Human trafficking is a form of traumatic stress, and a public health issue, that has been gaining increasing attention over the past two decades. Forced labor and commercial sexual exploitation are two of the most common forms of human trafficking. Central to the trauma of human trafficking are the elements of force, fraud and coercion, including intense psychological and emotional manipulation (Baldwin, Fehrenbacher, & Eisenman, 2015; Hopper & Hidalgo, 2006).
Funding for trafficking-related education, outreach and comprehensive services has led to greater public awareness, improved identification of children and adults who have experienced trafficking, and increased availability of services for this population. In 2019 alone, more than 22,000 potentially trafficked persons were reported to the National Human Trafficking Hotline (Polaris Project, 2020), and rates of reporting are increasing every year. However, more work remains to be done to improve health care’s response to human trafficking.
Although physical and social isolation are common experiences for people who have been trafficked, research has shown that the majority of identified trafficked individuals come into contact with health or behavioral health practitioners during the course of their exploitation (Chisolm-Straker et al., 2016). Individuals at risk of, currently experiencing or with a history of trafficking may encounter a range of health professionals, including substance use counselors, therapists, school counselors, emergency department staff, primary care physicians and nurses, specialists (e.g. gynecologists, intensive care staff), dental practitioners and community health providers. Health and behavioral health practitioners can be “first responders” who have a unique opportunity for identification of, and early intervention with, trafficked persons. Because many individuals experiencing labor and/or sex trafficking do not self-identify, health care providers must be aware of factors that increase the risk of exploitation, approaches to discussing experiences of violence, and resources to assist at-risk individuals (Powell, Dickins, & Stoklosa, 2017).
An effective health and behavioral health care response continues beyond the stage of initial identification and connection to resources. For many survivors, trafficking is associated with long-term physical and psychological consequences. In addition to injuries, gynecological conditions and long-term chronic physical health implications, many people who have experienced labor and/or sex trafficking suffer from depression, anxiety, posttraumatic stress disorder and/or complex trauma symptoms (Hopper, 2016; Hopper & Gonzalez, 2018; Ottisova, Hemmings, Howard, Zimmerman, & Oram, 2016; Ottisova, Smith, & Oram, 2018). Substance use can be a means of coping with the abuse endured during trafficking and is itself a risk factor for further victimization (Hopper, 2017). Complex comorbidities, including co-occurring physical health, mental health and substance use disorders, create challenges in identification and access to services for those who have experienced trafficking (Stoklosa, MacGibbon, & Stoklosa, 2017). Social determinants of health such as poverty, unequal access to health care, lack of education, stigma and racism create additional health care disparities (CDC, 2020). Thus, despite increasing identification, many people who have experienced trafficking continue to fall through the cracks of systems that are not adequately prepared to offer comprehensive, trauma-informed services to meet their unique needs (Powell et al, 2018).
Little is known about health professionals’ experiences of identifying and providing care for people at risk of, or who have experienced, exploitation. Qualitative research suggests that many health and behavioral health practitioners feel under-trained and under-supported by their organizations regarding anti-trafficking work (Kliner & Stroud, 2012). A survey of healthcare providers found that practitioners lacked knowledge and confidence regarding anti-trafficking work, including a lack of knowledge of how to ask about experiences of trafficking, a lack of sufficient training in how to assist people who have been trafficked, and a lack of confidence in making appropriate referrals (Ross, Dimitrova, Howard, Dewey, Zimmerman, & Oram, 2015). Even when training sessions are provided, trafficking-related knowledge deteriorates over time if education is not ongoing; further, education focused solely on knowledge and attitude change, rather than implementation of skills, does not necessarily translate into behavioral change for health care providers (Nordstrom, 2020).
This early research reflects the lack of a systematic approach within health care to pinpoint knowledge and skill sets required by health care providers in order to effectively identify, respond to and serve individuals who have experienced trafficking and those at risk of exploitation. In order to improve outcomes for these populations, health and behavioral health systems must receive appropriate education and training, empowering them to create effective, evidence-based, trauma-informed approaches to labor and sex trafficking.
In response to this need, the U.S. Department of Health and Human Services brought together a group of expert health and behavioral health professionals from across the U.S. to identify core competencies required within the medical and behavioral health sector responses to human trafficking. The interdisciplinary committee—representing general practitioners and pediatricians, behavioral health clinicians, nurses and nurse practitioners, psychiatrists, emergency room physicians, child abuse physicians, researchers, educators and administrators—along with contributions from experts with lived experience, created a resource entitled “Core Competencies for Human Trafficking Response in the Health Care and Behavioral Health Systems,” which can be used to both create standards of care across health care networks and ensure that health and behavioral health providers are trained in the necessary skills to care for this population. This tool provides a framework to build culturally responsive, survivor- and trauma-informed health care responses for adults and children who have experienced labor and/or sex trafficking. The guide is designed to assist individual health and behavioral health practitioners, as well as larger organizational systems, in effectively reaching those who are at risk of or who have experienced trafficking.
A trauma-informed, survivor-informed and culturally responsive approach was identified as a universal competency that provides an essential groundwork for all patient or client interactions, research, educational programs and programmatic initiatives. This type of approach recognizes the likely trauma exposure for individuals who have experienced trafficking and prioritizes patient or client safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice and choice; and cultural, historical and gender issues (Substance Abuse and Mental Health Services Administration, 2014). It is based on fundamental human rights, including those for privacy and confidentiality, access to information, for respect and dignity, and for care that is free of bias and discrimination (United Nations Human Rights, & Office of the High Commissioner for Human Rights, 1990). Input from experts and researchers with lived experience should inform all policies and practices in health and behavioral health care settings (Miller et al., 2020). A culturally responsive health care environment recognizes the wide variability of needs among clients or patients, adopting an approach of constant learning about culture and diversity and utilizing this learning to meet clients or patients “where they are.”
Beyond this universal competency, six core competencies were identified by the committee, including:
- Understanding the nature, epidemiology and social determinants of labor and sex trafficking
- Identifying and evaluating the risk of trafficking, including understanding indicators of trafficking and conducting evidence-informed assessment of risk
- Evaluating the needs of individuals who have been trafficked or who are at risk of trafficking
- Providing patient-centered, resiliency-focused care
- Applying relevant legal and ethical standards
- Integrating trafficking prevention strategies into clinical practice and systems of care
These evidence-informed core competencies emerge from a public health approach, which improves the health of communities by understanding and responding to the root causes of human trafficking and other forms of violence. The principles apply to individuals with a known history of labor and/or sex trafficking exposure, as well as individuals who demonstrate risk factors, with the ultimate goal of preventing human trafficking.
Core competencies were developed for four separate but overlapping groups: individual health care providers, health care organizations, scholars engaged in research on trafficking, and educators of health care providers. If health care systems, practitioners, researchers and educators incorporate standardized evidence-based principles into their anti-trafficking work, persons experiencing trafficking and those at risk are more likely to be identified and offered access to services. Health and behavioral health care may be improved and integrated, decreasing the likelihood of revictimization.
Because of the central role of trauma-informed care as a universal competency in this work, clinicians and researchers who specialize in traumatic stress are needed to support implementation of trauma-informed care for adults and children who have experienced human trafficking. Members of ISTSS are encouraged to use this tool to explore a potential role in contributing to trauma-informed research, education, and direct health and behavioral health services for people who are at risk of, or who have experienced, sex and/or labor trafficking.
To access the full report and associated documents, please visit the National Human Trafficking Training and Technical Assistance Center.
About the Authors
Elizabeth Hopper, PhD, is a licensed clinical psychologist with a specialization in traumatic stress. Dr. Hopper has been engaged in anti-trafficking work for close to two decades. She currently oversees the New England Coalition Against Trafficking (NECAT), a regional network of cross-discipline professionals engaged in anti-trafficking work, and directed a national mental health services program for trafficking survivors in the U.S. Dr. Hopper co-chairs the Mental Health Council for HEAL Trafficking, a national network of health and public health professionals engaged in anti-trafficking work. She is a consultant for the National Human Trafficking Training and Technical Assistance Center and the Office for Victims of Crime Training and Technical Assistance Center. Dr. Hopper is also currently Project Director of the Metropolitan Boston Complex Trauma Treatment Initiative (MB-CTTI), a mobile service network delivering evidence-based trauma interventions to high-risk and underserved complex trauma-exposed children and youth ages 0-21 living in the Metropolitan Boston region. Dr. Hopper is the co-author of two books that address body-oriented intervention for trauma and has written numerous scholarly articles and book chapters on complex trauma, trauma-informed care, homelessness and human trafficking. She has particular interests in the development of trauma-informed care systems and in integrative treatment models for traumatic stress.
Jordan Greenbaum, MD, is a child abuse physician in Atlanta, Georgia. She has worked in the field of child maltreatment for over 20 years. She is the medical director of the International Centre for Missing and Exploited Children and manages the Institute on Healthcare and Human Trafficking at the Stephanie Blank Center for Safe and Healthy Children at Children’s Healthcare of Atlanta. She co-chairs the Education/Training committee for HEAL Trafficking, an organization of medical professionals working on human trafficking issues.
Rachel Robitz, MD, completed residency in combined family medicine and psychiatry and a fellowship in community psychiatry at University of California San Diego. She is currently the Training Director for UC Davis’ Family Medicine/Psychiatry residency. Clinically she works as a primary care physician at Sacramento County Health Center and as the assistant medical director of Sacramento County Mental Health Urgent Care. She previously worked as psychiatrist for a program for homeless youth and for multiple programs for adult and youth victims of human trafficking. She is the co-chair for HEAL Trafficking's Direct Service Committee.
Hanni Stoklosa, MD, MPH, is the founding executive director of HEAL Trafficking, an emergency physician at Brigham and Women's Hospital (BWH) with appointments at Harvard Medical School and the Harvard Humanitarian Initiative. Dr. Stoklosa is an internationally recognized expert, advocate, researcher and speaker on the wellbeing of trafficking survivors in the U.S. and internationally through a public health lens. She has advised the United Nations, International Organization for Migration, U.S. Department of Health and Human Services, U.S. Department of Labor, U.S. Department of State and the National Academy of Medicine on issues of human trafficking and testified as an expert witness multiple times before the U.S. Congress. Moreover, she has conducted research on trafficking and persons facing the most significant social, economic and health challenges in a diversity of settings including Australia, China, Egypt, Guatemala, India, Liberia, Nepal, Kazakhstan, the Philippines, South Sudan, Taiwan and Thailand. Among other accolades, Dr. Stoklosa has been honored with the U.S. Department of Health and Human Services Office of Women's Health Emerging Leader award, the Harvard Medical School Dean's Faculty Community Service award and has been named as an Aspen Health Innovator and National Academy of Medicine Emerging Leader. Her anti-trafficking work has been featured by the New York Times, National Public Radio, Fortune, Glamour, Canadian Broadcasting Corporation, STAT News and Marketplace. Dr. Stoklosa published the first textbook addressing the public health response to trafficking, Human Trafficking Is a Public Health Issue, A Paradigm Expansion in the United States.
Jessica L. Peck, DNP, APRN, is an expert pediatric nurse practitioner and anti-trafficking advocate who provides innovative and award-winning leadership to develop and lead inclusive and diverse interprofessional teams to provide outcomes of high-quality health care. Dr. Peck served as founding chair of the Alliance for Children in Trafficking, a national campaign of the National Association of Pediatric Nurse Practitioners Partners for Vulnerable Youth, where she worked with national partners to equip health care professionals to respond to human trafficking of children and advocate for other vulnerable youth populations. She serves as the lead medical consultant for Unbound Houston and helped create and pass legislation mandating trafficking continuing education for all direct care providers in Texas. Dr. Peck is currently president of the National Association of Pediatric Nurse Practitioners and professor of nursing at Baylor University in Dallas, Texas. She holds active credentials as a Pediatric Nurse Practitioner, a Nurse Educator and a Clinical Nurse Leader.
References
Baldwin, S.B., Fehrenbacher, A.E., & Eisenman, D.P. (2015). Psychological coercion in human trafficking: an application of Biderman’s framework. Qualitative Health Research, 25(9), 1171-1181.
Centers for Disease Control and Prevention. (n.d.). Social determinants of health: Know what affects health. https://www.cdc.gov/socialdeterminants/index.htm
Chisolm-Straker, M., Baldwin, S., Gaïgbé-Togbé, B., Ndukwe, N., Johnson, P. N., & Richardson, L. D. (2016). Health care and human trafficking: we are seeing the unseen. Journal of Health Care for the Poor and Underserved, 27(3), 1220-1233.
Hopper, E.K. & Hidalgo, J. (2006). Invisible chains: Psychological coercion of human trafficking victims. Intercultural Human Rights Law Review, 1, 185-209.
Hopper, E.K. (2016). Polyvictimization and developmental trauma adaptations in sex trafficked youth. Journal of Child and Adolescent Trauma, 10, 161-173. doi.org/10.1007/s40653-016-0114-z
Hopper, E.K. (2017). Trauma-informed treatment of substance use disorders in trafficking survivors. In Chisolm-Straker, M & Stoklosa, H. (Eds). Human Trafficking is a Public Health Issue: A Paradigm Expansion in the United States. Springer International Publishing.
Hopper, E.K. & Gonzalez, L.D. (2018). A comparison of psychological symptoms in survivors of sex and labor trafficking. Behavioral Medicine, 44, 1-31. doi:10.1080/08964289.2018.1432551.
Kliner, M & Stroud, L. (2012). Psychological and health impact of working with victims of sex trafficking. Journal of Occupational Health, 54(1), 9–15.
Miller, C. L., Chisolm-Straker, M., Duke, G., & Stoklosa, H. (2020). A framework for the development of healthcare provider education programs on human trafficking part three: recommendations. Journal of human trafficking, 6(4), 425-434.
Nordstrom, B.M. (2020) Multidisciplinary human trafficking education: Inpatient and outpatient healthcare settings, Journal of Human Trafficking, DOI: 10.1080/23322705.2020.1775049
Ottisova, L., Hemmings, S., Howard, L.M., Zimmerman, C, & Oram S. (2016). Prevalence and risk of violence and the mental, physical and sexual health problems associated with human trafficking: An updated systematic review. Epidemiology and Psychiatric Sciences, 25(4), 317-341. doi:10.1017/S2045796016000135.
Ottisova L, Smith P, & Oram S. (2018). Psychological consequences of human trafficking: Complex posttraumatic stress disorder in trafficked children. Behavioral Medicine, 44(3), 234-241.
Polaris Project (2020, July 30). 2019 U.S. national human trafficking hotline statistics. https://polarisproject.org/2019-us-national-human-trafficking-hotline-statistics/
Powell, C., Asbill, M., Louis, E., & Stoklosa, H. (2018). Identifying gaps in human trafficking mental health service provision. Journal of Human Trafficking, 4(3), 256-269.
Powell, C., Dickins, K., & Stoklosa, H. (2017). Training US health care professionals on human trafficking: where do we go from here? Medical Education Online, 22(1), 1267980.
Ross, C., Dimitrova, S., Howard, L.M., Dewey, M., Zimmerman, C., Oram, S. (2015). Human trafficking and health: a cross-sectional survey of NHS professionals’ contact with victims of human trafficking. BJM, 5(8), 1-7. doi:10.1136/bmjopen-2015-008682
Stoklosa, H., MacGibbon, M. & Stoklosa, J. (2017). Human trafficking, mental illness, and addiction: Avoiding diagnostic overshadowing. AMA Journal of Ethics, 19(1), 23-34. http://nrs.harvard.edu/urn-3:HUL.InstRepos:34638828
Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS Publication No. (SMA) 14-4884. https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf
United Nations Human Rights, & Office of the High Commissioner for Human Rights. (1990). Convention on the rights of the child. http://www.ohchr.org/EN/ProfessionalInterest/Pages/CRC.aspx