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For health providers to provide safe and appropriate care to persons who have been trafficked, it is useful to understand the nature of human trafficking and the context of individuals who have been trafficked. This chapter offers basic information about human trafficking and gives a sense of the characteristics and dynamics of what is, in reality, a very complex and diverse phenomenon.
What is the definition of trafficking? The most widely accepted definition of ‘trafficking in persons’ is found in the Protocol to Prevent, Suppress, and Punish Trafficking in Persons, Especially Women and Children, Supplementing
the United Nations Convention against Transnational Organized Crime:
(a) “Trafficking in persons” shall mean the recruitment, transportation, transfer, harbouring 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 labour or services, slavery or practices similar to slavery, servitude or the removal of organs;
(b) The consent of a victim of trafficking in persons to the intended exploitation set forth in subparagraph (a) of this article shall be irrelevant where any of the means set forth in subparagraph (a) have been used;
(c) The recruitment, transportation, transfer, harbouring or receipt of a child for the purpose of exploitation shall be considered “trafficking in persons” even if this does not involve any of the means set forth in subparagraph (a) of this article;
(d) “Child” shall mean any person under eighteen years of age.1 Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention against Transnational Organized Crime, United Nations, New York, 2000, Article 3. See http://untreaty.un.org/English/TreatyEvent2003/Texts/treaty2E.pdf
8 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSKey features of the crime include movement or confinement of an individual, accompanied by coercion and exploitation, usually for the financial profit of the trafficker.
How many people are trafficked? Although human trafficking is recognized as a global phenomenon, there are no reliable statistics on how many people are trafficked. It is clear, however, that this is a global crime that is not abating, because it is both profitable and difficult to detect.
What types of trafficking-related exploitation are common? Individuals may be trafficked and exploited in a variety of ways. The trafficking of women and children for sexual exploitation has been the most commonly recognized form of trafficking. Yet, many, if not more, men, women and children are trafficked for such forms of labour exploitation as work in factories, in the agriculture, construction, fisheries, textile, and mining industries, and for domestic servitude and care services. Traffickers frequently target children for begging, domestic servitude, adoption and petty street theft.
Who are traffickers? There is no single profile of those who traffic and exploit others. A trafficker may be female or male, a member of an organized crime network, part of a small family business or an amateur operator who assists, for example, in the transportation, documentation or logistics of a trafficking operation. Family members, friends and acquaintances of the person who has been trafficked may have participated in or lead the recruitment or other stages of the trafficking and exploitation process. Some traffickers are former victims of trafficking who now recruit and control other victims.
Who do traffickers recruit? Poverty, unemployment, war, natural disasters and desperation are good predictors of vulnerability to being trafficked. However, those who fall prey to traffickers may also be relatively wealthy, relatively educated and come from urban centres.
Where are people trafficked to and from? While international trafficking is often in the spotlight, people who are trafficked may be transported internationally, regionally or, as is the case with many trafficked persons, within their own national borders. Each region has common routes, many of which lead trafficked persons from areas of relative poverty to locations of relative wealth.
What types of abuse do trafficked persons suffer? Trafficking is a crime that is not always evident, its victims not always readily identifiable. It is a form of violence that occurs on a spectrum. Some individuals will suffer extreme physical abuse or torture-like violence, such as beating, burning,
CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSrape and confinement, while others may be subjected to less obvious – but nonetheless coercive and menacing – tactics, including physical and verbal threats to themselves or their families (particularly those with children). Coercive measures may include blackmail, extortion, lies about an individual’s ability to gain help from police or others, warnings about being imprisoned for immigration or other crimes and confiscation of such vital identity documents as passports and personal identity cards.
Why do trafficked persons stay in exploitative situations? People who are trafficked very often perceive no other option than to remain under the control of traffickers. Traffickers use common control tactics to force, manipulate and manage victims. Tactics may include: physical, sexual and psychological violence; debt-bondage; threats against family members; lies and deceit; withholding documents, maintaining victims in unpredictable or uncontrollable conditions; and emotional manipulation. When individuals are transported to unfamiliar locations, particularly to places where they do not speak the local language, it is extremely difficult for them to know where to go for help, whom to trust (many come from places where law enforcement is corrupt or indifferent) or how to ask for assistance, and how to navigate an unfamiliar city or remote area. Individuals may fear reprisals for escape attempts or feel afraid of being arrested and imprisoned. Those trafficked outside their home country may fear deportation and returning indebted and without the income that may have been promised them. Paradoxically, many individuals often, therefore, place their hopes for returning home safely in the hands of the very individuals who are exploiting them.
What is the trafficking cycle? Human trafficking is best understood as a process rather than a single act (see figure 1).2 The trafficking cycle begins at the pre-departure or recruitment stage, followed by the travel and destination/exploitation stages. Upon release or escape from the period of exploitation, individuals are often received and/or detained by authorities after which they enter the integration (if remaining at destination) or re-integration (if returned home) stage. Each stage of this cycle poses risks to an individual’s health, as well as opportunities for health care professionals and others to intervene with information and assistance.
This section is based on the conceptual models and study findings developed in Zimmerman, C. et al., The Health Risks and Consequences of Trafficking in Women and Adolescents: Findings from a European study, London School of Hygiene and Tropical Medicine, London, 2003.
10 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS
The complex circumstances of trafficked persons The situation of individuals who are trafficked is almost always complicated. Whether still under a trafficker’s control, trying to leave or already out of the trafficking environment, trafficked persons are generally mired in difficult physical, psychological, social, legal and, not least, financial circumstances. To care for individuals who have been trafficked, it is helpful to try to imagine how the world might look through their eyes.
Based on the conceptual models and study findings developed in Zimmerman, C. et al., The Health Risks and Consequences of Trafficking in Women and Adolescents: Findings from a European study, London School of Hygiene and Tropical Medicine, London, 2003.
Adapted from Zimmerman, C. and C. Watts, WHO Ethical and Safety Recommendations for Interviewing Trafficked Women, World Health Organization, Geneva, 2003.
CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS
Any one of these reactions can make seeking help difficult for a trafficked person. Once an individual is able to access care, these sensitivities, particularly shame, can make disclosing concerns, posing questions and expressing frustrations stressful. People who have been trafficked need assurance that they are not to blame for what happened to them. They also need to regain a sense of being respected and accepted.
12 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSParticular complexities Some trafficker-victim situations are particularly complex, and may pose special challenges in work with trafficked persons. There are many reasons that may prevent a person who has been trafficked from disclosing information or cause them to alter details about themselves, their situation, their intentions or their family.
Each of these situations can complicate the provision and acceptance of assistance. For the trafficked person, these circumstances may pose problems of dual loyalty, ongoing fear or intimidation and wavering intentions about the future. Health care providers may find that patients do not keep appointments and are not able to adhere to treatment, or that patients’ health care needs become intertwined with other support needs.
Responses to human trafficking
Responses to human trafficking usually focus on three broad areas known as the three ‘Ps’: Prevention, Protection and Prosecution. Prevention activities include awareness-raising and education to warn potential victims about trafficking, for example, and activities to prevent exploitation of migrant workers. Protection encompasses the support mechanisms and resources aimed at assisting victims and ensuring their safety. Prosecution actions are associated with law enforcement and aimed at identifying, arresting and criminally prosecuting perpetrators of trafficking.
The following chapter describes some of the evidence around the health risks and consequences associated with human trafficking and discusses the implications for providing health care.
CHAP Chapter 2:
The health consequences of human trafficking
Trafficked persons may have health problems that are minor or severe, but few individuals are unscathed. Many will experience injuries and illnesses that are severe, debilitating and often enduring. Abuse, deprivation and stress-filled or terrifying circumstances are all hallmarks of human trafficking.
The Protocol to Prevent, Suppress, and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention against Transnational Organized Crime establishes the basis of the assistance measures that should be provided for trafficked persons [Article 6 (3)]:
“Each State Party shall consider implementing measures to provide for the physical, psychological and social recovery of victims of trafficking in persons, including, in appropriate cases, in cooperation with nongovernmental organizations, other relevant organizations and other elements
of civil society, and, in particular, the provision of:
(a) appropriate housing;
(b) counselling and information, in particular as regards their legal rights, in a language that the victims of trafficking in persons can understand;
(c) medical, psychological and material assistance; and (d) employment, educational and training opportunities.” 6 Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention against Transnational Organized Crime, United Nations, New York, 2000. See http://untreaty.un.org/English/TreatyEvent2003/Texts/treaty2E.pdf
16 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSAdditionally, Article 6 (4) also recognizes the needs of particularly
“Each State Party shall take into account, in applying the provisions of this article, the age, gender and special needs of victims of trafficking in persons, in particular the special needs of children, including appropriate housing, education and care.”7 In meeting the requirements of this Protocol, medical and other health providers are a vital link in the chain of care required by persons who are trafficked.
Diagnosing the health needs of trafficked persons is often complex because their symptoms generally reflect the cumulative effects of the health risks they face throughout the trafficking process (see chapter 1, figure 1).
Current knowledge indicates that most people who are trafficked are exposed to health risks before, during, and even after the period of exploitation, such as when they are held in detention centres or prisons, or when they are on the streets, often left isolated from assistance. It is worth noting that health care for trafficked persons may also be challenging because of what might be termed ‘hostile environments’, e.g., when patients are in a closed facility, or in locales where medical care is not state-supported, or in places where law enforcement cannot be trusted,8 or when deportation or relocation procedures are uncertain.
Table 1 summarizes some of the basic categories of health risks to trafficked persons, as well as their consequences. Many of these overlap, particularly psychological morbidity, which is linked to most physical, sexual and social health risks.