Human trafficking is a global health crisis with victims identified in every region of the world.1 The eradication of human trafficking and forced labor are included in the Sustainable Development Goals for 2030.2
The United Nations defines “trafficking in persons” as:
The recruitment, transportation, transfer, harboring or receipt of persons by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability, or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person for the purpose of exploitation. Exploitation shall include at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude or the removal of organs.
Trafficking could be described using the three essential elements, Act-Means-Purpose as depicted in Figure 1. When children younger than age 18 years are involved, “means” becomes irrelevant (one does not need to show force, fraud, coercion, etc.) as a child cannot legally consent to exploitation. In addition, adults may be considered trafficking victims once force, fraud, or coercion are introduced, regardless of previous consent to work. Human trafficking may include, but does not require, movement of victims. It may be domestic (involve persons victimized in their own country) or transnational (persons brought across national borders).
The elements of human trafficking (act, means, and purpose).
The International Labour Organization3 includes labor trafficking in its definition of the worst forms of child labor. For the purposes of this article, we primarily use the term “worst forms of child labor” as it encompasses trafficking, hazardous labor, and other forms of exploitation.3
Vulnerability Factors for Child Trafficking
Trafficking affects people of every age, gender, race, and immigration status. However, similar to all crimes based on exploitation, it especially targets the most vulnerable, making children in general at high risk of victimization.1 Traffickers can be foreign nationals or US citizens, men and women, family members, intimate partners, acquaintances, and strangers. They are usually from the same ethnic background as the victim.1 Many factors increase a child's vulnerability to being trafficked. These may be understood in the context of a social-ecological model of risk,4 whereby vulnerability factors may be identified at the individual, relationship, community, and societal levels (Table 1). One particularly high-risk group is homeless youth and those with a history of running away from home who may become victims of “survival” sex (ie, sexual acts in exchange for shelter, food, or money).5 The presence of multiple risk factors may markedly increase the risk of exploitation and trafficking. Immigrant children are at particularly high risk of exploitation, trafficking, and the worst forms of child labor.
Vulnerabilities to Child Trafficking
In the United States, forced labor exploitation of immigrant children is under-recognized, but when identified, involves a wide variety of occupational sectors and activities.6 These include, but are not limited to, various forms of sex trafficking, forced illicit activities (often involving drug trade),6 and travelling sales crews.7 It also involves work in the massage, health, and beauty industry (eg, nail salons, hair-braiding), domestic work, work in cantinas, bars, and strip clubs (labor and sex trafficking), work in restaurants and food service, peddling and begging, work in agriculture and animal husbandry, factory work, work in commercial cleaning, and construction work.6,8
Health Impact and Presentation
Children may exhibit physical and psychological health effects due to long working hours with few or no breaks, poor nutrition, physical and sexual violence, emotional abuse, exposure to harsh climate conditions, social isolation, as well as unsafe and unsanitary working and living conditions.3 Potential health consequences of hazardous child labor vary according to the occupational sector and activity involved. Although some forms of hazardous labor are characterized by unique health impacts, most types are associated with one or more of the following: exhaustion, chronic pain, malnutrition, infections (including sexually transmitted infections), traumatic injury from accidents or assault, scarring and decreased function from prior injury, untreated chronic medical conditions, exposure to toxins, dust, pollutants or other irritants, depression, signs or symptoms of posttraumatic stress disorder, and anxiety.3,9 Children who are victims of sex trafficking seek medical care for a variety of problems, including sexual assault, physical injury, infection, exacerbations of chronic conditions, complications of substance abuse/overdose issues, or pregnancy testing, contraceptive care, and other reproductive issues.10
Some trafficked persons have access to medical facilities for routine testing for sexually transmitted infections (STIs), reproductive health care, and general health care, but others have limited or no access, seeking care only when their conditions are severe. In one US study, child victims of domestic sex trafficking had frequent contact with medical providers, with 81% seen in the year before referral for sex trafficking. 11 Children had medical problems (eg, 32% had sexually transmitted infections) and psychiatric needs (eg, acute suicidality in 20%). Almost one-half (46%) reported at least one previous psychiatric admission, and most (88%) reported substance use. Of note, more than one-half (63%) had a history of running away, but 71% of children presented with a parent/guardian or relative.11
Other children who have been exploited may face numerous barriers to accessing health care.12–15 Distances between work site and health facility may be far and transportation unavailable, unreliable, or costly. Trafficked children may lack knowledge of available resources and may resist taking time to seek care at the expense of making money (eg, a laborer is paid by unit of production, and a sex trafficked child must earn a “quota”). These children may avoid medical care in fear of arrest and/or deportation, or due to lack of money to pay for treatment. Language and cultural barriers may be prohibitive, and traffickers may actively prevent victims from seeking health care.12
Because many victims do not self-identify, the medical provider must be aware of certain potential indicators suggesting the possibility of human trafficking (Table 2).16–18 Although these factors are nonspecific, they may help identify children at risk for exploitation and prompt the clinician to screen for trafficking and offer resources. Increasingly, health care facilities, especially emergency departments, are establishing human trafficking protocols to recognize and respond to suspected exploitation.
Possible Indicators of Human Trafficking and Children
Pediatricians may suspect labor or sexual exploitation when an immigrant child presents with one or more health conditions associated with the worst forms of child labor, especially if there are accompanying social and historical risk factors, as described above. The exploitation may have happened before or after the immigration and arrival to the United States. Unfortunately, clinicians lack access to clinically validated screening tools designed for the health care setting and targeting immigrant/refugee children at risk of exploitation. However, some screening questions targeting the adult labor-trafficked population may prove helpful,19 especially if embedded in a trauma-informed,20 culturally sensitive approach. Open-ended, non-threatening questions about general aspects of the child's work and living situation may reveal concerns for labor exploitation (eg, “Can you tell me about a typical day at work? What things do you do?” “Tell me about where you live.”). A screen for youth sex trafficking has been developed for a health center in California with predominantly Asian patients,21 and another has been developed and validated in emergency departments, teen clinics, and child advocacy centers in the US, although it has not been tested with immigrant/refugee patients.22 Further work needs to be done to develop and validate brief, effective screening tools for immigrant/refugee children who are vulnerable to sex and labor exploitation.
Medical Evaluation of the Child at Risk for Trafficking and Exploitation
When interacting with a patient who may have experienced the worst forms of child labor (including sexual and/or labor exploitation and trafficking), it is helpful for the clinician to use a trauma-informed, 20 human rights-based, culturally appropriate, and gender-sensitive approach.23 Essential aspects of trauma-informed care include an understanding of how prior and ongoing trauma may affect a child's beliefs, attitudes, and behaviors. It also includes an emphasis on establishing physical and psychological safety, maintaining an open, nonjudgmental attitude, and empowering the patient to participate in all aspects of the medical visit. Respecting patient rights is critical in building trust and minimizing the trauma of the visit, including the right to an explanation regarding the reasons for the questions being asked as well as the purpose and elements of the examination and diagnostic evaluation. A frank discussion of the limits of confidentiality is important prior to asking sensitive questions. Patient and caregiver should be aware of any sensitive information that will be documented in the medical record and/or conveyed to third parties (eg, social services, law enforcement), and their desires should be respected whenever possible (consistent with legal requirements). It may be helpful for the clinician to stress to the patient (and family) that they are not working for police or immigration authorities and their only interest lies in finding out how they can best help the child. Besides obtaining informed consent from the guardian as appropriate, it is important to obtain informed assent from the patient for all steps of the process.
Additional points that may be helpful when working with children who have been exploited for sex or labor include the following:24
- Children who have been trafficked and exploited may have had even less access to health care than immigrant children who have not been exploited, and they may have been exposed to numerous adverse conditions, so it is important to identify, carefully document, and address acute and chronic medical conditions, remote injuries and their sequelae, as well as dehydration, malnutrition, vitamin deficiency, stunting, and possible developmental delays.
- Additional laboratory testing may be indicated to assess for toxins common in the occupational sector in which they are involved (eg, lead and mercury if a child has been in gold mine, nicotine if working on tobacco farm).
- Working and living in squalid conditions may increase the risk of communicable diseases such as tuberculosis, scabies, and diarrheal diseases. Open wounds may require tetanus immunization.
- Substance misuse should be considered, and drug/alcohol testing may be indicated (with patient assent) if the child reports recent substance use and/or recent periods of memory loss.
- Providers may find it helpful to use the guidelines from the US Centers for Disease Control and Prevention (CDC) regarding sexually transmitted infection (STI) testing and prophylaxis. Additional resources on laboratory testing for STIs and non-STIs may be obtained from the CDC ( https://www.cdc.gov/) or World Health Organization websites ( http://www.who.int/en/). Typically, STI assessment includes tests for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, HIV, syphilis, and hepatitis B and C viruses. Also, depending on the geographic regions where exploitation occurred, additional STIs may be relevant.
- Emergency contraception and other methods of birth control (especially long-acting reversible contraception) should be discussed with the patient as feasible.
- A sexual assault evidence kit may or may not be indicated in cases of sex trafficking and should only be done with the child's assent. One should become familiar with the specific state laws regarding timing and indications.
Most children who have been exploited have immense and varied needs that extend well beyond the purview of the pediatrician. A multidisciplinary team approach and community collaboration are needed to ensure all of the child's needs are met. It is helpful for the clinician to advocate for the child's immediate, short-, and long-term health needs (Table 3).
Immediate, Short-Term, and Long-Term Health Needs for Children Who Have Been Trafficked
Reports, Referrals, and Resources
Given the inherent dangers involved in sex and labor exploitation, a thorough risk assessment and safety planning are indicated.19 This includes a discussion with the patient (and caregiver as applicable) of safety concerns and resource needs. This is often done by a trained advocate or social worker. Every attempt should be made to engage the child (and caregiver) in the process, asking for their input, opinions, and suggestions. It is critical to understand and respect cultural and religious influences that may affect the child's views of their bodies, their condition, and their desired treatment.
Training health care providers on human trafficking has increased over the past decade, with many programs adding protocols and required training. Some states even require health care providers to be trained as a prerequisite to license renewal. Health professionals need to be aware of and comply with mandatory reporting laws in their state. However, notification of authorities must be done in a way that minimizes the risk of causing further harm to the child or their family.25 Fears of arrest and deportation are real and must be addressed. With patient/family consent, efforts should be made to contact victim service and/or refugee organizations that provide legal and immigration assistance. For those practicing within the US, assistance on interpreting laws, working with suspected victims, making reports to authorities, and identifying local referral sources may be obtained by contacting the National Human Trafficking Resource Center (1-888-373-7888). Additional assistance may be procured from state or local anti-trafficking task forces or local child advocacy centers.
Pediatricians and health care providers also need to advocate for legislation and policies that promote child rights and victim services, as well as those that address the social determinants of health, which influence the vulnerability to human trafficking.24 This role may be further expanded through the pediatrician's routine incorporation of human trafficking prevention strategies into their practice. The pediatrician may also take part in anti-trafficking initiatives directed by professional organizations and medical societies. They may advocate for formalized guidelines on human trafficking to be developed and implemented within their own facilities. There are many ways for pediatricians to assist in combating human trafficking.
Children in general are at risk for the worst forms of human trafficking, including sex and labor trafficking and exploitation. Immigrant and refugee children are at an even higher risk of exploitation. Such abuse may occur before, during, or after the migration event and may be associated with significant physical and mental health consequences. Although access to health care may be limited, when victims do present to medical facilities, the clinician should be aware of possible indicators and common health issues. Use of a trauma-informed, rights-based, and culturally sensitive approach may allow the child and family to develop the trust needed to reveal concerns and allow services to be offered. Health care needs often are extensive and may change over time, so flexibility, consistency, and multidisciplinary collaboration are essential.
- United Nations Office on Drugs and Crime. Global report on trafficking in persons. https://www.unodc.org/unodc/data-and-analysis/glotip.html. Accessed April 20, 2020.
- United Nations General Assembly. Transforming our world: the 2030 agenda for sustainable development. http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E. Accessed April 20, 2020.
- International Labour Organization. Towards the urgent elimination of hazardous child labour. https://www.ilo.org/ipec/Information-resources/WCMS_IPEC_PUB_30315/lang--en/index.html. Accessed April 20, 2020.
- Centers for Disease Control and Prevention. The social-ecological model: a framework for prevention. https://www.cdc.gov/violenceprevention/publichealthissue/social-ecologicalmodel.html. Accessed April 20, 2020.
- Greene JM, Ennett ST, Ringwalt CL. Prevalence and correlates of survival sex among runaway and homeless youth. Am J Public Health. 1999;89(9):1406–1409. doi:10.2105/AJPH.89.9.1406 [CrossRef] PMID:10474560
- Chester H, Lummert N, Mullooly A. Child victims of human trafficking: outcomes and service adaptation within the U.S. Unaccompanied refugee minor programs. http://www.usccb.org/about/anti-trafficking-program/upload/URM-Child-Trafficking-Study-2015-Final.pdf. Accessed April 20, 2020.
- Polaris Project. Knocking at your door: labor trafficking on traveling sales crews. https://polarisproject.org/wp-content/uploads/2019/09/Knocking-on-Your-Door-Sales-Crews.pdf. Accessed April 20, 2020.
- Polaris Project. The typology of modern slavery: defining sex and labor trafficking in the United States. https://polarisproject.org/wp-content/uploads/2019/09/Polaris-Typology-of-Modern-Slavery-1.pdf. Accessed April 20, 2020.
- International Labour Organization, Food and Agriculture Organization of the United Nations, Arab Council for Childhood and Development. Child labour in the Arab region: a quantitative and qualitative analysis. https://www.ilo.org/beirut/publications/WCMS_675262/lang--en/index.htm. Accessed April 20, 2020
- Varma S, Gillespie S, McCracken C, Greenbaum VJ. Characteristics of child commercial sexual exploitation and sex trafficking victims presenting for medical care in the United States. Child Abuse Negl. 2015;44:98–105. doi:10.1016/j.chiabu.2015.04.004 [CrossRef] PMID:25896617
- Goldberg AP, Moore JL, Houck C, Kaplan DM, Barron CE. Domestic minor sex trafficking patients: a retrospective analysis of medical presentation. J Pediatr Adolesc Gynecol. 2017;30(1):109–115. doi:10.1016/j.jpag.2016.08.010 [CrossRef] PMID:27575407
- Albright K, Greenbaum J, Edwards SA, Tsai C. Systematic review of facilitators of, barriers to, and recommendations for healthcare services for child survivors of human trafficking globally. Child Abuse Negl. 2020;100:104289. doi:10.1016/j.chiabu.2019.104289 [CrossRef] PMID:31787336
- Buller AM, Vaca V, Stoklosa H, Borland R, Zimmerman C. Labour exploitation, trafficking and migrant health: multi-country findings on the health risks and consequences of migrant and trafficked workers. https://publications.iom.int/system/files/pdf/labour_exploitation_trafficking_en.pdf. Accessed April 20, 2020.
- Pocock NS, Kiss L, Oram S, Zimmerman C. Labour trafficking among men and boys in the greater Mekong Subregion: exploitation, violence, occupational health risks and injuries. PLOS One. 2016;11(12):e0168500. doi:10.1371/journal.pone.0168500 [CrossRef] PMID:27992583
- Pocock NS, Tadee R, Tharawan K, et al. “Because if we talk about health issues first, it is easier to talk about human trafficking”; findings from a mixed methods study on health needs and service provision among migrant and trafficked fishermen in the Mekong. Global Health. 2018;14(1):45–50. doi:10.1186/s12992-018-0361-x [CrossRef] PMID:29739433
- Armstrong S, Greenbaum VJ. Using survivors' voices to guide the identification and care of trafficked persons by U.S. Health Care Professionals: a systematic review. Adv Emerg Nurs J. 2019;41(3):244–260. doi:10.1097/TME.0000000000000257 [CrossRef] PMID:31356251
- Baldwin SB, Eisenman DP, Sayles JN, Ryan G, Chuang KS. Identification of human trafficking victims in health care settings. Health Hum Rights. 2011;13(1):E36–E49. PMID:22772961
- Macias Konstantopoulos WL, Munroe D, Purcell G, Tester K, Burke TF. The commercial sexual exploitation and sex trafficking of minors in the Boston metropolitan area: experiences and challenges faced by front-line providers and other stakeholders. J Appl Res Child. 2015;6(1):1–20.
- Macias Konstantopoulos W, Owens JNational Human Trafficking Training and Technical Assistance Center. Adult human trafficking screening tool and guide. https://www.acf.hhs.gov/sites/default/files/otip/adult_human_trafficking_screening_tool_and_guide.pdf. Accessed April 20, 2020.
- Substance Abuse and Mental Health Services Administration. SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.
- Chang KSG, Lee K, Park T, Sy E, Quach T. Using a clinic-based screening tool for primary care providers to identify commercially sexually exploited children. J Appl Res Child. 2015;6(1):1–15.
- Greenbaum VJ, Dodd M, McCracken C. A short screening tool to identify victims of child sex trafficking in the health care setting. Pediatr Emerg Care. 2018;34(1):33–37. doi:10.1097/PEC.0000000000000602 [CrossRef] PMID:26599463
- Greenbaum VJ. Child trafficking for sex and labor. In: Kliegman RM, St Geme JW, Blum NJ, eds. Nelson Textbook of Pediatrics. Philadelphia, PA: Elsevier; 2020:95–98.
- Greenbaum J, Bodrick NCommittee on Child Abuse and NeglectSection on International Child Health. Global human trafficking and child victimization. Pediatrics. 2017;140(6):e20173138. doi:10.1542/peds.2017-3138 [CrossRef] PMID:29180462
- Institute of Medicine and National Research Council. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States. Washington, DC: The National Academies Press; 2013.
Vulnerabilities to Child Trafficking
||Young age (relative to adults)
History of abuse/neglect/sexual exploitation
Untreated behavioral and mental health problems
Involvement with the legal system or child protection system
Lack of legal status/birth certificate/identification
Lengthy duration of migration (>3 months)
Sub-Saharan African origin
||Family dysfunction (substance misuse, mental health issues, violence, criminality)
Illness of family member
Poverty, unemployment, and limited education
Parent involvement in commercial sex work
Dependence on smugglers
||High levels of gang and other organized crime activity (especially drug sales)
Differential access to humanitarian aid related to political alliance
Lack of access to resources (eg, education, health care)
Widespread lawlessness; weak state institutions
Corruption by authorities
||Weak recognition of child rights
Poor government anti-trafficking response
Law enforcement/political corruption
Xenophobia and racism Restrictions on adult refugees working, and/or moving within country
Possible Indicators of Human Trafficking and Children
|Initial presentation for medical care
Acute sexual assault
Sexually transmitted infection testing
Intoxication or ingestion
Child accompanied by a domineering person
Child appears depressed, withdrawn, or gives inconsistent/changing history
Child is unfamiliar with the city/town
||Signs of malnutrition or exhaustion
Very flat affect with signs of post-traumatic stress (eg, anxiety or dissociation)
Child has large amounts of cash or expensive items not consistent with the remainder of the appearance
Signs concerning for inflicted injury
Anogenital trauma or signs of infection
Tattoos (especially of a name)
Immediate, Short-Term, and Long-Term Health Needs for Children Who Have Been Trafficked
Behavioral health assessment and treatment (emergent or non-urgent): trauma-focused, preferably conducted by a professional trained in trauma therapy; must be culturally sensitive and appropriate
Evaluation at a child advocacy center (forensic interview; forensic medical examination; behavioral health assessment/therapy)
Primary medical home (primary and preventive care including anticipatory guidance, nutrition, hygiene counseling, immunizations, periodic sexually transmitted infection testing and treatment, reproductive health)
Specialized medical services
Substance abuse assessment/treatment
Physical and/or occupational therapy and rehabilitation
Vision and/or hearing assessment and care
Resources for children identifying as LGBTQ