Human trafficking is the trade of humans, most commonly for forced labor, sexual slavery, or commercial sexual exploitation for the trafficker or others. This may encompass providing a spouse in the context of forced marriage or the extraction of organs or tissues, including surrogacy and ova-removal. Human trafficking can occur within a country or trans-nationally. Human trafficking is a crime against the person because of the violation of the victim’s rights of movement through coercion and commercial exploitation. Human trafficking is the trade in people, especially women and children, and does not necessarily involve the movement of the person from one place to another. Dentists and dental hygienists should look for the subtle signs of victimization so they can offer the appropriate treatment, resources, and referrals.
According to the International Labor (ILO), forced labor alone (one component of human trafficking) generates an estimated $150 billion in profits per year.
Human trafficking is thought to be one of the fastest-growing activities of trans-national criminal organizations.
Human trafficking is condemned as a violation of human rights by international conventions. In addition, human trafficking is subject to a directive in the European Union.
TRAFFICKING PROTECTION ACTS
The Trafficking Victims Protection Act of 2000 (TVPA)
As a result of the 2000 Trafficking Victims Protection Act (TVPA), law enforcement was given the ability to protect international victims of human trafficking through several forms of immigration relief, including Continued Presence and the T visa. Continued Presence allows law enforcement officers to request temporary legal status in the U.S. for a foreign national whose presence is necessary for a human trafficking investigation’s continued success. The T visa allows foreign victims of human trafficking to become temporary U.S. residents, through which they may become eligible for permanent residency after three years. The TVPA also established a law requiring defendants of human trafficking investigations to pay restitution to the victims they exploited.
The Justice for /victims of Trafficking Act of 2015 ( JVTA)
The Justice for Victims of Trafficking Act (JVTA)of 2015 is a positive step forward in ensuring perpetrators of human trafficking are held accountable.
The JVTA includes important provisions that will enhance the capacity of the U.S. government to tackle human trafficking and will further empower survivors in the context of criminal proceedings, especially in the area of restitution. The bill codifies important provisions related to training for law enforcement personnel to identify and investigate human trafficking. The JTVA will also improve law enforcement reporting on the incidence of trafficking across the United States—an essential step for determining the scope of this crime and designing effective policies to tackle it.
The JVTA works to fight human trafficking by reducing demand for sex trafficking, providing more services for victims, depriving convicted offenders of criminal assets, and using forfeited assets to satisfy restitution orders for victims and giving law enforcement more and better tools to fight sex trafficking.
DEFINITION and TYPES
Sex trafficking affects 4.5 million people worldwide. Most victims find themselves in coercive or abusive situations from which escape is both difficult and dangerous.
Trafficking for sexual exploitation was formerly thought of as the organized movement of people, usually women, between countries and within countries for sex work using physical coercion, deception, and bondage through forced debt. However, the Trafficking Victims Protection Act of 2000 (US) does not require movement for the offense. The issue becomes contentious when the element of coercion is removed from the definition to incorporate consensual involvement in prostitution. For example, in the United Kingdom, the Sexual Offenses Act 2003 incorporated trafficking for sexual exploitation but did not require those committing the offense to use coercion, deception, or force so that it also includes any person who enters the UK to carry out sex work with consent as having been “trafficked.” In addition, any minor involved in a commercial sex act in the US while under the age of 18 qualifies as a trafficking victim, even if no force, fraud, or coercion is involved, under the definition of “Severe Forms of Trafficking in Persons” in the US Trafficking Victims Protection Act of 2000.
Sexual trafficking includes coercing a migrant into a sexual act as a condition of allowing or arranging the migration. Sexual trafficking uses physical or sexual coercion, deception, abuse of power, and bondage incurred through forced debt. Trafficked women and children, for instance, are often promised work in the domestic or service industry but instead are sometimes taken to brothels where they are required to undertake sex work while their passports and other identification papers are confiscated. They may be beaten or locked up and promised their freedom only after earning – through prostitution – their purchase price, as well as their travel and visa costs.
Labor trafficking is the movement of persons for forced labor and services. It may involve bonded labor, involuntary servitude, domestic servitude, and child labor. Labor trafficking happens most often within the domain of domestic work, agriculture, construction, manufacturing, entertainment, and migrant and indigenous people are especially at risk of becoming victims.
Trafficking for Organ Trade
Trafficking in organs is a form of human trafficking. In some cases, the victim is compelled to give up an organ. In other cases, the victim agrees to sell an organ in exchange for money/goods but is not paid (or paid less). Finally, the victim may have the organ removed without the victim’s knowledge (usually when the victim is treated for another medical problem/illness – real or orchestrated problem/illness). Migrant workers, homeless persons, and illiterate persons are particularly vulnerable to this form of exploitation. Trafficking of organs is organized crime involving several offenders:
- the recruiter
- the transporter
- the medical staff
- the middlemen/contractors
- the buyers
Trafficking for organ trade often seeks kidneys. Trafficking in organs is a lucrative trade because, in many countries, the waiting lists for patients who need transplants are very long.
Bonded Labor or Debt Bondage
Bonded labor or debt bondage is probably the least known form of labor trafficking today, yet it is the most widely used method of enslaving people. Victims become “bonded” when their labor, the labor they themselves hired, and the tangible goods they bought are demanded as a means of repayment for a loan or service in which its terms and conditions have not been defined or in which the value of the victims’ services is not applied toward the liquidation of the debt. Generally, the value of their work is greater than the original sum of money “borrowed.”
Forced labor is a situation in which victims are forced to work against their own will under the threat of violence or some other form of punishment; their freedom is restricted, and a degree of ownership is exerted. According to the International Labor Organization, men are at risk of being trafficked for unskilled work, which globally generates 31 billion USD. Forms of forced labor can include domestic servitude, agricultural labor, sweatshop factory labor, janitorial, food service, other service industry labor, and begging. Some of the products produced by forced labor are clothing, cocoa, bricks, coffee, cotton, and gold.
The International Organization for Migration (IOM), the single largest global provider of services to victims of trafficking, reports receiving an increasing number of cases in which victims were subjected to forced labor. A 2012 study observes that “… 2010 was particularly notable as the first year in which IOM assisted more victims of labor trafficking than those who had been trafficked for purposes of sexual exploitation.”
Child Labor is a form of work that may be hazardous to children’s physical, mental, spiritual, moral, or social development and can interfere with their education. According to the International Labor Organization, the global number of children involved in child labor has fallen during the past decade – it has declined by one-third.
Human exploitation is the unethical, selfish use of human beings to satisfy personal desires and/or profitable advantage. There are several areas where individuals are exploited, including the trafficking mentioned above and media exploitation, pornography, and bullying.
Media exploitation can involve the over-sexualized pictures in vogue and sites such as Facebook and Twitter to attack others. Media exploitation can also involve propaganda to persuade people’s attitudes, beliefs, and behaviors.
Exploitation infests the production of pornography. Exploitation also pervades the consumption of pornography. The production and promotion of pornography can very easily and usually do exploit the individuals involved.
Bullying on every level is a form of exploitation. The very definition of bullying is to use superior strength or influence to intimidate (someone), typically to force him or her to do what one wants.
Human trafficking differs from people smuggling, which involves a person voluntarily requesting or hiring another individual to covertly transport them across an international border, usually because the smuggled person would be denied entry into a country by legal channels. Though illegal, there may be no deception or coercion involved. After entry into the country and arrival at their ultimate destination, the smuggled person is usually free to find their own way.
According to the International Center for Migration Policy Development (ICMPD), people smuggling is a violation of national immigration laws of the destination country and does not require violations of the rights of the smuggled person. Human trafficking, on the other hand, is a crime against a person because of the violation of the victim’s rights through coercion and exploitation. Unlike most cases of people smuggling, victims of human trafficking are not permitted to leave upon arrival at their destination.
While smuggling requires travel, trafficking does not. Trafficked people are held against their will through acts of coercion and forced to work for or provide services to the trafficker or others. The work or services may include anything from bonded or forced labor to commercial sexual exploitation. The arrangement may be structured as a work contract, but with no or low payment, or on terms that are highly exploitative. Sometimes the arrangement is structured as debt bondage, with the victim not being permitted or able to pay off the debt.
Vulnerable groups at risk of becoming trafficked include migrant workers, migrant women, new immigrants, at-risk youth, and socially or economically disadvantaged. This latter group might include youth, teenage runaways, or those who may have been lured to urban centers or who have gone of their own free will with the hopes of bettering their lives. Recent convictions for human trafficking for the purpose of sexual exploitation demonstrate that Canadian girls and women are often victims.
HOW ARE VICTIMS RECRUITED AND CONTROLLED
Human traffickers use violent methods such as coercion, extortion, violence, including both physical and emotional abuse. Still, they also use subtle methods, such as blackmail or even seduction of the victim. They often establish direct contact with the person or members of his/her family through impersonation as a prospective employer or a love interest or through misleading ads that promise jobs and opportunities to earn money. It is not rare for victims to be recruited via the Internet.
Why don’t people who are affected by trafficking escape:
- The threat of violence against family
- Restrictions on freedom of movement: traffickers remove passport/identity documents
- Fear of authorities: trafficked person scared of being imprisoned or deported
- Debt bondage: trafficked person owes money to the trafficker or his/her family
- Isolation: the trafficked person does not know the language of the country or how to get around
- Emotional attachment: a trafficked person may have an emotional attachment to a trafficker (boyfriend or only person feeding them)
WHO ARE THE TRAFFICKERS
Traffickers can be lone individuals or part of extensive criminal networks. What they have in common is the desire to exploit people for profit. A wide range of criminals, including individual pimps, family operations, small businesses, loose-knit decentralized criminal networks, and international organized criminal operations, can be human traffickers. Based on human trafficking cases that the National Human Trafficking Resource Center has identified, examples of traffickers may include:
- Brothel and fake massage business owners and managers
- Employers of domestic servants
- Gangs and criminal networks
- Growers and crew leaders in agriculture
- Intimate partners/family members
- Labor brokers
- Factory owners and corporations
- Small business owners and managers
WARNING SIGNS OF HUMAN TRAFFICKING
- Physical and sexual violence signs of abuse, such as unexplained bruises, black eyes, cuts, or marks.
- Exhibit behaviors including fear, anxiety, depression, submission, tension, and/or nervousness.
- Exhibit “hyper-vigilance” or paranoid behavior.
- Sexually exploited children and youth often express interest in or are in relationships with adults or older men.
- It is evidence of controlling or dominating relationships, including repeated phone calls from a “boyfriend” and/or excessive concern about displeasing partner.
- Unexplained shopping trips or possession of expensive clothing, jewelry, or a cell phone could indicate the manipulation of an exploiter.
- Not in control of their own money.
- Use of lingo or slang from “the life” among peers, or referring to a boyfriend as “Daddy.”
- Secrecy about whereabouts.
- Unaccounted for time, vagueness concerning whereabouts, and/or defensiveness in response to questions or concerns.
- Keeping late-night or unusual hours.
- A tattoo that he or she is reluctant to explain may the result of tattooing or branding by a pimp. Pimps and other sexual exploiters often tattoo or brand children and youth, particularly girls. Youth are commonly branded with their exploiter’s name tattooed on the neck, chest, or arms.
- Wearing sexually provocative clothing can be an indicator of sexual exploitation. But it should be noted, so as not to rely on stereotypes, that not all children in the commercial sex industry wear such clothing. Sexually provocative clothing is not a warning sign in and of itself. Wearing new clothes of any style, or getting hair or nails done with no financial means to this independently, is a more general indicator of potential sexual exploitation.
- Most sexually exploited children have been trained to lie about their age. Sometimes a child’s appearance and/or actions can contradict the information they give. Be sensitive to clues in behavior or appearance that could indicate that a child is underage.
- Personal information such as age, name, and/or date of birth – might change with each telling of his or her story, or the information given might contradict itself.
- Has no identification or is not in control of his or her identification documents.
ASSESSING FOR HUMAN TRAFFICKING
The following was developed by the National Human Trafficking Resource Center and contains questions that can be used to assess a client for potential signs that they have been victims of human trafficking. The suggestions and indicators below are not exhaustive or cumulative in nature, and each question taken alone may not indicate a potential trafficking situation. Assessment questions should be tailored to your program and the client’s specific needs.
As with any assessment of a victim of crime, there are some general points to be aware of when evaluating a client’s needs. Listed below are general tips for conducting an assessment with a potential victim of trafficking.
The term “controller” is used generally to describe the potential trafficker or the person(s) who maintain(s) control over the potential victim(s).
Assessment Environment and Tone
- Conduct the assessment in a comfortable and safe environment. If you are in a police station or in a place where the physical space/conditions are limiting, attempt to create an environment that is as calming and positive as possible.
- Provide the individual with space when speaking with them.
- Be relaxed and use an approachable tone, demeanor, and body language. Ask yourself the question, “To what degree does my present posture communicate openness and availability to the client”?
- Use empathic listening. Empathic listening centers on being attentive, observing, and listening in order to understand the client’s situation without making judgments.
- While you engage in empathic and reflective listening, make sure you are maintaining good eye contact with the client. Good eye contact is another way of conveying, “I want to hear what you have to say.”
- If at all possible, try not to take notes and instead engage in active listening and write your notes immediately following the meeting with the client. If note-taking is necessary, let the individual know why you need to write notes and what purposes they may use.
- Be clear about your role and goals and about the services that your agency can and cannot provide.
- Explain why you care about the individual’s situation and that you have worked with and assisted other individuals in situations that may be similar to his/her own. Explaining who you are and why you are there is particularly important to correct your role’s misperceptions.
Assessment Language and Questions
- When appropriate, attempt to engage in casual conversation about lighter topics and ask questions to try to get the individual to open up, even if it’s not about their trafficking situation or service needs.
- Although the client might be confused, scared, and/or distracted, engaging in casual conversation before the assessment helps to build trust and set the tone for effective, non-defensive communication.
- In your initial assessment, try to focus predominantly on assessments of their service needs but weave in other questions naturally and when appropriate.
- It is often useful to start with questions that ascertain the lesser degrees of control before moving onto the more severe methods of control.
Example: Inquiring about living or working conditions may be an easier topic to tackle initially than directly inquiring about physical or sexual abuse that the victim may have sustained.
- Be conscious of the language that you use when speaking with a potential victim of trafficking. Mirroring the language that the potential victim uses can be a helpful first step.
Example: If the potential victim refers to her controller as her boyfriend, referring to that person as a “pimp” or a “sex trafficker” may have a negative impact. Although these are terms that can be used for controllers in the commercial sex industry, the potential victim may not identify this person in this way.
- The phrasing of all questions included in this assessment should be changed, amended, or revised to fit the client and context you are in.
- It is also important to conduct assessments in a potential victim’s native language whenever possible.
- Use trained interpreters sensitive to the nature of the crime and who is not in any way tied to the potential victim or the potential trafficker’s community of origin.
- Ensure that the interpreter is introduced and their role is fully explained.
Important Dynamics For Your Assessment
- Keep in mind that many victims do not self-identify as “human trafficking victims” due to a lack of knowledge about the crime itself and the power and control dynamics typically involved in human trafficking situations.
- Be conscious of the fact that their trafficker has typically conditioned an individual in a trafficking situation not to trust law enforcement and/or service providers.
- Be aware of power dynamics when a third party is accompanying or interpreting for a potential victim. Try to speak to the potential victim alone or secure an outside interpreter.
- Be aware that canned stories are common and that the true story may not emerge until trust has been built with the potential victim after multiple meetings.
- Each client is going to tell his/her story differently, and no client will present all of the elements of their trafficking situation in a neat package.
- It is imperative that the assessor remain flexible and prioritize the client’s needs and safety as the primary reason for the assessment.
Be sure to conduct a safety check if the individual has recently exited the situation or if they are still in the situation.
- Is it safe for you to talk with me right now? How safe do you feel right now? Are there times when you don’t feel safe?
- Do you feel like you are in any kind of danger while speaking with me at this location?
- Is there anything that would help you to feel safer while we talk?
If speaking with the individual over the phone:
- Are you in a safe place? Can you tell me where you are?
- Are you injured? Would you like for me to call 911/an ambulance?
- If someone comes on the line, what would you like for me to do? Hang up? Identify me as someone else, a certain company/person/friend?
- Also, remind the individual to feel free to hang up at any point during the conversation if they believe that someone may be listening in.
- How can we communicate if we get disconnected? Would I be able to call you back/leave a message?
- Would you prefer to call me back when you are in a safe place?
General Trafficking Assessment Questions
The following questions could be applicable to both situations of sex and labor trafficking. Please note that the order listed is not intended to indicate the order in which the questions should be asked. The type and order of questions should be tailored to a given situation and should be amended to react effectively and supportively to the client.
- How did you meet this person/find out about your job?
- What were you told about the job before you started/what promises were made about the relationship?
- Did your experience meet your expectations?
- Do you feel you were ever deceived about anything related to your job/your relationship?
- Did anything surprise you about this job/relationship?
- Did the conditions of your job/relationship change over time?
- Did you feel like you understand your rights in this job/situation?
Domestic Servitude Questions
- Did you have days off? Were you able to leave the house on your days off? Were you ever expected to complete work on your days off (still provide childcare, complete household chores before leaving, etc.)?
- Were you ever able to leave home to run errands, transport children to school, or go to church? Were you monitored or timed when you left home for these things?
- Did you have your own room in the home? Where did you sleep?
- Did you have consistent access to food? Were you ever made to go without food?
- Did you have access to medical care while you lived in the home?
- What were your tasks in the home (childcare, cleaning, cooking, etc.)? How many hours did you work during the day or night?
- Were you allowed to communicate with your family/friends while you lived in the home?
- Are you afraid that your controller might harm your family back in your hometown?
- Did the controller ever force you to engage in sexual acts against your will at any time they requested it? What did you think would happen if you refused to do this?
- Did your partner/family member ever ask you to engage in commercial sex acts in order to “help the relationship/the family”?
- Did your partner/family member ever force you to engage in commercial sexual acts with friends or business associates for favors/money?
- Did your partner/family member ever force you to engage in commercial sex through online sites, escort services, street prostitution, strip clubs, truck stops, fake massage businesses, or residential brothels?
- Did your partner/family member ever threaten you or abuse you if you indicated that you did not want to engage in commercial sex or did not do what this person asked of you?
- Did your partner/family member ever withhold financial support or restrict access to your children?
Dental Hygienist and Dentist’s Role
Victims may present for dental services as a result of restricted access to dental hygiene products or deleterious effects on oral health from sex or labor work, as well as for cosmetic purposes. Additionally, a sex trafficker’s interest in seeking cosmetic dental services would most likely stem from a desire to make the victim more attractive to clients. Thus, the responsibility of identification relies on the provider’s ability to recognize the sometimes subtle signs of victimization and follow up with focused questions to assess immediate treatment and referral needs. That said, oral health professionals’ role in assisting victims of human trafficking has not been extensively discussed in the literature. In some cases, dentists and dental hygienists may be the first responders in rendering care to trafficked individuals. A survey of U.S.-based survivors of human trafficking shows that while being trafficked, 26.5% were seen by a dentist, along with other health care providers, but these clinicians identified few victims.
Signs of abuse or other indicators of human trafficking warrant follow-up and a one-on-one conversation without the presence of the victim’s attendant. The online version of this article provides examples of questions that can be used to assess whether a patient has been a victim of human trafficking; while this is neither an exhaustive nor cumulative list, it may prove helpful in the assessment process.
In recognition of the suspected frequency with which (as yet unidentified) trafficking victims are being seen in health care facilities, efforts to educate clinicians about human trafficking have increased in the last 10 years. At the same time, documentation of the health consequences and risks of human trafficking is improving, as is science’s understanding of the gaps in health care providers’ knowledge about this growing problem. Dentists, mental health workers, emergency room professionals, gynecologists or other specialty physicians, nurses, and midwives would benefit from training designed to increase recognition of trafficking victims so an interdisciplinary response can be initiated.
- Unmet health and dental care needs
- Appears malnourished and dehydrated
- Branding and tattooing
- Signs of abuse
- Few personal belongings
- Fearful, withdrawn, nervous
HOW TO REPORT HUMAN TRAFFICKING
Human trafficking is abuse, so the rules for mandatory reporting are the same for human trafficking. If the division of quality medical assurance licenses you, you need to report suspected trafficking. The need doesn’t end there, though. Everyone has a role to play in combating human trafficking.
If you suspect or know of human trafficking activity, please contact your local police, the National Human Trafficking Resource Center at 1-800-96-ABUSE, or Homeland Security at 802-872-6199.
Do not attempt to confront a suspected trafficker directly or alert a victim to your suspicions. Your safety, as well as the victim’s safety, is paramount.
You can also submit a tip at www.ice.gov/tips. Highly trained specialists take reports from both the public and law enforcement agencies on more than 400 laws enforced by ICE HSI, including those related to human trafficking.
By identifying victims and reporting tips, you are doing your part to help law enforcement rescue victims, and you might save a life. Law enforcement can connect victims to services such as medical and mental health care, shelter, job training, and legal assistance that restore their freedom and dignity. The presence or absence of any of the indicators is not necessarily proof of human trafficking. It is up to law enforcement to investigate suspected cases of human trafficking.
NEEDS and MENTAL HEALTH ISSUES ASSOCIATED WITH TRAFFICKING AND EXPLOITATION
Once emergency needs are met (safety, food, and clothing), other needs that present themselves in the short- and long-term are housing (transitional and permanent for adults, and foster care or permanent placement for minors), legal assistance (e.g., help in understanding legal rights, legal representation and, for international victims, assistance with filing T-visa applications, and immigration petitions), and advocacy (e.g., assistance retrieving identification documents, completing applications, attending appointments, and navigating the different systems, including criminal justice, child welfare, immigration, human services, transportation, etc.).
Most victims also need health screening (tuberculosis, sexually transmitted diseases, pregnancy), vaccinations/immunizations, medical treatment for physical injuries, and dental care. Other service needs include child care (for both adults and minors with children), education (GED assistance, enrollment in school, technical training/certification), life skills training (including assisting some international victims with the operation of basic household appliances, using public transportation, using a telephone, mailing a letter, etc.), job training, finding employment, financial management, and where appropriate, family reunification or repatriation.
A number of studies have identified the serious and often complex mental health needs of victims of human trafficking. The majority of research related to this population’s mental health needs focuses on the significant levels of post-traumatic stress disorder (PTSD). Victims of human trafficking have often experienced, witnessed, or been confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, and their response to these events frequently involves intense fear, helplessness, or horror. This exposure and common reaction are two of the main criteria for PTSD. While there is some evidence that preexisting conditions related to social supports, history, childhood experiences, personality variables, and preexisting medical disorders can factor in the diagnosis of PTSD, exposure to trauma is the most important feature in the development of PTSD.
In addition to PTSD, victims of human trafficking have been found to suffer from other anxiety and mood disorders, including panic attacks, obsessive-compulsive disorder, generalized anxiety disorder, and major depressive disorder.
Substance-related disorders are often found to be co-morbid in victims of human trafficking. While a few victims of trafficking reported prior substance addictions, the majority of victims who reported alcohol and drug use said they began using after they were in their trafficking situations. Some victims reported using alcohol and drugs to help them deal with their situations; however, others reported being forced or coerced to use drugs or alcohol by the traffickers.
While victims of human trafficking can suffer from a range of mental health problems, the most prominent and those for which there is significant research documenting their presentation tend to be anxiety disorders, mood disorders, dissociative disorders, and substance-related disorders.
Treatment for trauma is a crucial part of a victim’s recovery. In trauma-informed care, treatment is guided by practitioners’ understanding of trauma and trauma-related issues that can present themselves in victims.
While there are numerous therapy approaches, the purpose of all trauma-focused therapy is to integrate the traumatic event into the person’s life, not subtract it. Many therapists combine different types of therapies. As a dental professional, your role is to recognize the signs and have the knowledge to be able to report potential trafficking.
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