appropriately . In this issue of AMA Journal of Ethics, Carrie A. Bohnert, Aaron W. Calhoun, and Olivia F. Mittel discuss the ethical imperative to support human trafficking education for all health care workers—starting at the student level—and the need for advocacy, research, and curriculum development.
As of 2016, only 14 states have enacted legislation that specifically covers sex trafficking in mandatory reporting laws . This lack of specific legislation to guide health care professionals in ethically complicated situations leaves them vulnerable to performing illegal actions. Jonathan Todres examines the legal consequences of clinicians’ assisting traffickers by treating women whom they know are selling sex and suspect might be trafficked. The lack of specific legislation and policy also raises questions about the consequences of various policy options for trafficked persons. Abigail English uses experience with mandatory child abuse reporting laws to evaluate the potential benefits and risks of harm to trafficked persons of expanding such laws to cover human trafficking. And Emily F. Rothman presents three models available for policing commercial sex—criminalization, decriminalization, and partial decriminalization—arguing a different position than Erin Albright and Kate D’Adama do in their contribution to this issue.
Although improving federal and state policies on human trafficking is crucial, there is a dearth of evidence-based research to guide new legislation. Rochelle Rollins, Anna Gribble, Sharon Barrett, and Clydette Powell explain the importance of adopting a public health perspective on human trafficking and employing practice-policy feedback loops. These feedback loops, currently in their infancy for anti-trafficking work, make possible the evaluation and development of evidence-based practices to continuously improve both practice and policy. The creation of these evidence-based practices, however, requires better data. Patrick L. Kerr and Rachel Dash evaluate mandating disclosure of data from medical records, weighing the benefits of more accurate data against the risks of identification.
Given the lack of relevant education and guidelines, it’s not surprising that in their everyday interactions with patients, health care professionals may lack the knowledge to identify trafficking victims or offer them the right kind of help and care. Wendy L. Macias-Konstantopoulos presents a trauma-informed care framework for the treatment of trafficking victims and survivors that incorporates the bioethical principles of respect for autonomy, beneficence, nonmaleficence, and justice. In their commentary on a case about a pregnant and possibly mentally ill trafficking victim, Hanni Stoklosa, Marti MacGibbon, and Joseph Stoklosa discuss how a clinician can respond to these issues within a multidisciplinary, trauma-informed approach to care. And Monir Moniruzzaman reviews strategies for ethically intervening in a culturally unfamiliar context in commenting on a case in which a medical student discovers a victim of labor trafficking while on an international rotation.
Beyond their traditional scope of practice, physicians can assist with the prosecution of traffickers through documentation of human trafficking in war zones. Christina Bloem, Rikki Morris, and Makini Chisolm-Straker discuss whether disaster relief physicians should create records that could be used to provide transitional justice and create accountability for traffickers. Closer to home, additional possibilities exist for health care workers interested in anti-trafficking advocacy. Terri Davis explores one such possibility: the risks and benefits to trafficking survivors of using their therapeutic artwork in promotional exhibits to raise awareness of human trafficking. As an example of such therapeutic artwork, Margeaux Gray contributes two images to the project that are interpreted by Mary Richards. And in the podcast, Ranit Mishori discusses ways all of us can become anti-trafficking advocates.
With an estimated 21 million trafficked persons around the world, why aren’t more health care workers educating themselves, maintaining awareness, and advocating for anti-trafficking policies? William Polk Cheshire, Jr., encourages us to analyze our personal motivations and justifications in discussing why it’s easy, even as health care workers, to be oblivious to trafficking.
Anti-trafficking research, policies, legislation, and practice guidelines are all in their infancy. Yet all health care professionals have a moral imperative to actively work against human trafficking. There are many ways to help human trafficking victims and survivors, starting with awareness of the problem. This issue of the AMA Journal of Ethics contributes to that goal.
US Department of Justice; Bureau of Justice Assistance. Anti-human trafficking task force initiative: overview. https://www.bja.gov/ProgramDetails.aspx?Program_ID=51. Accessed October 2, 2016.
National Human Trafficking Resource Center. The victims. http://www.traffickingresourcecenter.org/what-human-trafficking/human-trafficking/victims. Accessed October 2, 2016.
United Nations Office on Drugs and Crime. Global Report on Trafficking in Persons. http://www.unodc.org/documents/data-and-analysis/glotip/Trafficking_in_Persons_2012_web.pdf. Published 2012. Accessed October 2, 2016.
US Department of State. Trafficking in Persons Report. http://www.state.gov/documents/organization/82902.pdf. Published 2007. Accessed October 2, 2016.
- Atkinson HG, Curnin KJ, Hanson NC. US state laws addressing human trafficking: education of and mandatory reporting by health care providers and other professionals. J Hum Trafficking. 2016;2(2):111-138.
Stoklosa H, Showalter E, Melnick A, Rothman E. Health care providers’ experience with a protocol for the identification, treatment, and referral of human-trafficking victims [published online ahead of print October 8, 2016]. J Hum Trafficking. doi:10.1080/23322705.2016.1194668.
These include the American Academy of Pediatrics, the American College of Emergency Physicians, the American College of Obstetricians and Gynecologists, the American Medical Association, the American Medical Women’s Association, the American Nurses Association, the American Psychological Association, the American Public Health Association, the Christian Medical and Dental Associations, the Emergency Nurses Association, and the New York State Nurses Association. See HEAL Trafficking website. https://healtrafficking.org/. Accessed December 14, 2016.
- Stoklosa H, Grace AM, Littenberg N. Medical education on human trafficking. AMA J Ethics. 2015;17(10):914-921.
Titchen KE, Loo D, Berdan E, Rysavy MB, Ng JJ, Sharif I. Domestic sex trafficking of minors: medical student and physician awareness [published online ahead of print May 20, 2015]. J Pediatr Adolesc Gynecol. doi:10.1016/j.jpag.2015.05.006.
Todres J. Can mandatory reporting laws help child survivors of human trafficking? Wis L Rev Forward. 2016:69-78. http://wisconsinlawreview.org/wp-content/uploads/2016/04/Todres-Final.pdf. Accessed October 2, 2016.