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Although police and other members of law enforcement are essential counter-trafficking partners, sometimes individual police officers are involved with the criminal networks that traffic human beings. See action sheet 17 for more information.
CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS
Influences on a patient’s health may include pre-existing chronic or genetic conditions, exposure to infectious diseases, repetitive physical, sexual and psychological violence, chronic deprivation, hazards related to various forms of labour exploitation, and deterioration of conditions resulting from lack of diagnosis and care. As is the case with victims of torture, individuals who have been trafficked are likely to sustain multiple physical or psychological injuries and illnesses and report a complex set of symptoms.
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.
18 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS
Evidence on the health of trafficked persons To date, there is limited research-based data on the health of trafficked persons. Most existing evidence on health is based on individuals attending post-trafficking services, and primarily applies to women and girls trafficked for sexual exploitation.
Current knowledge suggests, for example, that, prior to being recruited, more than half of trafficked women and girls may have been exposed to physical and/or sexual abuse. This history of violence may, in fact, have influenced individuals’ vulnerability to recruitment and is likely to contribute to post-trafficking health problems.
Evidence from women and girls suggests that common post-trafficking
symptoms and problems include the following:
Additional health problems frequently noted include weight loss, eating disorders, sleep disturbance and insomnia.
For individuals trafficked into sectors other than sexual exploitation, there is currently little research-based data. Accounts from assistance organizations around the world suggest that individuals are forced into highrisk settings that pose numerous hazards related to their jobs and to their living conditions. Health and safety standards in such exploitative settings are generally extremely low.
Those caught in situations of exploitation may remain silent about their conditions because they often do not know where to seek help and may try
CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSto endure, in hopes of eventually gaining promised income. Table 2 gives examples of common industries for labour exploitation and general labourrelated health risks and consequences.
Psychological trauma and stress In the most extreme cases, trafficking-related abuses and post-trafficking psychological symptoms can be compared to the violence, restrictions and psychological reactions identified in torture victims.10 Characteristic features of torture and trafficking situations are life-threatening events and persistent stress and repetitive or chronic danger. Studies on torture have shown that the ‘unpredictability’ and ‘uncontrollability’ of traumatic events are features highly predictive of an intense or prolonged psychological reaction.11 Common post-trauma responses include such post-traumatic stress symptoms as post-traumatic stress disorder, depression, anxiety and hostility or irritability.
Where sexual abuse has occurred, these symptoms may be particularly acute.
Suicidal ideation and suicide attempts are not uncommon. Action sheet 12 Zimmerman, C. et al., 2003.
Baso¨ lu, M. and S. Mineka, “The role of uncontrollable and unpredictable stress in post-traumatic stress g responses in torture survivors” in Torture and Its Consequences: Current Treatment Approaches, M. Baso¨ lu, g Ed., Cambridge University Press, New York, 1992.
20 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSprovides detailed information on post-trafficking mental health and offers suggestions for addressing the psychological health of trafficked persons.
Detecting and responding to a person who may have been trafficked There are no definitive symptoms by which to identify a person who has been trafficked. However, a health provider may suspect that an individual has been trafficked or has suffered extreme forms of exploitation when she or he presents with industry-related morbidity and post-trauma reactions and reports having migrated for a trafficking-related form of labour.
If a provider suspects or learns that an individual has been trafficked, it is important to be prepared with appropriate and up-to-date referral information and to offer care in a sensitive, confidential way. Caring for persons who have been trafficked may pose a number of challenges, but if the health provider is informed and attentive, assistance can be provided safely and effectively. Providing good health care requires adopting approaches that take into account, among other things, past or current risk of being subject to violence, post-trauma reactions, social or cultural differences, economic circumstances associated with debts and legal status (see action sheets 1, 2, and 3).12 Providers should take time to gain trust and learn about the individual’s risks and restrictions. They should also make the effort to act in ways that assure individuals that they are respected and not held responsible for the crimes that occurred.
The role of the health care provider While trafficking often appears to be an elusive and impenetrable phenomenon, health providers have multiple opportunities to intervene with information and care. As countries, law enforcement and non-governmental organizations give greater attention to the industry of human trafficking, more trafficked persons are likely to be identified.
Although many of the medical needs of trafficked persons may be treated through standard clinical practices, persons who have been trafficked are often hidden or alienated from services and exposed to multiple dangers which can pose diagnostic and treatment challenges. Intervention approaches may be similar or linked to activities designed to reach marginalized or vulnerable International Organization for Migration, The IOM Handbook on Direct Assistance for Victims of Trafficking,
groups, such as migrants, refugees or mobile populations, minorities and lowwage or irregular labourers.
Based on growing information about the abuses and health problems suffered by victims of trafficking, and the lessons learned about protecting hard-to-reach populations, the health care community should now try to become equipped with well-considered approaches to address the diverse – and often highly sensitive – needs of people who have been trafficked.
RefeRenCeS And ReSouRCeS Anderson, B. and B. Rogaly 2005 Forced Labour and Migration to the UK, Oxford: Centre for Migration, Policy and Society (COMPAS), in association with the Trades Union Congress, TUC, London, 2005.
Anti-Slavery International 2006 Trafficking in Women, Forced Labour and Domestic Work in the Context of the Middle East and Gulf, working paper, AntiSlavery International, London, 2006.
Anti Slavery International and International Confederation of Free Trade Unions (ICTFU) 2001 Forced Labour in the 21st Century, Anti-Slavery International, London, 2001.
Canadian Centre for Occupational Health and Safety 2008 “Extreme hot or cold temperature conditions”, web information, available at « http://www.ccohs.ca/oshanswers/phys_agents/ hot_cold.html » CCOHS, Hamilton, Ontario, Canada, page last updated 20 October 2008 (accessed 2 January 2009).
Hossain, M. et al.
2005 Recommendations for Reproductive and Sexual Health Care of Trafficked Women in Ukraine: Focus on STI/RTI Care, First Edition, London School of Hygiene & Tropical Medicine and the International Organization for Migration, Kiev, 2005.
22 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS
United States Centers for Disease Control and Prevention Electronic library of construction occupational safety and health http://www.cdc.gov/elcosh/
United States Department of State 2007 Health Consequences of Trafficking in Persons, fact sheet, Department of State Office to Monitor and Combat Trafficking in Persons, Washington, DC, USA, 8 August 2007.
Zimmerman, C. et al.
2006 Stolen Smiles: The physical and psychological health consequences of women and adolescents trafficked in Europe, London School of Hygiene and Tropical Medicine, London, 2006.
Zimmerman, C. et al.
2003 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.
Zimmerman, C. and C. Watts, 2003 WHO Ethical and Safety Recommendations for Interviewing Trafficked Women, World Health Organization, Geneva, 2003.
CHAP Chapter 3:
Caring for persons who have been trafficked requires special attention to an individual’s health, safety and well-being that often goes well beyond the basic medical principle of ‘do no harm’. Individuals who have been through traumatic events need to regain a sense of safety, dignity and control over their bodies and actions. They need to be encouraged to seek information, question their options and assert their choices. Health care providers can help foster feelings of security, self-esteem and self-determination by adopting approaches to care that emphasize confidentiality, information-giving, informed consent and respect for individual decision-making. Practitioners may help protect patients from present and future harm by ensuring that their services and staff are sensitive to the vulnerabilities of trafficked persons and that referral options are safe, appropriate and convenient.
The following guiding principles are considered good practice for all professionals involved with persons who have been trafficked. Health providers should integrate these ethical and human rights standards into all aspects of health care for trafficked and exploited persons.
1. Adhere to existing recommendations in the WHO Ethical and Safety Recommendations for Interviewing Trafficked Women13 (see Figure 2 at the end of this chapter).
2. Treat all contact with trafficked persons as a potential step towards improving their health. Each encounter with a trafficked person can have positive or negative effects on their health and well-being.
3. Prioritize the safety of trafficked persons, self and staff by assessing risks and making consultative and well-informed decisions. Be aware of the safety concerns of trafficked persons and potential dangers to them or their family members.
Zimmerman, C. and C. Watts, WHO Ethical and Safety Recommendations for Interviewing Trafficked Women, World Health Organization, Geneva, 2003.
28 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS
4. Provide respectful, equitable care that does not discriminate based on gender, age, social class, religion, race or ethnicity. Health care should respect the rights and dignity of those who are vulnerable, particularly women, children, the poor and minorities.
5. Be prepared with referral information and contact details for trusted support persons for a range of assistance, including shelter, social services, counselling, legal advocacy and law enforcement. If providing information to persons who are suspected or known victims who may still be in contact with traffickers, this must be done discretely, e.g., with small pieces of paper that can be hidden.
6. Collaborate with other support services to implement prevention activities and response strategies that are cooperative and appropriate to the differing needs of trafficked persons.
7. ensure the confidentiality and privacy of trafficked persons and their families. Put measures into place to make sure all communications with and about trafficked persons are dealt with confidentially and that each trafficked person is assured that his or her privacy will be respected.
8. Provide information in a way that each trafficked person can understand. Communicate care plans, purposes and procedures with linguistically and age-appropriate descriptions, taking the time necessary to be sure that each individual understands what is being said and has the opportunity to ask questions. This is an essential step prior to requesting informed consent.
9. obtain voluntary, informed consent. Before sharing or transferring information about patients, and before beginning procedures to diagnose, treat or make referrals, it is necessary to obtain the patient’s voluntary informed consent. If an individual agrees that information about them or others may be shared, provide only that which is necessary to assist the individual (e.g., when making a referral to another service) or to assist others (e.g., other trafficked persons).
10. Respect the rights, choices, and dignity of each individual
• Conducting interviews in private settings.
• Offering the patient the option of interacting with male or female staff or interpreters. For interviews and clinical examinations of trafficked women and girls, it is of particular importance to make certain female staff and interpreters are available.