research articles on human trafficking

• Open access
• Published: 11 December 2023

Human trafficking risk factors, health impacts, and opportunities for intervention in Uganda: a qualitative analysis

• Robin E. Klabbers   ORCID: orcid.org/0000-0002-1462-0046 1 , 2 ,
• Andrea Hughes 3 ,
• Meredith Dank 4 ,
• Kelli N. O’Laughlin 1 , 2 ,
• Mutaawe Rogers 5 &
• Hanni Stoklosa 6 , 7 , 8  

Global Health Research and Policy volume  8 , Article number:  52 ( 2023 ) Cite this article

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Human trafficking is a global public health issue that is associated with serious short- and long-term morbidity. To address and prevent human trafficking, vulnerabilities to human trafficking and forces sustaining it need to be better understood among specific subpopulations. We aimed to explore risk and protective factors for human trafficking, the health impact of exploitation, and barriers and facilitators of seeking help throughout the human trafficking trajectory among forced labor and sex trafficking victims in Kampala, Uganda.

Between March and November 2020, in-depth, semi-structured qualitative interviews were conducted with 108 victims of forced labor and sex trafficking who had completed a human trafficking survey conducted by the Uganda Youth Development Link (UYDEL). Participants who experienced various forms of exploitation were purposively invited for qualitative interviews and a convenience sample was interviewed. Interviews explored personal history, trafficking recruitment, experiences of exploitation and abuse, and experiences seeking help. Interviews were analyzed using a combination of deductive and inductive thematic analysis. Themes and subthemes were organized using an adapted conceptual framework of human trafficking.

Poverty and an abusive home life, frequently triggered by the death of a caretaker, underpinned vulnerability to human trafficking recruitment. Limited education, lack of social support, and survival needs pushed victims into exploitative situations. Victims of human trafficking were systematically exploited and exposed to dangerous working conditions. Victims suffered from sexually transmitted diseases, incontinence, traumatic fistulae, musculoskeletal injuries, and mental health symptoms. Lack of awareness of resources, fear of negative consequences, restrictions on movement, and dependence on the trafficker and exploitation income prevented victims from seeking help. The police and healthcare workers were the few professionals that they interacted with, but these interactions were oftentimes negative experiences.

Conclusions

To address and prevent human trafficking, localized interventions are needed at all stages of the human trafficking trajectory. Health impacts of human trafficking are severe. As some of the few professionals trafficking victims interact with, police and healthcare workers are important targets for anti-trafficking training. Improved understanding of human trafficking drivers and barriers and facilitators to seeking help can inform the design of necessary interventions.

Human trafficking is defined by the United Nations Office on Drugs and Crime as the action of “ recruitment, transportation, transfer, harboring or receipt of people” using “ force, fraud or deception” to achieve the goal of “ exploiting them for profit” [ 1 ]. Human trafficking encompasses sexual exploitation, forced labor, slavery, servitude, and the removal of organs [ 2 ]. Recruiting, transporting, transferring, harboring or receiving a child under the age of 18 for the purpose of exploitation is always considered trafficking, even when force, fraud, or deception is not present [ 2 ]. An estimated 27.6 million people are exploited worldwide [ 3 ].

Human trafficking has historically been regarded as a criminal justice issue and has consequently been responded to through regulatory and law enforcement action. In recent years, however, there is increasing recognition of the importance of taking a public health approach to human trafficking [ 4 , 5 ]. Framing human trafficking as a global public health issue draws attention to its health impacts on victims and its preventable nature. Human trafficking victims suffer detrimental physical and mental health impacts in the short- and long-term as a result of the hazardous working conditions and spectrum of abuse that they are exposed to [ 6 ]. The first step to prevent human trafficking, and to reach Sustainable Development Target 8.7: to eradicate forced labor, modern slavery, and human trafficking by 2030, is to understand the complex interplay among risk and resilience factors.

Human trafficking has been presented by Zimmerman et al. as a series of sequential event-related stages: recruitment, travel and transit, exploitation, and integration (and in some cases re-trafficking/re-integration) [ 7 ]. Conceptualizing trafficking in this way, presenting it as a series of stages that victims may pass through, emphasizes the cumulative nature of health risks across this trajectory and highlights the different timepoints at which intervention could take place. In 2017, Zimmerman et al. published a second model that focuses on labor exploitation specifically. This model reiterated that exploitation and harm occur throughout all stages of the exploitation process, but added a focus on social and economic inequalities as structural drivers of exploitation [ 4 ]. Both models underscore the complexity of the human trafficking problem showing that it is influenced by multiple determinants which may vary across contexts and forms of exploitation.

Uganda is a source, transit, and destination country for human trafficking; 1,476 trafficked persons were identified in Uganda in 2020 [ 8 ]. The concealed nature of human trafficking and barriers to help-seeking make the identification of trafficked persons challenging, but estimates suggest that 2,057,000 children are involved in child labor and 7000–18,000 children are victims of sex trafficking in Uganda, with a lifetime sex trafficking prevalence as high as 11.9% in some Ugandan districts [ 9 , 10 , 11 ]. Given that school attendance in Uganda is only mandatory until the age of thirteen and the legal age of employment is sixteen years, children aged thirteen through fifteen are particularly vulnerable to human trafficking [ 8 , 12 ]. Children are often trafficked from their villages to more industrialized centers such as Kampala, the capital of Uganda [ 13 ]. Without access to shelter and other resources, many of these children, an estimated 2,600 children aged seven to seventeen in Kampala alone, end up living on the street where they are vulnerable to exploitation through forced begging, selling of goods, sexual exploitation, and illicit activities [ 14 , 15 ].

In this study, we aimed to qualitatively explore the lived experience of individuals exposed to forced labor and/or sex trafficking in Uganda using a public health conceptual model of human trafficking influenced by the 2011 Zimmerman et al. model to identify patterns in vulnerabilities to human trafficking. For each human trafficking stage, we strived to (1) identify risk factors and protective factors for human trafficking (2) assess the health impact of exploitation, and (3) explore barriers and facilitators of seeking help to leave exploitation. While there is a growing body of public health trafficking research and much is known on a general level about the risk factors for trafficking globally, a more nuanced understanding of the local modifiable drivers of human trafficking among specific subpopulations is necessary to guide the design of interventions to address it [ 5 ]. Using a public health framework to systematically explore these drivers for the unique context of human trafficking in Uganda is a novel generalizable approach that will yield locally relevant knowledge.

Study design

The Prevalence of Forced Begging and Sex Trafficking in Kampala, Uganda study took place in Kampala, Uganda between January 2020 and November 2020. It was funded by the Human Trafficking Institute and conducted by John Jay College of Criminal Justice of the City University of New York (CUNY) in collaboration with Uganda Youth Development Link (UYDEL), a non-governmental organization in Kampala focused on enhancing socioeconomic opportunities for disadvantaged youths. As part of this study, UYDEL field teams collected 1787 quantitative surveys and conducted 108 in-depth interviews with individuals aged ten years and older with lived experience of sex trafficking and minors under the age of 18 who were forced to beg and/or sell goods. Here, we report the findings from the analysis of the qualitative interview data. Quantitative survey findings were presented in a report to the Human Trafficking Institute and are available on UYDEL’s website [ 16 ].

Participant sampling and recruitment

Participants were recruited from all five divisions (Nakawa, Central, Rubuga, Makindye and Kawempe) of the greater Kampala district in Kampala, Uganda. A snowball sampling approach was taken in which youth who were in contact with UYDEL who had been forced to beg/sell goods or were engaged in commercial sex were approached by service providers for participation in a quantitative survey about their experiences of exploitation. Participants were compensated Ugandan Shilling (UGX) 5000 (approximately $1.34, €1.24) upon completion of the survey and received UGX 5000 for each additional participant (up to a maximum of three) that they recruited to the study. The survey covered demographic characteristics, migration decisions and debt situations, work conditions and earning experience, workplace abuse and help-seeking behavior. From the group of survey completers, participants were recruited for qualitative interviews with an emphasis on recruiting those participants who were trafficked and had experienced severe exploitation, i.e. participants who experienced various forms of exploitation across multiple survey indicators. Determination sex trafficking and adult forced labor was made in accordance with the United Nations trafficking definition [ 1 ]. A stricter definition of child forced labor was applied, requiring elements of force, fraud, or coercion in accordance with International Labor Organization guidance [ 17 ]. Interested participants were provided with dates and times that UYDEL field staff would be on site and available to conduct qualitative interviews to eliminate the need to record participant contact information. From this purposively sampled population, a convenience sample of ~ 50–60 participants who had experienced sex trafficking and forced begging or selling of goods, respectively, who were able to speak either Luganda or English, and were available at the times interviewers were present, were interviewed.

Data collection

Semi-structured interviews were conducted by six female UYDEL field staff fluent in Luganda and English with a background in social work (for a completed consolidated criteria for reporting qualitative research (COREQ) checklist see Additional file 1 : Appendix A). Participants were asked about their personal history, trafficking recruitment, experiences of exploitation and abuse, and experiences seeking help from justice and social agencies (interview guide included in Additional file 2 : Appendix B). Field teams were trained to recognize severe emotional distress and if distress indicators were present, participants were excluded from participation.

All interview participants provided consent (adults) or assent (children) prior to participation. To protect interview participants, a waiver of parental permission was obtained for children participating in the study as some had been placed into forced begging, selling of goods, or commercial sex work by their parents, and others were at risk of negative repercussions if their parents were to gain knowledge of their involvement in the commercial sex work industry. Age and literacy level appropriate consent/assent forms were read aloud to participants, and a hard or electronic copy was provided for participants to read along and keep.

Following informed consent/assent, interviews were conducted in a private room at a community-based organization or in private spaces in the communities where the participants were recruited with no one but the interviewer and interviewee present. Based on the participant’s preference, interviews were conducted in either English or Luganda and audio recorded with permission to facilitate transcription. Interviews lasted 40 min on average. Participants completing qualitative interviews were compensated UGX 5000 for their time. All individuals approached for study participation were provided a resource card with information on where to access services. Interviews were transcribed and translated into English when necessary by multilingual transcribers. Any mention of potentially identifying information by participants in the interviews was redacted and deleted from transcripts.

Data analysis

Conceptual framework of human trafficking.

To guide the analysis, elements from the 2011 human trafficking conceptual model and the 2017 framework of the socioeconomic determinants of labor exploitation and harm by Zimmerman et al. were combined by the research team to conceptualize human trafficking in the Ugandan context (Fig.  1 ) [ 4 , 7 ]. The adapted conceptual framework characterized human trafficking as a multi-stage trajectory which starts with an individual’s life pre-trafficking (stage 1) in which risk and protective factors determine their vulnerability to being trafficked. At a certain point in time, individuals may be approached by an intermediary and recruited to a place of exploitation, or themselves travel to a new context where they are subsequently recruited. During this recruitment and travel/transit stage (stage 2), several risk and protective factors contribute to an individual’s vulnerability to progress to exploitation. During travel and transit, individuals may experience their first exposure to exploitative practices and harm and the associated health impacts. At this stage, barriers and facilitators influence the extent to which individuals are able to seek help. After initial recruitment, most individuals will continue to the exploitation stage (stage 3) in which they are exploited and harmed leading to negative health impacts. Various risk and protective factors influence how long individuals remain in the exploitation stage. Depending on the barriers and facilitators that are present, individuals may or may not be able to seek help during this stage to improve their circumstances. Help can take on many forms and can have an impact on the individual’s health. While for some individuals, exploitation ends and they can integrate back into society after being exploited (stage 4), many remain in exploitation or exit and are re-trafficked resulting in multiple cycles of exploitation.

Human trafficking framework adapted from Zimmerman et al. [ 7 ]

Interview transcripts were split into two groups by a human trafficking expert on the research team according to whether the type of exploitation described was forced labor or sex trafficking. If both exploitation types were experienced, the focus of the interview determined to which analysis group or groups the transcript was assigned. The two groups of interviews were analyzed using separate codebooks created through a combination of deductive and inductive thematic analysis. Open coding was applied to a random sample of 10 interviews by two researchers (AH, REK) independently to identify themes and subthemes. Identified themes and subthemes were subsequently organized using the adapted conceptual framework of human trafficking designed by the research team. Organized themes were compared between the two researchers and discussed until consensus on a preliminary codebook was reached. The codebook was then applied to the remaining interviews, which were divided equally between the two researchers (random assignment of first vs second half of the list of interviews). As new themes emerged from the interviews, the codebook was iteratively refined, and after every 10–20 interviews, codes were discussed between the two researchers, resolving unclarities and discrepancies by consensus. After coding all interviews, the findings were assessed for patterns in vulnerabilities to human trafficking throughout the human trafficking trajectory. Specifically, risk and protective factors for human trafficking were considered, health impacts of exploitation, and barriers and facilitators to seeking help. For each of these, differences between the lived experience of sex trafficking and forced labor victims were noted.

Demographic characteristics of the participants

Interviews were conducted in Kampala between March 2020 and November 2020 with a total of 108 participants. Of them, 72 participants had lived experience of sex trafficking, 31 participants had been subjected to forced labor, and 5 participants had been exposed to both types of exploitation (two analyzed as sex trafficking victims, one analyzed as a forced labor victim, and two analyzed in both groups). Most interview participants were female (80%) and the median age was 18 years (min 11, max 30 years). The interviews conducted with victims of forced labor focused on children under 18 years of age and consequently, interview participants exposed to forced labor were younger (median age 14 years versus 20 years) and had lower education levels than sex trafficking survivors (Table 1 ). Participants who were sex trafficking survivors were more frequently female than participants who were forced labor victims (97% vs 42%). Almost all interviews were conducted in Luganda.

Participants’ lived experience was explored through a public health lens. Various human trafficking risk factors, barriers to seeking help, and health impacts of exploitation and harm were identified (Fig.  2 ). Key findings are presented in Table 2 . Similarities and differences were observed between the experiences of victims of forced labor and victims of sex trafficking. Of note, participant quotes are presented to highlight experiences, risk and protective factors, and barriers and facilitators of interest, and therefore do not always contain all the data used to determine whether participants’ experiences met criteria for human trafficking.

Patterns in the lived experience of forced labor and sex trafficking victims

Warning: results section contains potentially disturbing content including graphic descriptions of violence, child abuse, sexual assault, and bestiality, which may be emotionally challenging to engage with . Reader discretion is advised.

Vulnerability resulting from life-circumstances pre-trafficking

Broadly, vulnerability could be split into two main categories, namely vulnerability resulting from financial hardship and vulnerability stemming from an abusive home situation. These vulnerabilities could co-occur. Participants described living in difficult circumstances in which there was insufficient money to meet basic survival needs including food, clothing, and medicine. Often, multiple family members were dependent on a single income. The need to repay a debt caused by medical costs, funeral costs or gambling addiction compounded financial hardship in some cases. One participant described, “ My mother has some debts in the village, however her debts are ever unending, school fees debts for my young siblings and also before the death of my father he left so many debts” (Forced labor, Female, age 11).

Financial difficulties repeatedly had a clearly identifiable trigger – the death of (one of the) the family breadwinner(s), usually a parent. Approximately half of all interview participants reported the death of a family member or caretaker. Causes of death varied and included disease, war, natural disasters, and suicide.

From primary one up to primary four, life was very easy because my dad was still there. I used to stay with my dad and my mum, and that is why life was very easy, but since my dad passed away, life became very hard. From primary five to primary six, up to primary seven, it was very hard because I was the one who was paying my [school] fees, struggling for it, and my mum didn’t have enough money. – Sex trafficking, Female, age 22

In situations of financial hardship, school fees were often an expense that could no longer be covered causing participants to drop out of school which explained the very limited education among interview participants. One participant regretted the consequences of her family’s economic circumstances for her schooling saying, “I stopped in primary six truthfully, because of school fees issues…I liked studying, but did not have the chance” (Sex trafficking, Female, age 18). In these dire circumstances of poverty, any work opportunity or offer to take the responsibility for a child or a child’s school fees off a parent’s hands, was considered very welcome. A participant described how her mother was presented with a financial opportunity saying, “So when she [participant’s mother] failed to get money, there was a friend of hers who told her that there was someone who wanted a maid this side of [medium size urban neighborhood in southern Kampala], so I came. But my mother was told that I was going to be a house girl, so I came thinking that too” (Sex trafficking, Female, age 17).

The second main determinant of vulnerability that could be identified in the interviews was an abusive home life. Interview participants gave accounts of beatings, neglect, mistreatment, withholding of food, sexual abuse, and being forced to carry out all the housework. Often, the abusive situation started when there was a new influence in the family, someone who was not a blood relative. One participant recounted how the abuse started when she moved in with her stepmother after her mother passed away:

My mother got sick and they took her to the hospital … When she died, my father took me to his mistress in [medium size urban neighborhood in Northern Kampala], that’s where we were staying, but she would mistreat me and I didn’t have any peace. … She would cook food and only give to her children, yet I was the one who would do all the work. – Sex trafficking, Female, age 18 My father gives a lot of attention to my stepmother. When she tells him something we had not done, he beats us, ties us on ropes, he starves us and [makes us] work all day. She doesn’t want to give us what to eat [something to eat]. When my father comes back, she tells him that we don’t want to work. There was a day I washed clothes. I washed three basins full of clothes. These big ones while she was beating me with a mingling stick [kitchen utensil] in the back. My back is paining! She could abuse my siblings telling them things like "Was I the one who killed your mother? You children don’t work!" While she treated her children like princesses, I even don’t know. They could also abuse us like that. – Forced labor, Male, age 15

Participants who did not feel safe or well-treated at home were often driven to run away and find alternative living arrangements. One participant described how he decided to leave the village and try his luck elsewhere saying, “I felt tired of the village… because in the village, it was pain and mistreatment. I was tired of being tortured and beaten in the village like a thief. I got fed up and decided to go to the city.” (Sex trafficking, Male, age 17).

The life-circumstances pre-trafficking that culminated in vulnerability to human trafficking were similar for participants who experienced sex trafficking and participants involved in forced labor.

Risk factors for recruitment and travel & transit

Among the interviewees, there was a general trend of movement from the village where participants grew up to the “big city,” Kampala. For some participants, recruitment into exploitation took place while they were still living in the village. Other participants traveled to the city first and were recruited from there. Participants were recruited by family members, friends, acquaintances and sometimes strangers.

Recruitment in the village

For participants who were trafficked from the village, an “opportunity” was often presented by traffickers that leveraged the vulnerability caused by financial hardship or an abusive home situation. For those who entered forced labor, it was often a family member or an acquaintance that offered to take participants in, cover their school fees, or provide them with work. In some interviews, the venue for recruitment was at the funeral of one of the participant’s caretakers at a time when it was unclear who would support the child. Others were approached during sports tournaments and dance performances.

When my father passed on … after the burial, there was a lady who was too, too close friend to my mother. She spent mourning for one or two weeks when she was around. She said she can help me get a job, telling my mother, because my mother had no capacity to take care of us. My siblings were so many yet I was the elder, so she said I should go and work. – Sex trafficking, Female, age 18

Another participant recalled how acquaintances had offered to take her in and cover her school fees after her father passed away saying, “ During father’s burial, there came his friends saying, ‘Am going to educate such a child. Give me this child'” (Sex trafficking, Female, age 16). The situation participants entered into, however, was rarely as promised. Instead of being sent to school, the children were put to work begging, selling, and collecting scrap. One participant described how her grandmother was deceived saying, “she said she would take me to school, so my grandmother accepted … because she didn't have money for my school fees. She just told me to go with her. When I reached there, it was only after one week and then she started giving me pancakes to sell” (Forced labor, sex unknown, age 11). Another participant spoke of false promises made by her uncle:

[I was] 5 years old when my uncle got me from the village and brought me here to Kampala in [small size urban location in the central business district of Kampala]. He told my parents that he was taking me to a certain school in Kampala that was offering full bursaries [scholarships] … My parents accepted because I was studying from the village and it was still hard for my parents to get school fees … I was so happy for the opportunity that I was offered, but to my surprise when I came to Kampala, things changed because after two days of my staying with them, the following day aunt decided to take me to the street so that we can beg together. I asked them, "What about the bursaries you told my father about?". My uncle told me not to question him but rather do as they say. – Forced labor and sex trafficking, Female, age 21

For participants that ended up in sex trafficking, the opportunity presented was usually a work opportunity in the city such as work in a house, hotel, or salon. Sometimes it was work that was already being done by a friend who appeared to be doing well. In many cases, the work opportunity turned out to be fictitious and what participants were actually being recruited for was commercial sex. One participant recalled how her friend visited and told her about her exciting life in Kampala saying,

One holiday, she came back to the village and told me that Kampala was so interesting. …I had a tough mother. One day, she [my mother] beat me and my heart ran to [I thought of] my friend. I said, "Why don’t I pick my things and I go?". When we came to the city, she [my friend] never told me anything. … When we arrived at [medium size urban neighborhood near the central business district of Kampala], she took me into a house but the house had only girls; I later discovered that the house was like a lodge. Men come in and use you and give you some money around five to ten thousand shillings. – Sex trafficking, Female, age 21

Once they started their new work opportunity, several participants were subjected to forced sex for the first time. These participants described a distinct initial trauma, typically rape by a customer or (a family member of) their employer. After going through this, they either chose to endure in their employment because they felt like there was no other option, or they left the work opportunity and found themselves living on the streets. After this initial gateway experience many resorted to engaging in commercial sex, and ultimately experienced sex trafficking.

When I was brought here, I was taken to her [the recruiter, a family friend’s] home. I studied for some little time while coming from her home. She was married and her husband raped me, so I left home. I met a friend who brought me here. – Sex trafficking, Female, age 23

Sometimes, participants were indebted to the trafficker who had recruited them from the village, making it difficult to leave their current situation. One participant recounted how she was not able to leave when she found out what she would be doing and said,

Yes, and that lady gave me a room and told me that I was going to start working from there, but I told her that I won’t be able to do it. But she said that I would work whether I liked it or not and that I didn’t know anyone in Kampala and that they also had to do that in order to survive. But I told her that I won’t manage and she assured me that I would manage. So when we reached, after two days, men started coming to me. The first one asked me, "Do you know this?" So, I asked him what he meant, but he just told me, "Set-up yourself quickly, I have other things to do and I have somewhere I am going". So, I also didn’t have a choice. So after five days had passed, I was getting used to it. I had nothing to do, nowhere to go, but in my mind I wanted to run. But I didn’t have a phone maybe to call my mother, had nothing on me that could help me go back home, so I just let it be. After two months I was used to everything. – Sex trafficking, Female, age 16

Recruitment in the city

The second group of interview participants reported coming to the city of their own volition, being abandoned in the city, or being put on a bus to the city by family members. Once on the streets, participants needed to find a means to survive. The lack of a place to go, not knowing anyone in the city, and lack of income put participants at risk of human trafficking. The limited educational background that most participants had left few options for a stable income. Many younger participants described finding safety in numbers by joining groups of street kids for survival. They then typically started doing the work that other street kids did such as collecting scrap metal, bottles, or selling soap. One participant shared his experience of first arriving in Kampala saying,

I stayed there in the city and started hustling. While I was there, I found people speaking our mother tongue. I joined them. They were home people, they understood me and I clung on them. They took me to their place. When we reached there, they told me that it was hustling throughout to sustain you. They told me that their bosses needed money therefore you had to go and look for it. I went into scrap; they took me to trenches, they have given me drugs to sell. There are those people we sell to. That is how I started living with them. – Forced labor, Male, age 15

For interview participants with lived experience of sex trafficking, who were typically older than the forced labor participants, having dependents, often children, added to the pressure to find work by any means. It was difficult to meet their own survival needs as well as those of their dependents, and they began engaging in commercial sex acts to provide for the family unit, which ultimately became a situation of sex trafficking.

I had two children! I have no job! I commenced from where I had ended. I had to look for money for both children. I could not even imagine the number of men I had to sleep with to get what to eat and yet I also had to look for money for rent. – Sex trafficking, Female, age 30 Sometimes a bad situation can drag you into something that you would not wish to do. ... First of all, I have to buy myself food, secondly I need rent, thirdly I needed school fees to educate my child. – Sex trafficking, Female, age 27

Human trafficking internationally

A minority of interview participants reported being trafficked internationally including to Malaysia and Dubai. One male participant described how a friend presented him with a work opportunity abroad that would allow him to pay back a debt he owed the friend,

[The friend] promised to take me to a money source so that we can work and earn. …The country he took me to was Malaysia. We arrived in a big house. We found some children, men, and girls going through torture and I asked my friend, "Is this the work you have brought me to do?" He said, "Don’t worry, this is where we get the money, and you yourself are the money." … Some of the boys would rape fellow boys. The girls were also raped. They would set cameras to record what we do and then take the recordings for sale to get money. – Sex trafficking, Male, age 19

The international setting compounded participants’ vulnerability to exploitation. Participants found themselves in a foreign country, often with no means of contacting their family, and frequently had their travel documents confiscated by the trafficker. One participant described, “ I was taken to a foreign country without my family knowing, and the contacts I had were just written on a paper. But after reaching Malaysia, they took everything we had. So, I had no way I could contact my family even if I got a chance of contacting them” (Sex trafficking and forced labor, Female, age 21).

Exploitation and its impacts on health

Once recruited, participants entered into a life of exploitation, which resulted in impacts on their health.

Forced labor exploitation

Participants who were exploited through forced labor described being made to collect different items such as scrap metal, bottles, and boxes from the street for their exploiter to sell. Others were forced to beg or steal. Participants often had to work long days, six or seven days a week, and were given almost no time off. One participant reported having no reprieve saying, “There is no resting day unless when there is scarcity of maize [if all the maize has been sold or if it has not been brought to the market yet]. That’s when we rest. However, if it’s seen on market, we go back to work.” (Forced labor, Male, age 14).

[I start work] at 06:00 or 05:00 in the morning....I work until 20:00, that's when I come back and of course I am always feeling tired, yet I actually have to figure out what to eat.....from the time I come back at 20:00, I eat well with what I have gotten from [medium size urban market in the central business district of Kampala] and then I go to beg ... I beg until midnight and then I come back ...I work six days in a week. – Forced labor, Female, age 17

The work frequently took place by the roadside exposing participants to the risk of road traffic accidents and environmental hazards.

Apart from that big accident, I got there some minor accidents. I get like a motorcycle knocking me, but causing minor injuries … Kampala Capital City Authority always chases us and we pass through big trenches where sewage passes, but remember we don't wear shoes because we don’t have them. – Forced labor, Male, age 13

Participants reported being harmed while carrying out their work. Most of the abuse forced labor victims were exposed to was physical. Participants described beatings from strangers, groups of older kids on the street, from customers that they sold their goods to, and from their trafficker/employers. Abuse that was mentioned included beatings with electrical cords, pouring of boiling water over them, being hit with heavy canes, being strangled, and being kicked. Psychological abuse also occurred, and participants reported being subjected to verbal abuse including insults and shaming, being threatened with beatings, not being allowed to leave without permission, and sometimes having food withheld as punishment.

Yes she forces me, when I don’t want to work. … she drags me and starts beating me severely and then she tells me to go and work. So when I come back at night, she tells me to do the housework while beating me and sometimes she ends up not giving me food. … She tells me to treat her well that she’s my mother and father...she ties me up and starts beating me and sometimes she undresses me which shames me in the presence of people. She brings my history that I am an orphan and how she got me from the rubbish pit. Then she strangles me. For sure, this situation treats me so bad and I hate myself. – Forced labor, Female, age 11

While most abuse among forced labor victims was physical, sexual abuse also occurred. Young age contributed to the vulnerability of forced labor victims. They were often dependent on others for their housing or dependent on older street children for safety while living on the street. Multiple participants provided accounts of rape and sometimes sexual exploitation by these individuals that they depended on.

So I decided to keep in the traffic jam selling such that by the time Uncle comes back he does not harass me. … I could come back home at around 10:00pm in the night and immediately he asks money from me and accompanying them with utterances like "You are coming from men". There, he forces you into the sexual acts telling me that "If you got no money, do not waste me, come over here or else I will chase you out of my home" and yet I had nowhere to go. There I bear with and I give in to him. – Forced labor, Female, age 16

For many forced labor victims, the trafficker was a family member. Victims lived with this family member and were dependent on them for food, housing and other essentials. They typically had to hand over all the money they earned and were extremely isolated.

Health impacts of forced labor

The abuse and dangerous exposures victims of forced labor faced in their work resulted in physical injuries that sometimes necessitated hospital admission. Reasons for consulting a healthcare professional described by forced labor victims included road traffic accidents, stepping on broken glass, and injuries from blunt and penetrating force trauma inflicted by others. The impact of their experiences on mental health was also significant and participants described how their life burdened them, how they felt sad and hated themselves.

Sexual exploitation

Interview participants with lived experience of sex trafficking described sexual exploitation with varying degrees of control by the exploiter. The most common situation described was that of commercial sex at a bar or lodge where the exploiter determined which customers participants saw and which types of services they provided them. Customers were seen on the lodge or bar property. Sex trafficking victims were exposed to physical, sexual, and psychological abuse during their work. Physical abuse was perpetrated by customers and employers. Participants described beatings, strangulation, being hit with a belt, cable, or brick, and being stabbed.

I have ever been hit with a bottle; customer came and we did what we had to do. Then he told me that he had no other money yet he wanted another round. So, I told him I was leaving and going somewhere else. When I was leaving, he hit me with a bottle....I don’t really know, that’s when I stopped understanding. – Sex trafficking, Female, age 16 Yes, she [exploiter] cut me with a knife here. I had refused to do what she wanted me to do. She had told me to go and sleep with a man and get money because the man had promised her 50,000 UGX so she told me to sleep with him. I said "No, I will not. What if the man is already infected with a disease and I die?". She said to me, "Haven’t you heard what I told you?". She instead beat me, got a knife which was on a table that she used it to cut me. She told me to go inside the house and stay there, I will not be given food, so I went. – Sex trafficking, Female, age 15

Common triggers for violence towards victims included participant refusal of sex without a condom and disputes over the price of services. There were many accounts of customers refusing condoms, or removing the condom before sex.

When I told him about wearing a condom, he pulled out a knife and put it on me. When he put the knife on me, I plead for mercy. I pleaded with him to have mercy on me. He had really put the knife and told me that I didn’t know the person I was playing with. "I can kill you and leave you here dead and then move away. Where will you find me?" He ignored my plea and still fucked me without putting on a condom. – Sex trafficking, Female, age 27 We always feared contracting it [human immunodeficiency virus (HIV)], but as you know men of nowadays, they come with condoms but leave them at the table. You try to quarrel a bit but they are strong and would tell your boss. We were at the mercies of God. – Sex trafficking, Female, age 21

Initiation into sex trafficking frequently happened through rape, sometimes by multiple people, and in some cases was preceded by drugging the participant. One female explained,

When they took me to a room, they used me. The man used me. After him using me, he was using my anus. When I was sobering up, I felt myself weak. I did not understand what was going on. When I started gaining my sight, I was seeing three men. I did not understand. They were big. I was nude. They had gotten their phone and were taking pictures of me while laughing. I felt my anus paining a lot. I think they took when I was not sober. When I gained my consciousness, I understood that these men had sex with me through my anus. They got out. – Sex trafficking, Female, age 23

Vaginal, anal, and oral rape occurred. In a number of interviews, participants described being subjected to bestiality with dogs and horses.

He brought his two men and caught both my legs and hands. Then he put his dog on me. That day it was not easy because even the dog scratched me in the ear at the beginning. … He then told me that, "It is you who caused it to do this, but if you come when you are calm, it doesn’t hurt in any way". I also started to learn the behaviour of the dog… They could dress it on a condom. He did not want his dog to get sick. – Sex trafficking, Female, age 16 In the morning, girls would be taken to kennels to sleep with dogs; the dogs would have sex with them. The medicine that was injected in us would make the girls seductive to themselves and they would be put to the kennels and let the dogs do all they want to them. The girls would cry, but they had no way out because they would be tied. The medicine injected in boys would enlarge our penises and they would send us to the horses. The horses also seemed to be used to this kind of treatment. You would have to have sex with the horse. – Sex trafficking, Male, age 19

Participants were frequently verbally abused and threatened verbally or with weapons. Their movement was often limited by their exploiter and sometimes food was withheld. Participants had to work when they did not want to and sometimes had to work even when sick. Money was paid either directly to the exploiter who later gave a small proportion to the participant, or participants received money from the customers directly but had to give most of it to their exploiter. It was a common occurrence that customers would not pay after sex or paid less than they had promised. When participants received money from their exploiters, sometimes unexpected fees were deducted such as the cost of the room they worked from or the cost of their meals at the bar.

Health impacts of sex trafficking

The health impacts of sex trafficking were significant. Health impacts could be grouped into three main categories, namely urogenital injuries (i.e., injuries of the urinary or genital organs), musculoskeletal injuries (i.e., injuries relating to bones, muscles, and soft tissues) and mental health consequences (i.e., disturbance in mood, cognition, and the ability to interact with others). Through their work, participants were at high risk of acquiring sexually transmitted infections (STIs) including HIV. One participant described the physical discomfort she felt saying, “I got sick; I first got these diseases that catch in the private parts. It would be hard for me to walk. I would feel pain. When I go to urinate, the urine wouldn’t come out properly, it would be hurting every time I urinated” (Sex trafficking, Female, age 18). Another participant reported contracting multiple STIs saying, “First of all, I contracted HIV/AIDS (acquired immunodeficiency syndrome). We get syphilis infections, candida and those others illnesses that is the second. The third illness that I see coming, if I don't fight for myself, is death.” (Sex trafficking, Female, age 21).

Rape and rough sex caused vaginal and anal injuries leading to the development of fistulas and incontinence problems. Participants described abdominal pain and localized genital pain impacting their ability to sit and to walk. One participant reported fecal incontinence saying, “I did not have brakes behind. Wherever I sat, stools would just flow out. I was treated badly. I could not even sit at times. I would feel a lot of heat at my bottom and pain.” (Sex trafficking, Male, age 17).

Multiple interview participants reported becoming pregnant through their work. Some participants kept the pregnancy and others sought an abortion.

I have only one child, she is 7 months old, but I was not ready to have a child because I was working on the streets and I got pregnant because I did not have safe sex … Yes, I was looking for clients and that is how I got pregnant. I could have aborted it, but I did not have money for abortion. And the little money that I had, I was using it for rent. – Sex trafficking, Female, age 20

Blunt and penetrating trauma inflicted by customers or exploiters resulted in bruises, wounds and fractures that sometimes required hospital care. A participant listed the different places where she had been wounded saying, “Some of us have scars. Like me, I have scars at my back. They cut me with a blade. I have scars in my face” (Sex trafficking, Female, age 20).

The experiences participants went through in their exploitation impacted their mental health. Multiple participants reported taking drugs or alcohol to be able to endure and described how others in their line of work had developed addiction. One participant explained how he used substances as a coping mechanism, saying “You still get some problems. Nowadays, if I am going to do it [sex work], I first sniff some fuel or take drugs to relieve the pain. They do it while I am high” (Sex trafficking, Male, age 17).

Some participants suffered from flashbacks and intrusive thoughts and displayed depressive symptoms. A minority of participants described times when they had suicidal thoughts and ideations. They told of feeling worthless.

Sometimes I pretend around so that they can pass and forget them, but am hurt inside. However much you see me eating and smiling, for sure I really don’t mean it. My heart is filled with something more than sorrow...You don’t know the sadness we have faced on this Earth! You don’t know what it means to sleep with a man you have just met on the street and then you have sex with him without you having feelings for him. – Sex trafficking, Female, age 30

Ongoing vulnerability

Lack of financial means was one of main factors contributing to ongoing vulnerability for both victims of sex trafficking and forced labor. While sex trafficking victims earned money through their work, after rent, food, and other basic necessities were deducted, there was usually little left to save. In many cases, the money participants earned was sent to help support dependents. Other lines of work usually earned less or required initial capital which participants did not have. Some participants reported being part of a savings club, or trying to put aside money themselves, but this was a slow process. For forced labor victims, there was the added complication that in many cases, the trafficker was a family member with whom they lived. This person was their source of housing, meals and all basic necessities. Participants had nowhere else to go, they were frequently underage, and because of their lack of education, had few other employment prospects. One participant explained the hopelessness of her situation saying, “No, l will stay with my stepmother [exploiter] because she’s the only family I have, however much she mistreats me. If I try to do it, she can call the chairman, people in the village, and also beat me to death” (Forced labor, Female, age 11).

Barriers to seeking help

While being exploited, participants experienced many barriers to seeking help. A major barrier was the lack of awareness of the organizations and resources available to them. Most participants were unable to list any organizations that could help them by name. Among participants that had sought help, the police and healthcare professionals were the most frequently approached. Participants recounted having reported stolen property, rape and in a few select cases, the trafficker, to the police. Physical injuries and STI symptoms were the most common reason medical staff were consulted. However, encounters with these professionals were not always positive experiences. One participant described how he was not believed when he reported sexual assault to the police,

At night, he wanted to sodomize me … While I was asleep, he started to remove my trouser. I ran away and went to the police. When I reached at police, I narrated my story, but they instead called me a mad person. They said that I didn’t wear my trouser properly and my words were false. – Forced labor, Male, age 13

The fact that many help services required money including services like filing a police report, receiving medication, and getting an abortion, acted as a deterrent to seeking help. In some cases, when participants did not have the required money, help services employees exploited participants’ vulnerability and requested sexual favors instead.

By the time you take there your case to him [police officer], and he is aware that you are a sex worker, he doesn’t take you as someone important … he wants to use you. Not once! Not twice! Many have been taken advantage of in the offices. You take there your case and the man says that, "If you want my help, first remove your underwear". Will you refuse? If you refuse, your case won’t be worked on. – Sex trafficking, Female, age 30

Fear also played a strong role in participants’ decision to not seek help. Participants reported feeling threatened by the trafficker who warned them that they or their family would be hurt or killed if they left or talked to anyone about the exploitation. Participants also feared the help services describing that sometimes help services were complicit in the abuse, worked together with the trafficker, or were the clients of their exploitation.

Going to the police … you might want to take there your issues and you find that they know her [exploiter]. So, there is nothing they are going to help with. Instead, you are the one who is considered to be in a mistake when you reach. I had a friend of mine sometime back who went there [the police], but it ended on her being imprisoned. She is the one who was taken to be having a criminal case. Like now the police that is nearby, they know our boss. So, even if went there, would be no help. – Sex trafficking, Female, age 23

Sometimes seeking help was made difficult by restrictions on freedom of movement and communication placed on participants by the trafficker.

Where would you report? There was nowhere to report. They could not even allow moving out of that house. …We were inside there as prisoners. At the gate, there was a security guard and he was commanded that anyone that dared to move out, bullet. There were even two of our friends that were killed when they tried to escape. – Sex trafficking, Female, age 24

Especially in those cases where the trafficker was a family member (mainly for those involved in forced labor) participants’ loyalty and personal ties to the trafficker caused them to be conflicted about seeking help. One participant described this dilemma saying, “I don’t want the police to arrest my mother, because [participant becomes emotional] I love her so much” (Forced labor, Female, age 12).

If the trafficker were to be arrested, participants would lose their source of income which caused some participants to be hesitant about seeking help.

Shame and fear of gossip also formed important barriers to seeking help. Participants were weary of confiding in others, and in many cases their family was unaware of the exploitation. A participant explained why she could not open up about her situation saying, “ Some people are not easy. You tell them your problems and they will tell them to anybody else. So it is better to stay quiet and live on.” (Sex trafficking, Female, age 15).

Facilitators of help-seeking

A minority of participants were aware of different non-governmental organizations (NGOs) that offered assistance to victims of human trafficking. These organizations offered services like legal counsel and sometimes vocational training. In those cases where participants sought help, this sometimes had a positive impact. Incidents were described in which seeking help from the police led to the recovery of stolen goods and the arrest of perpetrators. Similarly, seeking medical care contributed to resolution of physical symptoms. Multiple participants also reported receiving help from strangers. Usually, this help was a one-off and consisted of receiving a small amount of money, some food, or assistance with transport. Support was also offered by friends and co-workers. Participants reported appreciating the ability to confide in them and share their experiences. The advice they received from their social network, however, was often not very useful and was usually limited to encouragement to endure.

Interviews with victims of forced labor and sex trafficking in Kampala, Uganda, illustrate the complexity of human trafficking and reveal the substantial physical and psychological morbidity associated with it. Vulnerability to human trafficking can be traced back to financial hardship and abusive home situations in rural villages not uncommonly triggered by the death of a victim’s caretaker. These dire circumstances may cause children to drop out of school and accept work opportunities and promises of a better life that are offered to them. When these opportunities and promises prove false, their limited educational background coupled with the unfamiliar surroundings they find themselves in, where they lack a support system and the basic needs for survival, leave them vulnerable to being trafficked. Their lack of other employment prospects stemming from curtailed education, little to no vocational training, and reliance on income from trafficking for survival, sustain the cycle of exploitation. Victims are generally unaware of organizations that can offer assistance and help is rarely sought out of fear of retribution by the trafficker and other negative consequences. Negative accounts of what happened when participants did seek help, including not being believed, accusations of criminal activities, shaming, and exploitation of their vulnerability, illustrate that this mistrust is not always misplaced.

The victims of human trafficking who participated in this study reported being exploited, exposed to dangerous working conditions, and suffering a host of horrific forms of abuse. Physical abuse and hazardous working conditions led to injuries including lacerations, contusions, and fractures. Forced unsafe sex put forced labor and sex trafficking victims at risk of sexually transmitted diseases, unwanted pregnancy, and the debilitating sequalae of traumatic fistulae. Human trafficking victims in this study were systematically made to feel worthless and depressive symptoms, symptoms of post-traumatic stress disorder, and negative self-perception were common. Our findings are in line with data from other human trafficking studies in Africa which showed psychological, sexual, and physical violence against human trafficking victims at different stages of the trafficking cycle [ 18 , 19 , 20 , 21 ]. For example, in a mixed-methods study among human trafficking survivors in Nigeria and Uganda, sexual violence and hunger were reported during transit, and abusive working conditions, restricted freedom, and sexual and physical violence were reported during the exploitation phase [ 18 ]. A retrospective cohort study in Ethiopia among 671 trafficked women found prevalent sexual violence during predeparture, in transit, and the trafficking destination [ 19 ], and among 43 trafficked children in Ghana, maltreatment including starvation, sleep deprivation, denial of healthcare, and verbal and physical abuse was found [ 21 ].

The interviews make it clear that much of the vulnerability to trafficking in Uganda is rooted in structural factors like poverty. While the Government of Uganda has made strides in poverty eradication and has succeeded in lowering the proportion of the population living in monetary poverty from 56% in 1992 to 21% in 2017, a United Nations Children's Fund (UNICEF) report revealed that nearly half of Ugandan households (47%) continue to experience multidimensional poverty [ 22 ]. Poverty is not uniformly distributed in Uganda with a higher prevalence of multidimensional poverty found in rural (55%) compared to urban (23%) settings, which most of the interview participants originated form [ 22 ].

Despite the existence of the Universal Primary Education (UPE) program, under which primary education in Uganda is free, hidden costs associated with uniform purchase, school meals and examination fees are the motivation behind stopping education for six out of ten children who leave school [ 23 ]. Our interviews confirm this finding, illustrating how the additional costs associated with school attendance form a barrier to education for children from families facing financial hardship. Research shows that girls in Uganda in particular suffer from financial barriers to education as male children are often prioritized when funds are insufficient [ 23 ]. Discontinuation of education is problematic given the strong correlation between education levels and the likelihood of attaining stable employment for young people in Uganda [ 24 ]. The financial hardship described in our interviews was often triggered by the death of a caretaker, with almost half of interview participants reporting to have lost a family member. The apparent ubiquitousness of early death in this setting, also noted in other human trafficking research from Uganda and Nigeria, is a worrying public health finding in and of itself and raises questions about the cause of this mortality [ 18 ]. The HIV epidemic, armed conflict and natural hazards and disasters likely contribute to these untimely fatalities, once again underlining the need for holistic public health interventions. Research from other African settings shows limited human trafficking awareness, particularly in rural areas and among youth. This lack of awareness among potential victims and others in a position to protect them makes it unlikely that they will question opportunities offered to them, feeding into trafficking vulnerability [ 25 , 26 ].

We discovered that despite the substantial barriers victims faced to help-seeking, they succeeded in accessing health services for the somatic sequelae of exploitation. Services sought commonly included treatment for acute injuries and illnesses as well as reproductive health services. This highlights the unique position that healthcare workers are in as some of the few professionals that interact with this largely hidden and highly isolated group [ 27 , 28 , 29 ]. Health workers have successfully been leveraged in Uganda to improve access to care for other marginalized groups such as men who have sex with men and may be able to play a role in administering human trafficking interventions [ 30 ]. As a result of low awareness and gaps in knowledge among health professionals, however, human trafficking is often not recognized and opportunities to identify and help trafficking victims are missed [ 31 , 32 , 33 , 34 ]. Providers lack training on the issue of human trafficking and do not feel confident in their ability to identify victims [ 35 , 36 , 37 ]. Training for healthcare workers needs to be developed and woven into medical curricula or provided as continued medical education to ensure providers possess the skills necessary to identify trafficked persons and provide trauma-informed care [ 38 , 39 ]. Assessment tools to help providers recognize high-risk patients may be helpful in this regard, but few are validated for healthcare settings, especially in low- and middle-income countries.

Once victims are identified, it is imperative that health workers have the resources necessary to safely and appropriately respond to their complex needs. Health systems should have response plans in place which provide practical clinical guidance to health professionals and connect trafficking victims with available services [ 40 ]. More research directed towards contextualized and locally specific solutions needs to be funded to determine the best approaches. Interventions that are offered or assistance programs that survivors are linked to should go further than solely addressing medical complaints. Stakeholders involved in the response to human trafficking have emphasized the importance of offering integrated comprehensive interventions and advocate for a ‘one-stop-shop’ at which survivors of human trafficking can receive all the services they need [ 41 ]. In a qualitative needs assessment conducted in Ethiopia among key human trafficking stakeholders including service providers, academics, lawyers, and NGO workers, stakeholders underscored that an array of services including shelter, food, legal support, and vocational training should be provided that meets the complex needs of trafficking survivors [ 41 ]. Stakeholders highlighted that trafficking victims themselves often consider financial and employment needs to be of greater priority than their physical and mental complaints [ 41 ]. A qualitative analysis of in-depth interviews with 37 human trafficking survivors in Ghana who had completed a 9-month post-trafficking assistance program demonstrated that ensuring access to basic necessities including food, clothing, hygiene and sanitation allowed survivors to focus on developing the vocational skills they would need to start a micro-business after program completion [ 42 ]. Human trafficking survivors were found to often lack basic life and survival skills as a result of the young age that they left home. By assigning them roles and responsibilities, the program ensured that survivors were informally provided with critical skills including cooking, caring for a home, decision making, and effective communication [ 43 ].

The accounts collected in this study emphasize the public health burden associated with human trafficking and the need for interventions that interrupt the human trafficking trajectory. Possible interventions might be grouped into interventions aimed at decreasing vulnerability in villages pre-trafficking, services to support high-(trafficking)risk individuals surviving on city streets, and programs aimed at identifying those in exploitation to facilitate presentation of an exit strategy to reintegrate back into society. Multi-level interventions are necessary to prevent human trafficking [ 44 ].

Based on our study findings, we offer the following recommendations. Interventions are needed at all stages of the human trafficking trajectory (Fig.  1 ). In Uganda, pre-trafficking vulnerability can be addressed through poverty eradication, supporting families in financial need through covering school fees, strengthening health systems, and raising awareness about human trafficking in rural villages. The transition from recruitment to exploitation can be disrupted by advertising free resources to victims at transits centers and other entry points to the city, outreach activities for at risk-youth on the streets of Kampala, and the creation of drop-in centers. The unique position of healthcare workers can be leveraged to identify human trafficking victims and link them to available services. To achieve this, training in the recognition of human trafficking and the provision of trauma-informed care is needed, as well as the development of comprehensive after-care programs.

Our findings should be considered in the context of the study’s limitations. Snowball sampling was used to obtain the sampling frame that yielded the interview participants. Youth already working with UYDEL were asked to assist in study participant identification which may have led to the recruitment of individuals in their direct social circles, perhaps individuals less isolated than other trafficking victims. For the in-depth qualitative interviews, trafficking victims with severe forms of exploitation based on their survey answers were oversampled and their experience may not be representative of all human trafficking victims. Some of the study participants, mainly those with lived experience of forced labor, were as young as eleven years old at the time of participation. Considering their young age and limited educational experience, a different interviewing technique may have been more effective. Finally, the reported findings represent the experiences of the interview participants and may not be generalizable beyond the study population.

Human trafficking is an issue of serious global public health concern. In Uganda, structural determinants including poverty and dysfunctional family dynamics force children to drop out of school and drive them into a life of exploitation. Forced labor and sex trafficking victims suffer a host of physical, sexual and psychological abuse during exploitation which results in detrimental short- and long-term health impacts. Fear, lack of awareness, restrictions on movement, and a high degree of dependence on exploiters prevent victims from seeking help. Victims are extremely isolated and healthcare providers and the police are some of the few professionals with whom victims interact, but oftentimes with negative consequences. The improved localized understanding of the human trafficking trajectory in Uganda and its drivers gained through this study can inform the design of interventions to address and prevent human trafficking.

Availability of data and materials

The interview recordings and transcripts generated and analyzed as part of the current study are not publicly available due the sensitive nature of some of the topics covered and potential for identification of the participants, but will be made available by the corresponding author on reasonable request.

Abbreviations

Acquired immunodeficiency syndrome

City University of New York

Human immunodeficiency virus

Non-governmental organization

Sexually transmitted infection

Ugandan shilling

United Nations Children's Fund

Uganda Youth Development Link

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Zimmerman C, McAlpine A, Kiss L. Safer labour migration and community-based prevention of exploitation: The state of the evidence for programming. The Freedom Fund and London School of Hygiene and Tropical Medicine; 2015.

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Acknowledgements

We are grateful to the survivors of sex trafficking and forced labor who were willing to gift their time and in some cases risk their safety to share their lived experiences. We appreciate the dedication and compassion of the UYDEL research assistants without whose efforts this study would not have been possible.

The Prevalence of Forced Begging and Sex Trafficking in Kampala, Uganda study was funded by the Human Trafficking Institute [grant number 7H270-00–01]. The Human Trafficking Institute was not involved in study design, data collection, analysis, and interpretation or in the writing of this manuscript.

Human Trafficking Institute,7H270-00-01

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Robin E. Klabbers & Kelli N. O’Laughlin

Department of Global Health, University of Washington, Seattle, WA, USA

Independent Research Consultant, New York, NY, USA

Andrea Hughes

Marron Institute of Urban Management, New York, NY, USA

Meredith Dank

Uganda Youth Development Link, Kampala, Uganda

Mutaawe Rogers

Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, USA

Hanni Stoklosa

Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA

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AH and MD were involved in the study conceptualization and design, and MR was involved in data collection. AH, HS, KNO, MD and RK participated in qualitative analysis and codebook design. AH and REK read all interview transcripts and applied the agreed upon coding framework. REK drafted the study manuscript with input from HS. All authors provided feedback on the manuscript and approved the final version.

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Correspondence to Robin E. Klabbers .

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Ethical approval for the Prevalence of Forced Begging and Sex Trafficking in Kampala, Uganda study was obtained from the John Jay College of Criminal Justice Institutional Review Board at City University of New York (IRB File #2019–0886) and Makerere University School of Social Sciences Research Ethics Committee (MAKSS REC 10.19.344). Additionally, final approval was obtained from Uganda National Council for Science and Technology (SS 5156) prior to the start of data collection.

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The authors declare that they have no competing interests.

Supplementary Information

Additional file 1:.

Appendix A. Completed consolidated criteria for reporting qualitative research (COREQ) checklist.

Additional file 2:

Appendix B. Interview guide questions.

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Klabbers, R.E., Hughes, A., Dank, M. et al. Human trafficking risk factors, health impacts, and opportunities for intervention in Uganda: a qualitative analysis. glob health res policy 8 , 52 (2023). https://doi.org/10.1186/s41256-023-00332-z

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The Fight Against Human Trafficking

Sidebar to the article Crime Victim Awareness and Assistance Through the Decades by Stacy Lee.

Human trafficking continues to be a research priority for NIJ; however, many challenges are involved. For example, victims are highly vulnerable and largely hidden from the public, which makes it particularly difficult to obtain accurate statistics on the amount of people trafficked per year.

The United Nations defines human trafficking as “the recruitment, transportation, transfer, harboring, or receipt of persons by improper means (such as force, abduction, fraud, or coercion) for an improper purpose including forced labor or sexual exploitation.” [1] On October 28, 2000, the Victims of Trafficking and Violence Protection Act of 2000 (TVPA) [2] became the first comprehensive federal law to address the issue and provided a three-pronged approach: prevention, protection, and prosecution. On November 15, 2000, the United Nations General Assembly passed the United Nations Convention Against Transnational Organized Crime and the Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children. [3]

“The passage of the TVPA launched trafficking in the spotlight,” said Amy Leffler, a social science analyst who manages NIJ’s Human Trafficking Portfolio. “Since that time, NIJ has developed a robust trafficking research portfolio, which continues to focus on five core areas of knowledge: the nature and extent of trafficking; identifying and investigating traffickers; prosecuting traffickers; services for trafficking victims; and reduction in demand for trafficking.”

Over the years, NIJ-funded research has revealed many important details about both labor and sex trafficking, which has helped guide policy and practice throughout the country. For example, an official White House statement on the passage of the Allow States and Victims to Fight Online Sex Trafficking Act of 2017 (FOSTA) cited a 2014 NIJ-funded study by the Urban Institute. The study reported that the internet introduced new markets for sex work and sex trafficking advertisement and recruitment, and that persons seeking to commit a crime consider pimping to involve less risk than other crimes, such as drug trafficking. According to the study, pimps move in circuits among other cities with underground commercial sex economies and use social networks to gain information and arrange transport. They also rely on people already under their control to recruit others for sex work. [4]

“This groundbreaking study not only provided the first scientifically rigorous estimates for the revenue generated in the underground commercial sex economy, but also included rich qualitative analysis of trafficking operations, law enforcement perceptions and response, and victimization,” Leffler said.

Understanding more about the victims of trafficking is important as we strive to better identify this population. A 2011 NIJ-funded study by the Urban Institute found that most labor trafficking victims were recruited to come to the United States from within their home country, which was usually in Latin America or Asia. The study found that 71% of the victims surveyed came to the United States legally on a temporary visa. However, by the time they escaped their labor trafficking situation and pursued help from a service provider, 69% had lapsed visas. The employers often used immigration status as a threat to control their victims along with other forms of force, fraud, and coercion. Labor trafficking occurred in many industries, the most common being agriculture, domestic service, and hospitality. [5]

Also in 2011, the Vera Institute of Justice used NIJ funding to develop, test, and validate a screening tool for victims of human trafficking. It determined that 87% of the screening tool questions identified human trafficking victimization and 53% of the 180 screening question respondents were human trafficking victims. The final report indicated that the screening tool has the potential to help not only victim service providers but also investigators and prosecutors of human trafficking cases. [6]

Evaluation of victim services is important for gauging proper protection and prevention of such crimes. In 2009, NIJ awarded a grant to RTI International to evaluate three programs funded by the Office for Victims of Crime (OVC) that serve victims of sex and labor trafficking who are under age 18. The study found that human trafficking victims are diverse and, although these programs did relate to some trafficked youth, they did not meet the needs of others. It ultimately determined that “OVC-funded programs offered unique expertise in trauma and resiliency, understanding of street economies, and the ability to align themselves with young people in a way that formal agencies rarely could.” [7]

To gain a holistic understanding of human trafficking, we must understand the demand. A 2008 NIJ-funded study by Abt Associates examined criminal justice strategies and collaborative programs around the country that decrease the demand for commercial sex. As a result of the study, the website DemandForum.net was launched in 2012. The website details successful tactics used around the country to deter men from buying sex and offers a guide for cities, counties, and practitioners to begin, improve, and maintain anti-demand initiatives. [8]

NIJ-funded research [9] has shown that human trafficking can happen anywhere in the United States; it does not occur only in large cities. There is a common misconception that human trafficking victims are mostly brought to the United States from other countries; however, many victims are U.S. citizens. Leffler stated that NIJ remains committed to research that will develop the building blocks needed to better understand sex and labor trafficking and the unique challenges that affect victims, law enforcement, and the judicial system, and also to dispel misconceptions and provide clarity to this complicated crime.

[note 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 Office on Drugs and Crime, April 2009.

[note 2] Victims of Trafficking and Violence Protection Act of 2000 , U.S. Department of State, Pub. L. 106-386, 114 Stat. 1464 (2000).

[note 3] United Nations Convention Against Transnational Organized Crime and the Protocols Thereto, United Nations Office on Drugs and Crime, 2004.

[note 4] Meredith Dank et al., “ Estimating the Size and Structure of the Underground Commercial Sex Economy in Eight Major US Cities ,” Final report to the National Institute of Justice, grant number 2010-IJ-CX-1674, March 2014, NCJ 245295.

[note 5] Colleen Owens et al., “ Understanding the Organization, Operation, and Victimization Process of Labor Trafficking in the United States ,” Final report to the National Institute of Justice, grant number 2011-IJ-CX-0026, October 2014, NCJ 248461.

[note 6] Laura Simich, Lucia Goyen, Andrew Powell, and Karen Mallozzi, “ Improving Human Trafficking Victim Identification - Validation and Dissemination of a Screening Tool ,” Final report to the National Institute of Justice, grant number 2011-MU-MU-0066, June 2014, NCJ 246712.

[note 7] Deborah Gibbs, Jennifer L. Hardison Walters, Alexandra Lutnick, Shari Miller, and Marianne Kluckman, “ Evaluation of Services for Domestic Minor Victims of Human Trafficking ,” Final report to the National Institute of Justice, grant number 2009-VF-GX-0206, January 2015, NCJ 248578.

[note 8] Michael Shively, Kristina Kliorys, Kristin Wheeler, and Dana Hunt, “ A National Overview of Prostitution and Sex Trafficking Demand Reduction Efforts ,” Final report to the National Institute of Justice, grant number 2008-IJ-CX-0010, June 2012, NCJ 238796.

[note 9] The studies highlighted here are a small sample of the research that NIJ has funded on human trafficking. For more information, visit NIJ.ojp.gov .

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Innovations in empirical research into human trafficking: introduction to the special edition

• Published: 25 July 2019
• Volume 72 , pages 1–7, ( 2019 )

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• Ella Cockbain 1 &
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When it comes to human trafficking, hype often outweighs evidence. All too often, the discourse on trafficking – increasingly absorbed under discussions of so-called ‘modern slavery’ too – is dominated by simplistic treatments of a complex problem, sweeping claims and dubious statistics [ 1 , 2 , 3 ]. Such an approach might help to win attention, investment and support for an anti-trafficking agenda in the short term, but ultimately risks causing credibility problems for the entire field and contributing to ineffective, even harmful, interventions [see, e.g., 2 , 4 – 6 ]. From the 1990s onwards, levels of interest and investment in counter-trafficking expanded rapidly [ 3 , 7 , 8 ]. In tandem, the literature on trafficking has proliferated [ 9 , 10 ]. Yet, actual empirical (data-driven) research remains relatively rare [ 11 , 12 , 13 , 14 ]. Of course, non-empirical approaches have value too – for example in challenging how we conceptualise trafficking or highlighting tensions in governments’ or businesses’ commitments to anti-trafficking measures. Nevertheless, empirical research is clearly crucial to advance understanding of the trafficking phenomenon and shape nuanced, evidence-informed policy and practice. Even where empirical research exists, its quality can be highly variable, with many publications (even peer-reviewed ones) found to fall short of even rudimentary scientific standards [ 13 , 15 ]. Additionally, there is a particular dearth of rigorous, independent evaluations of interventions [ 7 , 13 ] – despite the many millions of dollars spent thus far on anti-trafficking efforts worldwide [ 12 , 16 ].

Before proceeding, it is worth acknowledging some fundamental tensions in researching human trafficking. First, trafficking is not a neatly delineated phenomenon that can be consistently identified and readily counted [ 1 , 2 ]. Instead, it is a relatively fuzzy social construct that exists upon what is increasingly recognised as a ‘continuum  of exploitation’ running from decent conditions through to severe abuses [ 17 ]. Second, trafficking is not – and has never been – ‘discursively neutral terrain’ [ 18 ]. Instead it is contested territory that has long been tied up with broader political, economic and ideological agendas [ 3 , 19 ]. Third, trafficking is a sensitive topic involving hidden populations [ 20 ]. Whether those involved are identified at all – let alone assigned the trafficking label – is heavily contingent on other factors, ranging from victims’ willingness to disclose abuses to funding and prioritisation of counter-trafficking efforts [for further discussion, see 21 , 22 ].

Despite these issues, it would be hard to argue that the extremes of exploitation that are – or could be – conceptualised as trafficking do not merit attention and intervention. If the trafficking field is to evolve and maintain credibility, therefore, more high-quality empirical research is needed. With so many gaps, there are many directions its expansion could take. Here, we highlight some of the gaps and limitations that are particularly pronounced and well-documented. Traditionally, research has focused overwhelmingly on sex trafficking and other trafficking types have been relatively overlooked [ 12 , 13 ]. Victim-focused research dominates the literature, leaving offenders comparatively neglected [ 23 , 24 , 25 ]. Most trafficking research is qualitative in nature and quantitative studies are far rarer, particularly those that go beyond descriptive statistics alone [ 9 , 13 ]. Accessing research data and participants is notoriously challenging and remains a key barrier to the development of the field [ 11 , 21 , 26 ]. On the one hand, existing datasets (e.g. police or other administrative data) have obvious under-tapped potential for academic research and could be used far more extensively and effectively [ 21 , 27 , 28 ]. On the other, increased investment in primary data collection – such as via survey methods – is also necessary to address questions that existing data cannot answer. Perhaps linked to difficulties accessing data, trafficking studies typically focus on a single country and robust comparative analyses across multiple jurisdictions are rare [see, e.g., 29 ]. Although researchers have often approached human trafficking through a criminological or sociological lens, trafficking is clearly not just a crime problem. Other disciplines, such as geography, public health, management and computer science (to name but a few), also clearly have much to contribute [see, e.g., 30 – 32 ]. Linked to this disciplinary expansion, pushback continues against exceptionalising trafficking: rather than treating it as the product of a few isolated criminals (i.e. ‘bad apples’), there is a need to examine more closely how exploitation can be enabled or exacerbated by broader systems (i.e. ‘bad barrels’) such as those involved in the neoliberal labour market and its regulation as well as migration policies [see, e.g., 33 – 36 ]. Finally, it is not enough just to do more research on trafficking: the research itself needs to consistently meet high standards, for example in terms of methodological transparency and rigour, solid research designs and robust ethical conduct [ 13 , 37 ].

Given this context, we are delighted this special edition begins to address many of these key gaps. The papers in it have been written by some of the world’s leading academic experts on trafficking and span a range of countries, topics and approaches. What unites the contents is a shared grounding in original, empirical research and innovative contributions to the literature, be it in thematic, methodological and/or conceptual terms. Thanks to funding from the Economic and Social Research Council of the UK, the process included a symposium in London in July 2018. Lead authors came together to present their first drafts and share their feedback on one another’s work; the resultant papers are all the stronger for the constructive criticism and vigorous debate that ensued. Overall, we are confident that this volume has much to offer for academics, policy-makers and practitioners interested in new perspectives on human trafficking. Below, we provide a short summary of each paper, followed by some brief concluding observations.

The special edition starts with a rare quantitative analysis of individual-level data on human trafficking, using data from the United Kingdom’s central system for identifying trafficking victims. For a sample of 2,630 confirmed victims, Cockbain and Bowers [ 38 ] systematically compare those trafficked for sexual exploitation, domestic servitude and (other) labour exploitation. They examine similarities and differences in terms of victim demographics, the trafficking process and official responses. They find both substantial and significant differences between types, demonstrating that human trafficking is a complex and diverse phenomenon. Although different forms of trafficking are routinely conflated in research, policy and interventions, this study highlights the value of a more nuanced approach that takes into account differences between – and indeed within – trafficking types.

Qiu, Zhang and Liu [ 39 ] provide a new perspective by focusing on trafficking for forced marriage – a particularly understudied issue – in the Chinese context. Women from poor neighbouring countries, such as Myanmar, frequently look for employment opportunities in China. Due to a severe imbalance in China’s sex ratio, a trafficking market has emerged to meet the demand for brides. The authors analyse 73 court cases involving 184 Myanmar women who were trafficked into China in the period 2003–2016. They find that most traffickers had limited education and were either unemployed or underemployed. The vast majority were Chinese nationals with good connections in both the cross-border trade and traditional matchmaking business. Most trafficking turned out to involve few formal organisational structures and occurred primarily under the guise of employment opportunities: it appeared that most victims were recruited within Myanmar in response to the offers of a job in interior China.

Wijkman and Kleemans [ 40 ] shed new light on female offenders involved in human trafficking, in particular trafficking for sexual exploitation. Analysing the court files of 150 women convicted for trafficking offences in the Netherlands, they conclude that popular conceptions of the role of women in trafficking are inaccurate and simplistic. Contrary to stereotypes of passive female victims/predatory male offenders, their analysis shows that female traffickers are neither rare nor unimportant. The roles they performed were not limited to low-ranking activities, nor were they exceptional: instead they could be similar to those of male offenders. Specific prior experiences of victimisation, such as a history of being sexually exploited, inadequately explained women’s involvement in the offending. Finally, the frequent presence of male co-offenders clearly shows that offending is embedded in social relationships, including intimate (romantic) relationships.

Brunovskis and Surtees [ 41 ] offer timely insights into the complexities of identifying trafficking victims in situations of massive and rapid transit movements. Their focus is on Europe’s so-called “refugee crisis” of 2015 and 2016. They draw on fieldwork in Serbia, where an extraordinarily high number of vulnerable migrants/refugees from different countries and cultural backgrounds passed through along the Balkan route over a short period of time. Opportunities to interact with these migrants/refugees in ways that would lead to victim identification and support proved heavily constrained. In such situations, the authors found it was difficult to set up appropriate and effective human trafficking screening mechanisms and to identify particular vulnerabilities. They conclude that the anti-trafficking framework can be difficult to apply in mass migration settings and does not always fit well with peoples’ experiences. Moreover, the protections on offer may not be suitable for or wanted by those who would be eligible.

Davies and Ollus [ 42 ] situate labour exploitation – including but not limited to trafficking at the extreme end of the spectrum – firmly within the context of developments in the economy, labour markets, and society at large. Breaking with dominant approaches to anti-trafficking that tend to centre individual offenders, they focus instead on how supply chains and business practices can enable and exacerbate the exploitation of vulnerable workers. Their analysis is based on qualitative, semi-structured interviews with both workers and supply chain stakeholders (e.g. employers, intermediaries and regulators) in the UK agri-food industry ( n  = 27) and the Finnish cleaning industry ( n  = 38). They identify industry dynamics, labour subcontracting and insufficient regulatory oversight as key factors in enabling exploitation in otherwise legitimate businesses. Given the significant role of corporate practices in facilitating exploitation, the authors argue in favour of framing labour exploitation as a form of corporate crime.

Van Meeteren and Wiering [ 43 ] take a fairly unusual approach in examining labour trafficking in the context of regular rather than irregular migration, specifically a labour migration scheme for the Chinese catering industry in the Netherlands. Through an in-depth qualitative analysis of investigative files from eight such cases identified as constituting labour trafficking, the authors explore various mechanisms through which exploitation is facilitated and sustained. They focus in particular on the impact of restrictions connected to regular migrant workers’ immigration status. The authors conclude that while employers and victims alike can manoeuvre within the space provided by immigration policies, these policies clearly shape relationships and dependencies in the labour market. They find, for example, that migrants’ reliance on their employers for work and residence permits makes them hesitant to disobey, run away and risk the large sums they have already invested in their migration ambitions. Tied residence and work permits emerge in this way as a particularly important contributor to vulnerability to labour exploitation.

De Vries, Nickerson, Farrell, Wittmer-Wolfe, and Bouché [ 44 ] extend research on the relationship between anti-immigration sentiment and criminal justice problems and solutions, by focusing on public support for anti-trafficking efforts in the United States. Using public opinion data from a nationally representative survey with 2,000 respondents, the authors find that anti-immigration sentiment is related to greater recognition that immigrants are vulnerable to human trafficking victimisation. While anti-immigration sentiment does not impact views on general governmental prioritization of counter-trafficking policies, it is associated with less public support for services for immigrant trafficking victims. These findings might explain why, according to the authors, public policies safeguarding migrant trafficked persons have been among the most difficult to pass in the United States, despite strong overall support for government prioritisation of anti-trafficking efforts.

Overall, this special edition covered a wide range of topics, geographies, datasets and methods. Despite the variety in the approaches, some common themes can be identified, which have important implications for research, policy and practice. First, many contributions underscore the complexity and diversity of both trafficking and counter-trafficking activity, including in terms of attributes and attitudes of victims, offenders and the general publics. Moving away from one-size-fits-all approaches is vital to become more effective at explaining and tackling this issue. Second, many papers highlight the importance of contextual factors in understanding how trafficking and exploitation are produced, sustained and exacerbated. Greater recognition of contextual factors - both at the individual- and systems-level - is crucial in supporting more nuanced responses and identifying a wider range of avenues for intervention. Third, the articles often challenge stereotypes, debunk myths and/or question assumptions about how trafficking and counter-trafficking function. With trafficking such a ‘hot’ topic, it is vital that rigorous empirical research continues to provide a measured and informed counter-balance to media and political treatments that are all too often simplistic and sensationalised.

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We are very grateful to the Economic and Social Research Council of the UK for funding the symposium in London via Dr. Ella Cockbain’s Future Research Leaders Fellowship (grant reference: ES/K008463/1). We thank the Department of Security and Crime Science at University College London for hosting the event and all who attended for their valuable contributions and feedback on others’ work. We thank all the anonymous reviewers for their generosity with their time and insightful comments. Our final thanks goes to the journal’s general editors, Professors Mary Dodge and Wim Huisman, for their support for this special edition and assistance throughout.

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Cockbain, E., Kleemans, E.R. Innovations in empirical research into human trafficking: introduction to the special edition. Crime Law Soc Change 72 , 1–7 (2019). https://doi.org/10.1007/s10611-019-09852-7

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Published : 25 July 2019

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DOI : https://doi.org/10.1007/s10611-019-09852-7

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ORIGINAL RESEARCH article

Human trafficking: results of a 5-year theory-based evaluation of interventions to prevent trafficking of women from south asia.

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Corrigendum: Human trafficking: Results of a 5-year theory-based evaluation of interventions to prevent trafficking of women from South Asia

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• 1 Gender Violence & Health Centre, Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
• 2 Lumos Foundation, London, United Kingdom
• 3 Faculty of Population Health Science, Institute for Global Health, University College London, London, United Kingdom

Preventing modern slavery is of global interest, but evidence on interventions remains weak. This paper presents findings from a 5-year theory-based evaluation of an empowerment and knowledge-building intervention to prevent the exploitation of South Asian female migrant workers. The evaluation used realist evaluation techniques to examine the intervention mechanisms, outcomes, and context. Findings from qualitative and quantitative data from Nepal, India, and Bangladesh indicate that the intervention mechanisms (trainings) were not well-targeted, not delivered by appropriate trainers, and did not address participants' expectations or concerns. The outcomes of empowerment and migration knowledge were not achieved due to poor integration of context-related factors, flawed assumptions about the power inequalities, including barriers preventing women from asserting their rights. Ultimately, interventions to prevent exploitation of migrant workers should be developed based on strong evidence about the social, political, and economic realities of their migration context, especially in destination settings.

Introduction

Human trafficking is a global phenomenon that touches most corners of the world, with ~40.3 million individuals estimated to be in situations of forced labor and forced marriage—broadly referred to as “modern slavery” ( 1 ). Studies over the past two decades have increasingly documented the physical, psychological, and socioeconomic harm caused by extreme exploitation, which generally affects the world's most vulnerable adults and children ( 2 , 3 ). Yet, there is astonishingly limited evidence on “what works” to prevent these abuses or to address the consequences ( 4 ). In a recent systematic review including 90 reports on trafficking programs, the authors concluded that organizations are still “struggling to demonstrate impact and discern what works to combat human trafficking” ( 5 ). Similarly, a Rapid Evidence Review of interventions in South Asia noted that “…the outcomes from the reviewed studies alone cannot be used as recommendations for policy and practice on trafficking…” ( 6 ). These findings undoubtedly come as disheartening news to the many policy-makers and donors who seek evidence-informed avenues to meet the 2030 Sustainable Development Goal Target 8.7, which aims to eradicate forced labor, end modern slavery and human trafficking, and secure the prohibition and elimination of the worst forms of child labor.

Human Trafficking in Nepal, India, and Bangladesh

The Asia and the Pacific region account for over half of the ~24.9 million people in forced labor globally. India is estimated to have the largest number of persons in modern slavery globally at 8 million, compared with an estimated 592,000 in Bangladesh and 171,000 in Nepal ( 7 ). Among those in situations of forced labor, the largest prevalence, 24%, are estimated to be in domestic work ( 1 ), where exploitation by employers and labor intermediaries are common.

Awareness and Knowledge-Building Antitrafficking Interventions

Premigration community-based awareness and knowledge building activities have been particularly popular among implementing agencies and donors because they are of relatively low risk and can reach large populations at fairly low cost ( 8 ). Safe-migration interventions are generally based on the assumption that if people had better knowledge about migration-related risks and regulations and knew their rights, they could avoid trafficking-related abuses and migrate safely ( 9 ). However, to date, there is no robust evidence that premigration knowledge promotes safer migration ( 9 – 12 ). Of activities that have been assessed, to whatever extent, the vast majority of evaluations has only measured outputs (e.g., number of sessions and participants) and intermediate outcomes (e.g., immediate levels of knowledge and awareness). No evaluations have measured how increased awareness or knowledge affects individual behaviors and, in turn, how different behaviors might affect incidence or prevalence of human trafficking or modern slavery ( 13 ). Studies examining awareness-raising and knowledge-building activities, including those using experimental designs, have stopped at the point of assessing whether messages were learned by the participants vs. tracking how the new knowledge was applied or measuring how it affected migration-related safety or trafficking outcomes ( 10 , 14 , 15 ). To date, there are no data indicating modifiable factors or actionable targets to reduce “vulnerability” to trafficking. Studies attempting to identify determinants have cited primarily broad development problems, such as “low income; few economic opportunities, and instability of the local economy” ( 16 ) or ‘'poverty,” “gender,” and “age” ( 9 ). Unfortunately, these insights are not particularly helpful for anti-trafficking programming because they could relate to most ailments in low-resource settings, which development programmes have been trying to address for decades. Moreover, for intervention purposes, these broad determinants are not generally actionable within current anti-trafficking budgets or timeframes.

SWIFT Study of the Work in Freedom Program in South Asia

The South Asia Work in Freedom Transnational Evaluation (SWIFT) was a 5-year program of research and evaluation in Nepal, India, and Bangladesh of the International Labor Organisation's (ILO) Work in Freedom Programme (WIF) ( 17 ). The SWIFT evaluation was conducted independently and sought to answer the question: How do the WIF community-based prevention interventions influence women's risk of forced labor (modern slavery) in domestic work and garment sectors? SWIFT is the first evaluation to follow a large-scale, multicountry trafficking intervention, from conception to implementation, using theory-based mixed-methods approaches. The WIF program theory was based on the concept that trafficking could be prevented by predeparture community activities comprised of women's empowerment strategies, including training on the value of women's work, the costs and benefits of migration, safe and informed migration, women's rights and workers' rights and knowledge, and skills capacity building ( 18 ). Sessions in some sites also included components to improve women's ability to make informed livelihood decisions either by equipping them to migrate safely or access to local livelihood options if they did not want to migrate. This paper analyses the combined SWIFT theory-based evaluation findings across the three country intervention settings, namely, India, Nepal, and Bangladesh, and examines the intervention theory, context, mechanisms, and outcomes. WIF in India focused on internal migration, while in Nepal and Bangladesh, the target was international migration.

Theory and Methods

SWIFT applied a mixed methods theory-based approach to evaluate the theory and implementation of the WIF program. Specifically, SWIFT investigated the validity of the intervention's theory and underlying assumptions that labor trafficking could be reduced or eliminated by enhancing women's autonomy and generating adoption of safe migration practices ( Figure 1 ). SWIFT examined whether empirical evidence supported the theory that migrant women's greater awareness and knowledge would decrease their risk of exploitation and explored implementation, causal pathways, and detectable effects on knowledge transfer, uptake, and application. Findings were intended to inform future replication and scale-up.

Figure 1 . Work in Freedom (WIF) theory, assumptions, and activities evaluated using theory-based methods.

A theory-based realist evaluation design was selected because of the early stage of intervention development and the programmatic need for evidence on intervention designs and implementation. Several important considerations influenced the evaluation design. First, the space–time complexity of human trafficking demands research approaches that integrate causal thinking to capture the complex causes–effects interactions vs. methods that tend to isolate single causes of observed effects ( 19 , 20 ). Second, many core components of the intervention were still under development, and the main outcome was relatively undefined at the start of WIF implementation. Third, at the start of WIF, there was little evidence on risks and protective factors to support the hypothesized causal pathways from empowerment to protection against exploitation , which meant that focusing on effectiveness measurement would not provide useful results ( 21 ). That is, even if our evaluation indicated some level of intervention effectiveness, we would not know if it could work elsewhere ( 22 ). If the evaluation did not find positive results, we would not know whether there was a problem with the implementation or with the theory. Fourth, the intervention's feasibility, acceptability, and uptake had not been previously assessed to justify a complex and costly experimental design, making it very difficult to assess external validity. Fifth, collection of SWIFT monitoring data specifically for the evaluation was not possible due to local constraints. Consequently, we could not conduct a process-outcome evaluation, which could have allowed us to more rigorously investigate processes of change, assess quality of implementation, and identify contextual factors linked to variations in outcomes ( 23 ).

Thus, to capture the subject's complexity, the nascent stage of the intervention, and to achieve the explanatory power needed, we used a multisite mixed-methods design and adopted innovative analytical approaches, which served as strong tools for reasoning under uncertainty ( 24 ). Following realist principles, we did not expect to find a definitive answer to the question of what works to prevent human trafficking but rather aimed to investigate what mechanisms were relevant to preventing human trafficking in the intervention contexts ( 25 ). The intended “impact,” women who choose to migrate for work are “empowered and informed to find safe and decent employment,” was the ceiling of accountability 1 for the WIF program vs. “prevention of trafficking” (see Figure 1 ). Using data from the three countries, we examined constraints and enablers for the immediate training outcomes (empowerment and information) and to the ultimate intended impact (reduced trafficking).

Forced Labor Measurement

To assess prevalence and types of exploitation within our study population, we followed the ILO's guidance by assessing three dimensions of forced labor: (1) unfree recruitment, (2) work and life under duress, and (3) impossibility of leaving the employer ( 27 ). For each dimension, a range of involuntariness and penalty indicators were measured, and these were classified as medium or strong, according to the ILO guidelines. Indicators were constructed from a number of questions asked in the survey about specific individual experiences ( 28 ). Participants who reported at least one indicator of involuntariness and one penalty within a dimension, of which one was a strong indicator, were defined as having experienced that dimension of forced labor. Experience of any one of the three dimensions constitutes forced labor ( 27 ).

Study Methods for Each Study Site

In Nepal, formative research was conducted in collaboration with the Centre for the Study of Labour and Mobility, Social Science Baha (CESLAM) in the district of Dolakha prior to the rollout of the community component of the WIF intervention. The formative research was conducted to provide initial prevalence figures on migration, as such data were not available. Subsequent research was conducted in three of the five WIF districts, Chitwan, Rupandehi, and Morang and included 519 returnee migrants who had previously migrated internationally for work purposes and 340 prospective migrants who planned to migrate internationally for work. Qualitative semistructured interviews were also carried out with 55 of the prospective migrant women who participated in the survey, of which six were reinterviewed following their attendance of the WiF 2-day training. Participants interviewed for the prospective migrant survey were followed up by telephone to track their migration process, including after their departure from Nepal. At the first follow-up, 188 women were reached, representing an attrition rate of 45%. Of the 188 women, one-third reported that they were no longer planning to migrate, reducing the sample size to 130. At the second follow-up, only 10 women participated, and the data were not included in further analysis.

In India, surveys were conducted in collaboration with the Centre for Women's Development Studies (CWDS) with 4,671 households, including detailed survey interviews with 1,218 women and 1,156 men in 20 probabilistically selected villages across the Ganjam District of Odisha. Among the participants, 112 women and 429 men had previously migrated ( 29 ). Pre- and posttraining questionnaires were also administered with women ( N = 347) who participated in WIF's 2-day premigration training session. To gage awareness levels, participants were asked a single question relevant to a concept and asked to answer free form in their own words, i.e., interviewers did not read out item lists. For example, to examine awareness of the benefits of migrating for work, women were asked: “What would you say are the main benefits of moving away from home to take up work somewhere else?” Enumerators could then select any of nine benefits that women could name ( 30 ). Vignettes were also used in some questions prior to eliciting women's awareness of particular concepts. Such depersonalization encouraged participants to reflect beyond their own individual circumstances, which is particularly useful when discussing sensitive topics ( 31 ).

In Bangladesh, qualitative research was carried out in collaboration with Drishti Research Centre, in three research sites in the district of Narayanganj: (i) a rural area; (ii) a former resettlement area for Dhaka slum dwellers—now an industrial district; and (iii) a densely populated semiurban area. The team conducted ethnographic observations and interviewed a cohort of 40 migrant women who participated in the WIF training and stated intentions to migrate. Women were interviewed five times between December 2015 and May 2017 ( 32 ).

In the intervention sites in Nepal and Bangladesh, most women who migrated internationally were engaged in domestic work. In the India intervention sites, most women migrated internally and the largest portion worked in construction.

Analysis for each research component was conducted and reported separately by country. In this paper, we conducted a synthesis of findings across the different studies, based on principles of realist evaluation. We consider the implications for future prevention interventions designed to inform and empower women to find safe and decent work and, in turn, avoid abuse and exploitation at destination.

Using the formative data collected in Nepal, we estimated key characteristics of migrant households and returnee migrants, including prevalence of labor migration, and findings on remittances, mobile phone use, common work sectors, and reported injuries ( 33 ). In the other three sites, we examined migration planning among prospective Nepali migrant women by comparing first-time and repeat migration using logistic regressions controlling for district, time until proposed departure, and age. Further methodological detail is available elsewhere ( 34 ).

To analyze past labor experiences and remigration intentions among Nepali returnee women, we examined their remigration intentions against their experiences (or not) of forced labor during their most recent migration. We used Bayesian networks to model the Nepal returnee dataset to examine causal interactions between variables and make predictions about the effect of potential interventions. We used multivariate logistic regression to examine the association between forced labor experience and speaking the destination's language among women who migrated to Arabic-speaking countries. The model was adjusted for destination country and work sector, based on the conceptual framework and findings published in the article by Kiss et al. ( 20 ).

Thematic analysis was used to analyze semistructured interviews in Nepal, and discourse and thematic analysis were used to analyze interviews in Bangladesh ( 32 , 35 ).

Descriptive analysis was used to describe the context of WIF's implementation in Odisha. We calculated the number of migrant households, prevalence of migration, predeparture indicators, working conditions, and prevalence of forced labor among migrants by gender. To analyze the pre- and posttraining data, we used descriptive analysis and unadjusted analyses (paired t -tests, McNemar's tests, Wilcoxon signed ranks tests) to estimate the differences in scores before and after predeparture awareness training. Adjusted analyses used mixed effects models to explore whether receiving information on workers' rights or working away from home prior to the training was associated with changes in before-and-after scores. Further information on analysis is available elsewhere ( 30 ).

We report overall findings using the Context–Mechanism–Outcome framework in realist evaluation ( 36 ). We first describe findings by Mechanisms of WIF, followed by the interventions Outcomes, before describing how context affected both mechanisms and outcomes in the Context section. We first describe findings on the intervention's mechanism rather than initially focusing on the context to reflect the way in which WIF was conceived and presented to stakeholders, in 2013. WIF's design relied on the scarce body of evidence that the field had accumulated at that time, in addition to inputs from researchers and practitioners in the field. These inputs were used to determine the mechanisms that were deemed effective to prevent trafficking (the intervention's intended impact). Contextual variables were not part of these initial discussions and were also absent in the first iterations of the program's theory of change and log frame. The basic assumption that guided the development of WIF's community-based component was that women's empowerment would lead to reduced incidence of trafficking.

Mechanisms of WIF

This section describes the main characteristics or mechanisms of the WIF intervention, i.e., what it was about the WIF interventions that brought about any effects in empowerment and information outcomes, and on the incidence of human trafficking in each intervention context. WIF's proposed mechanism was that predeparture training, targeting prospective migrants, would empower women, make them aware of their migration circumstances, thus changing their migration behavior, and ultimately protect them from human trafficking. We describe below the results from our research that relate to WIF's mechanisms, based on Dalkin et al. ( 37 ) conceptualization of mechanisms in realist evaluations ( 37 ). That is, we examine the mechanisms both as the resources offered by the intervention and the ways in which these resources change the reasoning of participants.

Intervention Content

In each country, the training was designed as premigration decision-making or premigration preparation sessions for prospective migrants, which aimed to help participants consider local employment opportunities, the pros and cons of migration, practical migration preparation, common problems encountered during migration, and emergency contacts. In Nepal, prospective migrants who completed the survey were followed by phone over time to track their migration planning and process. At the first follow-up interview, 50% of those reached reported having attended the WIF training ( n = 94/188) and noted that the most important information they received was related to the documents required to migrate (62%) and legal travel routes (40%) ( 38 ). In India, while the training was well-received, with 95% of participants reporting that they learned information about migrating safely that they did not know before, assessments of participant learning indicated that all knowledge domains covered by the training remained low after the training (see Outcomes below) ( 30 ). In Bangladesh, although some women appreciated the content of the training, they often did not think the guidance was relevant to their lives, and some found certain information to be incorrect. As noted by one participant in Bangladesh who was informed of local livelihood options that did not materialize: “We can now tell anyone who wants to hear, that all these beautiful words about getting a loan are pure lies” ( 32 ).

There were also misperceptions about a “hotline” at destination in case of emergencies, which, for some, had serious implications, as in the case of one Bangladeshi woman who had migrated to a Gulf State:

Eleven days after arrival, a distressed Shikha [alias] called her husband and her mother and asks to be repatriated, who contacted the NGO fieldworker. She recommends that they let the phone keep ringing because Shikha is acting childishly and is not taking sufficient time to adjust. Shikha also calls the NGO helpline from the employer's home. The NGO social worker does not seem to understand the sexual abuse that Shikha cannot reveal ( 32 ).

While there was a “hotline” as promised, the support workers' ability to respond was not sufficient to meet this woman's actual needs. Similarly, in Nepal, women attending the training felt safer to migrate after having heard about contact details of the implementing partners because they believed they would be rescued if needed ( 39 ).

Target Participants

Participants for whom WIF intervention content was largely irrelevant were recruited across sites, which likely affected retention and interest in program messages. The WIF intervention's target participants were identified and recruited by local organizations commissioned by the WIF program. For example, in Nepal, peer educators conducted house-to-house visits to identify women interested in migrating, who would then be invited to the 2-day WIF training. This broad targeting approach, which treated all women of working age as potential migrants, was deliberate due to the stigma associated with women's labor migration and the need to achieve a maximum number of participants to meet donor obligations. Unsurprisingly, findings from Nepal suggest that many who were identified as “prospective migrants” did not actually have any clear plans to migrate but rather a loose idea of considering migration if the opportunity arises. Among the 188 women interviewed during follow-up surveys, only one-third ( n = 58) stated that they still intended to migrate, while 15% ( n = 27) had arrived at their destination. This somewhat loose participant selection process inevitably raised questions about the extent to which the participants were appropriately targeted and selected, which may also have had the knock-on effect of lowering women's uptake of the training information. Among 347 training participants in India, just 10.4% had thoughts of moving away from their village before the training, which also reflected low female outmigration patterns in which only 7% of households had a female migrant ( 30 ). As with Nepal participants, the low proportion of training participants considering migration likely indicates poor participant identification. Poor intervention targeting was also reflected by the low numbers of women who actually migrated for domestic work in the India study site (vs. construction and agriculture, which were not WIF's focused sectors).

Participants also seemed to have mixed motives for agreeing to attend the training sessions. For instance, several participants in Bangladesh indicated that they joined primarily for the free meal. Numerous participants also had misguided expectations of the “premigration training,” explaining that they thought the training would provide them direct assistance to migrate. As a Bangladeshi participant noted: “I went to the [NGO] training hoping I would get a visa and they would help me to migrate but got nothing… [the NGO] needed us… Now they are finished with us.” As she indicated, some perceived that their participation was more beneficial to the program than to themselves ( 32 ).

Implementation

Each 2-day training program was implemented on a specific date and time, which may have meant that participants were receiving the information too far in advance of their possible travel to retain the knowledge when they needed it. In Nepal and India, the training sessions focused on helping women decide whether or not to migrate, which meant some would only be deciding to migrate after the training. As noted by one Bangladeshi participant: “I liked everything about the training. The way the sister talked, the food…. But if you ask me what was said I could not tell you. I forgot most of it.” The migration planning process can happen very quickly or extend over a year or more, suggesting that “one-off” interventions may not meet actual needs as well as ongoing services and guidance. In India, training was very well-received, with 98.8% stating that they could follow along and understand the information given and 94.1% reporting that they would recommend the training to other women, but at the same time, there were extraordinarily low levels of actual learning (see Outcomes below).

Observations about implementation also raised questions about whether the sessions were delivered by the right trainers. In a number of the sites, the training sessions were led by women who were of a higher socioeconomic class than the participants and who rarely if ever had their own migration experience. This social class difference may have led to participants' reluctance to accept some of the messages because of the messenger—especially messages pertaining to rights and empowerment. As one participant in Bangladesh explained: “I liked what they said about rights. There is nothing wrong with these beautiful words. But this kind of talk is not for us. It is good for educated people like you [pointing to the researcher]. What do we do with these nice words? We cannot implement them.” In Nepal, the training sessions were conducted by a peer educator from the implementing partner, alongside a social mobilizer who may or may not have had migration experience. In India, training sessions were conducted by implementing NGO's staff, and it was unclear whether any had migration experience.

Outcomes of WIF

WIF's intended outcome was “Women are empowered to make informed migration decisions and an enabling environment is created for their safe migration into decent work.” The program's theory relied on the premise that this outcome would lead to the intended impact of “reduced incidence of trafficking of women and girls within and from India, Bangladesh and Nepal into domestic and garment sectors, through economic, social and legal empowerment.” This section describes the outcomes of the WIF premigration sessions for women, specifically addressing women's understanding and ability to acquire and apply a greater sense of empowerment and information to find safe and decent work when migrating .

Uptake of Empowerment and Rights Attitudes

The WIF training sessions sought to improve women's perception of the value of their work and their rights, both inside and out of the home. Among the 94 women in Nepal that attended the training, most appreciated messages about their rights, but only 2% indicated that the most important knowledge they gained was about the “rights of migrant workers” (of 20 items) ( 39 ). Low interest in worker rights may have been due, in part, to the fact that most women did not yet know the destination to which they would be migrating—or if they would be migrating at all. Actually, one in two Nepali women planning to migrate in the next 3 months knew nothing about contract details, including salary, living situation, hours, time off, contract length, or penalty for leaving early.

Interviews with women who had previously migrated indicated that migration itself conferred a sense of empowerment. Many Nepali women described feeling empowered via earning their own income, deciding how to spend their money, and their wider knowledge of the world from going abroad. Conversely, findings also suggest that the association of women's migration with promiscuity was stigmatizing for some returnee women who described being gossiped about when they returned ( 40 ). Moreover, in settings such as Nepal, where women's labor migration is a relatively recent phenomena, women who challenge traditional gender roles are frequently stigmatized, and these concerns were not addressed by the WIF intervention.

The erroneous assumptions hindered outcomes on empowerment. In India, women's attitudes toward women's work remained relatively fixed even after the training. For example, when asked about the statement, “Woman's work is not as important as men's work,” before the training, 47.3% agreed, which only changed to 44.9% afterwards. Attitudes toward domestic work also remained broadly negative, with 43.6% of participants agreeing that “Sita should feel ashamed to do paid domestic work in someone else's home,” before the training compared with 46.7% after. Despite these findings, small positive changes were observed for respect and rights. For example, before the training, 47.3% agreed that “Paid domestic workers have the same rights as all workers,” which increased to 59.9% after. After the training, a majority reported they learned about women's rights (85.6%) and workers' rights (84.9%), but these changes were not reflected in their reported attitudes about these concepts ( 30 ).

Uptake of Migration-Related Learning

Outcomes on migration-related learning were also relatively low. In India, women's pre- and post-knowledge of migration risks and opportunities was assessed using single questions connected to a migration-learning construct, such as, “What would you say are the main risks in moving away from home to take up work somewhere else?” Before the training, participants could cite an average of 1.2 risks (of 13) compared to 2.1 risks after the training. Similarly, low learning scores were observed for virtually all topics included in the training, indicating very low to zero retention of training messages ( 30 ).

In qualitative interviews in Bangladesh, women's perceptions of risk following the training did not reflect WIF messages. For example, advice from the WIF training to migrate without a dalal (informal labor intermediary) was strongly rejected ( 32 ). Women believed it was necessary to use a dalal to migrate. While women recognized numerous risks related to migration, many believed that outcomes were due to chance, and some believed that spiritual practices would protect them. Participating in WIF training was interpreted by some women as a kind of “certificate,” which lent them a special advantage that would reduce their risks during migration ( 32 ). However, at the same time, women did not often follow the advice they received in the training (e.g., travel via formal routes and agencies). In qualitative interviews in Nepal, one woman reported that she learned she should obtain necessary migration documents and travel via safe routes. Nevertheless, she traveled through an irregular channel following the advice of her broker and discussions with her husband. These types of decisions suggest that WIF messages may be constrained by individual and contextual realities, spiritual or superstitious beliefs, and structural forces.

Reduction in the Incidence of Human Trafficking

Findings from Nepal indicate the premise that women's empowerment and awareness prevents human trafficking is misguided in that context. Instead, our results indicate that the most important risk associated with forced labor is their country of destination, which is determined by the labor recruiter. Women's individual characteristics, awareness, and participation in trainings did not affect their likelihood of unfree recruitment, work and life under duress, or impossibility of leaving their employer (the three dimensions of forced labor, as defined by the ILO) ( 20 ). Data from Bangladesh suggest that this might also have been the case in that context, where qualitative accounts of posttraining migration show the difficulties women had in implementing WIF's empowerment strategies, as described above.

This section analyses WIF's outcomes in the context of the underpinning theory and assumptions. The contextual conditions needed for the intervention mechanisms to be activated ( 41 ) were not theorized previous to WIF's implementation. The results presented in this section describe how these contextual conditions interacted with WIF's theory.

Formal vs. Informal Recruitment Agents in Migration

A core assumption in the WIF theory of change was that migrant women should and could use formally registered recruitment agents (vs. informal brokers). Therefore, a central WIF program message discouraged the use of informal brokers in favor of registered agents and included guidance about how women could secure the required travel documents, negotiate formal work contracts, and travel via legal migration channels. Our findings indicate that, in reality, many, if not most, of the women planning international migration have to engage with informal agents at some point in their journey ( 42 ), especially women who came from rural areas where there are few or no registered agents. Rural women in Bangladesh had greater trust in local recruiters because they had the impression that recruiters would be accountable in some way if something went wrong—even if plans would eventually involve registered agencies ( 43 ). In India, women migrated almost exclusively within India. Only 13.9% of migrant women relied on a broker. The vast majority of women's migration was facilitated by their friends or acquaintances without participation of a labor contractor (72.2%). Among those who used brokers, deception was commonly reported: “I had no idea to find out my whereabouts. The person (broker) was maintaining tight secrecy for which we were in doubt. We started querying to the broker regarding our work settlement. I was not in a favor of working in anybody's house. The broker had told us to wait till the next morning. But, he had cheated us.”

The Influence of Rights and Empowerment Messages Amidst Local Gender Norms and Socioeconomic Power Dynamics

A further assumption in the WIF theory of change was that empowerment training could lead women to exert their rights as women and as workers. However, one influential barrier hindering this behavior change may have been women's very low confidence in their own ability to assert their power in their communities or within their families—particularly in the face of the pervasive gender inequalities, especially the cultural norms related to female migration. In India, over half of the returnee female migrants (53.5% of n = 112) reported they had limited input in the decision concerning their migration. In Bangladesh, women explained that they would have great difficulty expressing the empowerment messages they heard in the training. Exercising their rights became even more problematic when women needed to negotiate with labor brokers and nearly impossible with employers once they arrived in the destination, not least because work conditions are rarely negotiable and rights related to foreign workers are not enforced even if they exist on paper, particularly for domestic workers ( 44 ). In other words, knowing about their rights could not protect women if the context did not provide space to assert those rights. It is not a coincidence that forced labor among Nepali female returnees was higher in countries with the kafala system at the time of the study, which gave employers full state-sanctioned rights over migrant workers, including their visas ( 45 ).

In addition, while the WIF intervention tried to normalize migration for the WIF participants, female migration in South Asia is still highly stigmatized because of its association with sex work or promiscuity ( 40 ). Nearly half of female returnees in India (48.6% of n = 112) reported suffering stigma when they returned home. In this sense, in women's own community, WIF's messages were hampered by the social reality of women's lives, where entrenched social norms and accepted power structures pose substantial barriers along the WIF-anticipated pathways toward empowerment, particularly when empowerment is specifically related to migration.

A further underlying, albeit more distal, assumption was that if women could be equipped with correct knowledge about migration and assert their knowledge with recruiters (e.g., contracts, rights, migration regulations), this could influence recruiters to change their behavior. That is, if women knew how to negotiate their contracts and understood the laws and their rights and necessary documentation, recruiters would have to treat them differently, i.e., could not exploit them. Yet to date, there is little to no evidence from our study or elsewhere indicating that intermediaries alter their practices—exploitative or not—if women are more knowledgeable about the migration processes. Conversely, our study showed that having contracts did not protect Nepali migrant women from forced labor at destination ( 20 ).

Risk Awareness Among Target Populations vs. Risk Tolerance

Another underlying WIF assumption was that being aware of the risks of forced labor can make one safer from exploitation—an assumption that has underpinned many trafficking prevention activities around the world ( 6 ). Yet, findings from our research and other studies indicate that most prospective migrants are actually aware of migration-related risks. Nevertheless, individuals frequently maintain fervent hopes that migration will work out for them personally , or are willing to take their chances, even if they believe there are risks for other people ( 10 , 46 ). Among SWIFT participants in Nepal, just over two-thirds (67.8%) of returnee migrant women reported having been aware that migrants may be deceived about their working terms and conditions prior to migrating. Most reported (91.2%) having suffered forced labor. Additionally, data from the Nepal survey with returnees and prospective migrants suggest that past experiences of forced labor are also not related to whether or not a respondent decides to return to the same destination or sector in which they were previously exploited. There does not even seem to be a “dose response effect,” as participation in trainings did not reduce the likelihood of experiencing forced labor—even among those women who had a work contract, which was suggested to be protective according to the WIF training ( 20 ).

Language Capability and Exploitation

Local language skills can influence women's negotiating power, but this was not a strong component in the trainings. For example, even for interstate migration in India, language barriers can affect their engagement at destination. As one study participant in India explained: “In Kerala, I could not understand their language. They too do not understand our language, I suppose. I felt like, I was mum almost all the time. There was only work, all the time. We could not take rest for a while during the duty hours. This is so exhausting. I feel very tired there. On the top of this, there is hardly any chance of social interaction. Sometimes, I feel like damning those people there” ( 29 ).

Among Nepali returnees who had migrated to Arabic-speaking countries, almost three in four (73.6%) reported that they could speak some Arabic. The assumption that they would be able to negotiate their contracts or working conditions in Arabic seems, however, farfetched. Results from regression analysis suggest that the prevalence of forced labor among returnees was not associated with speaking the language [crude odds ratio (OR), 0.75; 95% CI, 0.74: 4.0; AOR, 1.1; 95% CI, 0.41: 2.8]. Actually, the prevalence of forced labor was slightly higher among women who could speak the language (95.7%; 95% CI, 93.0: 97.6) vs. women who did not speak the language (92.8%; 95% CI, 86.8: 96.7).

Learning Uptake Among Participants

An important assumption in the WIF design was that the invited participants would be interested in, engage with, and take up the learning offered in the WIF curriculum. Yet, findings cast doubt on the learning uptake by participants. Although the vast majority of WIF training participants in Odisha reported previous training on worker's rights or labor migration, WIF participants' initial knowledge scores about migration risks, practices, rights, and collective bargaining were very limited, and their scores remained low even after the 2-day training, as noted above ( 30 ). Low learning levels might be explained by low prevalence of female migration (7% of households) in the site that ILO selected for the training and evaluation, which likely hindered participant interest and uptake of migration-related information. This finding was similar to the prevalence of female migration in the formative research site in Dolakha, Nepal (2%). As a result of the formative research, this site was dropped from the evaluation. Another possible reason for low learning uptake In India might have been the substantial training focus on domestic work when the larger portion of female migrants worked in construction (25.2%) vs. paid domestic work (19.1%). Moreover, women in India may not have been interested in the exploitation and trafficking messages offered in the training because of the generally low levels of reported forced labor (4%), especially when compared with Nepal (91.2%). At the same time, however, Indian women who had migrated within India working in non-domestic work sectors reported fairly poor work conditions, with 53% indicating that they worked in a dusty, smoky, fume-filled space without adequate ventilation; 50% did tasks that could hurt them or cause illness or sickness; and 37% were in uncomfortable or painful positions for long periods ( 47 ). Yet, occupational risks and protections were not part of the WIF training curriculum. Furthermore, in qualitative interviews, migrants in India reported non-payment of wages, reduced wages, or delayed payments, as well as restrictions in freedom, violence, and abuse by employers. One interviewee reported her experience: “In Kerala, the sister's (female employer) husband misbehaved with me. So at that time I was frightened. And I wanted to go home. About this matter I couldn't speak to anyone, because language was a big problem. Toward the end of my 5 years stay, I deliberately became more uncooperative…. The unpleasant experience of sexual assault by that old man in Kerala has indeed left a lifetime scar on me. I used to spread a mat under the bed of a room and sleep there with fear like a dog.” Despite regular evidence from this study and others, abuse, especially sexual abuse, was not integrated into the curriculum.

Intervention-focused evaluation on human trafficking, forced labor, extreme exploitation—or “modern slavery” —is a relatively nascent field of study. As human trafficking is an emerging area for interventions, it is not surprising that findings on trafficking prevention currently suggest more weaknesses than strengths in the WIF intervention theory, assumptions, mechanisms, and outcomes. Moving forward toward more effective and cost-effective programming, results from this evaluation offer crucial insights about future antitrafficking prevention programming that relies on premigration training. Our findings add to the growing body of evidence on the ineffectiveness of premigration knowledge building as an antitrafficking strategy ( 10 , 15 ). Furthermore, this evaluation highlights the importance of understanding the full context in which interventions are intended to have an effect, not solely the site where the intervention is delivered. This study also has implications for future methodological approaches to intervention development and evaluation.

First and foremost, when addressing modern slavery, and even when considering “everyday exploitation,” there is no denying that the dynamics in each context play the most significant role. The asymmetric power relationship between workers and others involved in their recruitment and employment will continue to hinder mechanisms such as premigration training from achieving the outcome of making women safer because it relies on women to be able to apply these rights and information. In other words, while the WIF intervention's messages about women's rights as women and their rights as workers are undeniably inherently beneficial, it nonetheless remained unreasonable for women to believe in these rights and even more difficult for them to assert them in settings in which these rights are rarely, if ever, respected ( 48 ). Exerting these rights is especially difficult in countries where employment contracts bind employees to employers through migration sponsorship programs, such as the Kafala system in the Gulf countries. Evidence from our research and many other studies show that migrants face increased risks of exploitation, violence, and reduced access to justice under this system ( 20 , 48 – 50 ).

This context of often-extreme power imbalances suggests that it may be problematic to invest in premigration interventions alone, as these single location initiatives do not take sufficient account of the full migration trajectory, especially the later stages toward the destination and workplace, where the power asymmetry widens and most of the abuses occur. Because women themselves are not able to confront the entrenched and unequal power dynamics with recruiters or employers, interventions must be designed to address multiple points in a woman's migration trajectory. Figure 2 highlights how power asymmetries grow over the course of migration, which will limit the potential effectiveness of interventions that solely aim to arm women with knowledge before they migrate without addressing the increasing power differentials women encounter throughout their migration journey. The WIF community-based intervention's theoretical assumption, that if women were equipped with the migration-related knowledge, awareness of their rights and a budding sense of empowerment, they could manage the forthcoming negotiations, was not credible in the face of the severe inequalities related to gender, socioeconomic status, and migrant discrimination, particularly the state-sanctioned inequalities in destination locations. While there have been international legislative achievements that should influence local laws, such as the adoption of the International Labor Organization's Domestic Workers Convention 189 ( 51 ); to date, there have been only 29 ratifications, few of which include common destination locations for migrant domestic workers and no Gulf states. Moreover, while these tools lay the essential scaffolding for future improvements, there is little evidence of their earnest implementation and even less evidence that women workers experience any enforcement or benefit from regulatory provisions. These intervention challenges were also noted in the 2020 report by the United Kingdom's Independent Commission for Aid Impact (ICAI), “It also makes little sense to address international trafficking and forced migration in source countries without also taking necessary action in destination countries and along migration pathways” ( 52 ). Unfortunately, the original Work in Freedom programmatic theory of change for the community-based activities relied on assumptions about the potential for individual empowerment and awareness raising to translate into reduction in vulnerability when migrating. However, WIF did engage local implementing partners that worked closely with migrant populations or had expertise with gender issues.

Figure 2 . Migration intervention trajectory and increasing power asymmetries.

While WIF recruited a broad range of participants, many anti-trafficking programmes target participants based on poverty, sex and education status as supposed “risk factors”, which are non-modifiable characteristics that generally fall beyond the scope of anti-trafficking programming. Findings from our work suggest that identifying at-risk groups based on these individual indicators is likely to be misleading at best and wasteful at worst. Moreover, this study indicates that individual situations have to be carefully considered in the gendered and socioeconomic context to avoid assumptions about the promise of empowerment against exploitation. That is, programs to prevent labor exploitation among international migrants need to address more than just the predeparture characteristics of prospective migrant women but must consider interventions that shift the power imbalances for migrant workers in relation to larger structural determinants, particularly recruitment processes and the employment context at the end of the migration trajectory. Targeting modifiable determinants of a migrant's experiences, for example, recruiter behaviors, which fall further up the structural pathway, may yield better results (see Figure 2 ).

Furthermore, the political context of interventions matters. Definitions of trafficking and forced labor are highly contentious, and governments of both origin and destination locations often dispute the use of these constructs and measurements to describe the situation of their citizens or their foreign workers. During the course of our evaluation, there was some resistance to the subject of forced labor and human trafficking. Moreover, the release of prevalence measurements of trafficking and forced labor was seen as particularly sensitive to governments and the international organizations operating in these sites. In particular, international agencies were concerned about the potential negative implications of the numbers of migrants being exploited and feared that the findings would cause government to (re)instate the female labor migration bans ( 53 ).

From a realist evaluation perspective ( 21 ), WIF lacked some clear initial theorizing about what were potentially successful pathways to influence change in deeply constrained migration trajectories. Moreover, having the programmatic ceiling of accountability fixed on women's empowerment and awareness meant that the actual effectiveness of the program was left mostly unchecked throughout implementation, with only the emerging findings from SWIFT, especially the qualitative component in Bangladesh, able to reveal some of the unintended and often harmful outcomes. Comprehensive monitoring systems that inform a program's adaptation would have been necessary to ensure prevention of harm via early detection of unintended outcomes.

Limitations

Methods for data collection and analysis were not the same across sites. In each setting, we prioritized robust methodological approaches that were complementary and could address our main evaluation question, i.e., to what extent the rationale and assumptions of WIF were supported by context-specific evidence, and what were main enablers and barriers to implementation. We relied on the knowledge and experience of our local partners to ensure that we implemented feasible, acceptable, and ethical methodological approaches for research in each site. Triangulation across sites showed many similarities in findings, even considering the different methods used for data collection. This consistency in findings provided strong indications of the strength of the evidence produced by SWIFT on WIF's theory and implementation.

Of the four cross-sectional surveys we conducted, two relied on representative population samples. Unfortunately, both were conducted in WIF intervention sites with very low prevalence of female migration (Dolakha in Nepal, and Odisha in India). These sites were initially selected by the ILO to be the focus of the SWIFT evaluation, but Dolakha was ultimately removed for Nepal. The surveys with prospective and returnee migrants in three other Nepal districts relied on WIF's strategy for identification of their target population. This strategy aimed to avoid underreporting of migration experiences and aspiration by relying on identification of migrant women by peer educators hired by the ILO's local partners that operated in the specific districts. This population cannot, therefore, be considered representative of the overall population of female migrants living in the evaluation sites. We can, however, safely assume that they represent WIF's target population, since these were the women who were invited to participate in WIF's activities.

Loss to follow-up was very high in longitudinal data collection in India and Nepal, especially after women left home. We put in place several strategies to reduce attrition, but we were not able to conduct many interviews after women reached their destination. Findings on outcomes, in particular (especially quantitative data), were limited by the ethical and logistical challenges to follow women throughout their migration journeys, especially women in exploitative, abusive, or unfree work conditions. In Nepal, follow-up was particularly challenging, partly due to the 2015 earthquake that occurred at the end of the fieldwork. In the aftermath of the earthquake, women's contact details and migration plans may have changed, which may explain in part why there was such a large number lost to follow-up. Details of limitations in each of the individual studies are available elsewhere ( 20 , 28 , 30 , 34 , 35 ).

We acknowledge that the WIF intervention involved more than the community-level activities and also worked with governments, trade unions, employers, and others. These other components may have had positive effects, but our remit with SWIFT was to evaluate only the community-level activities.

This theory-based evaluation strongly indicates that the community-based component of the WIF intervention was not sufficiently researched or well-designed to prevent the exploitation of migrant women. This evaluation also contributes further evidence against premigration knowledge-building and awareness-raising because they are extremely unlikely to sufficiently equip migrants to overcome the power inequalities that they will encounter throughout the migration journey, especially once they are in their employment situation. While these findings are disappointing, they are nonetheless crucial for the field of human trafficking prevention precisely because the results demonstrated that the intervention did not work. There is growing recognition of the necessity to publish null findings of rigorously produced evidence for interventions that do not do what was intended and offer explanations for apparent failure. Scientists reporting weak or null findings are arguably among the most valuable soothsayers in policy or programming realms because of their ability to explain what should be done differently or more effectively in the future, to avoid the waste of precious funds ( 54 ). While our research did not indicate that the intervention was effective in reducing women's risk of exploitation, the results most certainly emphasized that women who decide to migrate for work need and deserve better migration policy protections and effective interventions, so they can be safe when they strive for better livelihoods for themselves and their family.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Ethics Statement

The studies involving human participants were reviewed and approved by Ethics approvals were obtained from the London School of Hygiene and Tropical Medicine (LSHTM) (reference numbers 8840, 7021, and 8895), the Centre for Women's Development Studies, Indian Council of Social Science Research for India, the Nepal Health Research Council (reference numbers 1040 and 1441) and the South Asian Network on Economic Modeling, an autonomous research institute in Bangladesh. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

CZ and LK: conceptualization, funding acquisition, supervision, and writing—original draft. LK, JM, and NP: data curation and formal analysis. CZ, LK, JM, and NP: investigation, methodology, and writing—review & editing. All authors contributed to the article and approved the submitted version.

This evaluation was funded by the Foreign & Commonwealth Development Office (previously known as the Department for International Development), Grant No. GB-1-203857-102, awarded to LK and CZ at the London School of Hygiene and Tropical Medicine. The funders did not play a role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Funding URL: https://devtracker.fcdo.gov.uk/projects/GB-1-203857 .

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We are grateful to the many female and male participants who agreed to participate in the study. We thank Samantha Watson for her role in designing and implementing the study, Christine McLanachan for overall study leadership and coordination, and partners at AAINA, SEWA , and the Centre for Women's Development Studies in India, the DRISHTI Research Centre in Bangladesh, and Centre for the Study of Labour and Mobility at Social Sciences Baha in Nepal. We thank Tanya Abramsky at LSHTM for her role in analyses for Nepal. We are grateful to the FCDO colleagues for their consistent support throughout the evaluation.

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Keywords: human trafficking, modern slavery, migrant women, realist evaluation, South Asia

Citation: Zimmerman C, Mak J, Pocock NS and Kiss L (2021) Human Trafficking: Results of a 5-Year Theory-Based Evaluation of Interventions to Prevent Trafficking of Women From South Asia. Front. Public Health 9:645059. doi: 10.3389/fpubh.2021.645059

Received: 22 December 2020; Accepted: 23 March 2021; Published: 17 May 2021.

Reviewed by:

Copyright © 2021 Zimmerman, Mak, Pocock and Kiss. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Cathy Zimmerman, cathy.zimmerman@lshtm.ac.uk ; Nicola S. Pocock, nicola.pocock@lshtm.ac.uk

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

United Nations

Office on drugs and crime.

• Technical tools and publications

UNODC report on human trafficking exposes modern form of slavery

A Global Report on Trafficking in Persons launched today by the United Nations Office on Drugs and Crime (UNODC) provides new information on a crime that shames us all.

Based on data gathered from 155 countries, it offers the first global assessment of the scope of human trafficking and what is being done to fight it. It includes: an overview of trafficking patterns; legal steps taken in response; and country-specific information on reported cases of trafficking in persons, victims, and prosecutions.

At the launch of the Report in New York, the Executive Director of UNODC, Antonio Maria Costa said that "many governments are still in denial. There is even neglect when it comes to either reporting on, or prosecuting cases of human trafficking". He pointed to the fact that while the number of convictions for human trafficking is increasing, two out of every five countries covered by the UNODC Report had not recorded a single conviction.

According to the Report, the most common form of human trafficking (79%) is sexual exploitation. The victims of sexual exploitation are predominantly women and girls. Surprisingly, in 30% of the countries which provided information on the gender of traffickers, women make up the largest proportion of traffickers. In some parts of the world, women trafficking women is the norm.

The second most common form of human trafficking is forced labour (18%), although this may be a misrepresentation because forced labour is less frequently detected and reported than trafficking for sexual exploitation.

Worldwide, almost 20% of all trafficking victims are children. However, in some parts of Africa and the Mekong region, children are the majority (up to 100% in parts of West Africa).

Although trafficking seems to imply people moving across continents, most exploitation takes place close to home. Data show intra-regional and domestic trafficking are the major forms of trafficking in persons.

The United Nations Protocol against Trafficking in Persons - the foremost international agreement in this area - entered into force in 2003. The Report shows that in the past few years the number of Member States seriously implementing the Protocol has more than doubled (from 54 to 125 out of the 155 States covered). However, there are still many countries that lack the necessary legal instruments or political will.

"This Report increases our understanding of modern slave markets, yet it also exposes our ignorance", said Mr. Costa. "We have a big picture, but it is impressionistic and lacks depth. We fear the problem is getting worse, but we can not prove it for lack of data, and many governments are obstructing", he admitted. The head of UNODC therefore called on governments and social scientists to improve information-gathering and -sharing on human trafficking. "If we do not overcome this knowledge crisis we will be fighting the problem blindfolded", he warned.

In a Panel Discussion on "Exposing Denial and Benign Neglect", Mr. Costa called on governments, the private sector, and the public at large to step up the fight against trafficking in persons. "More must be done to reduce the vulnerability of victims, increase the risks to traffickers, and lower demand for the goods and services of modern-day slaves", he said.

To increase public awareness of human trafficking and rally the world to fight it, Mr. Costa appointed Academy Award-winning actress Mira Sorvino as a Goodwill Ambassador to Combat Human Trafficking. "We know that Mira's commitment to the plight of trafficking victims will move people to take action against modern-day slavery", said the Executive Director of UNODC.

Full report English

Executive Summary

Country profiles.

Central America and the Caribbeans

East Africa

East Asia and the Pacific

Eastern Europe and Central Asia

Middle East and North Africa

North America

South America

South West Asia

Southern Africa

West and Central Africa

Western and Central Europe

Research Expert talks about making the report

Interview on trafficking in persons in Asia

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Peer-reviewed

Research Article

Operations research and analytics to combat human trafficking: A systematic review of academic literature

Roles Conceptualization, Data curation, Formal analysis, Methodology, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Data Science Program, Worcester Polytechnic Institute, Worcester, MA, United States of America

Roles Funding acquisition, Supervision, Writing – review & editing

Affiliation Business School, Worcester Polytechnic Institute, Worcester, MA, United States of America

Affiliation Mechanical and Industrial Engineering Department, Northeastern University, Boston, MA, United States of America

Affiliations Data Science Program, Worcester Polytechnic Institute, Worcester, MA, United States of America, Business School, Worcester Polytechnic Institute, Worcester, MA, United States of America

• Geri L. Dimas, 
• Renata A. Konrad, 
• Kayse Lee Maass, 
• Andrew C. Trapp

• Published: August 29, 2022
• https://doi.org/10.1371/journal.pone.0273708
• Reader Comments

Human trafficking is a widespread and compound social, economic, and human rights issue occurring in every region of the world. While there have been an increasing number of anti-human trafficking studies from the Operations Research and Analytics domains in recent years, no systematic review of this literature currently exists. We fill this gap by providing a systematic literature review that identifies and classifies the body of Operations Research and Analytics research related to the anti-human trafficking domain, thereby illustrating the collective impact of the field to date. We classify 142 studies to identify current trends in methodologies, theoretical approaches, data sources, trafficking contexts, target regions, victim-survivor demographics, and focus within the well-established 4Ps principles. Using these findings, we discuss the extent to which the current literature aligns with the global demographics of human trafficking and identify existing research gaps to propose an agenda for Operations Research and Analytics researchers.

Citation: Dimas GL, Konrad RA, Lee Maass K, Trapp AC (2022) Operations research and analytics to combat human trafficking: A systematic review of academic literature. PLoS ONE 17(8): e0273708. https://doi.org/10.1371/journal.pone.0273708

Editor: Yong-Hong Kuo, University of Hong Kong, HONG KONG

Received: May 5, 2022; Accepted: August 11, 2022; Published: August 29, 2022

Copyright: © 2022 Dimas et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data files are available on GitHub at https://github.com/gldimas/Dimas-et.-al-2022_Human-Trafficking-Literature-Review .

Funding: This work was in part funded by the National Science Foundation ( https://www.nsf.gov/ ) grant (Operations Engineering grants CMMI-1841893 and CMMI-1935602, awarded to principal investigator, R. Konrad. The lead author, G. Dimas receives a student stipend from CMMI-1935602 and previously received funding from CMMI-1841893. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Human trafficking (HT) involves the commercial exchange and exploitation of individuals for monetary or other gain using force, fraud, or coercion [ 1 ] and is a widespread social, economic, and human rights issue. While the trafficking of individuals is a centuries-old phenomenon, over the past two decades there has been growing public and research awareness, in part with the ratification of the 2000 Palermo Protocol to Prevent, Suppress, and Punish Trafficking in Persons [ 2 ]. Although precise figures are elusive, the Global Estimates of Modern Slavery Report estimates that HT impacts 25M individuals and annually generates more than 150 billion USD in illicit gains globally [ 3 , 4 ]. HT is broadly classified as labor and sex trafficking; while all trafficking features exploitation, the actions and means by which HT occurs may differ [ 5 ]. Labor trafficking takes place in a wide variety of sectors, including the agriculture, domestic work, construction, fishing, food service, and beauty industries. Sex trafficking is a part of the broader commercial sex industry, occurring in industries such as escort services, brothels, and pornography.

Because the scope of HT activity is vast and there are diverse ways in which individuals are exploited [ 6 ], context is critical, and effectively addressing HT increasingly requires efforts from multiple disciplines, including interdisciplinary collaborations. For example, HT interventions include approaches from multiple sectors and disciplines such as social work [ 7 – 9 ], healthcare [ 10 , 11 ], criminal justice [ 12 – 14 ], and economics [ 15 , 16 ]; each domain brings unique perspectives and methods to understand and address HT.

Owing to the breadth of domains that contribute to anti-HT research, a wealth of literature exists that has been well-documented in surveys over the years [ 10 , 11 , 17 – 21 ]. Existing reviews focus on social science, healthcare, and law enforcement approaches; whereas OR and Analytics have much to offer [ 22 ], no systematic review exists for the emerging landscapes of Operations Research (OR) and Analytics as applied to anti-HT.

The present study identifies and classifies the existing OR and Analytics literature related to anti-HT operations. Building off the earlier work of Krammer-Kerwick et al. [ 23 ] and Caulkins et al. [ 24 ], this systematic review proposes an agenda for future research in this field, filling a gap in the current literature. This study focuses on the four broad principles of anti-HT: prevention, protection, prosecution, and partnership (4Ps) [ 25 ], extending their definition in relation to the OR and Analytics fields. We examine the following research questions:

• (i). What aspects of HT are being studied by OR and Analytics researchers?
• (ii). What OR and Analytics methods are being applied in the anti-HT domain?
• (iii). What are the existing research gaps associated with (i) and (ii)?

We organize the remainder of our study as follows. In the method of collection and categorization section we define the scope of this review, and in the data section we define the data features for analysis. In the implications and observations section we discuss the implications of the survey and, based on the observed gaps, suggest areas for future work. We conclude our study in the final section.

Method of collection and categorization

We conducted a systematic literature review inventorying studies to answer the three research questions outlined in the introduction. The methodology used for this systematic review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [ 26 ]. The collection process ( Fig 1 ) was based on keyword searches that generated a set of research studies for analysis. Two sets of search words were defined using the combined knowledge of the authors on HT terminology and OR and Analytics methods. These keywords were used in a procedure to identify and select studies that met a set of pre-defined criteria. The first set of keywords reflects terms related to HT, while the second reflects common methods in the OR and Analytics fields (see Table 1 ). The search and selection of studies was performed by the lead author (G.L.D.), and any uncertainty regarding a study’s inclusion was resolved through discussion with the coauthors.

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Each search query followed the format: “Keyword One” + “Keyword Two” (such as “Debt Bondage” AND “Integer Programming”), each keyword pair was applied across three bibliographic databases: Scopus, Web of Science, and Google Scholar. The database search was conducted from June 2021 through March 2022. The search results were truncated to studies available through the end of 2021 to provide a comparable year-over-year basis for the research landscape. The sum of these two searches resulted in a total of 449,407 studies for potential inclusion. After the keyword search identification process, a two-step selection process was followed (see Fig 2 ). An initial screening process was conducted that evaluated the search results returned for each query, where titles and abstracts were screened and added to the set based on the criteria outlined in Table 2 . The stopping criteria for each keyword pair search followed a heuristic approach: if at least 50 results returned no eligible results, then the current keyword search was stopped and the next keyword search began. The intuition behind this approach is that by design, search engines return the most relevant results first, and therefore if after a certain point no relevant results are produced (at least 50 results in our context), then it is highly unlikely relevant results exist past that point. After the initial screening process, the set included 230 unique studies for review. A more in-depth review using the eligibility requirements checklist ( Table 2 ) was followed in step two for each of the 230 studies.

https://doi.org/10.1371/journal.pone.0273708.g002

https://doi.org/10.1371/journal.pone.0273708.t002

First, only studies that fell into one of the three themes: Operations Research methodologies, Analytical methodologies, or Position / Thought pieces related to Operations Research and Analytics were included. Second, only studies whose primary application area was anti-HT and was written completely in English text were included. Third, book chapters, workshops, and reports (governmental, intragovernmental, non-government organizations, think-tanks) were excluded. Finally, if multiple studies related to a single work were found, only the most complete version were included. Peer-reviewed studies, dissertations, and pre-print studies were included to produce a full and comprehensive review of the current research landscape. The full article screening process resulted in a total of 142 studies included in the set for final review.

As with any search process based upon a predefined set of keywords and checklist requirements, the 142 identified studies may not be exhaustive in scope. However, given our collective experience in researching at the intersection of anti-HT and OR and Analytics, we believe the generated set of studies is representative of current literature at this confluence. A repository containing our classification data can be found publicly at https://github.com/gldimas/Dimas-et.-al-2022_Human-Trafficking-Literature-Review .

While the focus of this study was to capture the general trends in anti-HT research within the OR and Applied Analytics communities, we acknowledge there exist many relevant studies that either fall outside of the scope of the present analysis (such as reports) or focus on the problem domain of anti-HT but do not have a specific OR or Analytics-related attribution, and therefore were excluded. We have included such studies in the S1 File and further point the reader to reviews such as Raets and Janssens [ 27 ], Farrell and De Vries [ 28 ], and Weitzer [ 29 ] to better capture the broader scope of anti-HT research.

The classification of studies was independently conducted by the lead author (G.L.D.) who throughout the process conferred with all coauthors. Each of the 142 studies in the set were reviewed and assigned labels to nine key features: Publication Year , Category , Context , Demographics , Target Region , Data Source , Theoretical Approach , Methodologies , and 4Ps . We next explain each feature and its respective values.

Publication Year : Observed years were 2010—2021 , inclusive. Only studies available through December 2021 were included in our scope to allow for comparison across complete calendar years. This feature offers valuable information about the progress and patterns of research in OR and Analytics over more than ten years.

Category : We considered three categories: Operations Research (OR), Analytics , and Position / Thought . Whereas the first two categories are distinguished by their methodological focus, the latter includes position / thought pieces from either the OR or Analytics domains. We required a single category to be assigned to each study, and thus selected the category that we felt best matched the primary theme of the work.

Context : We classified the primary topical HT area (as stated or inferred) into three contexts: Sex, Labor , and General . If the application was not specified, we assumed it to be general and thus applicable to both sex and labor trafficking.

Demographics : We classified studies into five demographic groups based on the population of interest (such as victims, potential victims, and survivors): Female, Male, Child, LGBTQ+ , and Unspecified / All Individuals . If no specific demographic characteristics were stated or could be inferred, we assumed it to be applicable to all individuals. A study could be classified into multiple demographics such as a study focused on female children.

Target Region : We subdivided the geographic location specified either by the data used in the study or by the region discussed in the background of the study, into world regions: Africa, Asia, Australia/Oceania, Europe, North America, South America, Unspecified / All regions . A study could cover multiple geographic locations and therefore have multiple target regions identified.

Data Source : We classified the type of data used in the study into four categories: Primary, Secondary, Mixed, N/A . Primary data are collected directly from anti-HT organizations or researchers, including interviews and surveys. Secondary data are data that have already been collected for other purposes or are publicly available such as data from websites hosting illicit advertisements (such as backpage.com and rubmaps.com) and government reports. While many studies used their own methodologies to scrape public data sources such as escort and massage websites, we still consider these to be secondary sources. We classify studies utilizing expert judgements for determining data estimates to be secondary data. Mixed data means the study used both primary and secondary data in their work, and N/A indicates data was not used in the study.

Theoretical Approach : We classified the central theoretical approach to address HT into six categories: Decision Support, Inferential Statistics / Detection, Network Flow, Resource Allocation, Supply Chain , and Other / Unspecified . Decision Support explores ways to inform decision makers about initiatives to improve and better address HT, often building tools or systems for practitioners to use. Inferential Statistics / Detection focuses on identifying, estimating, or inferring aspects of HT. Network Flow studies are related to the flow of individuals and possibly trafficking network interaction. Resource Allocation addresses the use and allocation of resources in anti-HT efforts. Supply Chain studies examine the supply and demand of HT within a network. If a study approaches HT from a theoretical approach not listed, we label these studies as Other / Unspecified. A study may be classified under multiple theoretical approaches.

Methodologies : We classified the main methodologies used in the set of studies into 21 categories:

• Active Learning
• Clustering or Classification
• Data Envelopment Analysis
• Empirical Analysis
• Facility Location
• Game Theory
• Graph Construction
• Investigative Search
• Link Inference
• Machine / Deep Learning (General)
• Natural Language Processing
• Information Extraction
• Integer Programming
• Network / Graph Theory
• Network Interdiction
• Queueing Theory
• (Social) Network Analysis
• Unsupervised or Minimally Supervised Learning
• Web Crawling / Scraping

We ascribe methods to a study based on the introduction, conclusion, and main method or focus throughout the study. A study may apply a variety of different methods and therefore be classified into multiple methodologies.

4Ps : Activities to fight HT are often discussed under four broad principles: prevention, protection, prosecution, and partnership. These principles are collectively referred to as the 4Ps—a well-recognized classification within the anti-HT community [ 22 ]. A study may be classified under multiple principles. The 4Ps naturally correspond with efforts in the social science, healthcare, and law enforcement disciplines, and their alignment with OR and Analytics works is less evident. Thus, we adapt the 4Ps definitions to define each as it relates to OR and Analytics using the collective knowledge and experience of the authors in the anti-HT and OR and Analytics fields. To the best of our knowledge, this is the first attempt to define each of the 4Ps as it relates specifically to the OR and Analytics fields and constitutes an important contribution of this study. Prevention, Protection, and Prosecution were originally referred to as the 3P paradigm [ 25 ] which has since been informally expanded to include a fourth “P” representing Partnership. Prevention refers to efforts focused on a proactive approach to prevent trafficking such as awareness campaigns and education; Prosecution refers to efforts to punish traffickers; and Protection involves meeting post-trafficking victim needs such as counseling, job training, housing, and other support to facilitate survivor recovery and restoration.

Partnership was introduced to serve as a complementary means to further improve the efficacy among the 3Ps, enlisting all segments of society in the fight against HT [ 25 ]. Together the 4Ps capture the spectrum of efforts in combating HT and therefore are an important feature for our literature review. Accordingly, we have adapted these 4Ps and classified studies in the following manner:

• Prevention : The goal of the study is the prevention of HT either now or in the future and assumes no trafficking is currently taking place. Such studies typically feature victim-centric methodologies to help potential victims avoid being trafficked, such as awareness campaigns and education. Studies that consider reducing the re-trafficking risk of survivors who have left their trafficking environment also fall within the scope of the prevention principle.
• Protection : The goal of the study is to protect and aid the survivor during and post-exploitation. We consider victim-driven detection and disruption of HT networks to be a form of protection, as the focus of the study is mitigating the risk to an individual of further exploitation (including studies that consider NGOs, healthcare, and other non-law enforcement detection).
• Prosecution : The goal of the study is to aid the prosecution of traffickers (often from a law enforcement perspective). We consider detection and disruption of HT networks aimed at locating, understanding, and stopping traffickers under the prosecution principle.
• Partnership : The goal of the study is to show the benefit of collaboration and data sharing across different sectors, countries, or groups working together toward the common goal of addressing one or more areas of HT.

Implications and observations

Of the 142 studies in the set, the majority (73.9%) were categorized as Analytics [ 30 – 134 ], with 15.5% classified as Operations Research [ 135 – 156 ] and 10.6% as Position / Thought [ 22 , 24 , 157 – 169 ]. Fig 3 depicts this breakdown. Fig 4 provides summary statistics on each of the nine key features. All percentages are calculated in relation to the total number of studies in the set (142) unless stated otherwise. As some studies contained multiple methods or were identified to have multiple values within a feature, a feature may not always sum to 100.0%.

https://doi.org/10.1371/journal.pone.0273708.g003

https://doi.org/10.1371/journal.pone.0273708.g004

Research question 1: What aspects of HT are being studied?

Although both sex and labor trafficking have been addressed in the OR and Analytics literature, an overwhelming number of studies focus specifically on sex trafficking. Fig 4 illustrates the inclination of OR and Analytics studies to focus on sex trafficking (4 7.9%), with only 1 2.0% concentrating on labor trafficking, while 4 0.1% apply to general (both) trafficking contexts. As observed in Fig 5 , studies overwhelming use secondary data, with fewer than 4.0% using a primary data source. The use of secondary data is likely due to accessibility; almost all studies on sex trafficking (60.3%) used data pulled from escort websites (or other online sites hosting illicit advertisements) which are public and therefore easier to access. The use of escort websites (in particular, backpage.com) as a source of data result in over 3 8.0% of the studies focusing on the North American region. Although the United States Department of Justice shut down backpage.com in 2018 [ 170 ], other escort and massaging sites offer illicit services and constitute the data source for several studies. Remarkably, 7 6.8% of studies were not tailored to a specific demographic, despite the differences between typologies and demographics of victims [ 6 ]. From the 4Ps perspective, prosecution is the most common principle (62.7%) among all studies, with considerably less focus on partnership, protection, and prevention ( Fig 6 ). A single study may be categorized under multiple 4Ps principles, and therefore the values in Fig 6 do not sum to 100.0%.

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Research question 2: What OR and analytical methods are being applied in the anti-HT domain?

Fig 4 provides summary statistics such as counts and percentages for the frequency each value was observed in the set of studies. While the percentages are calculated based on the 142 studies in the set, because a study may belong to multiple values within a feature, the total observations within each feature are provided in the parenthesis. The colors highlight the magnitude of studies within each feature value, with green indicating higher percentages, and red lower percentages. A study may fall under more than one value and therefore the percentages will not always sum to 100.0%. Methods related to machine learning (Machine / Deep Learning (General), Clustering or Classification, Unsupervised / Minimally Supervised Learning, Natural Language Processing, and Active Learning) were observed in over half of the studies. Machine / Deep Learning (General) and Clustering or Classification were the two most popular methods, accounting for about 32.0% of all methods observed (out of the total 404 methods identified, see Fig 4 ). Web Crawling / Scraping was used to generate a secondary dataset for analysis in 18.3% of the studies, reflecting our previous observations in Research question 1 regarding the high use of secondary data extracted from massage and escort websites. At least one method for the construction and analysis of networks (Graph Construction, Network / Graph Theory, Network Interdiction and (Social) Network Analysis) were observed in 34.5% of the studies, with most emphasizing Graph Construction.

The observed theoretical approaches are closely related to specific methods. For example, nearly half of the studies focused on Inferential Statistics / Detection or Decision Support, most of which applied various machine learning methods. Network Flow methods appear in nearly 24.0% of studies, specifically Graph Construction and (Social) Network Analysis.

Figs 7 and 8 depict each study on the x -axis. In Fig 7 we display all studies categorized as Analytics, and in Fig 8 we categorize studies on the left as Operations Research (in blue), and studies on the right as Position / Thought studies (in red). For each study, the top six y -axis labels indicate its Theoretical Approach(es), while the remaining 21 following labels indicate methods used. If a study includes a given feature value, the box is black, and grey otherwise. Theoretical approaches and methods are sorted in descending order based on the total count for each row. Fig 7 indicates that the majority of studies (over 77.0%) in the Analytics category take an Inferential Statistics / Detection or Decision Support theoretical approach. Fig 8 shows that studies in the Operations Research category are diverse, addressing the problem from distinct theoretical approaches and applying a variety of methodologies. Studies categorized as Position / Thought address a variety of theoretical approaches and topics, which is a good indication that OR and Analytics researchers are exploring HT from different fields.

The x -axis lists each study; and the y -axis depicts each of the Theoretical Approaches and Method. If a study includes a given feature value, the box is black, and grey otherwise. Theoretical approaches and methods are sorted in descending order based on the total count for each row.

https://doi.org/10.1371/journal.pone.0273708.g007

The x -axis lists each study; and the y -axis depicts each of the Theoretical Approaches and Method. Operations Research studies appear on the left (in blue), and Position / Thought studies appear on the right (in red). If a study includes a given feature value, the box is black, and grey otherwise. Theoretical approaches and methods are sorted in descending order based on the total count for each row.

https://doi.org/10.1371/journal.pone.0273708.g008

While Resource Allocation and Supply Chain roughly make up only 9.0% of all studies, they account for over 40.0% within the Operations Research category. Looking more closely at the relationship between Web Crawling / Scraping and Clustering and Classification methods we see a large majority (nearly 70.0%) of Web Crawling / Scraping studies apply Clustering and Classification methods. In addition, more than 72.0% of studies that applied both Web Crawling / Scraping and Clustering and Classification shared the goal of identifying sex trafficking in online advertisements or tweets.

To compare studies across all three categories: Analytics, Operations Research, and Position / Thought Figs 7 and 8 are combined and the resulting figure can be found in the supplementary materials (see S1 Fig ). We also provide a publicly available spreadsheet that can be used for closer examination of the individual studies, at https://github.com/gldimas/Dimas-et.-al-2022_Human-Trafficking-Literature-Review . This spreadsheet allows filtering studies on any combination of our nine features, returning all qualified studies. A screenshot of this tool can be see in Fig 9 . As seen in this review, research at the intersection of anti-HT and OR and Applied Analytics is rapidly evolving and there is necessary complexity in the reviewing process. The selected keywords, search engines used and growing literature streams may impact the articles included in this review. In an effort to counter this limitation and support the longevity of this study, the authors have created an online submission form where individuals can submit works they believe to be related to the present study. Related submissions will be added to the dashboard tool on a semi-regular basis (see Fig 9 ) and will provide an evolving source of knowledge for researchers. The link for this form can be found on the github link provided earlier in this paragraph.

https://doi.org/10.1371/journal.pone.0273708.g009

Research question 3: What are the existing gaps and opportunities for future research?

Several gaps emerged based on the classification and grouping of all 142 studies in the set on the prime principles (4Ps) ( Fig 6 ), methods (Figs 7 and 8 ), trafficking context ( Fig 5 ), and resulting observations to Research questions 1 and 2. The following sections present opportunities for new avenues of investigation for OR and Analytics researchers in anti-HT efforts.

Broaden the typology and demographics of trafficking studied.

The typology of trafficking activity, and by extension the demographic composition of victims, is diverse and under-explored in OR and Analytics [ 6 ]. As noted in [ 164 ], OR and Analytics researchers can increase the relevance and impact of their work by understanding the typology of trafficking and distinguish between various trafficking business models. To start, there is a clear need to expand the current focus to include labor trafficking. In OR and Analytics, sex trafficking ( Fig 6 ) has received by far the most attention; while labor trafficking is estimated to account for over 60.0% of all trafficking instances [ 3 ], it constitutes only 12.0% of the reviewed studies. There is a close relationship between data source and type of HT studied. The absence of reliable, available data likely contributes to the lack of both analytically-based labor trafficking research, as well as the lack of diversity in data used in sex trafficking research; this is a well-documented issue across the anti-HT literature [ 22 , 171 – 174 ]. The implications of the lack of data are also evident in studies using OR and Analytics methods and discussed further in the next section.

The diverse populations of those experiencing trafficking warrants further analysis. Nearly 7 7.0% of the studies observed were classified as applicable to Unspecified / All Individuals, indicating that the nuanced differences in victimology may be lacking. For example, no study we observed looked at trafficking through the lens of male victims or those who identify as LBGTQ+. These groups tend to be underrepresented in trafficking research despite their known presence [ 175 , 176 ]. Inclusivity of more diverse victims and trafficker demographics in trafficking research expands insights into the unique characteristics, needs and behaviors across trafficking.

Beyond the demographics of those impacted by trafficking, it is apparent that there is an opportunity to expand the diversity of the demographics of trafficking locations. Whereas trafficking occurs globally in various facets of society, and differs in its appearance across cultures, many of the sex trafficking studies we reviewed were conducted within developed countries (approximately 78.0%). Thus, a clear opportunity exists to conduct anti-HT research in developing countries.

It is altogether possible that the lack of research identified in these areas may be a direct result of constrained factors such as the limited amount of data available. Even so, greater research diversity in trafficking typology and demographics will allow for an improved understanding of the extent and impact of trafficking worldwide, as well as greater insights into how future research can help address associated needs in the fight against HT. This brings us to the next research gap observed: the need to diversity data sources.

Diversify the data sources.

Data collection and analysis have helped in the fight against HT in many ways, including the identification of HT victims [ 63 , 134 , 141 ], informing prevention campaigns [ 142 ], and detecting trafficking network behaviors [ 45 , 80 ]. While thorough data analysis lays the necessary groundwork for such discoveries, it relies upon the utilization of a variety of data from disparate sources.

Over 78.0% of all studies in the set used secondary data sources exclusively ( Fig 6 ). The use of secondary data is common across many domains and proves beneficial given that the data already exists, is oftentimes publicly available, and can provide researchers with large amounts of data they might not be able to obtain otherwise. In the context of the OR and Analytics studies observed, over 22.0% of the secondary data sources used were from the same source, the now defunct, backpage.com [ 170 ]. Of the secondary data sources, around 54.0% of these studies focused on sex trafficking. So, while secondary data sources have their place, as noted in the previous section the lack of data diversity compounds issues such as the typologies studied. Obtaining more robust data can broaden the information available, provide better insights into the scope of trafficking (such as prevalence), and examine changes that occur over time. Even with the limited current state of available data, OR and Analytics can still offer valuable contributions.

Researchers, particularly those in the Analytics community, could leverage collaborations and focus on developing the already existing, practitioner-collected data and help to operationalize it. For example, a common issue faced in anti-HT analysis pertains to missing and incomplete data [ 177 ]. Many analytical methods exist that could help bridge this gap and improve the current anti-HT data landscape. Additionally, although many disparate datasets are available and growing, the anti-HT community rarely leverages combined data sources in a way to assess the status, trends, and dynamics of trafficking activities, and is another avenue for future work.

Despite the usefulness of secondary data, they have drawbacks that may hinder the results of a study. Secondary data is often collected with another objective in mind and therefore the nuances of that data collection process may cause bias. For example, what constitutes trafficking may differ from study to study and is a well-documented issue across anti-HT research [ 178 – 180 ]. There may also be a context in which data simply does not exist. For these and other reasons, we advocate for the collection and use of primary data where possible. While primary data may be more resource-intensive to obtain, it provides researchers with curated data for their specific research goals. When possible, sharing this data within the anti-HT community provides additional resources for other work. In addition, embracing collaborations with practitioners or other researchers in the anti-HT domain throughout the data collection phase can serve to increase the quality of this data by providing domain-specific insights. Building such collaborations demonstrates effective employment of the partnership principle (the fourth P) and embodies our next recommendation.

Better inclusion and collaboration of the 4Ps.

The 4Ps (prevention, protection, prosecution, and partnership) are widely acknowledged as a holistic set of principles that accounts for the spectrum of anti-HT efforts. To date, the majority of OR and Analytics studies in the set appear to be focused on prosecution ( Fig 6 ). Thus, while there exists demonstrated impact for prosecution-related activities, there are opportunities to contribute to anti-HT efforts in the spheres of prevention, protection, and partnership. A key way to increase the impact of OR and Analytics research in the fight against HT is to be keenly aware of all stakeholders involved, their various objectives, and how the research addresses the 4Ps. For example, while law enforcement may make decisions based on the likelihood of prosecuting traffickers, possibly at the expense of additional trauma to victims, Non-Government Organizations (NGOs) may focus more on the immediate needs of the survivors, offering an avenue for research around prevention and protection.

NGOs and governmental agencies often work directly with victims and survivors and could both inform avenues for profitable research studies, and themselves benefit from collaboration with OR and Analytics researchers. Given the often extreme resource constraints under which NGOs and governmental organizations operate, examining ways to evaluate current operations and improve resource allocation is a direction that deserves more study; less than 3.0% of all studies considered these areas.

Beyond the scope of the present study, OR and Analytics can help in the fight against HT by looking at push factors associated with HT. These areas include and are not limited to poverty, abuse, and lack of resources to meet basic needs [ 181 ]. More broadly, looking at ways to help improve circumstances of vulnerable populations at risk of HT is a needed avenue for future research.

While there are many ways in which the OR and Analytics communities can apply methods in the fight against HT, researchers ought to judiciously evaluate the problem context at hand, and whether an off-the-shelf method is justified; likely, the context warrants in-depth understanding, so that proper methodologies can be developed to accurately model and address the trafficking context [ 164 ].

Conclusions

This survey provides a synopsis of the current state of the literature in OR and Analytics approaches in anti-HT contexts by surveying the research methodologies adopted in studies published from 2010 through 2021. A total of 142 studies were included in the set and examined, demonstrating the ability and promise of applying analytical methods to advance the fight against HT. A number of themes arose after careful review of the features of these studies, thereby illustrating opportunities for future research. We observed an increasing trend in the number of studies for both OR and Analytics, thus demonstrating a growing awareness of the issue of HT. However, the tendency of these works to focus specifically on sex trafficking underscores the need for future research in labor trafficking. Very few (less than 2 4.0%) of the studies on anti-HT in OR and Analytics focus on a specific sub-population, potentially failing to consider the diverse needs of victims and survivors. Existing OR and Analytics studies echo the anti-HT community at large for more available data. HT is diverse and nuanced, and researchers should make careful considerations when adapting existing methods to this vexing societal issue, considering efforts equally in prevention, protection, prosecution, and partnership.

Supporting information

S1 checklist. prisma 2020 checklist..

https://doi.org/10.1371/journal.pone.0273708.s001

S1 File. Related studies.

A list of related studies that fall outside of the scope of current work.

https://doi.org/10.1371/journal.pone.0273708.s002

S1 Fig. Granular view of theoretical and methodological topic inclusion for the set of 142 studies.

The x-axis lists each study; and the y-axis depicts each of the Theoretical Approaches and Method. Operations Research studies appear on the far left (in blue), Analytics studies appear in the middle (in black) and Position / Thought studies appear on the far right (in red). If a study includes a given feature, the box is black, and grey otherwise. Theoretical approaches and methods are sorted in descending order based on the total count for each row.

https://doi.org/10.1371/journal.pone.0273708.s003

Acknowledgments

We express our deep gratitude for Dr. Meredith Dank at New York University for providing insights on the current research gaps in the domain of Human Trafficking and supplying feedback on how Operations and Analytical researchers can help fill these gaps.

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• Published: 08 November 2018

Research trends on human trafficking: a bibliometric analysis using Scopus database

• Waleed M. Sweileh 1  

Globalization and Health volume  14 , Article number:  106 ( 2018 ) Cite this article

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Human trafficking is a crime against humanity. It is also a serious threat to global health and security. Globalization has made human trafficking an easier task for the criminal organizations. No data are available on the volume, research trends, and key players in this field. Therefore, the aim of this study was to assess the research activity and research trends on human trafficking.

A bibliometric method was adopted. Literature published in academic journals indexed in Scopus database was retrieved. The study period was set from 2000 to 2017.

Two thousand forty-four documents were retrieved. The average number of authors per document was 1.9. Over one third ( n  = 771; 37.7%) of the retrieved documents were about sex trafficking, 616 (30.1%) were about labor trafficking/forced labor, 199 (9.7%) were about child trafficking, and 138 (6.8%) were about organ trafficking. One third ( n  = 707; 34.6%) of the documents were in health-related fields while 1526 (74.7%) were in social sciences and humanities. The USA ranked first ( n  = 735; 36.0%) regarding the number of published documents. Geographic distribution of the retrieved document showed that world regions with a high prevalence of human trafficking had the least research contribution. International research collaboration has a limited contribution to the retrieved literature. The Harvard University (USA) was the most active institution ( n  = 39; 1.9%). International Migration ( n  = 35; 1.7%) was the most active journal in publishing documents on HT. Documents published in Transplantation journal received the highest number of citations per document (25.5) and two of the most cited documents were about organ trafficking.

There was an under-representation of health-related literature on human trafficking. Literature on sex trafficking dominated the field of human trafficking. Research networks and research collaboration between the source and destination countries is important. Future research plans need to focus on health issues and on exploited/trafficked laborers.

Human trafficking (HT), or modern slavery, is an old problem [ 1 ]. However, in the past few decades, HT became a global concern [ 2 , 3 ]. The most accepted definition of HT is presented by the Trafficking Protocol [ 4 ]. Human trafficking was addressed by several international agreements and conferences such as the International Agreement for the Suppression of White Slave Traffic (1904) [ 5 ], International Agreement for the Suppression of Traffic in Women and Children (1927) [ 6 ], the Trafficking Protocol (2000), and the Protocol against Smuggling of Migrants by Land, Sea, and Air (2000) [ 4 ]. The last two protocols recognized HT as a transnational crime rather than just human rights or migration issue [ 7 ]. Different countries used the UN Trafficking Protocol to develop criminal codes for HT. As of 2016, over 150 countries had criminal laws for HT [ 8 ]. In the USA, the Office to Monitor and Combat Trafficking in Persons releases an annual report (TIP Report) about international efforts to combat trafficking. The European Union adopted the Brussels Declaration on Preventing and Combating Trafficking in Human Beings which aimed to fight HT in Europe [ 9 ]. Other non-European and non-American countries developed their own national policies and protocols to criminalize and fight HT [ 10 ].

Sex trafficking is one of the most common forms of HT with more than half a million women being trafficked every year [ 6 ]. Forced labor, child labor, child soldiers, debt bondage, involuntary domestic servitude, and organ/tissue removal for transplantation are other common forms of HT [ 11 ]. Forced prostitution represents the highest percentage of HT victims with the majority being women from Eastern Europe, Central Asia, and North and South America [ 8 , 12 , 13 ]. In contrast, the majority of victims of forced labor are men from Africa, the Middle East, and Asia [ 8 , 12 ]. International organizations distinguish between HT and smuggling. In smuggling, the actor takes part in the process while HT involves some deception or coercion [ 14 ]. Unlike HT, migration and smuggling are less often involved with a criminal organization [ 14 ].

Human trafficking has a global dimension despite that trafficking could occur within the same country [ 8 ]. Human trafficking affects people of all races, religions, social class, and education. It often results in mental health disorders and life-threatening infections [ 8 , 15 , 16 , 17 , 18 , 19 , 20 ]. For example, a study of 207 trafficked women from 14 countries reported that 95% of women had experienced physical and/or sexual violence [ 21 ]. A study on trafficked Nepalese girls and women found that 23% of them tested positive for HIV [ 22 ]. Despite its negative social, health, and legal consequences, HT is a growing business for criminal organizations [ 21 , 23 ]. Poverty, social injustice, disasters, substance abuse, family breakdown, and homelessness are major push factors for victims [ 24 , 25 , 26 ]. Globalization has created a larger gap between developing and developed countries with poverty and marginalization being major push factors for victims [ 1 ].

The International Labor Organization (ILO) reported 12.3 million trafficking victims in 2005, 21 million victims in 2012, and 40.3 million victims in 2016 [ 27 ]. The 2016 report of the ILO estimated that 40.3 million people in modern slavery, including 24.9 in forced labor and 15.4 million in the forced marriage [ 28 ]. Out of the 24.9 million people trapped in forced labor, 16 million people in the private sector such as domestic work, construction or agriculture; 4.8 million persons in forced sexual exploitation, and 4 million persons in forced labor imposed by state authorities [ 27 ]. The ILO considers the Asia-Pacific region to have the largest number of victims of HT followed by Africa and Latin America [ 28 ]. It was estimated that over 40% of trafficked victims were detected in their own countries and that 71% of the trafficked victims were women while 28% were children [ 8 ].

Bibliometric analysis is a research method used to shed light on research activity [ 29 , 30 , 31 ]. It differs from systematic reviews, which aim to answer a specific research question based on a selected group of articles [ 32 , 33 ]. It also differs from scoping reviews, which aim to identify the nature and extent of research evidence [ 34 , 35 ]. Bibliometric studies were carried out to provide a snapshot of national and international contribution to literature [ 36 ] and to advance information and science [ 37 ]. Bibliometric indicators assess national and international efforts carried out to achieve a particular goal. Several bibliometric studies on migrants and refugees have been published [ 38 , 39 , 40 ]. However, none was carried out on HT. Therefore, the aim of this study was to analyze published literature on HT. Such a study will shed light on the global research activity and discussed themes in literature on HT. Bibliometric analysis may be useful for health authorities and UN agencies interested in mapping and identifying research gaps within the HT research landscape, which is important for advancing an evidence-informed research agenda. Findings of a bibliometric analysis are difficult to obtain by other research methods such as systematic or scoping reviews. For example, a recent systematic review of research methods on HT and health concluded that despite the presence of various quantitative and qualitative data collection and analysis methods, the implemented methodological approaches have limitations that affect what is known about HT and health [ 41 ]. Most available literature on HT is based on emotional stories rather than on empirical research [ 42 ]. Bibliometric analysis would give an accurate quantitative analysis of literature on HT that would serve as a basis for future studies. The findings of a bibliometric study on HT will shed light on the evolution, volume, and scope of research on HT and will help identify countries and regions lagging behind in this field [ 5 ]. A bibliometric analysis of literature on HT will also give detailed information on the number of publication on each type of HT and therefore a direct academic and research effort as well as funding towards less-researched types of HT.

Source of information

In the current study, SciVerse Scopus was selected to accomplish the objectives. Scopus is a bibliographic database created by Elsevier in November 2004 [ 43 ]. With 22,800 titles from over 5000 international publishers, Scopus delivers the most comprehensive view of the world’s research output in the fields of science, technology, medicine, social science and arts and humanities [ 43 ]. Scopus database includes all MEDLINE journals and allows for citation analysis [ 44 , 45 ]. Scopus database has several operating functions that facilitate bibliometric analysis. Such operating functions include journal name, type of document, year of publication, authors and their affiliations, the number of citations, and h -index metrics for documents [ 46 , 47 ].

Study design

A bibliometric method was implemented. The study period was set from 2000 to 2017. The study period was determined based on the assumption that HT has attracted a lot of public attention after the introducing the UN Trafficking Protocol ratified in December 2000.

Search strategy

In bibliometric analysis, selection of keywords is of utmost importance, as these keywords have a direct impact on the findings and results. In the current study, search strategy was based on title or title/abstract search with certain constraints to minimize false-positive results (Table  1 ) . Keywords were obtained from previously published literature on HT [ 20 , 48 , 49 , 50 , 51 ]. The search strategy was limited to documents published in academic journals but was not restricted to any language. The online search was performed on June 03, 2018.

Estimation of the number of health- and non-health-related documents

Using the function designated as “subject area”; it was possible to estimate the number of HT documents in health field, defined as documents in the following subject areas: medicine, nursing, psychology, pharmacology, neuroscience, general health, microbiology/immunology, biochemistry, and dentistry. The total number of health and non-health documents was greater than the total number of the retrieved documents because some journals are indexed in both medicine and social sciences; e.g. the Journal of Social Medicine which is categorized in both social science and medicine. Health-related documents were further divided into different domains such as mental health, health policy and systems, maternal and reproductive health, non-communicable diseases, and infectious diseases [ 38 ].

Bibliometric indicators, analytics, and mapping

In the current study, bibliometric indicators were presented as ten most active countries, institutions, journals, authors, and ten most cited documents. The choice of number ten as a threshold to list the results was an arbitrary selection that has been used in previously published bibliometric studies [ 40 , 52 , 53 , 54 ].

International collaboration

Research collaboration was assessed using author affiliation. For example, documents with authors having different country affiliations represent international research collaboration while documents with authors having the same country affiliation represent intra-country collaboration. Scopus allows for segregation of documents based on authoraffiliation. Therefore, for each country, the number of documents with international authors was calculated as a percentage of the total number of documents published by that country. Documents with international authors were referred to as multiple country publications (MCP) and represented the extent of international collaboration [ 55 , 56 , 57 , 58 ].

Bibliometric visualization maps

Co-authorship analysis, international collaboration, and keyword analysis were presented as network visualization maps using VOSviewer (Leiden University, Leiden, Netherlands) [ 59 , 60 ].The Statistical Package for Social Sciences (SPSS) (SPSS, Chicago, Illinois) was used to generate line presentation of the annual growth of publications. ArcGIS 10.1 software (Esri; USA) is a geographic information system used in bibliometric studies to map worldwide research contribution. The GIS map allows for a better understanding of regional contribution to a specific scientific topic.

Growth of publications and typology of documents

In total, 2044 documents were retrieved (Additional file  1 ). The retrieved documents were of eight different types: research articles (1553; 76.0%), reviews (280; 13.7%); notes (66; 3.2%); editorials (46; 2.3%), letters (30; 1.5%); short surveys (23; 1.1%), conference papers (22; 1.1%), and unclassified (24; 1.2%).

The number of retrieved documents have significantly increased during the study period (linear regression: β = .978, P  < .001, R 2  = .956; Figure  1 ). If this trend continues, it was estimated that 293 documents would be published in 2020.

Total number of published documents from 2000 to 2017

Mapping the most frequent keywords and typology of trafficking

Most frequent keywords were visualized (Fig.  2 ). The map showed five clusters: (1) organ trafficking; (2) child trafficking; (3) forced labor; (4) sex trafficking of women, and (5) slavery. Further analysis of the retrieved documents showed that 771 (37.7%) documents were about sex trafficking, 616 (30.1%) were about labor trafficking/forced labor, 199 (9.7%) were about child trafficking, and 138 (6.8%) were about organ trafficking. The remaining documents were general documents or ones that discussed multiple types of trafficking.

Mapping 10 most frequent keywords

Research domains

In total, 707 (34.6%) documents were in the health field while 1526 (74.7%) were in social sciences and humanities taking into consideration certain limited overlap between the health and health research domains. Analysis of the retrieved showed that 971 (47.5%) documents were about law and criminology, 238 (11.6%) were about health policy and systems, 200 (9.8%) were about social work, and 183 (9.0%) were about mental health (Fig.  3 ).

Research domains in the retrieved literature

Top 10 active countries

Authors from 91 different countries participated in publishing the retrieved documents. The top 10 active countries participated in publishing 1478 (72.3%) documents (Table  2 ). The United States ranked first (735; 36.0%) regarding the number of published documents. Five countries in the top 10 active list were in Western Europe, two were in Northern America, one in the Western Pacific region, one in Southeast Asia, and one in Latin America. The geographic distribution of the retrieved document showed that world regions with a high prevalence of HT, such as South East Asia, East Europe, Africa, and Latin America [ 8 ], had the least research contribution (Fig.  4 ).

Geographic distribution of publications based on the country affiliation of authors. The following is the color-coding for the map

Analysis of international research collaboration for the top 10 active countries showed that India had the highest percentage of documents (49%) with international research collaboration. In contrast, Brazil had the least percentage of documents (12%) with international research collaboration. For the US, which led in the number of publications, only 12.5% of documents with US authors included authors from other countries. Of the 1478 publications produced by the top 10 active countries, there were only 238 (16.1%) publications with international collaboration.

Top 10 active institutions

Harvard University (USA) ( n  = 39; 1.9%) was the most active institution in this field followed by University of British Columbia (Canada) and London School of Hygiene & Tropical Medicine (UK) (Table  3 ). The top 10 active list of institutions included four in the USA, three in Canada, and three in the UK.

Authorship analysis

In total, 3920 authors participated in publishing the retrieved documents, giving an average of 1.9 authors per document. Approximately 61% ( n  = 1250) documents were single-authored publications, 20.0% ( n  = 408) were two-authored publications, while the remaining 18.9% ( n  = 386) were multi-authored publications (≥ 3 authors per document). Professor Cathy Zimmerman (UK) was the most active author (22; 1.1%). Professor Jay Silverman (USA) ranked second (17; 0.8%) (Table  4 ).

Research networks

Mapping research networks for authors with a minimum research output of five documents showed only two research clusters (Fig.  5 ). The first cluster (red) included six authors with Zimmerman, C. as a member in this cluster. The second cluster (green) included five authors with Silverman, J as a member of this cluster.

Networks of active authors who published at least five publications and exist in a research network with a minimum of five authors

Preferred journals for publishing documents about HT

The retrieved documents were published in 998 different journals. The International Migration was the most active journal in this field. Top 10 active journals belonged to different fields including migration, criminology, medicine, social studies, gynecology, transplantation, violence, and human rights (Table  5 ). The majority of active journals were based in the USA. Documents published in Transplantation (25.5) journal received the highest number of citations per article followed by those published in International Migration (22.5).

Citation analysis

The retrieved documents received 15,505 citations giving a mean of 7.6 citations per document. The h -index of the retrieved documents was 48. The document that received the highest number of citations was published in 2007 in Politics and Society . Top ten cited documents discussed topics about organ trafficking, mental health, and HIV infections of HT victims. Table  6 showed the list of top 10 cited documents [ 22 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 ].

Volume and growth of publications

The current study aimed to assess and analyze published literature on HT. Quantitative analysis of literature on HT is complicated by the lack of academic and legal consensus on the definition of HT as well as the unclear distinction between trafficked victims, exploited people, and vulnerable migrants [ 71 ]. For example, some researchers consider illegal migrants who end up in prostitution as victims of HT [ 72 , 73 ]. Despite these technical difficulties, the current study was the first to analyze volume, growth, research trends, and research domains of literature on HT published in academic journals.

The findings of the current study showed that the total number of retrieved documents on HT was low when compared to the size of literature on the 21 million people described as refugees [ 74 ]. The number of publications on HT could be attributed to the methodological, operational, criminal, and hidden nature of HT [ 20 ]. The limited research collaboration, as evident from the mean number of authors per document and the percentage of documents with international authors, is another potential reason for the limited number of publications on HT. The finding regarding international research collaboration is difficult to explain but could be attributed to lack of communications, motivation, funding, or lack of international conferences that could help gather experts in this field [ 75 , 76 ].

Health versus non-health related research

The current study showed that there was an underrepresentation of health-related research on HT despite the potential threat of HT to national health security [ 1 ]. Health is a subject that has been neglected in anti-trafficking work efforts compared to activities in the fields of immigration and law enforcement [ 77 , 78 ]. Many experts in health and HT agree that the health sector has had limited engagement in trafficking dialogues and research [ 78 ] despite that HT is being considered as a threat to global health security [ 79 ]. The presence of sexually transmitted diseases and tuberculosis among trafficked victims place the general population at risk [ 80 , 81 ].

The findings of the current study regarding the under-representation of labor trafficking relative to sex trafficking were in agreement several previously published studies [ 18 , 82 ]. Promotion and advancement of research on health aspects of HT require intensive involvement of public health experts in the global debate about HT. Public health experts and editors of medical and health journals need to create an international forum to encourage researchers from different parts of the world to get involved in health research about HT. This will benefit global public health agendas by shedding light on aspects related to HT such as labor exploitation and smuggling in Africa, Asia, and the Middle East where labor exploitation might not be considered illegal or a human right violation [ 83 ]. Establishing research networks that include scholars from destination and source countries will create a more detailed analysis of health aspects of HT.

The source versus destination countries

The current study showed that the bulk of the retrieved literature and the topics discussed represent the perspective of the destination rather than source countries. It is believed that the source countries are ones with no or minimum level of democracy, high levels of corruption, and poor economic growth, which make engagement in research and academic investigation an unaffordable luxury. The source countries might not have enough public health researchers or experts HT, which influence their contribution to literature in this field. It is recommended that the source countries place migration and trafficking in their national and foreign policy agendas. Healthcare professionals, social care specialists, and experts in global health diplomacy in source countries need to get engaged in developing evidence-based information about methods used by traffickers in recruiting their victims from source countries [ 84 ]. Legal and labor experts need to provide detailed information for migrants to increase their awareness of labor exploitation and trafficking [ 85 ]. Awareness of being a potential victim to traffickers is important in source countries, particularly those with a humanitarian crisis or armed conflict where young desperate men and women will take a quick decision regarding migration in hope of a better life and better wages [ 86 ]. For destination countries, healthcare professionals, and public health experts need to identify working conditions and occupational health hazards of migrant workers who might end up being victims of HT. Policymakers need to develop strict regulation to provide migrants with legal and health protection equivalent to that of domestic workers [ 87 ]. Health policymakers need to develop mechanisms to discover victims of HT once they attend a healthcare facility [ 88 ] and offer them appropriate health services and social as well as financial support and compensation. Experts in criminology need to develop detailed criminal codes based on international diplomatic cooperation to fight organizations involved in HT [ 89 , 90 ].

Types of trafficking

In the current study, published literature on sex trafficking dominated the field of HT. The over-representation of sex trafficking suggests that research related to other forms of trafficking, particularly labor trafficking is being under-researched. Trafficked laborers live and work in harsh and mostly unhealthy conditions that might involve confiscation of passports, low wages, sex slavery, and deprivation of basic health need [ 91 , 92 , 93 , 94 ]. Research domain in labor trafficking needs to be strengthened, supported, funded, and encouraged to generate more evidence-based data in this field.

Study limitations

The current study has a few limitations. Using Scopus database to retrieve literature on HT created a certain bias toward countries with a large number of journals indexed in Scopus. Scopus is biased toward academic journals in which documents are published in English. Therefore, documents in HT published in non-English were not retrieved. The current study, like all other bibliometric studies, did not include grey literature. The search strategy used in this study might have led to some false-negative or false-positive results. Therefore, interpretation of the results should take into consideration these limitations.

The current study is the first to assess research activity in the field of HT. The current study showed that health aspects of HT were under-represented compared to criminal, legal, and social aspects of HT. Similarly, research on labor trafficking was under-represented compared to sex trafficking and exploitation. The literature on HT represents the agendas of destination countries with limited contribution of countries in Asia, Latin America, Africa, the Middle East, and Eastern European. Future research plans should shed light on trafficking for non-sexual purposes. Furthermore, research networks need to be strengthened by including scholar from source and destination countries to investigate health conditions of trafficking survivors or exploited migrants. Greater investments in international research collaborations and research networks should be encouraged to help prioritize research on HT in various world regions.

Abbreviations

human trafficking

multiple country collaboration = international collaboration

single country collaboration = intra-country collaboration

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The author would like to thank An-Najah National University for facilitating this study. The author would like to thank Professors Adham abut aha and Ansam Sawalha for their language corrections

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Sweileh, W.M. Research trends on human trafficking: a bibliometric analysis using Scopus database. Global Health 14 , 106 (2018). https://doi.org/10.1186/s12992-018-0427-9

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About Sex Trafficking

• Sex trafficking exploits people of all races, ethnicities, sexual orientations, gender identities, citizenship statuses, and income levels.
• Learn to recognize the signs of sex trafficking, prevention opportunities, and know where to get help.

What is sex trafficking?

Sex trafficking is a type of human trafficking and is a form of modern-day slavery. It is a serious public health problem that negatively affects the well-being of individuals, families, and communities. Human trafficking occurs when a trafficker exploits an individual with force, fraud, or coercion to perform commercial sex acts or work.

Sex trafficking is defined by the Trafficking Victims Protection Act of 2000 as "the recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purpose of a commercial sex act." It involves the use of force, fraud, or coercion to make an adult engage in commercial sex acts. However, any commercial sexual activity with a minor, even without force, fraud, or coercion, is considered trafficking.

This type of violence exploits women, men, and children across the United States and around the world. Trafficking victimization and perpetration share risks and consequences associated with child abuse and neglect , intimate partner violence , sexual violence , and youth violence .

People at increased risk

Perpetrators often target people experiencing poverty, living in an unsafe situation, or searching for a better life. Victims can come from all backgrounds and become trapped in different locations and situations.

Many victims are women and girls, though men and boys are also impacted. Victims include all races, ethnicities, sexual orientations, gender identities, citizens, non-citizens, and income levels. Victims are trapped and controlled through assault, threats, false promises, perceived sense of protection, isolation, shaming, and debt. Victims do not have to be physically transported between locations to be victimized.

The consequences of sex trafficking are similar to the consequences of sexual violence. Consequences can be immediate and long-term including physical and relationship problems, psychological concerns, and negative chronic health outcomes. Read more about common issues seen in victims of trafficking .

Sex trafficking is preventable. Many prevention and response efforts are focused on increasing community awareness of human trafficking and addressing exploitation after it occurs. To prevent trafficking from occurring, more research is needed to evaluate programs and policies that reduce factors that put people at risk.

Understanding the shared risk and protective factors for violence can help us prevent trafficking from happening in the first place. Strategies based on the best available evidence exist to prevent related forms of violence, and they may also reduce sex trafficking. Read more about HHS' National Human Trafficking Prevention Framework , which outlines a public health approach to preventing human trafficking.

States and communities can implement and evaluate efforts that:

• Encourage healthy behaviors in relationships.
• Create safe homes and neighborhoods by addressing factors like economic conditions, housing, and education.
• Identify and address vulnerabilities during health care visits.
• End business profits from trafficking-related transactions.

Everyone can learn to recognize the signs of trafficking and know where to get help.

Need help? Know someone who does?‎

Sexual violence prevention.

Sexual violence can have a profound impact on lifelong health, opportunity, and well-being. CDC works to understand the problem of sexual violence and prevent it.

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May 10, 2024

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Q&A: Researcher exposes child labor trafficking as a hidden crime after investigating 132 victims

by Cynthia McCormick Hibbert, Northeastern University

Children trafficked for their labor often work in public view in restaurants, laundromats, agricultural fields and water parks, but little has been known about their plight.

A new study co-authored by Northeastern University professor Amy Farrell provides insights about these children, those who traffic them and what makes children vulnerable to dangerous work—and conditions that too often rob them of a chance for an education, and leave them exhausted, hungry and sometimes injured.

Farrell, the director of Northeastern's School of Criminology and Criminal Justice, answered questions from Northeastern Global News about what researchers discovered in their investigation of 132 victims, as well as their recommendations for a better future for trafficked children.

The research says the average age of victims you studied was 14. Where do trafficked children work?

It's shocking how many different industries where we found children trafficked for their labor. They are all around us. They are on our roofs, they are in our gardens doing landscaping.

They work cleaning dentists' offices, for storage facilities and in restaurants, agriculture and poultry farms. They work in waterparks, hotels and in private homes providing child care and domestic labor.

There was another subset of labor in which children were trafficked called forced criminality. This is a situation where kids work in illicit economies—panhandling, organized theft and drug cultivation, packing and distribution.

When people think about child trafficking of children, they commonly think about sex trafficking . That's not because 90% of the human trafficking that is identified by the police is for sex trafficking, but because that's where most of the public awareness is.

Child labor trafficking remains very hidden.

We often think of child labor trafficking as a migrant issue. But 42% of the child victims in your study were American. What makes both U.S. and foreign-born children susceptible to trafficking?

Poverty and housing instability are really big factors.

We find minors in situations where they're working because they need to bring money into the family or because they've left their family and are unhoused and living with a group of other minors who are unhoused.

Housing is super expensive and hard to navigate for young people who often cannot independently secure housing. Young people need to survive.

In our data, we've also seen cases of familial trafficking where a parent or guardian traffics kids into family businesses or into doing childcare and domestic labor in the home.

We've had situations where sponsors of unaccompanied minors were coercing children into work—sometimes overtly. Other times economic pressure in the sponsor's household forced young people into jobs, in addition to trying to go to school.

There are some well-documented child labor trafficking cases where minors got sponsored out to nefarious actors who pretend they are going to take care of these kids and end up exploiting them.

Sponsors are needed to handle the influx of unaccompanied minors into the U.S., but much more accountability and oversight of sponsor programs are needed.

Family disruption is another huge piece of this. Lots and lots of young people, particularly those who are U.S. citizens, come from families with histories with the child welfare system.

Those kids, both girls and boys, are particularly vulnerable to both sex and labor trafficking. In some ways, it's about who gets to them first.

What motivates child labor traffickers?

It's just about extracting money from them. They're throwaway kids—no one cares about them. They are disposable.

They are going to labor until they run away, get hurt or maybe get arrested. And then there will be more kids right behind them to take their place.

There's not a lot of care to even be sure that they can continue to be exploited because they can so easily be replaced by someone else. So if they get hurt, they don't get medical care.

It's really heartbreaking.

If sounds as if it's very difficult to leave child labor trafficking situations

They leave with nothing on their back—no money but sometimes a lot of debt to smugglers or others who have loaned them money or provided housing. The reliance on traffickers to meet basic needs is one of the mechanisms that traffickers use to keep kids laboring.

One of the victims we studied came to the U.S. from Guatemala with a group of teenagers as young as 14 or 15, many of whom were exploited in an egg farm.

Although the teen we studied avoided the exploitative farming situation, he ended up being exploited by someone else who had portrayed themselves as a good Samaritan willing to take him in. He was eventually trafficked to a woodworking factory.

It's a really difficult situation, because even when young people get away from a trafficking situation, they are still vulnerable to being abused or re-trafficked by others.

When do labor abuse issues become child labor trafficking violations?

Labor abuses become trafficking crimes when a person is coerced, defrauded or forced into laboring.

Unlike sex trafficking, where proving force, fraud and coercion are not required for children under the age of 18, these elements are required to prove child labor trafficking.

A major finding of this study is that coercion was omnipresent in situations where adults are providing things for kids to meet their daily needs.

For example, adults trafficking child laborers often provided young people with a place to stay, clothes or food. In other cases, adults provide love or acceptance to young people who are seeking their approval and care.

Fraud was another issue, even for children. People pay money to come to the United States and stay in unsafe jobs to pay off their debts or the debts of their family.

Is child labor trafficking getting worse?

We don't know because we lack comprehensive data. We really have no way of knowing what child trafficking was like 10 years ago in comparison to what it's like today.

This study is one of the first to lay out the kinds of conditions under which a wide cross section of children experience victimization.

Here in Boston we are undergoing a migration crisis where we have lots of families coming into Massachusetts who are not able to work or find stable housing.

That is a situation that is ripe for exploitation of both adults and minors.

What can be done to stop child labor trafficking?

We're not saying kids shouldn't work. We're not saying foreign national kids shouldn't work. Work is often a very helpful and developmentally appropriate activity for young people. What we're saying is kids need to work in situations where they won't be harmed.

One of our recommendations is that if kids experience a violation of the Fair Labor Standards Act or any of the existing wage, hour and work protections, coercion should be assumed if there's an adult involved. More attention is needed to young people laboring in situations where there is clear labor abuse.

Police and child welfare agencies have a role to prevent trafficking, but the people who may be in the best position to identify child labor violations are inspectors and regulators who ensure workplaces across a variety of industries are safe.

.It is critically important that legal advocates and worker rights organizations are provided with resources to help serve young people who are in precarious situations of workplace abuse.

We also recommend that vocational programs be expanded to provide teenagers with valuable skills in safe, lawful employment and alternative housing be funded for minors to reduce their vulnerability to dangerous forms of illegal employment.

Do you think efforts by states seeking to roll back child labor protections are ill-informed?

It's important for young people to have developmentally appropriate opportunities to work.

But we don't want young people working 12 hours overnight at a factory making potato chips or dog food and falling asleep in school—then dropping out of school and continuing to work at the dog food factory, where what they do is dangerous.

When communities face economic need and housing insecurity that drive young people into dangerous jobs, it is time to step back and ensure we have shored up the safety nets that help children and families meet basic needs without children laboring in exploitative situations.

Provided by Northeastern University

This story is republished courtesy of Northeastern Global News news.northeastern.edu .

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News | Human trafficking advocates insist exploited…

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News | human trafficking advocates insist exploited children shouldn’t be treated like criminals, experts want the justice system to factor in forced criminality when it deals with some young people.

That kid is committing crimes, right?

Now, picture a different kid doing the same stuff. But instead of pocketing his illegal earnings he turns it over to a third party, a presumably older and more powerful person, someone who might do him or his family harm if that money isn’t paid.

Turns out, that second kid is living in a version of human trafficking known as “forced criminality.”

And, legally speaking, he, too, is committing crimes.

While police and prosecutors can (and often do) take an offender’s circumstances into account, they do so at their discretion; the law doesn’t carve out broad, automatic exceptions for cases of forced criminality. Crime is crime and, sometimes, the option to prosecute and incarcerate wins the day, even when the offenders in question are children and their lives suggest they don’t have much, or any, freedom.

But there’s an effort underway to change that.

A growing number of human trafficking advocates and some legislators are pushing for a shift in both public opinion and legal theory, one in which young people who commit crimes while under the control of human traffickers are recognized as victims, not just perpetrators.

“Children do not choose the way they’re exploited,” said Stephanie Richard, an attorney and human trafficking expert who helps run a new think tank at Loyola Law, the Sunita Jain Initiative.

“Why is it that the criminal justice system doesn’t question if there is a third party benefitting a child’s illegal services?”

Loyola Law’s location, Los Angeles, is part of the story. Southern California – already seen as a hub for forced sex work and, recently, for forced child labor in industries like poultry processing and garment manufacturing – is also widely viewed as a national epicenter for forced criminality. There isn’t reliable data about exactly how many local underage trafficking victims currently fall into that legal abyss, but experts peg a low-ball estimate at hundreds of children per year.

For now, Richard isn’t pushing for a broad shift in the law. And other trafficking advocates note that people who are victims of crimes, particularly violent crime, deserve justice, and that punishment of perpetrators, regardless of their circumstances, can be part of that.

Instead, Richard wants better training for police and prosecutors and judges to recognize when a child is being coerced into breaking the law, and how that coercion can color the rest of that person’s life.

There’s already precedent for what she’s seeking.

‘Change is possible’

As recently as 15 years ago, children who were caught up in prostitution sweeps were considered criminals. This was true even though the age for legal consent in California is 18, so any adult having sex with someone under that age – for money or by force or even consensually – was committing a crime.

But in recent years laws surrounding child sex trafficking changed. Today, an underage sex worker is viewed by police and courts as a victim, not a criminal; there no longer is any such thing, legally speaking, as a “child prostitute.” Experts say the shift has prevented thousands of young people in California from being prosecuted, and kept felonies off their criminal records.

“It makes sense now, of course, but that was a big change when it happened,” said Sandra Morgan, a long-time human trafficking advocate and director of the Global Center for Women and Justice at Vanguard University in Costa Mesa.

“So this kind of change is possible.”

Advocates point out that underage victims of forced criminality, involving non-sex-related crimes, are considered children in virtually every other aspect of their lives. By law, 15-year-olds aren’t deemed emotionally or intellectually capable of voting or drinking alcohol or driving. They aren’t old enough to sign many binding contracts or, in many cases, to have full control over their own finances.

Yet the same children are considered mature enough to be responsible for a smash-and-grab robbery or a meth sale or boosting a high-priced sports car.

Richard, among others, said trafficked children live in a constant state of fear of the people controlling their lives. Such conditions can compromise anybody’s decision-making, involving virtually any behavior, no matter their age.

“It’s egregious that our child welfare system has been trained to only identify sex trafficking victims, and not others, as victims,” she said.

But Richard also suggested a legal shift could happen when more people are taught the basics of human trafficking. Three primary forces – physical coercion, threats against family, and duplicity – can render anyone subject to being victimized in a human trafficking scheme that can involve any type of profit-oriented behavior, illegal or otherwise.

“If you have a two-minute conversation with someone, and explain that (trafficking) can happen without commercial sex being involved, they get it,” Richard said.

“It’s not a difficult situation to explain.”

How it can happen

Jimmy Lopez was 9 when older members of a neighborhood gang told him he had to join with them or they’d hurt him or his family.

That was in Honduras, in the early 2000s. Lopez, now 30 and living in Southern California, said he believed – and still believes – they would make good on their threat.

“I had to leave. So I went to Mexico,” Lopez said. “I went alone.”

By the time he was 12, Lopez was in Los Angeles. He was working in – and living in – a furniture manufacturing operation, paying off what he believed was a debt he’d incurred during his journey to the United States. He says he didn’t go to school or see people who didn’t approve of his servitude. He added that he was beaten regularly.

He also didn’t have a phone, or know anything about making long-distance calls. So he was dependent on the owners of the furniture company for, among other things, any chance of speaking with his mother.

Still, after two years, he ran away again. He eventually found a restaurant and talked with owners who he thought were friendly. He accepted a job and a room, but again he wasn’t going to school or seeing people who knew about, or asked about, his living situation.

The restaurant owners soon asked him to do something else; drive cars to different locations in and around Los Angeles. He thought that since his treatment was better than it had been in the furniture plant he could trust his employers.

Soon, while driving one of those cars – without a license and, he says, with a face that looked far too young to have one – he was stopped by police. A search found two kilos of cocaine in the car.

“I had no idea,” Lopez said.

At 16, he was convicted of drug trafficking and sentenced to 30 years in prison. For two years, Lopez said, he served time at the Los Padrinos Detention Center in Downey, with little support or hope for the future.

At 18, as he was about to be transferred to a men’s prison, Lopez tied a blanket around his neck and tried to hang himself.

“I was depressed, and not really even scared anymore. Just depressed,” Lopez said.

While recovering, he encountered a friendly public defender who, Lopez said, started a legal push that eventually led to his freedom.

Over the past 10 years, he’s worked as a cook and an airport security guard. He’s also worked in construction and recently attended school to learn more about that business. He said his family now lives in Long Beach.

He sometimes tells his story to groups working to help trafficking victims and others. He even testified in Congress.

“Almost all the time, like 98%, people hear my story and they feel compassion,” Lopez said. “But after I was done speaking in Congress, a man came up to me, after, and said ‘I don’t believe you at all.’”

When Lopez insisted otherwise, that what he said happened happened, he said the man just laughed and walked away.

“I guess there are some people who’ll always think that way,” Lopez said.

“But I know this: I’m not a criminal.”

Both kinds of trafficking

The effort to change thinking about forced criminality – and to raise awareness, generally, about labor-related human trafficking – figures to include at least some legislation.

Richard and others at Loyola Law pointed to two such proposals now being debated in Sacramento.

One idea, SB1157, from state Sen. Melissa Hurtado, a Democrat from Bakersfield, would prevent the state from buying products known to have been made with forced labor.

Another proposal, SB998, authored by state Sen. Susan Rubio, a Democrat who represents a district that includes Azusa and Baldwin Park, would expand services currently offered only to victims of sex-related human trafficking to people who’ve been victimized under labor-related trafficking, including those forced to commit crimes.

But the broader idea of recognizing the needs of people who suffered as victims of labor-related trafficking or even forced criminal behavior isn’t necessarily popular among people struggling to recover from forced sex work.

“I can see the argument. I don’t agree with it; I think everybody is victimized in these circumstances, and there isn’t any one group who is somehow hurt more than others,” said Aja Houle, a trafficking survivor and advocate.

“But I can understand why some people feel that one is more damaging,” she added.

“I did both.”

Houle said she was forced into sex work at age 13, in Oakland, after being released following a stay in a juvenile hall near where she grew up, in Santa Rosa. Her trafficker was a man she thought was her friend’s boyfriend.

“I learned on that first night that he wasn’t what I’d been told,” said Houle, now 32.

“I was being trafficked.”

Soon, Houle was pushed into working for another man, also in Oakland. In his house, she was forced to provide sex work and help tend to his illegal indoor cannabis farm.

If she’d been caught at that time, she might’ve been charged with drug crimes, even though her labor was coerced.

“I was providing work as a form of forced criminality,” Houle said.

“It took me several years to realize that, but that’s what it was.”

Though Houle said her trafficker routinely threatened her life, and carried a gun that he said he’d use to carry out his threat, she escaped, at age 17, in a fairly simple way. She took the regional metro across the bay to downtown San Francisco.

She said that ride, about 40 minutes, was a mix of exhilaration and abject terror.

“I remember feeling I was about to be free, finally. But I also remember thinking he was going to catch me, and kill me,” Houle said.

In the years since her escape, Houle said, she’s earned a high school GED, an undergraduate degree from Sonoma State University and a master’s degree from the University of California.

Houle also learned that her second trafficker was convicted of murder in Washington. He shot a former domestic partner 14 times as the woman was on the phone, to police, saying she was in fear for her life, Houle said.

At the time of the shooting, the man was the subject of at least one restraining order related to domestic violence, and subject to warrants in California that were issued after Houle filed charges against him. He’s now serving a life sentence, though Houle remains wary of any future release.

“Throughout his trial, I was afraid he would get away, come to California, and kill me,” Houle said. “I really believed that.

“That feeling, that fear, doesn’t totally go away, ever.”

She sometimes explains all that in her current job. She’s a human trafficking consultant, helping counties and others set up programs to help trafficking victims.

“I’ve experienced all kinds of human trafficking,” Houle said.

“And I’d say they all offer enough pain.”

Note: This story was updated to correct the spelling of Aja Houle’s name.

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Human trafficking.

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• Continuing Education Activity

Human trafficking, a human rights violation, is a pressing public health concern that transcends all races, social classes, demographics, and gender. No population is exempt from the ever-present threat of traffickers. Healthcare providers come into contact with individuals being trafficked, usually in the emergency department. Trauma-informed care acknowledges patients’ life experiences to deliver effective care, improve patient engagement, minimize the risk of continued trauma, and reduce missed opportunities. Identifying signs of trauma, recognizing verbal and nonverbal cues, assessing a victim’s response, and referring to appropriate team members are key components of effective trauma-informed care. Missed opportunities to identify, inform, and empower these victims perpetuate this physically and psychologically debilitating disease.

• Understand the financial, legislative, and global implications of human trafficking.
• Identify the red flags of human trafficking.
• Improve communication and better assess responses during interviews of patients who are potential human trafficking victims.
• Describe interprofessional team strategies for improving care and early detection of human trafficking victims.
• Introduction

Human trafficking is a pressing public health concern that transcends all races, social classes, demographics, and gender. No population is exempt from the ever-present threat of traffickers. Human traffickers are motivated by greed, driven by quota, lack respect for human rights, prey upon the vulnerable, and damage their victims' psychological and physical well-being. The extent of the economic and social impacts on society are unknown and require further research to define and guide community-based care, protocols, and formal curriculum changes. [1]

Financial and Global Statistics

Human trafficking is a $150 billion industry globally. The International Labour Organization's (ILO) 2016 estimate reveals that 40.3 million people were victimized worldwide through modern-day slavery, 5.4 victims per every thousand people worldwide. Of these 40.3 million victims in 2016, 29 million were women and girls (72% of the total). Almost 5 million in 2016 were victims of forced sexual exploitation globally, with children making up more than 20% of that number. According to new 2016 global estimates, data collected by the ILO and the Walk Free Foundation (WFF) in partnership with the International Organization for Migration (IOM) as part of their contribution to the Sustainable Development Goals (SDG), puts the number close to 25 million persons who have been subjected to forced labor worldwide and 15.4 million in forced marriages. Loss of freedom is the common thread that binds them together. The exact number of trafficking victims is difficult to quantitate due to the concealed nature of the rapidly progressing disease and public health emergency. [2]

Trafficking Versus Smuggling

Distinguishing between human trafficking and human smuggling is essential. According to the Trafficking Victims Protection Act (TVPA), an anti-trafficking federal law established in 2000 under President Clinton's administration, human trafficking is defined as the exploitation of a person or persons for sex or labor using "force, fraud, or coercion."

Smuggling differs from trafficking because it involves the illegal crossing of borders and is usually consensual. Typically, the relationship between the smuggler and the person being trafficked terminates upon arrival to the destination country. Smuggling indebtedness can lead to trafficking as a means to resolve a fee owed to the smuggling entity. 

Trafficking in persons (TIP), also known as modern-day slavery, is a crime in all 50 states under federal and international laws and does not require the physical transport of a person. TIP can and often does occur in local communities and schools as well as near popular sporting venues. [3]

Essential Elements: A-M-P Model

Human trafficking involves three essential elements: action, means, and purpose. According to the National Human Trafficking Resource Center (NHTRC) and the TVPA, the Action-Means-Purpose, or A-M-P Model, helps determine whether force, fraud, or coercion was present, indicating the encounter was not consensual. A trafficker recruits, harbors, transports, provides, or obtains an individual. Force, fraud, or coercion is used to compel the victim to provide commercial sex acts, labor, or other services. [4]

Federal law defines sex trafficking as "the recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purposes of a commercial sex act, in which the commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age." Force, fraud, or coercion do not need to be present for minors under 18 years involved in any commercial sex act because minors cannot consent to sex with an adult. Minors are easier to exploit and manipulate, thus vulnerable to trafficking.

The TVPA's definition of labor trafficking is "the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage or slavery."

The United States Department of Health and Human Services's (HHS) "Look Beneath the Surface" campaign and SOAR training in 2017 provided much-needed insight into TIPs based on the latest amendments to the TVPA. For example, force may involve rape, torture, beatings, or imprisonment and can be psychological or physical.

Physical confinement is rare; however, "invisible chains" are often used to maintain power and control, similar to intimate partner violence. Fraud may include false claims of a job, marriage, promises of a better life, or a family. Coercion also involves threats, debt, or bondage that help foster a climate of fear and intimidation and may consist of abuse of the legal process.

According to the TVPA, a commercial sex act is any sex act where anything of value is given to or received by any person, such as survival sex, drugs, transportation, food, or clothing. 

Legislative Victories: The 3P's Approach

Over the past 18 years, the US Congress has passed several comprehensive bills to bring this crime to light in domestic and international communities. This legislative process finds its basis in the 13th Amendment to the US Constitution, which banned involuntary servitude and slavery in 1865. One such law adopted in 2000 is the TVPA that combats TIPs using the "3 Ps" approach: protection, prosecution, and prevention. [5] [6] [7]

The TVPA established several necessary protective measures for trafficking victims in the United States. Regardless of immigration status, trafficked foreign persons are eligible for federally funded benefits, such as healthcare and immigration assistance. The T nonimmigrant status (T visa) is a protective measure that prohibits deportation or removal of a trafficked victim and sometimes offers a path to permanent residency. Human trafficking victims are especially vulnerable to re-trafficking within two years of first being trafficked and upon return to an originating country due to debt bondage or psychological, emotional, and economic conditions. Reintegration into society, coupled with functioning within societal pre-determined norms, can be traumatic for an already traumatized person who traffickers have exploited. Re-victimization must be avoided by enacting protective measures. 

Prosecution

Under the TVPA Act, federal prosecutors were armed with additional tools to bring traffickers to justice for their crimes against humanity. The TVPA explored the existing statutes and broadened its conservative approach. The new legislation mandated financial restitution to the persons they had exploited through trafficking and offered more substantial penalties for those convicted of trafficking crimes. Revisions of the TVPA and subsequent enactments further defined human trafficking as "severe forms of trafficking in persons," including both sex trafficking and labor trafficking.

The third "P," prevention, is perhaps the most important. The TVPA strengthens prevention efforts on behalf of the US government. International incentives were enacted to improve economic conditions around the world to deter TIPs. The Office to Monitor and Combat Trafficking in Persons was created within the State Department due to the TVPA. According to the US Department of State, annual TIP reporting was mandated and rated countries on their efforts to reduce TIPs. [8] [9] [10] [11]

Furthermore, the TVPA required the creation of an Interagency Task Force to Monitor and Combat Trafficking, and TVPA reauthorizations were enacted in 2003, 2005, 2008, and 2013. In 2015, the adoption of the Justice for Victims of Trafficking Act allowed for additional tools to address this human rights issue and directed the Attorney General to create a National Strategy to Combat Human Trafficking and ensure its ongoing maintenance. [12] [13]

These legislative directives, ensured by the passage of the TVPA and the Trafficking Victims Protection Reauthorization Act (TVPRA), bring human trafficking to the forefront of the conversation internationally. Prevention through education is paramount in efforts to curb the growth of this $150 billion industry, which is thought by some to surpass the drug trade in the market value of criminal enterprises. Healthcare providers are on the frontline of these efforts as the first point of contact for most victims. 

The US Department of State also prosecutes human trafficking and smuggling cases. Diplomatic Security Service (DSS) agents and analysts often support foreign law enforcement agencies in an attempt to combat the global epidemic of TIP. On a domestic front, the US Department of State works with federal, state, local, and tribal leaders to investigate potential modern-day slavery cases for sex or labor exploitation.

The disease of human trafficking may find its etiology in a multitude of contributing factors that make a person susceptible to a trafficking situation.

Adverse Childhood Experiences

Adverse Childhood Experiences (ACES) can increase the likelihood of risk-taking behavior that could predispose a person to a trafficking situation. A better understanding of how a high ACE score can potentiate a trafficker's hold on a victim is best explored through research. The CDC-Kaiser Permanente Adverse Childhood Experiences study was a massive study, which began in 1995 and concluded in 1997, that investigated the ramifications of child abuse and neglect on health and well-being later in life. [14] The CDC continues ongoing surveillance of study participants. Annually, through local state-based Behavioral Risk Factor Surveillance System (BRFSS) reporting, the effects of ACES on survivors, communities, and overall public health are measured. The ACE Pyramid conceptualizes the framework for the ACE study as it relates to individual health and well-being across the lifespan, from conception to death.

According to the ACE Pyramid, neurodevelopment is disrupted or stunted following an adverse childhood experience. Social, emotional, and cognitive impairments can result in high-risk behaviors that negatively impact overall health. Disease, disability, and social problems ensue, cascading to an early death. Therefore, a correlation exists between a higher ACE score and an increased risk of poor physical and mental health due to poor choices, risky behaviors, and social issues.

An ACE questionnaire asks difficult, emotion-provoking questions about growing up during the first 18 years of life. Questions are related to physical, emotional, and sexual abuse and the frequency of such insults. The suicide of a family member, drug addiction, and mental health issues play roles in score calculation. ACE scores range from zero to 10, with zero representing no exposure. 

According to a Florida study conducted between 2009 and 2015, trafficking abuse reports were highest among children with an ACE score of six or higher. Children with a sexual abuse history in connection with a higher ACE score had an increased chance of exploitation by traffickers. According to a 2017 study, sexual abuse was the most reliable predictor of a person's exploitation by traffickers. [5]

Lesbian, Gay, Bisexual, Transgender, and Questioning (LGBTQ) Population

A critical distinction among the lesbian, gay, bisexual, transgender, and questioning (LGBTQ) population was revealed by the 2012 North Carolina, 2011 Washington, and 2011 and 2012 Wisconsin Behavioral Risk Factor Surveillance System (BRFSS) surveys. Lesbian, gay, and bisexual (LGB) individuals had higher ACE scores than their heterosexual counterparts. In this 2016 study, Austin, Herrick, and Proescholdbell concluded that the higher prevalence of ACES among LGB individuals might account for some of the increased risks for poor adult health outcomes, poor choices, and heightened risk of being trafficked. [15]

The transgender community may seek expensive hormone therapy and resort to "survival sex." This vulnerable position of needing money to buy hormone therapy from black-market suppliers at inflated prices with exorbitant interest rates can increase the chances of being lured into trafficking. Transgender youths may have additional vulnerabilities that heighten their risk of being trafficked, such as homelessness, addiction, depression, lack of financial or emotional support from family, being victims of intimate partner violence, and a history of sexual abuse as a child. Transgender individuals with HIV are also vulnerable to being trafficked if they struggle to meet their basic needs of food and shelter.

The National Center for Transgender Equality (NCTE) conducted a 2015 US Transgender Survey and found that 5% of all participants had engaged in sex work for income in the past year. Fifty-five percent of those who had resorted to survival sex in the past year were transgender women. Approximately 19% had participated in "survival sex" for money, food, sleeping quarters, or other goods or services. According to one study, those who had engaged in sex for money were more likely to have experienced some form of intimate partner violence or sexual assault. Debt bondage places an invisible chain that binds a victim to a "Romeo" or "guerilla" pimp. The invisible chain tightens with unmet quotas and may become a physical one. [16]

Further resources provided by the Polaris Project address the risks of being trafficked within the LGBTQ community and are available on their website.

Trafficking Risk Factors and Vulnerability

Sexual abuse puts an individual at risk for substance abuse, mental health issues, and a lack of social norms, belonging, or a sense of family. Vulnerability and feelings of distrust towards authority figures take the place of security. Often those who are supposed to protect an individual are the initial perpetrators of the insult or crime. "Forgotten," "invisible," "different," "broken," and "discarded" are all words used to describe the feelings of victims of human trafficking. Traffickers prey upon this vulnerability, use it to their advantage, and strategically place themselves nearby. Often seen as a rescuer who offers a chance at a better life, security, or a remote possibility that better days are ahead, a trafficker is a profiler, trolling for victims to turn a profit.

Traffickers do not discriminate based on gender, race, social demographic, immigration status, or economic status. No exact mold fits a victim. Anyone is at risk, but specific populations have a higher vulnerability risk. The US Department of Health Office on Trafficking in Persons provided a fact sheet in 2017 to further highlight at-risk groups, such as survivors of child abuse, sexual abuse, assault, interpersonal or intimate partner violence, gang violence, or community-violence exposure. [1]

The SOAR Campaign further delineates at-risk, vulnerable individuals as those lacking a stable support structure or home life, such as a runaway, a foster child, a child in the juvenile justice system, a homeless youth, an unaccompanied minor, a person displaced due to a natural disaster, or an individual with a language or cultural barrier. Increased risk also involves those with substance abuse problems, undocumented or migrant workers, and the LGBTQ population. Minorities, those with disabilities, and those on Native American reservations can be at a higher risk of being trafficked.

The US Department of Education published a fact sheet for schools entitled "Human Trafficking of Children in the United States" that discussed the vulnerability of school-age children and human trafficking incidence. In identified child-trafficking cases, children commonly were involved in stripping acts, pornography, forced begging, commercial sex, and drug sales. Children at most significant risk were identified as working in restaurants, in hair and nail salons, as nannies or au pairs, or in agricultural settings. Signs of child trafficking include unexplained absences, poor attendance, runaway behavior, boasting about frequent travel to other cities, inappropriate dress for the current weather, being sleep-deprived or malnourished, or impairment due to drugs or alcohol. [17]

Lack of a stable support structure and social media accessibility may put a child at risk of being targeted for sexual exploitation. Social media websites, classified advertisement sites, chat rooms, and after-school programs are potential venues for youth exploitation. School hallways pose a risk, as a trafficker may be another student. A trafficker may promise a "happening" party or a good time to entrap an unsuspecting, troubled, or bored youth. 

Educational campaigns, such as the Blue Campaign created by the US Department of Homeland Security, offer much-needed insight into the identification and treatment of victims of human trafficking. The Blue Campaign by the Department of Homeland Security offers sex trafficking awareness videos to educate youth on the risks of being trafficked in familiar places such as schools, coffee shops, malls, sporting venues, and other hangouts.

• Epidemiology

The National Human Trafficking Hotline: Reported Cases

When exploring the epidemiology of human trafficking, one must first examine data collection, results, and the organizations that provide this service. The US Department of HHS funds the National Human Trafficking Hotline, operated by Polaris, a nongovernmental organization. The National Human Trafficking Hotline's data collection gathers invaluable information to assist training programs and victims domestically and abroad. For example, 2017 data collection indicates that California, Texas, and Florida rank the highest in reported cases and referrals. [18] [19] [6]

To date, the hotline has answered more than 100,000 calls; 7,000 were from potential victims of human trafficking. According to Polaris hotline statistics for the United States, more than 30,000 cases of trafficking in persons and more than 8,000 tips to law enforcement were identified since 2007. The National Human Trafficking Hotline is a 24-hour, confidential, multilingual hotline covering more than 200 languages for victims, survivors, and witnesses of human trafficking.

• The hotline number is 1-888-373-7888.
• Text "HELP" to 233733.
• Live chat at humantraffickinghotline.org.
• Email [email protected].

Childhood Statistics/Cases

Another resource for reporting cases and gaining information as it relates to the trafficking of minors is the National Center for Missing and Exploited Children (NCMEC). In 2016, The NCMEC estimated that one in six endangered runaways were likely victims of sex trafficking. Sex traffickers target children as young as nine, with the average age between 11 and 14. Labor trafficking ages vary. The Global Estimates of Modern Slavery by the ILO, WFF, and IOM reported that of the 4.8 million sexually exploited in 2016, 20% were children. [2] [20] [21]

• To report sexually exploited or abused minors, call the National Center for Missing and Exploited Children’s (NCMEC) hotline at 1-800-THE-LOST, 1-800-843-5678.
• In the case of an immediate emergency, call the local police department or emergency access number.
• Child protective surfaces and local law enforcement will assist healthcare providers in local reporting requirements for minors involved in a possible abuse situation. Ages of sexual consent may vary from state to state. Thus, the need to consult local agencies. 

Global Repository of Data

The International Organization for Migration (IOM), in partnership with Polaris and the UN Migration Agency, has launched a Counter-Trafficking Data Collaborative (CTDC) with a global repository of data on trafficking in persons. Victim identities are protected, and the information gathered assists in bridging gaps in publicly available data. Essential components of the CTDC's role to combat the war on human trafficking are data collection efforts and providing public access to the data. The first of its kind, this global repository of data combines data from the IOM records of more than 45,000 human trafficking cases and more than 31,000 cases from Polaris. This collaborative data tracking system fosters a data-rich environment and transcends borders and individual agency operational challenges. This comprehensive, international database is a positive byproduct of this partnership. See the CTDC website .

Global Report on Trafficking in Persons

Each year, thousands of individuals fall victim to national and international trafficking. Almost no country is exempt from human trafficking infractions or being the originating, transient, or destination country. The United Nations Office on Drugs and Crime (UNODC) Global Report on Trafficking in Persons further explores the bond between trafficker and victim and the trafficking origin.

The 2016 UNODC Global Report on Trafficking in Persons shines a light on the trafficker's profile and relationship with the one who is trafficked. Traffickers and their victims tend to originate from the same geographical area, speak the same language, and share the same ethnic background. These commonalities foster a level of trust between the trafficker and the victim. The trafficker exploits this relationship for financial benefit. Traffickers rarely travel abroad to recruit, instead focusing on domestic recruitment. 

Globally, local trafficking is on the rise. A trafficker will go to a destination country to exploit the victim. Countries most vulnerable to trafficking are those with high levels of organized crime and those ravaged by conflicts. From 2012 to 2014, more than 500 different trafficking flows were detected, and countries in Western and Southern Europe identified victims of various citizenships. The 2016 UNODC Global Report on Trafficking in Persons reports 79% of classified trafficked individuals globally are women and children and documented a clear link between migration and human trafficking. The movement of migrants and refugees is the most substantial reported migration since World War II, with an estimated 244 million international migrants worldwide. 

Forced migration resulting from refugees fleeing war-torn areas makes women and children especially vulnerable to exploitation by traffickers. The movement of Syrians escaping the war is one such example. Children face exploitation as "child soldiers." Armed guards abduct individuals on migratory routes and exploit them as slaves for forced labor or sex. In September 2015, world leaders adopted the 2030 Sustainable Development Agenda and embraced the war against trafficking in persons on a global front. This plan called for all forms of violence against women and girls to cease. 

According to the 2016 UNODC Global Trafficking in Persons Report, no country is immune from trafficking in persons, and over 500 migratory flows of trafficking were detectable. Sub-Saharan African and East Asian victims are trafficked to numerous global destinations. Affluent areas, such as Western and Southern Europe, North America, and the Middle East, have victims from all parts of the world. In Southeast Asia, forced marriages are on the rise. Central America, the Caribbean, and South America frequently report cases of girls becoming victims of sexual exploitation. Trafficking in fishing villages for forced labor is a problem in parts of the world, such as Ghana and Taiwan. Organ retrieval as a form of trafficking is less frequent but exists in some parts of the world. 

The UNODC 2016 study also reports a change in the victim profile over the past decade. The number of male victims is increasing. The total number of forced labor victims increased between 2012 and 2014, with 63% being men. Another alarming fact from this report is that female participation increased. Of 6800 persons convicted of human trafficking during 2012-2014, 60% were male. Young girls are recruited and controlled by older women. More couples are actively involved in trafficking. Posing as "stable couples" allows traffickers to seem more genuine and trustworthy while actively recruiting and exploiting victims as a team. Former victims become active participants in recruitment, some to reduce their debt bondage and end their sexual exploitation. Others who willingly participate in the abuse use tactics of power and control. If trafficked persons are engaged in criminal activity, they are less likely to cooperate with police, thus allowing the trafficker even more control.

According to the UNODC, the average number of trafficker convictions was low, with five victims per convicted offender. North America had the highest number of convictions compared to the rest of the world. The United States reported 150 to 200 convictions annually, while Europe reported the highest number of trafficking victims. [22] .

• Pathophysiology

Missed Opportunities and Myths

A recent study revealed that 87.8% of human trafficking survivors had been in contact with a healthcare provider in some capacity during their victimization. Furthermore, 68.3% had received an evaluation in the emergency department. (The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities, Lederer, 2014) Missed opportunities to identify, inform, and empower these victims allow this physically and psychologically debilitating disease to spread.

Recently, a smaller study of emergency department nurses in an urban setting concluded that the nurses want better awareness of the specific resources available to human trafficking victims. Ongoing research into the impact of institutional policy, human trafficking protocols, and continuing education regarding the recognition and treatment of trafficked individuals is required [22] .

Myths or misperceptions often lead to missed opportunities to identify victims [DOS, 2013] . Education on these potential media-induced sensationalized myths is essential for healthcare providers and first point-of-contact personnel. First, trafficking in persons is not just a crime that occurs in a faraway place or only involves migrants or foreign nationals. Individual exploitation happens in every part of the world, including suburbs, big cities, and hometowns.

Victims can be coerced to take part in crimes, thus landing them in a detention center or jail. They may present to the emergency department for medical clearance. Proper screening of these individuals is vital in our attempts to identify victims, recognize the red flags of trafficking, and take appropriate action. Having the mindset that this patient is "just a criminal or "just a prostitute" is a bias that inhibits practitioners from reading verbal and nonverbal cues and recognizing the patient as a human trafficking victim. A victim may be revictimized if returned to an exploitative environment. Revictimization is a chief concern for practitioners. The United Nations Convention against Corruption defines “revictimization” as "a situation in which the same person suffers from more than one criminal incident over a period of time." Perhaps more important when assessing and interviewing a potential victim of trafficking is the potential for "secondary victimization.”  The UNODC Model Law on Justice in Matters involving Child Victims and Witnesses of Crime defines secondary victimization as "victimization that occurs not as a direct result of the criminal act but through the response of institutions and individuals to the victim." [22]

If an individual is free to come and go, then he or she may not be recognized as a person being trafficked. As discussed previously, bonds are often not physical chains or cuffs but "invisible" or psychological ones. Fear paralyzes victims, acting as a shackle that emotionally confines them to the trafficking situation. Mental weapons used by the trafficker to exercise power and control over a victim may include threats of harm to children, siblings, or other family members; deportation or return to a traumatizing situation; calls to social services; and physical violence or reminders of past violence for misguided offenses. 

Debt bondage, withholding of pay, and maintaining possession of identifying documents may further lead to an invisible bond or tie to the pimp/trafficker. Trafficked victims may use a school bus, a public bus, a train, or a taxi. Control over the trafficked person is far beyond a physical wall, chain, or border. Much like intimate partner violence, victims usually do not self-identify, self-report, or recognize that they are being manipulated, controlled, stigmatized, or dehumanized.

Cultural Considerations

Language barriers and cultural misconceptions may lead to a missed opportunity to identify a potential victim. [23] Inconsistencies in stories or history may become lost in translation, especially if a provider fails to obtain an interpreter with no relationship to the exploited. A staff member versed in the same language or who shares the same culture as the victim may be able to spot these subtle clues and ease the cultural shock and miscommunication. However, the availability of staff members with the optimal background and primary language is not always feasible in a busy healthcare setting. When red flag behaviors are passed off as specific cultural behaviors, this demographic profiling could create a missed opportunity to identify the patient as a victim.

In suspected cases of human trafficking or intimate partner violence, it is imperative that no family member or accompanying party be allowed to translate. Ensure that your institution provides a certified interpreter.

Reasons Victims/Traffickers Access Medical Care

Seeking health care for victims presents the opportunity for discovery. Traffickers may only seek care for their victims when they become seriously ill. [24] A multitude of factors should lead a practitioner to seek medical services for a person who is a suspected victim of human trafficking.

• Emergent medical conditions, such as profuse bleeding or pain caused by a beating or forced abortion, injury on a job site, or complications during pregnancy, such as an ectopic pregnancy
• Gynecological services for sexually transmitted infections caused by debris in the vagina from packing during menstruation or forced sex without condom use
• Follow up with an OB/GYN for a repeat beta HCG or ultrasound for a possible ectopic pregnancy identified in an emergency setting
• Addiction issues such as a severe overdose or withdrawal signs and symptoms
• Dental emergencies or plastic surgery consultations
• Prenatal care or lack thereof
• Health-related mental problems such as depression, suicide attempts, or anxiety disorder
• A patient on a psychiatric hold or court-mandated order
• Severe wound infections with signs of septicemia may force introduction into the healthcare system

Traffickers seek out the quickest means of care, and lengthy emergency department waits may lead to their decision to leave with the victim before receiving medical treatment. They may also "hospital shop" for quicker wait times from door to the provider. An accompanying "family member" that is impatient, "in your face," or upset over lengthy delays in overcrowded emergency rooms or clinics may, in fact, be a trafficker. Another indicator is the "spouse" or "boyfriend" that insists that a high-risk patient, such as one with a possible ectopic pregnancy or appendicitis, leave without being seen, against medical advice, or before care is completed.

Remember, a victim comes from all walks of life and may be perceived as having a stable home in a suburban community. Victims will never look or act the same; their individual responses to their traumatic event will follow no specific protocol. Healthcare providers must be diligent in identifying these silent victims, forced into a situation of no fault of their own and made to carry out acts that reap emotional and social ramifications for years to come.

• History and Physical

Exploitive Environments

When healthcare workers encounter potential victims of trafficking, a detailed work and social history will assist in identifying red flags. A better understanding of the most common areas where persons are targeted for exploitation will help practitioners assess a potential victim.

Victims of labor trafficking tend to be near farms, fisheries, factories, or businesses such as nail salons, massage parlors, restaurants, and areas with high immigrant populations. Labor trafficking victims are in traveling sales crews, peddling or begging rings, landscapers, construction workers, domestic workers, nannies, elder adult caregivers, and agriculture work. Victims who travel selling, peddling, or begging are vulnerable due to homelessness and working in unfamiliar settings. If left behind in an unknown city, they may resort to "survival sex." Immigrants may lack the power to communicate their situation due to language barriers; this enables handlers from similar backgrounds to approach them and speak for them. 

Some common sex trafficking sites are hotels or motels, street-based locations, residences functioning as brothels, commercial-front brothels, escort-service companies, truck stops, bars, and strip clubs. Sex trafficking can happen at home, with parents, intimate partners, or other family members being the perpetrators. Victims may not see themselves as victims and may refer to the trafficker as their "daddy" or "boyfriend."  [25] [22] [20]

Labor Trafficking Considerations

Common presenting complaints of victims of human trafficking are much like those of intimate partner violence but may vary depending if the patient is a victim of labor or sex trafficking. Labor traffickers prey on specific vulnerabilities to entice individuals to accept substandard working conditions. Workers in the agriculture industry, factories, and domestic servitude sectors are vulnerable to human trafficking due to their work visas and immigration status being controlled by one employer. This power over the individual and fear of deportation allow the trafficker to manipulate the worker, leading to victimization. 

Agricultural and industrial workers who are forced to work long hours with substandard wages may be isolated and confined by using dogs, armed guards, barbed wire or other fences, or locks. The seasonal nature of their work and movement from place to place heightens their vulnerability due to regularly being subjected to unfamiliar surroundings. 

Domestic workers are also isolated, forced to live on the premises, and may lack access to cell phones and other communication devices. Language barriers add to vulnerability and the inability to communicate their situation and needs. Workers in strip clubs and bars may have fraudulent work visas and ties to organized crime, rendering them vulnerable to trafficking. Drugs and alcohol are used as manipulation tools.

Labor laws may not apply to subcontractors or independent contractors, thus increasing vulnerability risk. A common theme among persons who are exploited and traffickers exists. The victim is kept isolated by proximity or language, vulnerable due to immigration status, without resources, indebted, without the protection of labor laws, controlled, and manipulated. 

Trafficking in persons for labor exploitation may put a patient at risk for malnutrition, communicable diseases such as hepatitis and tuberculosis, pesticide and chemical burns, or exposure and work-related injuries due to lack of safety equipment such as safety belts, gloves, goggles, and masks. 

Labor Trafficking Red Flags

Stop, Observe, Ask, and Respond (SOAR) will guide practitioners in determining whether red flags indicate a potential case of human trafficking. Healthcare providers must decide if a crime occurred or if all three elements of trafficking in persons exist: force, fraud, and coercion. The provider's role is to recognize a potential case of human trafficking, empower the person being exploited, educate the victim on resources and established support structures, and provide a framework for a trauma-informed, victim-centered approach to healthcare.

Providers should observe for verbal and nonverbal clues and ask open-ended questions in a private, non-judgmental way to determine if the patient is a potential victim of human trafficking. Questions to ask regarding labor trafficking suspicions may include, but not be limited to, the list below.

• Are you being paid the wages that were part of the initial agreement?
• Can you change jobs if you want to?
• Would anything happen to you if you quit your job?
• Can you come and go as you, please, take bathroom breaks, and eat when you want?
• Do you live with others? What are your home conditions, and where do you sleep? Do you have a bed? Do you sleep on the floor? Is it too cold or too hot where you live?
• Did you pay a fee to get your job? Do you owe a debt to your employer?
• Do you have access to your money and your identification? 
• Has your employer ever threatened you? 
• Did you have eye protection, a mask, or a safety harness? Personal protective equipment such as gloves? Respirators?
• Does your employer provide your housing? 
• Are you working in the job you were hired to do? 
• Are you concerned about your safety? Your family or your children's safety?
• How many hours do you work a day? How many days per week?
• Have you moved around a lot? Do you know your address? Can you give me directions or the location of your house?
• Do you take care of others?
• Are there locks on the doors or bars on the windows? Can you leave freely? [26]

Barriers to Identification of Victims

Healthcare providers, for a variety of reasons, may fail to stop, observe, and ask questions to identify a potential victim of human trafficking. The absence of protocols, myths, stereotypes, biases, fear of no available resources, lack of education regarding human trafficking red flags, time constraints, lack of privacy, or an inability to separate the person from the potential trafficker all may play a part in the failure to identify victims. The victim declining to give a history and self-identify are hindrances in identifying human trafficking. [23]

Diagnostic Overshadowing

A patient who presents with multiple visits and complains of pain that has no organic cause, a "frequent flyer," as labeled by some, may be an overlooked victim of trafficking. Patients who present with stress-related issues on multiple visits or who return over and over with psychological holds for overdoses or suicidal ideations may be victims of trafficking. They risk being released back into the trafficking situation and victimization each time. Providers must recognize the potential for "diagnostic overshadowing" and be attuned to their own emotions and potential for bias. [27]   Traffickers can pose as parents, grandparents, or spouses. As providers, practitioners must stop, observe, ask, and respond. [4]

As front-line participants in the battle to combat human trafficking, healthcare workers must be aware of these potential barriers to victim identification. Often, providers rush from patient to patient or exam room to exam room, are caught between documentation and hands-on assessment and care, and treat patients in hallways, lobbies, or corridors. These practice realities add to the potential for a missed opportunity. 

Sex Trafficking Red Flags  

According to the National Human Trafficking Resource Center (NHTRC) and hotline, general indicators or red flags of trafficking in persons may include but not be limited to the following with some modifications:

• Inconsistent history or a history that appears coaxed. It may be difficult to determine if a language barrier is present.
• Resistant to answer questions about the injury or incident.
• Avoids eye contact, is nervous, fearful of touch.
• No idea of the address or general area where they live.
• No control over their finances and lacks decision-making capacity.
• Accompanied by a controlling companion or family member that refuses to let the patient speak for themselves or be alone for care or insists on being the translator.
• Exhibits bizarre, hostile behavior. Resistant to care and assistance. May have initially consented but changed their mind after being asked to undress for an exam.
• No identification or the companion has it in their possession.
• Under age 18 and involved in a commercial sex act.
• Tattoos or branding signs. Markings may say "daddy" or "for sale," imply ownership or read as an advertisement for a product.
• Multiple sex partners.
• Inappropriate attire for the environmental conditions of the area.
• Attempt to reason away bruises or ligature marks by claiming a bruising or rare blood disorder.
• Silent, afraid to speak, cringes at the sound of a loud voice.
• Uses trafficking "lingo" such as "the life" or other words common in the commercial sex industry.
• Has addiction issues such as opioids.
• Admits to a forced sexual encounter or being forced into sex acts. [22] [28] [29]
• Has a cover story to avert suspicion, but details may vary or be inconsistent with a query. Law enforcement may refer to this as a "legend."

Head-to-Toe Assessment

A head-to-toe, full assessment in this patient population is vital. An examination may prove difficult due to the emotional and psychological state of the victim. These patients may appear as uncooperative or vague and give an inconsistent history. These reactions are manifestations of their trauma. Provider frustration or stereotyping may arise, leading to the desire to exit the room quickly, with a quick determination of probable diagnosis and treatment. As discussed above, the potential exists for "diagnostic overshadowing." As with any trauma patient, a high index of suspicion should be present for co-existing conditions and comorbidities.

Conduct the assessment in private, not allowing anyone accompanying the patient to be present. A chaperone may be present and a certified interpreter, if required, to facilitate a feeling of trust, establish rapport, and build a trusted network of people and organizations willing to help. If possible, provide a same-sex provider for the physical exam/assessment with the available staffing mix. During the exam, the patient may seem emotionally absent, hyperventilate, and not verbalize feelings of discomfort. Be alert to nonverbal signs. Reassure frequently and promote a relaxed, non-rushed atmosphere. Avoid interrogating the victim; ask only direct, pertinent, open-ended, yet neutral questions. Maintain eye contact with the victim, barring cultural considerations, and avoid writing while the victim speaks. Ensure the victim is entirely undressed and in a gown so a complete trauma assessment can be initiated. Specifically, examine for the following:

• Bruising; old, healing, or new lacerations; hematomas; signs of acute or chronic head trauma or a headache; missing hair or bald spots.
• Trouble hearing; damage to the auditory canal or eardrum; signs of trauma to the oropharynx such as lacerations or burns, blood in the mouth, ulcerations, tooth decay, broken teeth, gingival irritation, tongue abnormalities; signs of anemia or dehydration in the oral mucosa.
• Visual defects, sudden or gradual onset; tattoos or brands in the hairline or on the neck; signs of strangulation such as bruising.
• Signs of chest trauma, murmurs; cigarette burns; tattoos that imply ownership; bruising in various stages of healing; signs of stress-related cardiovascular issues such as arrhythmias or high blood pressure.
• Respiratory issues that would indicate inhalation injuries from chemical exposure, toxic fume exposure, asbestos exposure, or mold exposure.
• Signs of tuberculosis such as night sweats, coughing up blood, fever, and weight loss.
• Signs of stress-related respiratory or gastrointestinal problems.
• Damage to lung tissue due to prolonged exposure to chemicals or pesticides, aspiration pneumonia, or other inhalation injuries; meth lab exposure can produce burning to the eyes, nose, and mouth, chest pain, cough, lack of coordination, nausea, and dizziness.
• Hypothermia or hyperthermia from environmental exposure from working in damp, cool, poorly insulated factories or buildings; mold exposure signs/symptoms.
• Signs of gastrointestinal issues such as nausea, vomiting, diarrhea, constipation, or abdomen pain; rectal pain, itching, trauma, or bleeding; parasites in the feces or signs of abdominal trauma.
• Bruising to the back or scarring; tattoos that imply advertisement, ownership, or are sexually explicit in the pubic hair.
• Obstetrical and gynecological complaints such as sexually transmitted infections (STI) or recurrent STIs. An STI, especially if recurrent, in a minor may be the first and only sign of sexual abuse; repeated unwanted or unplanned pregnancies or forced abortions; anogenital trauma; evidence of retained foreign bodies such as in the vagina from packing during menstruation, vaginal bleeding, discharge, rashes, itching, signs of injury or forced sex. [30] [30] [31]
• The number of sexual partners; condom use; genitourinary symptoms present such as burning, frequency, odor, dark urine, or history of frequent urinary tract infections.
• Signs of bruising or lower back scarring from repeated beatings; musculoskeletal issues such as signs of repetitive trauma; work-related injuries or injuries such as back problems from wearing heels for hours walking the streets or neck and jaw problems from frequent, forced oral sex.
• Fractures, old or new, any contractures. Cigarette or scald burns. Ligature marks/scars around ankles or wrists. Signs of scabies, infestations (scalp or body). Impetigo. Fungal infections.
• Signs of nutritional deficits such as Vitamin D deficiencies from lack of exposure to sunlight, anemia, or mineral deficiencies; brittle or fine hair.
• Signs of anorexia, bulimia, loss of appetite, malnutrition, and severe electrolyte abnormalities.
• Growth and development abnormalities in children, dental cavities, or misaligned poorly formed teeth. 
• Neurological issues such as seizures, pseudo-seizures, numbness or tingling, migraines, inability to concentrate, vertigo, unexplained memory loss, and seizures.
• Insomnia, nightmares, waking up frequently.
• Signs of opioid or other addiction.

Signs of Physical or Psychological Torture

Signs of physical torture may present on a dermatological evaluation, such as abrasions over bony prominences, scratches or linear abrasions from a wire, or "road rash" to extremities from being thrown from or drug by a vehicle. Ropes and cords can leave elongated, broad-type abrasions. Ropes may leave areas of bruising mixed with abrasions. Belts or cords may leave loop marks and parallel lines of petechial with central sparing. Tramline bruising, two parallel lines of bruising, can result from being beaten with a heavy stick or baton. Cigarette burns tend to be circular with a 1-cm diameter and can fade in a few hours or days. Burns, in general, tend to take the shape of the object that inflicted the burn.

Trafficking victims may be beaten or subjected to torture for various reasons. The guerilla pimp may torture the victim due to not meeting a quota or breaking established rules, a displeased customer, or for no apparent reason other than to maintain control. Bruises, lacerations, marks, or scars may be present on the lower back where they are hidden more easily and do not disfigure the product/victim and inadvertently make the person being trafficked less marketable. 

Cupping therapy may leave bruises or scars that may be mistaken for abuse. Correlate this finding with a detailed history as well as the presence of other red flags. 

Psychological and Mental Status Examination

Mental health indicators of trafficking in persons may be missed or explained away as a panic attack. Again, one must stop and take an in-depth look, considering the red flags. Look for signs such as depression, suicidal ideations, self-mutilation injuries, anxiety, post-traumatic stress disorder (PTSD), and feelings of shame or guilt. Shame, a control tool used by a trafficker, may keep a victim bound to a trafficking situation. Does the patient report nightmares, flashbacks, irrational fears, irritability, social isolation, suicidal ideations, or depression?

A trafficking victim may describe a situation as if they were an outsider looking in. This mind-body separation creates a safe, alternate reality to help them cope with the atrocities they are facing and feelings of shame and guilt. They use a third-person omniscient point of view in their storyline. Sometimes patients exhibiting this behavior are categorized as impersonal or devoid of emotion, numb to their surroundings, or detached. This point of view is their survival mechanism.

Addiction issues may be present and result in withdrawal. The addiction may be fueled by the trafficker for control or by the victim to cope with the physical or emotional pain surrounding the trafficking situation. 

Documentation of Assessment Findings

Documentation of physical findings is important and may assist the victim in prosecuting their trafficker later if health records are subpoenaed. Follow established documentation guidelines and reporting requirements based on state and local statutes or federal law as addressed previously. Photo documentation may prove vital. Follow any protocols/policies specific to your institution regarding taking photos and their storage, and obtain all required consent forms. [3] [32] [33]

Recognition and Intervention

Once a practitioner identifies a potentially trafficked person, it is imperative to establish a private, quiet, safe place to assess the patient further, much like in cases of child or elder abuse. Building rapport and providing an opportunity for the victim to feel empowered is of utmost importance. Building rapport with the patient can build trust and begin to establish a trusted network of people and institutions to assist the victim. Do not start a dialogue until you can select a safe, private, and secure place.

In this era of mobile devices, where a smartphone is always within easy grasp, ensure cell phones are off and not nearby. Cell phones can be another way the traffickers control the victim. The victim may have arrived alone but is always on the cell phone. The cell phone may be the trafficker's way of "keeping tabs" or listening to everything going on in the room. 

Maintain eye contact during conversation, speak slowly and quietly, and avoid looking down at the potential victim. Instead, sit in a nearby chair where on-level eye contact, unless contrary to the patient's cultural norms, is possible. Ensure an environment where the victim can establish a sense of power and control. This empowering safe zone may allow the patient to open up and admit to being a victim. More importantly, ensuring the patient feels safe and empowered may provide the opportunity to identify the patient as a victim of human trafficking, share available resources, and convince the patient to trust and accept help.

Before starting the conversation, ask the patient if it is safe to talk now and if they feel comfortable with you in the room or if they prefer someone else. Never assume it is safe for the victim; they must confirm that it is safe. Safety is critical for the victim, staff, and nearby patients. Trafficking protocols will guide your care and determine a preset location readily available for an interview or a few minutes alone with the patient. A bereavement room for family notification in the event of trauma or sudden death may be one such place.

Inform the potential victim of trafficking that you are mandated by law to report certain disclosures. Monitor their verbal and nonverbal cues. Be alert to your facial expressions, body language, and any nonverbal signals you are exhibiting. Avoid stereotyping and revictimizing the potential victim as they disclose information. 

Communicating with Potential Victims

Communicating with victims of human trafficking can be intimidating for healthcare providers. The Department of HHS created a resource called Messages for Communicating with Victims of Human Trafficking as part of their Rescue and Restore Campaign in 2016. These messages assist healthcare providers in building a rapport with the victim and promoting a trusting environment. [34] [35]

Sample Messages to Ease Communication

Sample messages for communicating with a victim of human trafficking, according to the Department of HHS. [36] [37]

• We are here to help you, and our priority is your safety. We can keep you safe and protected.
• We can provide you with the medical care you need as well as find you a place to stay. 
• Everyone has the right to live without being abused or hurt, and that includes you. 
• You deserve a chance to live on your own and take care of yourself, be independent, and make your own choices. We can help you with that. 
• We can get you help to protect your family and your children. 
• You have rights and deserve to be treated according to those rights.
• You can trust me. I will do everything in my power to help you. Assistance is available for you under the law, and special visas allow you to live safely in this country.
• No one should have to be afraid all the time. We can help.
• Help us so this does not happen to anyone else. 
• You can decide what is best for you, but let me provide you with a number to call for help 24 hours a day. You do not even have to tell them your name if you do not want to. They are there to help you anytime, day or night. The National Human Trafficking Resource Center hotline number is 1.888.373.7888. 

Do not make false promises. Only offer what you can provide. 

Providers are not required to determine if a crime or a prosecutable offense has occurred. However, they can foster an empowering, caring environment to identify a victim for a potential rescue, provide invaluable resources to restore their lives, and help them to begin healing emotionally and physically. 

Creating an Opportunity for Intervention

The trafficker may be the accompanying family member that declines to leave the patient alone. Similar to intimate partner violence, the provider creates an opportunity to take the patient to the bathroom for a urine sample or to radiology for an x-ray or CT scan, informing the family member that they cannot go with the patient. Another way to get the victim alone is to notify the alleged family or significant other that hospital policy requires you to interview and examine everyone alone. 

Before you separate the potential victim from the family member or controlling individual, make sure you or a dedicated, trained staff member has the time to conduct an interview/assessment at that moment. 

Traffickers can be parents, "boyfriends," husbands, women, men, friends, and those you would otherwise see as protectors. Do not talk with the patient about suspected trafficking if the patient cannot be interviewed in private. The trafficker may cause the victim serious bodily injury after removing them from the facility if alerted that the healthcare provider is suspicious of the situation.

Assessment of the level of danger or threat to the patient and staff is imperative. Pay attention to your immediate area and follow preset protocols by your institution in notifying law enforcement and security personnel. 

The NHTRC can assist you in threat level assessment, danger risk, and contacting law enforcement if the patient consents. Is the trafficker still nearby? How will the trafficker act if the victim does not return? Are there minors or other family members that are in danger? Is the patient a minor? 

An interprofessional approach is best, if available, with a trained social worker nearby as predetermined in your trafficking protocol. Follow preset policies and procedures regarding abuse and neglect at your institution and according to local and state statutes. The NHTRC hotline offers invaluable assistance with resources, assessment, and the best courses of action. 

Just like when intimate partner violence occurs, ensure the patient has a safe place to go upon discharge. 

If a patient reveals they are a victim of human trafficking, ask the patient if it is all right to call the NHTRC hotline number. Encourage the patient to call and provide them with the phone number. It may be dangerous for them to keep the number on hand, so ask them if they can memorize it or give them a "shoe" or "key" card that can be hidden in their shoe or other discrete location. 

The National Human Trafficking and Resource Center hotline number is available around the clock, and reporting information is confidential to the extent of the law. The NHTRC is a tip hotline, a place to find out about services and to ask for help. The hotline can translate and communicate with individuals in more than 200 languages. A caller does not need to disclose personal information to the hotline; the caller can remain anonymous.

The NHTRC is available to help healthcare providers in the event of a potential trafficking case when no protocols are available. Healthcare providers can gain information on social referrals such as anti-trafficking organizations, shelters, local social services agencies, legal services, and law enforcement numbers. Tip reporting is available. The hotline website provides training information and technical support. The NHTRC can guide a provider in the assessment of a potential victim. 

• Report Online or Access Resources & Referrals: www.traffickingresourcecenter.org
• Call: 1-888-373-7888 (24/7). Email: [email protected]. Live chat: www.traffickingresourcecenter.org

Mandatory Reporting/HIPAA Considerations

Guidelines for reporting suspected human trafficking cases will vary depending on the facility, location, and state and federal laws. Adults may not want to report the incident; thus, the decision to alert law enforcement is based on predetermined protocols and local or state laws coupled with patient wishes. Some states mandate reporting if serious bodily injury or a firearm is involved. 

Health Insurance Portability and Accountability Act (HIPAA) concerns are essential considerations. The practitioner must obtain permission from an adult victim of human trafficking to release any protected health information (PHI) or personally identifiable health information to the NHTRC. The NHTRC may be contacted and provided general information for a consult as long as no protected, identifiable health information is released. If the victim is under 18 and involved in a commercial sex act, follow mandatory state reporting laws for child abuse and institutional child abuse policies. 

HIPAA will permit the release of protected health information under certain circumstances, such as suspected injury or abuse. For example, if the law mandates a disclosure as in the case of child abuse or neglect, elder abuse or neglect, and in cases reportable to the medical examiner. Reporting is permissible under HIPAA regulations if the disclosure involves a crime and is an emergency, is necessary to prevent harm with patient consent, and in any situation where local, state, or federal law requires reporting. However, follow institutional guidelines and policies in place for HIPAA reporting requirements.

• Treatment / Management

Trafficking Health Implications

Labor and sex trafficking carry inherent health risks and need exploration. Research studies in South Africa and West Bengal, India, regarding the effects of sex trafficking and HIV risk, determined that women and girls who experienced forced sexual encounters through being trafficked were 50% more likely to acquire HIV. One reason suggested that immature cervical epitheliums or cervical ectopy might lead to breaks in the vaginal mucosal and subsequent inflammation that increases the chance for HIV to spread during repeated sexual assaults in younger victims, but more research is required. [38] [22] [38]

Vulnerability and inexperience may lead to HIV and other sexually transmitted infections due to inadequate condom use and repeated exposure to older adult males throughout the trafficking lifespan. 

Sex Trafficking Health Implications

When treating these potential victims, screening for injury and STIs, such as HIV/AIDS, herpes, syphilis, gonorrhea, chlamydia, trichomonas, hepatitis, and molluscum contagiosum, needs consideration. If a recent forced sexual encounter, emergency contraception, and STI prophylaxis are considerations, following preset institutional guidelines. 

Sexual assault kits may need to be obtained. Follow sexual assault collection of evidence protocols in your local area and per institutional policy. Project Help , Rape Crisis , and women's shelters may be a resource. Pain from daily forced sexual encounters and trauma may be an issue. Problems with urinary tract issues may warrant a urinalysis or culture. A urine sample that is not a clean catch, often referred to as "dirty urine," may be obtained to test for a sexually transmitted infection such as chlamydia. A pregnancy test may be useful. Toxicology studies may be needed, and alcohol levels and withdrawal issues addressed. 

Complications surrounding forced tampon use or "packing of the vagina" by traffickers to facilitate sexual encounters (unnoticeable to customers) while victims are menstruating may be of concern. Foreign debris may be present in the vagina on pelvic examination, and cervical cultures are a possibility if any discharge is present. That "lost tampon" patient may be a victim of trafficking and require a more in-depth assessment, asking open-ended, neutral questions to spot red flags.

Labor Trafficking Health Implications

Labor trafficking victims may experience severe dehydration or malnutrition due to being forced to work long hours in construction, on farms, at factories, or in "sweatshops." Heat exhaustion or hypothermia may present in these trafficking victims.  

According to the 2016 Global Report on Trafficking in Persons, Southeast Asia is emerging as a destination for short, medium, and long-distance trafficking. Increasing in frequency, these individuals are made to endure long ocean voyages as they are smuggled into the United States and other countries on cargo ships. These overcrowded, unsanitary conditions have infectious disease ramifications. [39] [40]

Communicable or infectious diseases such as silicosis, tuberculosis, HIV, and typhoid may be an issue. Scabies, lice, and bacterial and fungal skin infections may be a concern. Malaria, Chagas disease, cysticercosis, toxoplasmosis, toxocariasis, and trichomoniasis also may be risks. Asbestos concerns exist for miners who are victims of labor trafficking. [41]

Migrant workers who are being trafficked in the fishing and seafood industry may suffer from exposure to Vibrio vulnificus  and subsequent necrotizing fasciitis with septicemia if left untreated. Vibrio vulnificus , found in warm climates with shallow, coastal waters, can infect a person through lacerations or breaks in their skin.

Labor trafficking victims may suffer from injuries related to poor ergonomics, such as back and neck injuries, vision problems, carpal tunnel syndrome, and headaches. 

• Differential Diagnosis

Intimate Partner Violence

Domestic violence or intimate partner violence (IPV) takes many forms and involves the maltreatment of another within a romantic union or partnership. Men, women, teenagers, heterosexuals, gays, lesbians, bisexuals, and transgender individuals may be affected. Domestic violence may include emotional, physical, sexual, economic, spiritual, or psychological insults. IPV involves one partner in the relationship subjecting the other to some form of abuse to exert power and control over them. 

Much like human trafficking, domestic violence is a significant public health issue that plagues millions of people. Individuals subjected to IPV, especially teenagers, are vulnerable to practicing risky behaviors such as drug use and sexual promiscuity. These vulnerabilities place them in high-risk situations of being victims of human trafficking. Traffickers feed off this opportunity to exert power and control over a victim. Power and control manifestation takes many forms of abuse on the part of the trafficker.

The Human Trafficking Power and Control Wheel

The Human Trafficking Power and Control Wheel finds its basis in the power and control wheel for domestic violence. The wheel for human trafficking depicts the different types of abuse inflicted on trafficking victims at the hands of traffickers. Power and control, the wheel center, represent the primary weapon a trafficker uses to manipulate a victim and keep them bound to the trafficker. [42] [43] [44]

Other tools in the arsenal to demoralize and dehumanize a victim involve coercion and threats. 

• Intimidation: Intimidation is another tactic used by the trafficker and involves physical violence inflicted upon children, pets, or other victims. It may include threats with a weapon or actual weapon use, destruction of property, and misleading information regarding police.
• Emotional Abuse:  Emotional and psychological abuse can be particularly devastating to a victim. The trafficker humiliates the victim in front of others, calls them names, blames the victim for the situation, and convinces them that they would be all alone if the trafficker did not love and care for them. The exploiter repeatedly tells the person under their control how worthless they are and that they are too weak to survive outside the existence the trafficker has created for them. They may threaten to expose or shame the victim by releasing sex tapes, nude photos, drug addiction, or participation in violence or sex acts against other victims. 
• Isolation: A trafficker may isolate a victim by confinement, frequently moving so the victim cannot become familiar with their surroundings or keep them cut off from others by a language barrier. A victim may be isolated from family and friends or be accompanied by the trafficker while in a public place. The trafficker may not allow the victim access to routine, preventative medical care. Thus, medical problems may be exacerbated, and overall health compromised.
• Minimizing, Denying, and Blaming:  A trafficker often blames the victim and denies there is anything wrong with the situation, minimizes their involvement in the abuse or exploitation, and lets the victim think the victim is the reason for their current circumstance: the victim is the one that ran away, reached out to them on social media, went to that party or hotel room.
• Sexual Abuse: Sexual assault may be useful to the trafficker as a means of power and control. The victim is treated as a sex object, only as good as the money they bring in. They may be forced to submit to sex with multiple partners daily or risk the wrath of the trafficker. Forced abortions, threats to end a pregnancy, or violence during pregnancy are control tactics. Unwanted pregnancies, either through forced sexual assault or consensual sex, are a way to control a victim.
• Using Citizenship or Residency Privilege:  The trafficker may use privilege or superiority as a means of control. The trafficker may hide or threaten to destroy immigration papers such as work visas, passports, or other forms of identification. A victim might be used as a servant or a pawn to entice others into trafficking. The trafficker or pimp may threaten the family and threaten to report to immigration.
• Economic abuse:  Debt bondage is used to manipulate and control. The victim may be charged enormous interest rates that they can never repay. They are restricted from leaving their situation because they have no access to money, are allowed only a small allowance, or have any earnings confiscated.
• Coercion and Threats: Threats of actual physical abuse are another manipulation tool used to exert power and control over the victim. It may involve shoving, punching, hitting, kicking, and strangulation injuries. Torture can take the form of cigarette burns or branding, as well as withholding basic needs such as food, water, and clothing. Threats to harm a child bind the victim to the trafficker for fear of no food or shelter or the actual threat of physical harm to the child. They may threaten to contact the Department of Children and Families or law enforcement. Traffickers may use drugs as a form of control over the victim. Introducing drugs to the victim or threatening to withhold drugs from a victim already struggling with addiction allows the trafficker to be in control. These addiction issues may have led the person trafficked to the initial point of contact with the trafficker or be a result of trying to cope with the trafficking situation.

Victim-Centered Approach

A victim-centered approach is paramount in delivering care to a victim of human trafficking. In victim-centered care, the provider precisely focuses attention on the victim, catering to the patient's needs to ensure the delivery of care in a compassionate, culturally sensitive, linguistically appropriate, nonjudgmental, and caring manner. A victim's wishes, safety, and well-being are important considerations. 

The heart of a victim-centered approach ensures a victim does not suffer re-victimization or re-traumatization. Trauma, as it relates to an individual from an initial insult, is a series of events or stressors that the individual experiences as either emotionally or physically life-threatening and has lasting ramifications on social, physical, mental, and spiritual well-being.

Trauma-Informed Approach

Human trafficking care must involve a trauma-informed approach where the healthcare provider recognizes the scope of the impact of the trauma on an individual victim’s lifespan and lessens any chance of inflicting more injury on this victim. Provider understanding of the signs of trauma, verbal and nonverbal cues, and their response by following predetermined protocols for identification, treatment, and appropriate referrals are essential elements of trauma-informed care.

Trauma-informed care involves the entire healthcare team and the incorporation of shared decision-making practices using an interdisciplinary, collaborative approach. Safety, transparency, and collaboration with peers and agencies are vital. The approach must account for culture and gender equality, LGBTQ considerations and support, and, most importantly, center around an empowering environment. [45]

Empowerment

Empowerment allows the victim to seek resources and take the first steps toward self-identifying. Educating staff to recognize the red flags of human trafficking, feel adequately trained, have the knowledge to offer appropriate resources, and provide follow-up care to trafficking victims is essential. 

The goal is for providers to enable others to champion change and advocate for protocol development. The Power and Control Wheel for Human Trafficking may be used in protocol development and is a tool to help identify the different types of abuse that can occur in labor and sex trafficking situations and the subsequent polytrauma complex care that is needed. The entire interprofessional team must work together to empower the survivor to become a productive, functioning member of the community. 

Human Trafficking Protocols

Providers must know the local resources available ahead of time and establish a human trafficking protocol much like the one for intimate partner violence or alleged sexual assaults.

Local resources such as Project Help, rape crisis centers, women's shelters, homeless shelters, addiction centers, and churches can provide needed materials and support services for these victims and clarify any rules, such as pet policies.

Know the resources available for potential victims of human trafficking through local law enforcement or task forces?

Human trafficking protocols need to include specific vital elements such as indicators and red flags; ways to separate the potential victim from the trafficker; interview procedures; ways to maintain and ensure safety for the victim, staff, and potentially other victims; and referral information.

Mandatory reporting requirements that address local, state, and federal laws need to be incorporated into protocols. Referral information must be accurate and easily understood by the victim and translated appropriately based on language needs. 

Provide NHTRC Hotline information. Incorporate follow-up data into a protocol. Another part of a protocol might include a critique of staff performance and ways to improve. Mandatory staff education will play a vital role in protocol implementation. 

Recognize that everyone on the interprofessional team plays a role in stopping human trafficking and identifying those at risk: social workers, case managers, customer service representatives, nurses, physicians, physician assistants, nurse practitioners, nursing assistants, medical assistants, nursing students, medical students, educators, dental assistants, law enforcement, security guards, support staff, and the community.

Referral Considerations

Long-term psychological impacts must be taken into consideration when referrals for treatment of these complex-trauma patients are incorporated into the treatment plan. Multifarious conditions exist emotionally and physically, rendering approaches to future care a challenge for healthcare providers. [46]

According to a study of male and female survivors of trafficking in England conducted between 2013 to 2014, healthcare, including physical, mental, and sexual healthcare, was a fundamental component of successful post-trafficking care. Follow-up care coordinated with multiple disciplines is essential. Basic needs of clothing, food, safe shelter, and transportation must be discussed. Ensure language barriers are addressed and provide resources on free classes to learn the local language. Discuss medical issues and refer to appropriate subspecialists.

Transitioning from Victim to Survivor - Potential Referrals

• Dietician consults in cases of severe malnutrition.
• Infectious disease consults for communicable diseases and sexually transmitted infections.
• Referral to obstetrics/gynecology for infertility concerns related to forced abortions, repeated trauma, frequent miscarriages, or medical problems such as prenatal concerns, addiction issues, and torch infections originating from lack of preventative care or poor access to care may need investigation. Hormone replacement therapy concerns must be met for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) victims.
• Surgical or dermatology referrals for removal of unwanted tattoos or brands or to treat burns and other injuries.
• Consultations with gastroenterologists for stress-related issues.
• Children often suffer developmental delays and need assistance with transitioning into a healthy life. 
• Social stigma implications of forced homosexuality can play a role in future psychological care. Crisis intervention teams and case managers will have a role in successful integration practices. [47] [48] [49]
• Perpetrators often use substance abuse to control victims, or victims use it as a form of escape from the abusive environment. Addiction and sobriety considerations will need implementing into daily routines. Community-based organizations, support groups, and faith-based programs may ease this transition period and lessen the impact of psychological stressors.
• Legal services referrals made for child custody issues, immigration assistance, protective/restraining orders, assistance with any offenses, and with the successful prosecution of the trafficking entity. 

Survivor's Role

Cultural shock impacts and language barriers play a role in the recovery period and successful transition into society as a survivor and not a victim. Survivors of human trafficking can offer much-needed insight into the thoughts, feelings, and interactions with members of the healthcare team and guide care and training programs going forward with this vulnerable patient population.

In 2015, a study conducted in New York City’s Rikers Island jail suggested that survivor-based input was essential in addressing healthcare concerns and improving care in this patient dynamic. Survivors shared that when cared for or interviewed by healthcare providers, they felt intimidated, judged, and stereotyped. They suggested providers and front-line personnel pay attention to their body language and the nonverbal cues they are displaying as they walk into the treatment room, up to the front desk, or after disclosure. This patient-provider interaction, if negative, can negatively impact the comfort of the victim to feel safe enough to open up and not be judged. These victims stated that instead of an interview, they preferred an approach in which the provider asks straightforward, normalized, direct questions in a compassionate, nonjudgmental way that reinforces a feeling of safety and confidentiality. [2] [43] [19]

Further research is needed in this area for conclusive results as this crime comes "out of the shadows," and researchers look beneath the surface, but survivors should play a role in the education of healthcare providers.

• Pearls and Other Issues

The Language of Trafficking

Languages are essential to understanding different cultures, environments, enterprises, and socioeconomic groups. Human trafficking and smuggling participants have a dialect unique to traffickers and victims. Exploration of "trafficking vocabulary" will help practitioners relate to and understand patients who have been trafficked. 

In a victim-centered approach, much like a patient-centered approach, it is imperative to communicate effectively with a potential victim or patient. The following are legal definitions and terms or "lingo" used by traffickers and victims or as they relate to human trafficking. This list continues to grow as we better understand human trafficking. Other terms may become recognizable as jargon unique to a trafficking situation. 

Trafficking "Lingo"

• Daddy: The word a victim is required to call their pimp/trafficker.
• Gorilla Pimp: A trafficker or pimp that resorts to violence to control a victim 
• Romeo/Finesse Pimp: The trafficker that uses a false romance; a false promise of money, clothing, or other gifts; or false hope of marriage to lure victims. Often referred to as "boyfriend."
• Branding: A carving, tattoo, or mark on a victim that implies ownership by a pimp/gang/trafficker. The tattoo may say, "Daddy," "Property of...," or "For sale." 
• Quota: The amount of money expected from their trafficker/pimp each night. If quotas go unmet, the victim may be beaten, tortured, or made to work exorbitant hours until the expected amount has been delivered.
• Circuit: A series of places where prostitutes/victims get moved. Keeping them in unfamiliar surroundings increases their vulnerability and facilitates the trafficker's control over the individual.
• Date: The time and location where the sex act is to take place. The buyer or "John" meet them at this pre-determined site.
• The Life: Sex-trafficking victims refer to their situation as being in "the life."
• Bottom: A victim is chosen by the pimp or trafficker to "handle" the other victims. They may train the new victim, post ads/control social media posts, inflict punishment if rules get broken, and book the "date." This individual victim may feel tremendous shame and guilt because of her actions and treatment of other victims. The pimp may further control the "bottom" by threatening violence, increasing quotas, or reporting her to the authorities. The "bottom" may be required to entice others into servitude by posing as a student, a concerned friend, or a mother figure.  

Trafficking Victims Protection Act Definitions

• Coercion: Threats of serious harm to or physical restraint against any person; any scheme, plan, or pattern intended to cause a person to believe that failure to perform an act would result in serious harm to or physical restraint against any person; or the abuse or threatened abuse of the legal process [22 U.S.C. 7102 (3)(a)(b)(c)].
• Commercial Sex Act: Any sex act on account of which anything of value is given to or received by any person [22 U.S.C. 7102 (4)] 
• Debt Bondage: The status or condition of a debtor arising from a pledge by the debtor of his or her personal services or those of a person under his or her control as a security for a debt if the value of those services as reasonably assessed is not applied toward the liquidation of the debt or the length and nature of those services, are not respectively limited and defined [22 U.S.C. 7102 (5)].
• Involuntary Servitude: Any scheme, plan, or pattern intended to cause a person to believe that, if the person did not enter into or continue in such condition, that person or another person would suffer serious harm or physical restraint [22 U.S.C. 7102 6 (a)].
• Labor trafficking: The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, or coercion for the purposes of subjection to involuntary servitude, peonage, debt bondage, or slavery (22 USC § 7102).
• Sex trafficking:  The recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purposes of a commercial sex act, in which the commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age (22 USC § 7102).
• Enhancing Healthcare Team Outcomes

Victims may suffer a diminished quality of life and fear of autonomy and independence. The long-term mental and physical health consequences of being a victim of trafficking are immeasurable. Health professionals must work as a team to identify victims and assist in their transition to a normal and productive everyday life.

Trauma-informed care involves the entire healthcare team incorporating shared decision-making practices using an interprofessional, collaborative approach. Safety, transparency, and collaboration with peers and agencies are vital. [45]

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Assessment for Human Trafficking. Screening questions to ask if considering human trafficking, including sex trafficking, in a clinical evaluation. U.S. Department Of Health And Human Services

Disclosure: Tammy Toney-Butler declares no relevant financial relationships with ineligible companies.

Disclosure: Megan Ladd declares no relevant financial relationships with ineligible companies.

Disclosure: Olivia Mittel declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Toney-Butler TJ, Ladd M, Mittel O. Human Trafficking. [Updated 2023 Jun 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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