“When I turned 13, I’d had enough of the abuse in home and I ran away. I didn’t know where to go so I went to the center of town and stood by the town hall. A man saw me hanging around there and said that he was looking for a ‘protégé.’ I didn’t know what that was, but it sounded fine to me. He said that I could stay at his house if I didn’t have a place to stay … When we got to his house he pulled out a bottle of gin and had me drink and drink. The next thing I remember is waking up drunk in his bed all wet and hurt. He took me out on the street and told me what to do … During that time, I saw 10 to 20 men a day. I did what he said because he got violent when I sassed him. I took all kinds of drugs — even though I didn’t really like most of them … Over the years I had pimps and customers who hit me, punched me, kicked me, beat me, slashed me with a razor. I had forced unprotected sex and got pregnant three times and had two abortions at [a clinic]. Afterward, I was back out on the street again. I have so many scars all over my body and so many injuries and so many illnesses. I have hepatitis C and stomach and back pain and a lot of psychological issues. I tried to commit suicide several times.”
—survivor of domestic sex trafficking
When many people hear about human trafficking and health care, they usually think about sexual health: sexually transmitted diseases, pregnancy, and so forth. However, the health problems of trafficking survivors are much more vast and complex. It is also important to note that not all trafficking survivors are trafficked for sex. Labor trafficking outnumbers sex trafficking both in the United States and around the world. The International Labor Organization estimates that worldwide about 19 million people are exploited for forced labor, and out of these individuals about 4.5 million are forced into the sex industry. Survivors leaving their trafficking situation have been shown to have 12 or more concurrent physical symptoms upon initially receiving health care services. It is therefore not just OB/GYNs and emergency medicine physicians who should be educated on identification and referral. Physicians in almost any discipline of medicine could see a survivor in the clinical setting, and would benefit from knowing how to recognize them.
This is not to diminish the prevalence or importance of reproductive health problems of trafficking survivors. Sexually transmitted infections, pregnancy, miscarriage and chronic pelvic pain are common health issues that survivors of sex trafficking face. Studies suggest that over 60 percent of survivors have pressing reproductive health issues that they seek treatment for. Interestingly, sexual and reproductive health problems are most likely to be both addressed and resolved in the short term. Once we treat these issues it seems our work has just begun. The following are four other categories of health problems of trafficking survivors that you should be aware of as a future physician.
“The worst pain is from the headaches, especially the constant pain in the left-side temple, caused by an extremely brutal hit to the head, in trafficking…”
—survivor of human trafficking
Neurological problems are some of the most common physical symptoms that survivors of human trafficking face. In a study of over 100 sex trafficking victims, above 90 percent of them reported experiencing issues related to neurological health. These problems included headaches, memory loss, insomnia, poor concentration and dizziness. Another study of over 200 trafficking victims similarly found a high prevalence of neurological symptoms. This study also showed that while most survivors experienced a reduction in many other physical health ailments, neurological problems were most likely to persist over time. Specifically, headaches, dizziness and memory problems were the most severe and persistent. These lasting symptoms are thought to be an unfortunate consequence of the physical and psychological effects of violence faced during trafficking.
“I’ve had a hard life during this time — 16 years on the street … I’ve been hit, punched, kicked, beaten, whipped with a belt, forced to have sex, threatened with a weapon, shot at and had my head split open…”
—survivor of human trafficking
Physical injuries are a reality for trafficking survivors. The trauma they face can be intentional at the hands of a trafficker or customer. Survivors can present with anything from bruising to fractures to head or blunt force trauma. Burns of all types, such as cigarette burns, chemical burns and even electrical burns, have been seen as a consequence of human trafficking. Trauma in this setting can also be accidental, as a result of dangerous or neglectful work conditions. For example, one labor trafficking victim slipped off of a chair while performing cleaning duties, hit her head and had fluid draining from her ear for 10 days before she was able to seek medical care. Studies to date have found that about 70 percent or more of survivors have experienced some form of physical violence during their victimization.
“I wish to forget, but this is impossible. These memories will stay for the rest of my life.”
—survivor of human trafficking
It is not surprising that mental health issues are prevalent in trafficking survivors. The range of psychological issues experienced as a result of trafficking are vast and include depression, PTSD, suicidal ideation, somatic symptom disorder, and substance abuse. Depression and feelings of shame and guilt are particularly prevalent, with studies showing that over 80 percent of survivors experience these feelings. Like the physical neurological consequences of trafficking, depression is often a long-term mental health issue for survivors.
General Well Visit
A trafficking victim presenting for a general check-up at the office is probably the last thing you would expect, but it is more common than you would think. In a study of over 200 sexually exploited youth in New York City, 82 percent had seen a doctor in the last six months, and the top reason for visiting a doctor was for a general check-up. Most of the individuals in this study were homeless youth who were well-connected with social services and knowledgeable about where to find free health care. However, people who are trafficked live in many different situations. There are individuals who are taken advantage of and exploited while living under their own roofs with their families. It is possible to see how in this situation these victims of trafficking could present for a routine health maintenance visit. Having a little more time during these visits to build rapport, take a good social history, and notice changes in behavior and red flags over time can give you a better chance to screen for potential victims.