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Human Trafficking Intervention: Standard Protocols for Dental Professionals

Mellissa Withers, PhD, MHS; and Tasfia Jahangir, BA

February 2022 Issue - Expires Friday, February 28th, 2025

Inside Dental Hygiene

Abstract

Healthcare providers, including dental professionals, are among the few outsiders that regularly interact with human trafficking victims. This contact puts them in a unique position to intervene and offer support. However, due to limited time, training, referral systems, standardized protocols, and opportunities to be alone, these opportunities may be wasted. The dentistry profession can adopt measures to combat human trafficking, including a wider adoption of education and training requirements specifically focused on dental professionals; greater representation of dental professionals in anti-trafficking taskforces around the country; and the development of local, state, or national committees to improve coordination and response efforts within the field.

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Human trafficking is one of the largest and fastest-growing criminal industries, generating an estimated $150 billion per year worldwide.1 It is defined as the recruitment, transportation, transfer, harboring or receipt of persons, by means of threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability, or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation.2

Most trafficking victims are exploited through fraud, coercion, and psychological manipulation. While exact figures are hard to pinpoint, an estimated 25 million people worldwide are experiencing human trafficking.3 An estimated 600,000 to 800,000 victims are reported to be trafficked across international borders worldwide, and about 20,000 of them are reportedly trafficked into the US.4 Approximately half of these victims are younger than age 18. About 80% of internationally trafficked victims are female, and 70% are trafficked for sex.5 These numbers do not account for victims who live in the US, where an estimated 55% of all human trafficking victims are born. Although it is difficult to determine, the US government estimates roughly between 244,000 and 325,000 American youth to be at risk for sexual exploitation. However, the quality and quantity of available data are hampered by the hidden nature of the crime, challenges in identifying victims, gaps in data completeness, and different stakeholders' barriers to sharing victim information.6

Anyone can be a victim of human trafficking, as victims come from all demographics. However, the circumstances or vulnerabilities of certain populations increase the risk of victimization. Although the majority of sex trafficking victims are women and girls, men and boys can also be trafficked. Within the US, people of color, people with disabilities, people living in poverty and/or with unstable housing, foster children, runaway teens, and LGBTQ+ people are more susceptible to being targeted and trafficked.7

Traffickers exploit victims through strategies involving physical, emotional, and psychological control. Not all trafficking victims are abducted or physically restrained—many are controlled on a more subtle, psychological level, such as through manipulation and grooming, as well as fraud and coercion. Such strategies deter victims from seeking help or accepting intervention from people who can help, such as law enforcement.

To control victims, traffickers will often:

• confiscate and hold victims' identification documents

• threaten victims with legal, physical, or financial consequences to themselves or their family

• exploit victims' financial or emotional debt to force them to work (eg, fees for housing, food, clothing, medical expenses)

• move victims frequently to disorient their sense of time and location

• foster emotional dependency through psychological abuse

• restrict the victim's freedom of movement

• withhold or control the victim's finances

• isolate victims who do not read or speak English

Health Consequences and Care

Research demonstrates that human trafficking victims are likely to suffer from a myriad of negative health consequences, both acute and chronic. These may include injuries from violence, head and neck trauma, chronic pain, gastrointestinal issues, headaches, mental health problems, sexual and reproductive health problems, and malnutrition.8-16 For victims of labor trafficking, work conditions tend to be primitive, dangerous, and exploitative. In addition to physical and psychological abuse and long working hours, workers are often at high risk of physical injury on the job. Denied access to medical care, victims of human trafficking may also present with serious chronic conditions at late stages. A lesser-known indicator of trafficking is poor oral and dental health, often due to a lack of preventative care.

Despite being hidden from general society, human trafficking victims may receive health services. Medical providers regularly interact with trafficking victims, as trafficking victims may seek treatment for health conditions, or for cosmetic purposes. Victims seek care in a variety of venues, including hospital emergency rooms, urgent care clinics, primary care offices, dental offices, and social services agencies.17 Indeed, a study of 106 trafficking victims found that an astounding 87.8% had had contact with a healthcare provider while being trafficked. Furthermore, over half of the study participants reported having dental problems, such as tooth loss, and over a quarter reported that they sought dental care while they were trafficked.16

Healthcare professionals—including dental professionals—are therefore in a unique position to recognize and respond to cases of human trafficking. In fact, they may be one of the few people to interact with victims while they are being trafficked, which provides an important opportunity to identify them and offer help.18 Yet, healthcare workers are rarely trained to recognize the signs of human trafficking, wasting any opportunity for intervention.

During dental treatment, dental assistants and hygienists are in a particularly unique position-perhaps even more than general practitioners—to identify human trafficking victims. Due to their regular contact with patients over the course of their care, hygienists can foster the trust needed to enable victims to disclose their situation.16 From an ethical and legal perspective, dental professionals should adhere to the American Dental Association's Principles of Ethics and Code of Professional Conduct, which says that dentists are "obliged to become familiar with the signs of abuse and neglect and to report suspected cases to the proper authorities, consistent with state laws."19 But not only can they identify abuse and neglect, they can potentially even offer forensic services related to evidence, collection of signs of abuse, patient medical history and background, and age estimation of adults and minors with no birth certificate.20-22

To begin to intervene appropriately, healthcare providers should be familiar with the indicators of human trafficking, which may include:

• signs of injury, trauma, and fatigue

• dirty or unkempt appearance

• unwashed clothing or revealing clothing that seems inappropriate for the weather

• submissive or fearful behavior

• withdrawn demeanor, fear of speaking, or restricted communication

• answers to questions that appear scripted or rehearsed

• always accompanied by another person

• sex workers seemingly young or under the age of 18

• few or no personal possessions

• memory loss or not knowing what city they are in

• tattoos or brands indicating trafficking

In terms of clinical symptoms, although the oral cavity can be a site of sexual abuse, visible oral injuries or infections are rare. However, possible signs include:23-25

• trauma to the teeth

• dental decay due to illegal drug use or neglect and lack of preventative care

• oral lesions, infections, or overall poor oral hygiene resulting from delayed preventative care or even lack of dental supplies available to the victim

• forced removal of crowns and appliances (in order to sell them)

• gags applied to the mouth may cause bruises, lichenification, or scarring at the corners of the mouth

• unexplained injury or petechiae of the palate, particularly at the junction of the hard and soft palate, resulting from forced oral sex

• forced pulling of teeth to avoid time off work or visiting a dentist

• temporomandibular joint problems after repeated exposure to blunt force trauma

This is not an exhaustive list, and not all of these signs will constitute a human trafficking situation. Nonetheless, these indicators are noteworthy for identifying potential victims.

Asking the Right Questions

Victim identification can be challenging. Due to the covert nature of trafficking, the warning signs can be inconspicuous. Interacting with a suspected trafficking victim is not easy or straightforward. In fact, victims are rarely eager to disclose their trafficking status; sometimes they may not even recognize that they are victims.26 Despite this, there are some crucial steps that can facilitate identification of human trafficking cases.

Health professionals are encouraged to have a private conversation with a potential human trafficking victim, to explain that resources and options are available. Dental professionals should prepare a standard set of questions to ask suspected victims, as well as strategies to ensure that these questions can be asked privately, away from a possible trafficker.13,16 For example, the provider can state that a diagnostic test is required in another area or ask the accompanying person (or suspected trafficker) to step outside of the exam room to assist with paperwork or a medical referral. Such strategies can divert the trafficker's attention so that the provider can speak to the patient directly and confidentially. Furthermore, providers are discouraged from using an interpreter who has a relationship with the patient, as it jeopardizes the patient's ability to be alone with the provider in suspected situations.

Questions to ask suspected victims include:

• Can you leave your job if you want to?

• Can you come and go as you please?

• Have you been hurt or threatened if you tried to leave?

• Has your family been threatened?

• Do you live with your employer?

• Where do you sleep and eat?

• Are you in debt to your employer?

• Do you have your passport/identification? If not, who has it?

Of note, providers are discouraged to start off by directly asking whether a patient is a human trafficking victim, as victims may not be ready to talk about their situation or even recognize that they have been victims of a crime. Due to trauma, victims are often distrustful of others, may be unable to recall events, have inconsistent or vague stories, and may seem hypervigilant, belligerent, angry, or withdrawn. They may also feel fear or embarrassment about their situation. Some victims adopt a defensive response to cope with their trauma. These coping mechanisms may manifest as deep shame or even as loyalty toward their traffickers. Other victims may experience a lack of emotion and flat affect, which allows them to appear neutral, unaffected, or reluctant to speak about their experiences and seek further help. During initial contact with healthcare professionals, law enforcement, or advocacy organizations, victims are likely fearful of retaliation, resorting to cover stories that the trafficker has taught them.

Because a potential victim may be enduring PTSD, anxiety, depression, or other forms of physical and psychological trauma, it is essential for dental professionals to be in constant communication with them throughout the appointment to ensure that they feel comfortable and personally in control of the situation. Non-verbal cues can also serve as important indicators. For example, dental professionals should be attuned to how patients prefer to be positioned in the chair, how they feel about items being placed in their mouth, or if they feel distressed or out of control during treatment.

Responding Effectively

In the event that a victim is identified, it is crucial to be prepared. Practitioners should develop standardized protocols for the reporting of human trafficking cases at each dental practice, and such protocols should align with state laws on mandatory reporting. Building connections with local agencies ensures that the victim can be quickly referred to an appropriate organization. Local law enforcement or state dental boards can also provide guidance.27

The most important step is to turn to experts for help. National networks, organizations, and hotlines can determine whether a situation constitutes trafficking, answer questions, and provide additional guidance. These networks can also offer local resources to support the victim. The National Human Trafficking Hotline is open 24/7 at 1-888-373-7888 (or text at 233733). This hotline, operated by the Polaris Project, can provide advice about next steps, referrals, and resources, including transportation, immediate shelter, food, and housing. The National Human Trafficking Hotline website (humantraffickinghotline.org) provides guidelines for identifying potential victims, as well as information about resources.

Written anti-trafficking materials, such as flyers or posters, should be visible to patients in the waiting room, bathroom, or exam areas. Brochures about helpful agencies, as well as information regarding victims' rights under US laws, are also recommended. Increasing visibility about this problem can also build more awareness among the public. Finally, the dentistry profession itself can adopt additional measures to join other industries that are combatting human trafficking. Examples of such steps include: a wider adoption of education and training requirements specifically focused on dental professionals; greater representation of dental professionals in anti-trafficking taskforces around the country; and the development of local, state, or national committees to improve coordination and response efforts within the field.

About the Authors

Mellissa Withers, PhD, MHS
Associate Professor
Keck School of Medicine
University of Southern California
Los Angeles, California

Tasfia Jahangir, BA
Graduate Student
Rollins School of Public Health
Emory University
Atlanta, Georgia

References

1. International Labour Organization. Profits and Poverty: The Economics of Forced Labour. International Labour Office; 2014.

2. United Nations Office on Drugs and Crime. United Nations Convention Against Transnational Organized Crime and the Protocols Thereto. United Nations; 2004.

3. International Labour Organization and Walk Free Foundation. Global Estimates of Modern Slavery: Forced Labour and Forced Marriage. International Labour Office; 2017.

4. United States Department of Health and Human Services. Human Trafficking Fact Sheet. Homeland Security Digital Library website. https://www.hsdl.org/?abstract&did=23329. Published 2004. Accessed November 9, 2021.

5. United States Department of State. Trafficking in Persons Report. U.S. Department of State; 2005.

6. United States Department of State. About Human Trafficking. U.S. Department of State website. https://www.state.gov/humantrafficking-about-human-trafficking/. Accessed November 9, 2021.

7. Polaris Project. Vulnerabilities & Signs of Recruitment. Polaris Project website. https://polarisproject.org/recognizing-human-trafficking-vulnerabilities-recruitment/. Accessed November 9, 2021.

8. United Nations Office of Drugs and Crime. An Introduction to Human Trafficking: Vulnerability, Impact and Action. United Nations; 2008.

9. Ahn R, Alpert EJ, Purcell G, et al. Human trafficking: review of educational resources for health professionals. Am J Prev Med. 2013;44(3):283-289.

10. Alpert EJ, Ahn R, Albright E, et al. Human Trafficking: Guidebook on Identification, Assessment and Response in the Health Care Setting. Massachusetts General Hospital Human Trafficking Initiative and Massachusetts Medical Society Committee on Violence Intervention and Prevention; 2014.

11. Macias-Konstantopoulos W. Human trafficking: the role of medicine in interrupting the cycle of abuse and violence. Ann Intern Med. 2016;165(8):582-588.

12. Garcia-Moreno C, Guedes A, Knerr W. Understanding and addressing violence against women. World Health Organization; 2012.

13. Baldwin SB, Eisenman DP, Sayles JN, et al. Identification of human trafficking victims in healthcare setting. Health Hum Rights J. 2011;13(1):36-49.

14. Oram S, Stöckl H, Busza J, et al. Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: systematic review. PLoS Med. 2012;9(5):e1001224

15. Zimmerman C, Borland R. Caring for Trafficked Persons: Guidance for Health Providers. International Organization for Migration; 2009.

16. Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law. 2014;23(1):61-87.

17. Chisolm-Straker M, Baldwin S, Gaïgbé-Togbé B, et al. Health care and human trafficking: we are seeing the unseen. J Health Care Poor Underserved. 2016;27(3):1220-1233.

18. Powell C, Dickins K, Stoklosa H. Training US health care professionals on human trafficking: where do we go from here? Med Educ Online. 2017;22(1):1267980.

19. American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to August 2011. ADA website. www.ada.org/194.aspx.  Accessed 3 Jan 2022.

20. O'Callaghan, MG. Human trafficking and the dental professional. J A Dent Assoc. 2012;143(5):498-504.

21. United Nations Office on Drugs and Crime. Anti-human trafficking manual for criminal justice practitioners, Module 7: Crime scene and physical evidence examinations in trafficking in persons investigations. Vienna, 2009. p.28-30. Accessed 3 Jan 2022. http://www.unodc.org/documents/humantraffiitcking/TIP_module7_Ebook.pdf

22. Nuzzolese E, Solarino B, Liuzzi C, Di Vella G. Assessing chronological age of unaccompanied minors in southern Italy. Am J Forensic Med Pathol. 2011;32(3):202-207.

23. Fisher-Owens SA, Lukefahr JL, Rao Tate A. Oral and dental aspects of child abuse and neglect. Pediatrics. 2017;140(2):e20171487.

24. Schlesinger SL, Borbotsina J, O'Neill L Petechial hemorrhages of the soft palate secondary to fellatio. Oral Surg Oral Med Oral Pathol. 1975;40(3):376-378.

25. Burkhart NW. Dental Exam Identifiers of Suspected Victims of Human Trafficking. Dental Academy of CE Website. https://dentalacademyofce.com/userfiles/4/files/Human_trafficking_Handout.pdf. Accessed 3 Jan 2022.

26. Stoklosa H, Dawson MB, Williams-Oni F, Rothman EF. A review of U.S. health care institution protocols for the identification and treatment of victims of human trafficking. J Hum Trafficking. 2017;3(2):116-124.

27. Chaffee T and English A. Sex trafficking of adolescents and young adults in the United States: healthcare provider's role. Curr Opin Obstet Gynecol. 2015;27(5):399-344.

Take the Accredited CE Quiz:

CREDITS: 2 SI
COST: $18.00
PROVIDER: AEGIS Publications, LLC
SOURCE: Inside Dental Hygiene | January/February 2022

Learning Objectives:

  • Describe the mechanisms and indicators of human trafficking
  • Analyze the role of the dental professional in recognizing trafficking victims
  • Discuss best practices for responding to suspected cases of human trafficking

Disclosures:

The author reports no conflicts of interest associated with this work.

Queries for the author may be directed to jromano@aegiscomm.com.