Intended for healthcare professionals

Practice Practice Pointer

Identifying human trafficking in adults

BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4683 (Published 22 December 2020) Cite this as: BMJ 2020;371:m4683
  1. Jane Hunt, GP and senior medical adviser,
  2. Rachel Witkin, head of counter-trafficking and publications,
  3. Cornelius Katona, medical and research director
  1. Helen Bamber Foundation, London, UK
  1. Correspondence to J Hunt jane.hunt{at}helenbamber.org

What you need to know

  • Psychological violence is integral to all forms of trafficking exploitation; physical and sexual violence are also prevalent

  • Trafficked people may live for years under the control of their traffickers, and the impact on their physical and mental health can be profound and enduring

  • Trafficked people are likely to have had pre-trafficking vulnerabilities (including poverty, destitution, experiences of war/community violence, domestic violence, adverse childhood events, disabilities, and learning difficulties) which can create cumulative harm

  • Stay curious in any consultation; ask appropriate, sensitive questions; create an environment where the patient can feel comfortable to talk openly; and apply “trauma informed” methods of working. Follow local safeguarding policies if you are concerned about a patient

A 24 year old woman from Nigeria presents to a male GP in the UK with vaginal discharge and inter-menstrual bleeding. She speaks limited English. Her notes show that she has received three diagnoses of sexually transmitted infections in the last year. She is accompanied by a man who looks older than she is, who offers to interpret for her. She responds without emotion to introductions and questions, and stares out of the window much of the time. An abusive or exploitative situation is suspected. The need for an intimate examination and further investigations is explained, and the accompanying man is politely asked to wait outside. The woman declines a chaperone. Further medical history is elicited through a telephone interpreter. The doctor asks gently whether she feels safe with the man and where she lives. The woman then becomes distressed and tearful and refuses to say anything further.

Trafficked adults experience, or have experienced, complex physical and/or emotional trauma, and are usually considered to be adults at risk. The UK’s Care and Support Statutory Guidance, first published in 2014,1 cites modern slavery as one of the 10 categories of adult abuse, and as a legally recognised form of child abuse in people under age 18, making it important for clinicians to have confidence in recognising possible victims and survivors, and in taking the first steps towards ensuring appropriate intervention.

When vulnerable adults and children are identified, clinicians are responsible for following local safeguarding pathways,1 and for urgently referring all victims, or suspected victims, of slavery under the age of 18 to children’s social care services (according to local child protection procedures). In this article we outline the principles behind identifying trafficked adults and what to do if you suspect or confirm a trafficking situation.

In the absence of much evidence in this area, the advice presented is based on the authors’ clinical and counter-trafficking experience, and draws from the international and UK guidance included in the CoE Trafficking Convention and Explanatory Report,2 IOM Guidance for Health Professionals,3 the OSCE/ODIHR forthcoming NRM Handbook (2nd edition), the UK Care Act 2014 Care and Support Statutory Guidance,1 UK Slavery and Trafficking Survivor Care Standards,4 and the Modern Slavery Act 2015, Statutory Guidance for England and Wales.5

The authors work in the UK and understand that variation exists in international practice; nonetheless, much of the content is applicable to all clinicians globally.

We consider a “victim” of trafficking as someone still in an exploitative situation and a “survivor” as someone who has escaped their trafficking situation. Survivors are likely to need support and remain vulnerable to further exploitation for a prolonged period of time after escape. In this article, when the term “trafficked adult” is used, it refers to both adult victims and adult survivors. This article is predominantly about identifying adult victims and adult survivors, but the term “trafficked people” will be used if a principle might also be applicable to victims and survivors under 18. For further information on trafficking in children, see BMJ Paediatrics Open.6

Covid-19

This article was commissioned and peer reviewed before the covid-19 pandemic. This public health crisis has increased the vulnerability of, and compounded the risks faced by, trafficked people; particularly those who have insecure immigration status, who are without leave to remain in the UK, or who have been granted short terms of leave to remain (one year or less). Many social factors contribute to trafficked people being unable to manage this crisis. For further information, please see UK Government Guidance26 and the Helen Bamber Foundation’s short report to the UK Home Office.27

Clinical scenario

A 44 year old Romanian man presents to an emergency department in the UK with severe dermatitis of his hands. He speaks little English and makes no eye contact. He looks pale and wears dirty, tired looking clothes. Using a telephone interpreting system, he explains that he works in a car wash and doesn’t use gloves. When it is suggested that he needs time off work because the dermatitis is most likely caused by the chemicals he uses in his job, he becomes distressed and says it is impossible for him to take time off.

The doctor gently asks how many hours a week he works, and if he has safe living accommodation. He admits that he works 14 hours a day, seven days a week, and is kept in one room with four other men. Bruising is noted on his arm and on questioning he admits that he is beaten regularly and that he is only given one meal a day. It is explained to him that this type of exploitation is not allowed in the UK and that he could be referred to the police or other sources of help such as support charities. He is also told that there is a helpline phone number that could give guidance on his situation, and that either he, or the doctor on his behalf, could call this number at any time. He doesn’t want police involvement, but takes the helpline number. He is encouraged to come back the following week for a review and is told that he could come back to the emergency department at any time if he needed help. The doctor documents her concerns and discusses the case with her colleagues, the receptionists, and the department’s adult safeguarding lead.

What is human trafficking?

The United Nations Palermo Protocol to prevent, suppress, and punish trafficking in human beings defines human trafficking as: the recruitment, transportation, transfer, harbouring, or receipt of persons by means of threat, force, coercion, or deception (no means needed if it involves a child) to achieve control over another person for the purpose of exploitation.7

In the UK the term “modern slavery” is also used as an umbrella term for human trafficking, forced and bonded labour, and forced marriage.

The main forms of adult trafficking are sexual exploitation, forced labour, and domestic servitude.8910 Other forms include forced or sham marriage, organ removal for sale, and enforced crime (eg, benefit fraud, drug cultivation, forced begging, gang crime, and “county lines” exploitation of young adults or children). Exploitation could be “mixed” whereby victims are exploited in more than one form in parallel, or “sequential” whereby they are used in one form followed by another. Victims may be subjected to physical violence, rape and sexual abuse, deprivation of their freedom, and being forced to work and/or live in poor conditions under constant threat. Such acts can occur sporadically or repeatedly. People may be trafficked by their own family members, with or without the victim’s knowledge.

Traffickers deliberately target vulnerable people (box 1) and use force, fraud, or coercion. The subjugation, degradation, and control undermine trafficked people’s personal identities and sense of self, and can have profound, enduring impacts on their physical and mental health.

Box 1

Potential pre-trafficking vulnerabilities

  • Poor socioeconomic status

  • Lack of educational and work opportunities

  • Child sexual and other forms of abuse

  • History of rape/sexual assault

  • Loss of family

  • Community or gender based violence

  • Background of state persecution/torture

  • Health conditions, learning difficulties, or disability

  • Natural disasters and times of crisis, including pandemics

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Prolonged and repeated acts of physical and/or psychological cruelty, abuse, neglect, and degradation mean trafficked people can feel threatened and face multiple difficulties and fears when it comes to seeking help. They may be psychologically controlled or conditioned by traffickers to the extent that they are unable to envisage escape.

In the UK a high percentage of trafficked people are British, highlighting that domestic trafficking can be as prevalent as transnational trafficking11 (fig 1).

Fig 1
Fig 1

Top eight claimed nationalities of people trafficked in the UK, according to National Referral Mechanism data from 201811

Even if a trafficked person has been removed from a harmful situation, they are at risk of re-victimisation, especially if they have previously experienced childhood sexual abuse, physical abuse, or multiple traumas.81213

How common is trafficking?

The number of trafficked people detected by, and reported to, the UN’s Office on Drugs and Crime has been increasing since 2011.14It is estimated that in 2016, 40.3 million men, women, and children worldwide were victims of forced labour or forced marriage.9 In the UK in 2019, 10 627 people were referred into the National Referral Mechanism1011 (the UK’s framework for identifying victims of trafficking). However, this number is likely to be a significant underestimation; no country’s data are representative of the total number of people entrapped in trafficking situations, as this crime is hidden by both the criminals and the trafficked people who find it so difficult to disclose their situation and to seek help.

How do trafficked adults present?

Trafficked adults might present to many services, particularly to maternity services, general practice, emergency departments, or sexual health clinics. They could present with one or more of a wide range of physical and/or mental health conditions. However, they may suffer from a loss of agency and autonomy, making it difficult for them to ask for help.

Ill health may be linked to previous abuse, pre-existing mental or physical disability, poverty, and/or the consequences of poor healthcare in the country of origin as well as from the conditions endured during exploitation in the country of current residence or during the journey to that country.

Physical injuries, psychological problems, and illnesses may not always be obvious or visible, and may not be easy for individuals to disclose, making identification of potential victims a complex process. Additionally, traffickers may provide stories for their victims and instruct them on what to say.

What clinical and social indicators might suggest a trafficking situation?

Identifying and managing health and social needs can be difficult in this patient group as physical and psychological illnesses can be deeply entwined, and under reporting is common.

Formal trafficking indicator lists exist to help.515 These lists are regularly reviewed and updated as trafficking is a crime that is constantly evolving. They cover situational and environmental indicators as well as indicators related to physical, psychological, and sexual health and pregnancy.161718 However, on their own, indicators do not definitively confirm or exclude trafficking. The RCN Modern Slavery Wheel16 is a handy pocket-sized tool for use in practice which summarises some of these indicators.

Indicators that are most relevant to healthcare professionals include161718

Acting as if under the control of another personConsider a trafficking situation if the relationship with an accompanying person seems suspicious, if it seems the patient is being instructed by someone else, if the accompanying person talks for the patient, and/or if a lack of rapport is evident between the patient and the accompanying person. An accompanying person refusing to leave the consultation when asked is considered a red flag.

Having a history of frequent address changes, and/or lacking knowledge or being vague about where they live or of their medical history—Individuals may not be registered with a GP, may be unsure of their medical history, may be reluctant to disclose their immigration status, or may not have the expected documents. They may be reluctant to seek help from you or the police. They may demonstrate “cagey” or nervous behaviour, be inconsistent in recounting their history, or become distressed or withdrawn with questioning.

Displaying manifestations of captivity, neglect, and/or poor environmental conditions—Patients may appear unkempt, neglected, withdrawn (lack of eye contact, minimal communication), or afraid. They may be inappropriately dressed for the circumstances. They may appear malnourished or have had exposure to communicable diseases, including tuberculosis. They may have unexplained deterioration or poorly treated existing chronic conditions.

Having injuries or illnesses that are not easily explained, sexual health concerns (in men and women), and/or mental health concerns—The person may have injuries with unclear explanations, or untreated or partially treated injuries, including work related injuries. They may have head injuries or genital injuries, and/or multiple or unusual scars. Patients might present with repeated or partially treated sexually transmitted infections, previous terminations of pregnancy, pelvic inflammatory disease, or unwanted or late presentation of pregnancy. They might show signs and symptoms of self-harm, suicidal ideation, depression, anxiety, post-traumatic stress disorder, or drug/alcohol misuse. Psychosomatic symptoms (symptoms without an identifiable physical cause) are also common and can be non-specific such as headaches, dizziness, or back pain, or may be related to trauma to a particular part of the body, for example, abdominal pain in people who have been raped.

How can you support voluntary disclosure?

Try to see the patient alone

Always remain aware of your own safety and that of the patient. Avoid raising the suspicion of any accompanying person by ensuring that all communications are calm and friendly. In some cases, all that may be needed is to ask the accompanying person politely but firmly to leave the clinic room so that you can examine the patient.

Avoid directly challenging the accompanying person or the possible trafficked person about their relationship with each other. This may risk curtailment of the interaction and loss of the opportunity to intervene. It may also put the victim at increased risk of further harm.

Make use of opportunities where patients are expected to be unaccompanied. For example, conducting an intimate examination or a blood test, or accompanying the patient into the radiography room.

Occasionally, other skills like negotiation and de-escalation may be needed. Guidance from the National Institute for Health and Care Excellence19 offers advice on these techniques.

Advise patients that your clinical protocol is to use professional/formal interpreters rather than friends or family.

Be patient and compassionate

Trafficked people become used to minimising, concealing, or denying their injuries and suffering in order to survive. It is common for victims to under report or deny their experiences as a way of coping (box 2).

Box 2

Why trafficked people find disclosure difficult

Methods used by traffickers to control and subjugate are designed to prevent escape and disclosure, and include violence and fear, threats to family, deception, perpetuation of “debt bondage,” or supernatural rituals such as Juju.

Other barriers to detailed disclosure of what has happened in the past or is happening now may include

  • Lack of understanding or recognition of themselves as victims

  • Limited knowledge of the language spoken in the host country

  • Fear of, and lack of, trust of authorities

  • Fear of having to recount a traumatic history with accompanying shame, distress, and risk of re-traumatisation

  • Lack of the autonomy and agency needed to seek help after long periods of being controlled

  • Inability to afford healthcare or transport

  • Lack of knowledge of services available to them

  • Difficulties in registering with health services

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Avoid attempting to force a disclosure; this is often counterproductive: it can cause the patient to leave the service and potentially put them at risk. In general practice or maternity services, it is possible to facilitate disclosure by gradually building a relationship of trust.

A gradual approach may not be possible in emergency departments and sexual health clinics, making it more challenging (but not impossible) to establish trust and gather sufficient information to identify possible victims of trafficking (box 3).

Box 3

Gaining trust

Create an environment where voluntary disclosure can happen, if the patient chooses

  • Use a private room rather than a bay on a ward

  • Introduce yourself and define your role

  • Explain your duty of confidentiality clearly and that it can only be breached in exceptional circumstances

  • Offer an appropriate chaperone

  • Provide opportunity to ask questions

  • Comply with patients’ religious, ethnic, or cultural preferences (eg, regarding gender when requesting chaperones or professional interpreters)

  • Introduce chaperones/interpreters and ensure all parties understand the duty of confidentiality

  • Allow time for responses and avoid conveying the sense of being in a hurry

  • Remain empathetic and non-judgmental

  • Listen carefully and understand the trafficked person’s view

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Always attempt to use a professional interpreter for those who do not speak the main language of the host country.

Consider the terminology you use. Many people may not self-identify as “victims” of “trafficking” or “slavery,” and so will not recognise these terms in relation to themselves.

Being sensitive, patient, and non-confrontational can help you to identify trafficking, encourage voluntary disclosure, and assess whether there is immediate danger.

Ask questions in a “trauma informed” way

To work in a trauma informed way is to consider the harmful effects of traumatic experiences while showing compassion and respect when conducting the consultations, speaking with the patient, and asking sensitive questions.20

Carefully selected questions can highlight indicators of potential trafficking. For example, a pilot programme looking at the effectiveness of a screening survey for sex trafficking in California suggested that simple screening questions have the potential to pick up most cases presenting to emergency departments.21

Questions which may be useful include:

  • Ask whether patients feel safe and whether any accompanying people aresafe for them”(a phrase that often enables disclosure). Has anyone threatened you or your family? Is anyone forcing you to do anything you don’t want to do?

  • Ask if the patient has children and where the children are—This could change the urgency of any intervention. If children are involved, or the patient is pregnant, the needs of the child, or unborn child, become a priority.22 Be aware that this may cause distress as the patient may have had to leave their children in their home country, or they may not know where they are.

  • Ask about their home life in the host country—Can you leave home when you want to? Is your housing safe? Do you share a room? Is there a window? Can you tell me about your diet—this week, this month?

  • Ask about work—How many hours do you work a day? (talk me through it). What happens about work when you are not well enough to work? Were you injured while working? Are you in control of your money and your documents?

  • Ask about their worries—What is worrying you most at the moment? Is there anything, or anybody, you are particularly concerned or frightened about now?

The IOM document Caring for Trafficked Persons: Guidance for Health Professionals3 is a handbook for health professionals that offers more detailed advice on assessment of potential victims of trafficking.

What do you do if you suspect or confirm trafficking?

Be sensitive and remain calm

The principles of safeguarding trafficked adults are similar to those for other vulnerable adults, such as those experiencing domestic violence, and patients should be treated with the same sensitivity.

The goal is to prioritise the safety of the potential victim, while always ensuring your own safety.

Observe principles of informed consent, remembering that a feature of trafficking can be a lost sense of agency and autonomy, and it can be difficult for trafficked adults to make their own decisions.2324 Encourage voluntary decision making even if you believe the person to be in imminent danger, for example, consider asking whether the individual thinks the best course of action is to call the emergency services.

Offer choices to the patient

When there is no immediate emergency, but a risk of human trafficking is identified, gently discuss referring to the police, a suitable non-governmental organisation or, in the UK, to the Modern Slavery helpline (box 4) (https://www.modernslaveryhelpline.org/, 08000 121 700).

Box 4

UK specific considerations

In the UK, designated “first responders” can refer possible trafficked people (with their consent) to the government’s National Referral Mechanism.15 This body is responsible for the identification, protection, and assistance of trafficked people. Any healthcare professional, other professional, or a trafficked person themselves can call the Modern Slavery Helpline on 08000 121 700, which is open 24 hours a day.

First responders include police, local authority and certain non-statutory services, and non-governmental organisations. At this time, healthcare professionals are not first responders because it is recognised that reporting can be complex, time consuming, and needs a level of legal knowledge not routinely found in healthcare professionals.

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If patients do not want to take action or “escape,” provide support by prioritising their health conditions with empathy, gaining trust, making clear records, and asking them if they want to come back to see you.

Address the patient’s health needs

A person who is currently in a trafficking situation may not access healthcare again in the same service, so always attempt to address any emergency and urgent health needs (including antenatal referral if pregnant) while the patient is there.

Arrange follow-up

Make efforts to bring the patient back for review; this can build trust and support further disclosure and/or opportunities for intervention. Try to ensure you have contact details for the patient, but do also check whether it is safe to contact them. Consider whether they will be able to attend further appointments unaccompanied (also consider cost) and if not, how provisions might be made. For example, clarify bus routes, give them documents to “prove” that they have an appointment, reassure them that if the accompanying person insists on attending they would still be made welcome, and that you would try to see the patient on their own discreetly.

If you see the patient in an acute care setting, ask for consent to call or email their GP.

Follow statutory local safeguarding procedures

Alert senior staff members, colleagues, and/or safeguarding leads about your concerns that this patient is, or may be, a potential victim of human trafficking. This is ideally done when the patient is still present, but this may not always be possible.

When to contact the police

If the patient’s safety is immediately threatened, try to encourage them to stay with you. Remain calm, and call for the police. Be prepared to have someone address the person who accompanied the patient. They might become irritable or demand to have the patient discharged. Reassure the patient that they do not have to go with that person and that measures will be taken to prevent that person from being in contact with the patient any further.

When the victim is a child, the local authority must always be contacted. All victims, including possible or potential victims of modern slavery who are under the age of 18 must be referred to children’s social care services urgently under local child protection procedures. Further information on children and trafficking is outside the scope of this article but for more information see BMJ Paediatrics Open.6

If the patient is pregnant refer for antenatal care as appropriate and follow local safeguarding protocols. These typically include informing the safeguarding maternity team so onward referrals to local authority safeguarding teams can be made as needed for protection of the unborn child.

Be aware of vicarious trauma

Looking after trafficked adults can be difficult and can even lead to vicarious traumatisation and/or stress and burnout. It can be upsetting to encounter someone you believe to be in danger, especially if you feel unable to help or they leave before you can intervene. Be mindful of the need to look after yourself and each other; be aware of red flags for these conditions and seek help and advice as needed.25

Debriefing with a colleague can be difficult in a busy surgery or clinic but it is important to share your experience, dilemmas, and thoughts.

Education into practice

  • How would you create an environment where voluntary disclosure can happen?

  • How would you avoid arousing suspicion in accompanying possible traffickers?

  • What interpersonal skills training might you find helpful in dealing with suspected traffickers?

How this article was made

This article was based on the expert opinion and experience of the authors, who work in the field of refugee and asylum seeker healthcare and counter-trafficking at the Helen Bamber Foundation in London. All authors teach and train in modern slavery/human trafficking to a wide variety of audiences including healthcare professionals, safeguarding teams, the UK Government Home Office, and specialist NGOs. Authors have contributed to key publications such as The UK Slavery and Trafficking Survivor Care Standards (2018)4 and the Trauma Informed Code of Conduct for All Professionals Working with Survivors of Human Trafficking and Slavery (2018),20 and have contributed to the UK Government’s Modern Slavery Act 2015, Statutory Guidance for England and Wales (published March 2020).5 Between them they sit on several bodies including the UK’s Human Trafficking Foundation and NHS England’s Modern Slavery Network. They have used their knowledge, clinical experience, and information from the accompanying references to form the basis of this article.

How patients were involved in the creation of this article

We are grateful to our client, a survivor of human trafficking, who offered valuable comment about what she felt healthcare professionals should know about the challenges faced by survivors.

We are also grateful to Minh Dang, director of Survivor Alliance, a leading survivor led charity dedicated to uniting and empowering survivors of human trafficking and slavery around the world, for her input, advice, and review throughout the writing of this article.

We would like to thank all our clients for their valuable contribution to our professional knowledge, understanding, and experience.

Further reading

  • The IOM Caring for Trafficked Persons—Guidance for Health Professionals;3 and The Trafficking Survivor Care Standards4 for more detailed and practical advice on working with trafficked people

  • The Office for Security and Cooperation in Europe (2013). Trafficking in Human Beings Amounting to Torture and Other Forms of Ill-Treatment (Part II) for a more detailed account of the sequalae of trafficking and how the team at HBF work with survivors13

  • The studies by C Zimmerman17 and S Oram18 are good resources for learning about the healthcare conditions seen in trafficked people

  • The Trauma Informed Code of Conduct (Helen Bamber Foundation) is a useful guide to using trauma informed practices in real life situations20

  • For more information on Child Trafficking read: Child modern slavery, trafficking and health: a practical review of factors contributing to children’s vulnerability and the potential impacts of severe exploitation on health6https://bmjpaedsopen.bmj.com/content/4/1/e000327

  • For an overview of modern slavery as a public health concern read: Such et al, Modern slavery: a global public health concern. BMJ 2019;364:l83828

Useful links

Footnotes

References

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