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«IOM is committed to the principle that humane and orderly migration benefits migrants and society. As an intergovernmental organization, IOM acts ...»

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The opinions expressed in the report are those of the authors and do not necessarily reflect the

views of the International Organization for Migration (IOM). The designations employed and

the presentation of material throughout the report do not imply the expression of any opinion

whatsoever on the part of IOM concerning the legal status of any country, territory, city or area,

or of its authorities, or concerning its frontiers or boundaries.

IOM is committed to the principle that humane and orderly migration benefits migrants and society. As an intergovernmental organization, IOM acts with its partners in the international community to: assist in meeting the operational challenges of migration; advance understanding of migration issues; encourage social and economic development through migration; and uphold the human dignity and well-being of migrants.

Editors: Cathy Zimmerman London School of Hygiene & Tropical Medicine Gender Violence & Health Centre Rosilyne Borland International Organization for Migration Migration Health Division Publisher: International Organization for Migration 17 route des Morillons 1211 Geneva 19 Switzerland Tel: +41.22.717 91 11 Fax: +41.22.798 61 50 E-mail: hq@iom.int Internet: http://www.iom.int ______________

ISBN 978-92-9068-466-4 © 2009 International Organization for Migration (IOM) © London School for Hygiene and Tropical Medicine (LSHTM) © United Nations Global Initiative to Fight Trafficking in Persons (UN.GIFT) ______________

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without the prior written permission of the publisher.





Acknowledgements This handbook was made possible through the generous support of the United Nations Global Initiative to Fight Trafficking in Persons. The development of this handbook was coordinated by the International Organization for Migration and the Gender Violence & Health Centre of the London School for Hygiene & Tropical Medicine.

We were privileged to facilitate a broad group of health and human trafficking experts from around the world in the development of Caring for Trafficked Persons: Guidelines for Health Providers. Principal authors and contributors included Dr. Melanie Abas (Institute of Psychiatry, Kings College London), Dr. Idit Albert (Centre for Anxiety, Disorders and Trauma, South London & Maudsley NHS Foundation Trust), Dr. Islene Araujo (Migration Health Department, International Organization for Migration), Hedia Belhadj-El Ghouayel (United Nations Population Fund), Rosilyne Borland (Migration Health Department, International Organization for Migration), Jenny Butler (United Nations Population Fund), Sarah Craggs (CounterTrafficking Division, International Organization for Migration), Dr. Michele Decker (Harvard School of Public Health), Dr. Sean Devine (Independent Consultant), Riet Groenen (United Nations Population Fund), Takashi Izutsu (United Nations Population Fund), Dr. Elizabeth Miller (UC Davis School of Medicine), Dr. Nenette Motus (Regional Office for Southeast Asia, International Organization for Migration), Tina Nebe (United Nations Population Fund), Dr. Anula Nikapota (Institute of Psychiatry, UK-Sri Lanka Trauma Group), Marija Nikolovska (Regional Office for Southern Africa, International Organization for Migration), Siân Oram (doctoral candidate, LSHTM), Donka Petrova (Animus Foundation), Dr. Clydette Powell (Bureau for Global Health, US Agency for International Development), Kate Ramsey (United Nations Population Fund), Timothy Ross (Fundación Social Fénix), Dr. Jesus Sarol (Migration Health Department, International Organization for Migration), Maria Tchomarova (Animus Foundation), Leyla Sharafi (United Nations Population Fund), Dr. Amara Soonthorndhada (Institute


for Population and Social Research, Mahidol University), Aminata Toure (United Nations Population Fund), Jacqueline Weekers (Migration Health Department, International Organization for Migration), Dr. Katherine Welch (Global Health Promise), Dr. Brian Willis (Global Health Promise), Dr. David Wells (Victorian Institute of Forensic Medicine), Dr. Teresa Zakaria (IOM Jakarta, International Organization for Migration), and Dr. Cathy Zimmerman (London School for Hygiene & Tropical Medicine).

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Chapter 1: Human trafficking

Chapter 2: The health consequences of human trafficking........... 15 Chapter 3: Guiding principles

Action Sheet 1: Trauma-informed care

Action Sheet 2: Culturally appropriate, individualized care.......... 41 Action Sheet 3: Working with interpreters

Action Sheet 4: Comprehensive health assessment

Action Sheet 5: Special considerations when examining children and adolescents

Action Sheet 6: What to do if you suspect trafficking

Action Sheet 7: Protection and security

Action Sheet 8: Self-care

Action Sheet 9: Patient data and files

Action Sheet 10: Safe referrals

Action Sheet 11: Urgent care

Action Sheet 12: Mental health care

Action Sheet 13: Sexual and reproductive health

Action Sheet 14: Disability

Action Sheet 15: Infectious diseases

Action Sheet 16: Medico-legal considerations

Action Sheet 17: Interactions with law enforcement



INTRO DUC Introduction

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Human trafficking is a harmful and sometimes deadly practice whereby individuals are enticed by jobs and hopes for a better future into a cycle of

migration and exploitation. Trafficking of persons has been called:

–  –  –

For health care providers, trafficking in persons is best understood as a very serious health risk, because trafficking, like other forms of violence, is associated with physical and psychological harm.

Evidence on human trafficking and exploitation indicates that no region of the world is free of the practice: Trafficking patterns exist in South, Central and North America, Africa, Europe, Asia and in the Pacific. The widespread nature of trafficking suggests that a health provider may at some point come into contact with a person who has been trafficked.

A trafficked person may be referred to a health care provider; a patient may disclose a trafficking experience; or a provider may detect signs that suggest an individual has been trafficked. The informed and attentive health care provider can play an important role in assisting and treating individuals who may have suffered unspeakable and repeated abuse. In fact, health care is a central form of prevention and support in the network of anti-trafficking assistance measures.

Purpose of the guidance This document aims to provide practical, non-clinical guidance to help concerned health providers understand the phenomenon of human


trafficking, recognize some of the health problems associated with trafficking and consider safe and appropriate approaches to providing health care for trafficked persons. It outlines the health provider’s role in providing care and describes some of the limitations of his or her responsibility to assist.

This resource attempts to respond to questions such as: “What special approaches are required for diagnosis and treatment of a patient who has been trafficked?” and “What can I do if I know or suspect someone has been trafficked?” Victims of trafficking, like victims of other forms of abuse, sustain injuries and illnesses that frequently fall to the health sector to address in a safe and confidential way. For a trafficked person, contact with someone in the health sector may be the first – or only – opportunity to explain what has happened or ask for help.

Special note: Human trafficking is a crime that can be easily confused with other high-risk situations of migrants, including people smuggling and labour exploitation. Although there are legal distinctions between trafficking, smuggling and abusive labour conditions, there are often commonalities between the health risks and needs of people in these different circumstances.

For health providers, distinctions in category should not affect the level of care they provide but may be important in determining which referral options they can use. All persons deserve and are entitled to health support and assistance based on human rights and humanitarian principles.

Although this document focuses on trafficked persons, its guidance is designed to be inclusive, with information that may be useful for meeting the health needs of other marginalized or abused populations. The aim is achieving the best health for all.

Target audience These recommendations are written for health providers who may now or in the future provide direct health care services for individuals who have been trafficked. They are designed to accommodate varying degrees of contact with and involvement in the care and referral of people who have

been trafficked. The intended audience includes the following:

–  –  –

• health centre staff, such as receptionists or technical staff

• clinicians, e.g., gynaecologists, neurologists, infectious disease specialists

• outreach care providers in fields such as sexual health or refugee/migrant health

• mental health care professionals, e.g., psychologists or psychiatrists.

These guidelines should be made accessible to all providers involved with direct care of trafficked persons. The care approaches described should, to the extent possible, be supported by training and sensitization to ensure appropriate and consistent implementation. Additionally, while this document offers guidance on good practice, different settings will undoubtedly have varying health care contexts and available resources. Recommendations should be adapted to local contexts.

Chapters and action sheets: what they are and how to use them

To encourage the use of these documents by busy health providers, this resource offers the main points of required knowledge and recommended approaches in a succinct manner. This document can be read in sequence or by topic of interest, therefore some concepts are repeated in different action sheets, where relevant. However, if you or your colleagues are unfamiliar with the phenomenon of trafficking or its health risks and consequences for trafficked persons, it is recommended that you read the introductory chapters first.

The guidelines begin with three chapters that provide:

• background information on human trafficking

• current knowledge on the health risks and consequences of trafficking

• guiding principles in the care of trafficked persons.

These chapters are followed by 17 action sheets covering the

following general areas:

• tools for the patient encounter, such as trauma-informed care and culturally and linguistically responsive care;

• approaches to various aspects of medical care, such as comprehensive health assessment, acute care, communicable diseases, and sexual and reproductive health;

• strategies for referral, security and case file management, and coordination with law enforcement.


Each action sheet begins with a rationale offering a basic description of the subject and its significance. This is followed by an outline of required actions providing guidance on the particular area of care or strategy.

At the end of most chapters and action sheets is a section on references and further resources to complement and support the information provided.

Overall, this guidance document draws from many sources, including such items as other guidelines, tools and standards; research and background materials; and other resources developed by the World Health Organization, the United Nations, non-governmental organizations and academic sources.

It is heavily informed by years of collective experience in addressing the consequences of human trafficking of the expert group that compiled the document. The principles and recommendations in this document are grounded in international norms and United Nations conventions. A complete list of all references is provided at the end of the book.

Current evidence on trafficking encompasses primarily the most extreme cases of trafficking, which generally involve severe abuse. The recommendations in this document tend to offer suggestions for treating those who are most affected by a trafficking experience. However, in reality, not all trafficking cases involve extreme abuse and not all trafficked persons experience profound post-trauma reactions. As more trafficking cases come to light in the coming years and individuals feel safer to disclose trafficking experiences, increasingly, cases that are less severe will be reported. Providers should readily adapt the advice in this document to meet the varying level of needs of their patients.

Making a difference

The abuses involved in human trafficking can pose many health risks.

In many cases, individuals experience physical and psychological damage and fears that seem overwhelming. The health provider who encounters a trafficked person or other exploited individual has a unique opportunity to provide essential medical care and vital referral options that may be an individual’s first step towards safety and recovery.


Chapter 1:

Human Trafficking

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