Economic exploitation: debt bondage, deceptive accounting. Legal insecurity: forced illegal activities, confiscation of documents. Occupational hazards: dangerous working conditions, poor training or equipment, exposure to chemicals, bacterial or physical dangers. Marginalization: structural and social barriers, including isolation, discrimination, linguistic and cultural barriers, difficult logistics.
Insufficient food or liquid, climate control, poor hygiene, risk-taking to repay debts, insufficient funds to pay for care. Restriction from or hesitancy to access services, resulting in deterioration of health and exacerbation of conditions. Dehydration, physical injury, bacterial infections, heat or cold overexposure, cut or amputated limbs.
Unattended injuries or infections, debilitating conditions, psychosocial health problems.
Note . Adapted from Zimmerman, C., Hossain, M., & Watts, C. (2011). Human trafficking and health: A conceptual model to inform policy, intervention and research. Social Science and Medicine , 73(2), 327-335. Isolation include preventing the trafficked person(s) from sleeping and eating.
People who are cut off from their social support networks or who have only weak support systems are less resistant to being exploited (Baldwin et al., 2014). Often, traffickers can achieve this type of isolation by transporting the person away from friends and family and cutting off communications and normal networks. (Zimmerman et al., 2011). Those who remain in their original residence may still experience extreme control in all of their social interactions. Monopolization of perception Traffickers typically limit the amount of information that trafficked individuals can access to ensure that the traffickers are the primary focus of attention; this allows the traffickers to mold the trafficked individuals’ thoughts based on their personal needs and wants (Baldwin et al., 2014). This manipulation, combined with restricted communications, makes it possible to control the person’s perspective, which enforces compliance and decreases resistance. Induced debility and exhaustion Trafficked persons are often pushed to the brink of their physical limits in an attempt to make them more malleable to the trafficker’s demands. By enforcing strict demands while depriving the person of basic needs, such as food, water, and health care, traffickers ensure that the trafficked person is too weak to flee or fight (Baldwin et al., 2014). Common exhaustion methods
Traffickers also dehumanize and degrade trafficked persons (Baldwin et al., 2014). This degradation is commonly evident in the lack of medical care trafficked persons receive. Health concerns further weaken the trafficked individual. Demonstrations of omnipresence Traffickers create a sense of always watching those they are trafficking. This often is achieved by involving other people in the trafficking operation or using other trafficked individuals as informants. Trafficked persons may be given cell phones as an indulgence, but these may contain tracking devices that alert the trafficker to the person’s movements and conversations (Baldwin et al., 2014). In other cases, traffickers may simply call those who are allowed to roam frequently as a means of monitoring their actions and movements. In healthcare settings, another person who poses as the patient’s friend or relative may accompany the trafficked person. The companion to the patient is sent to reinforce the trafficker’s omnipresence, serving as a minder. The minder (companion) will insist on staying with the patient throughout the clinical encounter (Baldwin et al., 2014). The minder is actively a part of the trafficking system and may report to the trafficker or may even be the trafficker.
CLINICAL SIGNS AND SCREENING TOOLS
Individuals who are trafficked are exposed to various health risks, including occupational exposures and physical, sexual, psychological, and social trauma (IOM, 2009; Zimmerman et al., 2011). Health conditions such as mental health disorders, including depression and anxiety, and substance use disorders may persist even after successfully escaping trafficking (IOM, 2009). Potential trafficked patients may present with one telling symptom or multiple comorbidities. Recognizing these Signs and symptoms of trafficking Many maladies can be attributed to the effects of trafficking, and some are more common than others depending on the type of trafficking. Note that some of the signs of trafficking are not unique to trafficking. For example, there may be overlap in cases of intimate partner violence. Regardless, further screening is warranted to help identify patients who may be victims of trafficking or other violent crimes (IOM, 2009). Psychological Trafficked persons often experience posttraumatic stress disorder (PTSD), depression, suicidal ideation, drug addiction, and associated symptoms as a result of psychological violence (Dovydaitis, 2010). Lederer and Wetzel (2014) reported that 54.7% of 106 trafficked individuals reported experiencing PTSD during trafficking; 88.7%, depression; and 41.5%, attempted suicide. According to Lederer and Wetzel (2014), substance abuse was frequently used by trafficked individuals to mentally
clinical symptoms and diagnoses as cues can lead to better identification of trafficked individuals. Clinicians can use social history and contextual cues when identifying trafficked persons. The healthcare professional needs to draw connections between the methods and patterns of trafficking and the health consequences (Table 1).
escape the trafficking and also was used by the trafficker to exert control. Many psychological symptoms that trafficking patients present with are a direct result of the manipulative measures their traffickers use, such as the Biderman’s framework (discussed in Table 1; Baldwin et al., 2014). One study found that restricted freedom is both a core factor of human trafficking and a large risk factor for poor mental health (Kiss et al., 2015). The authors reported that trafficked persons who were severely restricted in their activities were two times as likely to have symptoms of PTSD, anxiety, and depression compared with trafficked individuals with fewer restrictions. Psychological coercion methods affect the mental health of patients as well. Shame, guilt, poor self-esteem, and fear for family members (based on threats by traffickers) create complex psychological stress that affects trafficked individuals negatively and can feed into the cycle of victimization and traumatization
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