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Organizational Principles to Guide and Define the Child Health Care System

POLICY STATEMENT and/or Improve the Health of all Children

Global Human Trafficking


and Child Victimization
Jordan Greenbaum, MD,​a,​b Nia Bodrick, MD, MPH, FAAP,​c COMMITTEE ON CHILD
ABUSE AND NEGLECT, SECTION ON INTERNATIONAL CHILD HEALTH

Trafficking of children for labor and sexual exploitation violates basic human abstract
rights and constitutes a major global public health problem. Pediatricians
and other health care professionals may encounter victims who present with
infections, injuries, posttraumatic stress disorder, suicidality, or a variety of
other physical or behavioral health conditions. Preventing child trafficking,
recognizing victimization, and intervening appropriately require a public aStephanie V. Blank Center for Safe and Healthy Children at Children’s
Healthcare of Atlanta, Atlanta, Georgia; bInternational Centre for
health approach that incorporates rigorous research on the risk factors, Missing and Exploited Children, Alexandria, Virginia; and cUnity Health
health impact, and effective treatment options for child exploitation as well Care, Inc, Washington, District of Columbia

as implementation and evaluation of primary prevention programs. Health Both authors contributed to the writing and editing of the document
and approved the final manuscript as submitted.
care professionals need training to recognize possible signs of exploitation
and to intervene appropriately. They need to adopt a multidisciplinary, This document is copyrighted and is property of the American
Academy of Pediatrics and its Board of Directors. All authors have
outward-focused approach to service provision, working with nonmedical filed conflict of interest statements with the American Academy
of Pediatrics. Any conflicts have been resolved through a process
professionals in the community to assist victims. Pediatricians also need to approved by the Board of Directors. The American Academy of
advocate for legislation and policies that promote child rights and victim Pediatrics has neither solicited nor accepted any commercial
involvement in the development of the content of this publication.
services as well as those that address the social determinants of health,
Policy statements from the American Academy of Pediatrics benefit
which influence the vulnerability to human trafficking. This policy statement from expertise and resources of liaisons and internal (AAP) and
outlines major issues regarding public policy, medical education, research, external reviewers. However, policy statements from the American
Academy of Pediatrics may not reflect the views of the liaisons or the
and collaboration in the area of child labor and sex trafficking and provides organizations or government agencies that they represent.
recommendations for future work. The guidance in this statement does not indicate an exclusive course
of treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.

A critical role of the pediatric health care professional is to advocate for All policy statements from the American Academy of Pediatrics
automatically expire 5 years after publication unless reaffirmed,
the health and well-being of children and adolescents. Central to this role revised, or retired at or before that time.
is the conviction that health and well-being depend on a guarantee of DOI: https://​doi.​org/​10.​1542/​peds.​2017-​3138
fundamental human rights. Victims* of trafficking routinely are deprived of
Address correspondence to Jordan Greenbaum, MD. E-mail: jordan.
greenbaum@choa.org

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2017 by the American Academy of Pediatrics

To cite: Greenbaum J, Bodrick N, AAP COMMITTEE ON CHILD


*“Victim” is used here in its objective, legal sense as indicating a person who has been harmed ABUSE AND NEGLECT, AAP SECTION ON INTERNATIONAL CHILD
as a result of some event or action or who has suffered because of someone else’s actions. HEALTH. Global Human Trafficking and Child Victimization.
It does not refer to how the person may feel or perceive himself or herself as a result of the Pediatrics. 2017;140(6):e20173138
event(s) and is not intended to be used to label that person.‍91

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PEDIATRICS Volume 140, number 6, December 2017:e20173138 FROM THE AMERICAN ACADEMY OF PEDIATRICS
TABLE 1 Child Rights Violated by Human Trafficking (From the United Nations Convention on the world. The International Labour
Rights of the Child) Organization estimates that children
Right to… constitute 26% (5.5 million) of the
Privacy, liberty, and protection from violence, abuse, and exploitation 21 million victims of forced labor
Appropriate medical care and adequate nutrition globally.‍20 Accurate statistics on
Education prevalence of child trafficking are
Living conditions adequate for physical, mental, spiritual, and moral development similarly lacking in the United States,
Protection from economic exploitation and hazardous or inappropriate work
but researchers conducting studies
Protection from torture and cruel or inhuman treatment
of runaway and homeless youth
Source: United Nations; Human Rights, Office of the High Commissioner for Human Rights. Convention on the rights of the
child. 1990. Available at: www.​ohchr.​org/​en/​professionalinter​est/​pages/​crc.​aspx. Accessed October 27, 2017. have suggested that 9% to 28%
of such youth report survival sex
such rights, including several outlined Convention 138 on the Minimum (sexual activity exchanged for items
in the United Nations Convention on Age for Admission to Employment‍7). needed to survive).21–‍‍‍ 25
‍ In a study in
the Rights of the Child‍1 (see ‍Table 1). Additional discussion of child labor, San Diego County, it was estimated
hazardous work by children, and the that 31% of unauthorized migrant
According to US federal law, child worst forms of child labor is available Spanish-speaking laborers older than
sex trafficking involves engaging a elsewhere.‍8 16 years in that region were victims
person younger than 18 years in a of labor trafficking.11 Given that the
commercial sex act (sexual activity Child labor trafficking in the United National Human Trafficking Resource
for which there is an exchange of States may occur in a wide variety Center received information on
something of value).‍2,​3‍ This may of industries, especially in informal only 1621 cases of child trafficking
include exploitation of a child for sectors. Some of the more common in 2015, it is highly likely that the
prostitution (as a seller or a buyer), labor sectors in which youth are known cases represent only a small
sexual exploitation in the context exploited include domestic servitude, fraction of the total.‍26
of travel and tourism, the mail- construction, janitorial or cleaning
order bride trade and early forced services, door-to-door magazine Although the United States is a
marriage, production of child sexual sales,​‍9 agriculture, health and beauty “destination” country for trafficked
exploitation material (pornography), services, begging or peddling, and persons from anywhere in the world,
live online sexual abuse, and hotel and restaurant businesses.‍10–‍ 12‍ it was indicated in statistics from 2014
performing in sexual venues.‍4 US Outside the United States, forced that the leading “origin” countries
law also recognizes labor trafficking, labor involves children working in for federally identified victims (all
defined as “the recruitment, various hazardous settings, including ages, all types of trafficking) were
harboring, transportation, provision, brick kilns,​12 construction,​‍13 mines the United States itself as well as
or obtaining of a person for labor or and quarries,​‍14 fisheries,​‍15 and Mexico and the Philippines.‍27 In
services, through the use of force, farms.‍16 Children and adolescents data on trafficked persons identified
fraud, or coercion for the purpose of may serve as soldiers in armed between January 2008 and June 2010
subjection to involuntary servitude, conflict12,​17
‍ or as forced participants in cities with federally funded human
peonage, debt bondage, or slavery.”‍2 in drug trafficking.‍12 trafficking taskforces, it was indicated
Other types of child trafficking Reliable estimates of the incidence that 94% of sex trafficking victims
include forced begging or engaging and prevalence of child trafficking were female, and 55% were younger
in criminal acts, forced participation are not available. Efforts to than 18 years. Nearly 85% were US
in armed conflict, illegal adoption, or estimate these statistics are citizens or permanent legal residents.
forced organ removal for donation. thwarted by the criminal nature Persons trafficked for labor tended to
Globally, human trafficking is defined of the activity, lack of uniform be female (68%), adults (90%), and
in the Palermo Protocol,​5 although definitions among those collecting foreign nationals (98%).‍28 Of note,
interpretation of the definition varies data, the lack of a centralized researchers in other studies have
among countries. Although cultural database, and underrecognition shown a predominance of boys in
norms regarding child labor vary, 3 of victims (especially for victims labor trafficking, suggesting that there
international conventions outline the of labor trafficking)‍4,​18
‍ However, may be regional differences among
legal conditions of child labor (United in a study by the United Nations trafficking victims or a failure to
Nations Convention on the Rights Office of Drugs and Crime,​‍19 it was recognize male victims in the United
of the Child, International Labour determined that 33% of the 40 000 States.‍29,​30

Organization Convention No. 182 on identified trafficking victims were
the Worst Forms of Child Labor,​‍6 and children, and minors were subjected Factors at the individual, family,
International Labour Organization to exploitation in all areas of the community, and societal levels

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2 FROM THE AMERICAN ACADEMY OF PEDIATRICS
TABLE 2 Factors Contributing to Vulnerability to Child Trafficking
Individual Family Community Societal
LGBTQ‍37 Poverty Tolerance of sexual or labor Gender-based violence and
exploitation discrimination
Abuse or neglect Unemployment Natural disaster or community Cultural beliefs or stigma
upheaval
Sexual exploitation Intrafamilial violence Demand for cheap labor Weak recognition of child rights
Substance misuse Forced migration Community violence Political or social upheaval
Homeless, runaway, or thrown out — Lack of community resources/ —
of home support
Untreated mental health problems — Lack of awareness of trafficking —
practices
Behavioral problems — — —
Involvement with legal system — — —
Involvement with child protective — — —
services system
Lack of documentation (immigration, — — —
birth certificate, etc)
Unaccompanied status, including — — —
immigrant and refugee children
The following references were used as sources of information for this table: ‍​‍4,​‍12,​‍13,​‍17,​23,​‍27,​‍​​‍31‍‍–34,​‍38‍–‍40. —, not applicable.

contribute to human trafficking of the host language and culture, attention at some point during their
vulnerability in the United States and and precarious legal status.‍11 These period of exploitation,​‍44,​‍45
around the globe (‍Table 2). Children children are particularly vulnerable if trafficked immigrant children
and youth who identify as lesbian, they lack the necessary authorization detained at the United States border
gay, bisexual, transgender, or queer or documents required under may receive insufficient care,​‍43
(LGBTQ); those who are American immigration regulations and have and those trafficked abroad may
Indian girls; and boys and girls with a been smuggled across an international receive little or no care at all.‍46,​47
history of abuse or neglect, substance border; traffickers may subsequently However, it is important for health
misuse, or homelessness may lure them into situations of severe care professionals all over the world
constitute a significant proportion of exploitation or circumstances of debt, to be alert to possible indicators
‍ –‍ 34
trafficked youth.‍23,​31 ‍ Statistics reveal bondage, or other abuses and maintain of sex trafficking, and these are
high rates of child protective service control over them through violence, described in detail elsewhere.‍31
involvement among sex-trafficked threats, or economic or psychological With respect to labor trafficking,
young people: 78% of 1 group in manipulation. Unaccompanied children potential indicators may include
California reported a history with are likely to be reluctant to report a recent history of immigration,
child protective services, and 53% of abuses to authorities because of unfamiliarity with the city or town
another group reported residing in 1 concerns of corruption among officials where the clinic or hospital is located,
or more foster care group homes.‍35 (law enforcement, immigration, or apparent control and intimidation
Families experiencing financial crises, consular), highly stressful conditions by an accompanying adult. Additional
unemployment, or intrafamilial in Customs and Border Protection potential indicators are listed in
violence are particularly vulnerable to processing centers,​‍43 and the child’s ‍Table 3. It is important to remember
human trafficking.‍12,​13,​
‍ 17,​36
‍ fear of arrest and/or deportation. that the parents of the child may be
Finally, gender-based violence and victims of labor or sex trafficking,
Community or governmental tolerance discrimination, a cultural assumption with or without victimization of the
of labor or sexual exploitation, that boys cannot be victims, cultural child.
demand for cheap labor, or the beliefs that children must support
occurrence of a natural disaster the family in crisis, the sexualization The adverse health effects associated
or major social upheaval may and objectification of girls, and weak with child sex and labor trafficking
render children at risk.‍12,​36
‍ Massive recognition of children’s rights are are numerous and include traumatic
population migrations often involve societal factors that contribute to injury from sexual and physical
large numbers of unaccompanied ‍ 38–‍ 40
vulnerability.‍4,​36,​ ‍ assault or work-related injury,
minors.‍17,​41
‍ Unaccompanied children sexually transmitted infections,
are at significant risk for labor and sex Although researchers suggest that nonsexually transmitted infections,
trafficking,​42 given their young age, lack victims of sex trafficking in the United chronic untreated medical conditions,
of adult supervision, lack of knowledge States are likely to seek medical pregnancy and related complications,

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PEDIATRICS Volume 140, number 6, December 2017 3
TABLE 3 Possible Indicators of Labor Trafficking it in 1995. Thus, the United States
Recent immigration history (especially if patient or family lack access to immigration documentation) has indicated endorsement of the
Unfamiliarity with city or town principles of the Convention on
Apparent intimidation by person accompanying the child or family the Rights of the Child but has not
Inconsistencies in information provided
committed to being legally bound by
Report of excessive, hazardous, or other inappropriate work conditions
Work-related (typically preventable) injuries (eg, chemical burns, irritation from toxic gases) the Convention.
Delay in care (far-advanced medical conditions or untreated injuries)
Malnutrition or dehydration The cornerstone of US federal
Poor hygiene legislation is the Trafficking Victims
Report of crowded, unhygienic, or otherwise inappropriate living conditions
Protection Act of 2000,​‍2 which
Sources: Zimmerman C, Borland R, eds.; International Organization for Migration. Caring for trafficked persons: guidance
recognizes human trafficking as a
for health providers. 2009. Available at: http://​publications.​iom.​int/​system/​files/​pdf/​ct_​handbook.​pdf. Accessed May 24,
2014; and Polaris Project. Recognize the signs. Available at: http://​polarisproject.​org/​recognize-​signs. Accessed June 5, federal crime and offers protection
2016. in the form of T-visas. T-visas are
nonimmigrant visas for victims of
chronic pain, complications of of those programs and policies. human trafficking. These documents
substance abuse, and malnutrition When resources are limited, the protect victims, enable them to
and exhaustion. Mental health priority should be to target those qualify for services, and allow them
consequences may include most vulnerable to human trafficking. to stay in the United States for a
depression with suicide attempts, Much can be learned from other given period. Since the Trafficking
self-harm, flashbacks, nightmares, related public health problems Victims Protection Act was passed,
insomnia and other sleep problems, that have been studied extensively, all 50 states have enacted legislation
anxiety disorders, hypervigilance, including child maltreatment, criminalizing human trafficking,
self-blame, helplessness, anger and intimate partner violence, runaway to varying degrees. Multiple
rage control problems, dissociative or homeless youth, substance misuse, reauthorizations of the act have
disorders, posttraumatic stress and poverty. reaffirmed the US government’s
disorder, and other comorbid strategy to oppose human trafficking
‍ –‍‍‍‍ 53
conditions.‍30,​45,​
‍ 47 ‍ It is important and expanded on the scope of the
to note that major mental health PUBLIC POLICY initial act.‍55–‍ 57
‍ The Trafficking
issues may precede human Victims Protection Reauthorization
trafficking (contributing to the The “Protocol to Prevent, Suppress Act of 2013,​58 which was passed
child’s vulnerability) and/or develop and Punish Trafficking in Persons, as an amendment to the Violence
as a result of the complex trauma Especially Women and Children,​” Against Women Act, establishes and
experienced during the period of was adopted by the United Nations strengthens programs to ensure that
exploitation. Such problems may be General Assembly and enacted in US citizens do not purchase products
used as a ploy by the trafficker to December 2003.‍5 It is the first global, made by victims of human trafficking
discredit the victim, who may or may legally binding instrument with an and to prevent child marriage. It also
not actually have a disorder agreed definition on trafficking in puts into place emergency response
(eg, schizophrenia).54 persons. In response to the passage provisions within the US Department
of the protocol, the number of of State to respond quickly to areas
The global prevalence of human countries instituting antitrafficking that have experienced disasters or
trafficking, combined with its wide- legislation more than doubled from crises, where people are particularly
ranging adverse health consequences, 2003 to 2009. The United Nations susceptible to being trafficked. The
requires that these forms of severe Convention on the Rights of the reauthorization also strengthens
exploitation be treated as an Child is a human rights treaty that collaboration with state and local law
important public health problem. recognizes the rights of persons up enforcement to ease charging and
Applying public health strategies to the age of 18 years and includes prosecuting traffickers.
requires a multidisciplinary specific articles protecting children
approach to identifying and from violence, economic and Although every state has laws on
analyzing the vulnerabilities leading sexual exploitation, sexual abuse, human trafficking, the scope of these
to victimization and involves and all other forms of exploitation laws varies significantly, with some
creating a strong evidence base for prejudicial to any aspect of the laws restricting the protection to
programs, strategies, and policies child’s welfare.‍1 Of 196 countries and children younger than 14 to 15 years
of prevention and intervention dependencies, the United States is rather than the higher 18-year age
followed by rigorous scientific the only nation that has not ratified threshold.‍59 Information on related
research on the impact and efficacy the agreement, although it signed laws is available from the American

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4 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Academy of Pediatrics (AAP) Division identification of trafficking and are published outside of peer-
of State Government Affairs (stgov@ treatment of trafficking-related reviewed academic journals and
aap.org). In 2014, Congress enacted health conditions.‍63 may be difficult to access, leading to
the Preventing Sex Trafficking and inadequate dissemination.‍66,​67 ‍
Recent research has demonstrated
Strengthening Families Act (Pub L Empirical research is relatively
the need for training regarding the
No. 113–183). This law requires that limited. In 1 systematic review
identification and care of victims
state child welfare agencies develop in which researchers examined
of human trafficking. In 1 study
policies and procedures to identify, the health problems and violence
of health care professionals, 63%
document, and determine appropriate associated with human trafficking,
responded that they had never
services for children under their care only 19 studies were identified
received training on how to identify
or supervision who are victims of through August 2011. In the
sex trafficking victims. Those
sex trafficking or who are at risk for vast majority of these studies,
with training were more likely to
becoming victims of sex trafficking.‍60 researchers focused on women and
report sex trafficking as a major
girls experiencing sex trafficking,​‍50
In 2013, the Uniform Law problem locally (P ≤ .001), to have
revealing a paucity of research on
Commission adopted a Uniform Act encountered a victim in their practice
male victims and victims of labor
on the Prevention of and Remedies (P ≤ .001), and to have greater
trafficking. In an updated review of
for Human Trafficking,​‍61 which is confidence in their ability to identify
violence and health consequences,
built on the framework of penalizing victims (P < .001). The greatest
in which researchers covered the
traffickers, protecting human victims, barriers to identification of victims
period from 2011 to 2015, only 31
and building public awareness were a lack of training (34%) and
additional studies were identified.‍51
and can serve as a public policy awareness (22%) of sex trafficking.‍64
Of these, only 12 included forms
foundation for state lawmakers
In 2009, the International of trafficking beyond sexual
addressing this issue.
Organization of Migration published exploitation, and none of the latter
a manual for health professionals targeted the child population. In
MEDICAL EDUCATION to provide practical, nonclinical many studies on human trafficking,
Health care professionals and guidance on recognizing and researchers have included aggregate
medical societies are recognizing providing care to trafficked persons,​‍65 results for adults and children,​68–‍ 70

the need to include information the focus of which is primarily boys and girls,​‍30 or individuals from
about human trafficking in medical adults. In 2015, the AAP published a multiple countries of origin.‍71,​72
education curricula. At the 2014 clinical report on child sex trafficking, Some researchers also combine
AAP Annual Leadership Forum, with a focus on domestic victims.‍31 victims of differing forms of
human trafficking education was This report has been promoted at trafficking.‍44 Lacking disaggregated
ranked among the top 10 priority national and regional conferences. data, it is difficult to identify findings
resolutions. The AAP resolved to Additionally, there are emerging that may be specific to children or
“advocate that the subject of human international efforts to educate to subpopulations of child victims.
trafficking should be a component health care and other professionals Nonetheless, much can be learned
of medical education and pediatric on human trafficking and from related areas of study, such
training for medical students, professional organizations dedicated as work with homeless or runaway
residents, fellows and all who to training, advocacy, and policy. youth, some of whom engage in
provide healthcare for children and Some of these organizations include survival sex and are, thus, victims of
adolescents, to include information the American Medical Women’s human trafficking.‍21,​23,​
‍ 32,​
‍ 73 Studies
about recognition, management and Association’s Physicians Against the of adult populations are also helpful
linkages to community resources.”‍62 Trafficking of Humans and HEAL inasmuch as adult women involved
Stoklosa et al‍63 advocated for a Trafficking (Health, Education, in sex work were often recruited as
human rights-based framework when Advocacy, and Linkage). juveniles and continue to experience
training health care professionals on some of the same hardships as
human trafficking. They proposed sex-trafficked youth.‍69,​74
‍ In 1 study
that the medical education of RESEARCH of prostitution in 9 countries,
health care professionals should 32% to 68% of women engaged
be grounded in a victim-centered, Although research on human in prostitution began sex work as
culturally relevant, evidence-based, trafficking has increased in recent minors.‍75
gender-sensitive, trauma-informed years, there remains a narrow
perspective and include the essential evidence base, and many studies The lack of research on male victims
components of prevention and have significant limitations. Some of trafficking may indirectly support

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PEDIATRICS Volume 140, number 6, December 2017 5
the cultural belief that boys cannot important respects from the main from another country or when
be victimized and may exacerbate population of trafficked persons, trafficking investigations require
the problem of underrecognition. which would significantly limit the communication and cooperation
The paucity of research translates generalizability of study results. This between tribal communities and the
into limited empirical knowledge of possibility may be more relevant US federal government. In 1 national
factors that increase the vulnerability for studies conducted on trafficking study of service providers for human
of boys to trafficking, of the unique survivors who are actively seeking trafficking victims, 44% reported that
experiences occurring during the services than for studies involving ineffective coordination with federal
period of exploitation, of the gender- street outreach and interviews agencies was a common barrier to
specific adversities faced by male of homeless or runaway youth success, and 39% reported a lack
children, and of their unique needs engaged in survival sex. Research of coordination with local agencies
for recovery and reintegration. on trafficking victims, especially as being a significant barrier.‍85
A lack of knowledge and awareness child victims, is particularly difficult Health care professionals seeking to
likely contributes to the deficiency because it involves a vulnerable report cases to law enforcement and
of services for male trafficking study population.‍4 Appropriately, obtain services for victims often lack
survivors‍76 and a tendency to treat service providers offering care to knowledge of reporting procedures
them as offenders rather than survivors are often cautious about and available community partners.
as children in need of help and the possibility of exposing survivors Providers may not ask youth about
protection.‍77 to stressful situations and may be experiences of trafficking because
reluctant to approach their clients they do not have time to research
Another area with a relative scarcity
regarding study participation, which possible resources or may assume
of empirical research is labor
may limit access to survivors and no resources are available. National
trafficking in the United States,
discourage attempts to conduct hotlines exist for assisting victims.‍26,​86

especially forced labor involving
research. Finally, adults and youth Efforts are being made to educate
children. Existing studies tend to
who do participate may experience health care professionals and others
suffer from the limitations mentioned
recall bias, especially if recounting about these resources,​‍31,​84,​87

previously, especially with regard to
events that occurred years earlier. although much work remains to
researchers combining children with
Alternatively, they may provide be done. In 1 study of health care
adults in the sample population‍11,​78

inaccurate information in efforts to professionals, only 14% of the
and inadequately distinguishing
protect others or themselves from medical providers contacted the
victims of labor trafficking versus
stigma, shame, reprisals, or other national hotline or made service
sex trafficking.‍44,​70
‍ Research is also
consequences. referrals for suspected trafficking
difficult to conduct because of the
victims; they were significantly more
complexity involved in identifying
likely to do so if they had received
and distinguishing between child
training.‍64
employment, child labor, hazardous COLLABORATION
child labor, forced child labor,
Although multidisciplinary The percentage of US hospitals and
and trafficking.79 Because labor
collaboration in the investigation clinics with functioning protocols for
trafficking has not received the
and treatment of child abuse has recognizing, responding, referring,
public attention accorded to sex
become a widely accepted and and reporting cases of suspected
trafficking, there is little awareness
successful strategy in the United trafficking is unknown, but experts
of the possibility that patients or
States,​‍80–‍ 82
‍ similar collaboration believe it is small.‍88 Little is known
their parents may be victims of labor
is much less well developed in the about the prevalence of protocols in
trafficking, little impetus to conduct
area of human trafficking in the health facilities elsewhere around
research, and scarce financial support
United States and elsewhere.‍83,​84 the globe. A lack of guidance for
available for such research.
Within a community, there may health care professionals may
Another limitation in the be little communication between decrease the likelihood that victims
research is related to potential investigators and service providers, will be identified and receive critical
generalizability. Researchers jeopardizing prosecution success and assistance; health care professionals
suggest that identified victims thwarting the provision of services may, justifiably, be hesitant to ask
represent only a small fraction to victims. Collaboration may be patients about trafficking if they are
of the total number of persons rendered even more difficult when unsure of how to respond and how to
subjected to human trafficking.‍36 It there is a need to manage victim obtain assistance for the suspected
is possible that identified victims service referrals across borders victim. In addition, the lack of an
are fundamentally different in and communicate with authorities established process means that each

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6 FROM THE AMERICAN ACADEMY OF PEDIATRICS
time a victim is identified, the health services for all victims, increased of children to be protected from
care professional must rethink his interagency collaboration, all forms of exploitation and
or her response. What could be a improved screening for human encourages participating countries
routine set of activities may instead trafficking among immigrants to take appropriate measures
become a crisis, which can waste time detained at national borders, and to prevent the abduction, sale,
and health resources and increase assistance on immigration issues or trafficking of children for any
anxiety and stress for the health care for foreign nationals. Increased purpose or in any form.
professional and victim alike. access includes, but is not
limited to, establishing insurance Medical Education
Finally, the lack of connection and
coverage for medical and mental
collaboration among health care 1. Advocate for training of health
health expenses and increasing
professionals and community care professionals on human
the availability of trained pediatric
service providers and investigators trafficking issues, including
examiners and child-friendly
decreases the likelihood that victims recognition, assessment,
locations for victims to receive
being served in the community treatment, and referrals for
health care, especially in rural
will receive adequate medical services by using a trauma-
areas;
care for their many health needs. informed, culturally sensitive,
Professionals of all kinds tend to 2. Support state, federal, and rights-based approach. Training
view situations through their own international legislation and should emphasize both sex and
professional lens, and immigration policies that facilitate primary labor trafficking, the possibility
attorneys, law enforcement officers, prevention of child trafficking of encountering parents who are
and workers at shelters, job training through education of children and victims of trafficking, and specific
centers, and mentoring programs parents about risks, recruitment issues related to immigration for
may not think about medical issues strategies, and adverse effects. foreign victims and their families.
unless they routinely work with These preventive efforts may Health care professionals need
health care professionals who can include education of students in training on how to gather and
emphasize the victim’s physical and schools and also should include document critical psychosocial
mental health needs. efforts to reach those who are not and medical information to assist
attending school; trafficked children in obtaining
special visas that will allow them
3. Support US and global efforts to federally funded benefits and
RECOMMENDATIONS address the social determinants temporary residence in the United
of health, which are intimately States (T- and U-visas)‍43;
The following recommendations
connected to push and pull factors
apply to AAP chapters and to all
for human trafficking; 2. Advocate for timely medical
individual health care professionals
education on human trafficking at
serving children, including 4. Advocate for policies that protect the trainee level by encouraging
physicians, nurses, advanced practice children younger than 18 years the American Board of Pediatrics
providers, dentists, behavioral who are victims of any type of to include child trafficking, child
health professionals, social workers, trafficking from prosecution for rights, and trauma-informed care
and trainees in these fields. All related offenses, emphasizing in its content specifications, as
health care professionals and treatment and services instead; these guide residency curricula;
systems serving children (especially
physicians, nurses, advanced practice 5. Work with other medical 3. Encourage medical education
providers, dentists, behavioral health organizations in the United curricula to include strategies for
professionals, social workers, and States and abroad to facilitate addressing social determinants
trainees in these fields) can prevent a public health approach to of health, in particular including
child trafficking, recognize victims, human trafficking and empower questions about adverse
and intervene appropriately. The health care professionals to use a childhood events in the patient
AAP recommends: culturally sensitive, rights-based, assessment, connecting to
victim-centered approach to community resources, and
Public Policy human trafficking; and building community resilience;
and
1. Support relevant state, federal, 6. Advocate for US ratification of
and international antitrafficking the Convention on the Rights 4. Advocate for financial support
legislation and policies, including of the Child.‍1,​89
‍ The Convention and resources for development
increased access to direct specifically recognizes the right and global dissemination of

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PEDIATRICS Volume 140, number 6, December 2017 7
culturally appropriate, trauma- survivors, those who have community centers, and residential
informed curricula for health care experienced prostitution versus treatment programs specifically for
professionals addressing human production of child sexual abuse trafficking victims, resources for
trafficking. Encourage provision materials [formerly called “child LGBTQ youth, drug rehabilitation
of continuing education credit for pornography”] versus forced programs, food pantries, refugee
attendance (or other incentives labor); centers, legal professionals able to
relevant to professionals in a provide immigration assistance,
given country). 3. Advocate for research on trauma- etc). Encourage health care
informed care and on effective professionals to develop and test
Research ways to implement this approach referral mechanisms to facilitate
into a busy health care setting connection of victims with
1. Rigorous, empirically based
in which time restraints may appropriate service providers.
research on child trafficking is
impinge on the health care Having such mechanisms in place
necessary to (1) identify culture-
professional’s ability to build may not be practical for health
and gender-specific risk factors;
patient rapport and establish care professionals working in
(2) determine approaches to
the trust needed to identify and solo or small practices, in which
asking about child trafficking
address patient needs‍90; case collaborating with local,
in the health care setting; (3)
state, or national partners may
estimate prevalence in different
be beneficial. Recommended
sectors and locations; (4) 4. Advocate for centralized
collaborators include local
understand experiences during surveillance and data collection
public health departments, law
exploitation that place children on identified trafficked persons,
enforcement agencies, local school
at risk for serious harm; (5) allowing better determinations of
districts, and community health
evaluate the type and extent of prevalence, high-risk geographic
centers. Health care professionals
adverse physical and emotional areas, trends in trafficking,
may also contact national human
health consequences; (6) identify and other information to guide
trafficking hotlines (including
resiliency factors among child research and inform public
the National Human Trafficking
victims; (7) understand the policy‍37; and
Resource Center in the United
connections between child
States [1-888-373-7888]) or
trafficking, toxic stress, and 5. Advocate for the adoption of nongovernmental organizations
long-term health outcomes; and specific International Classification (eg, International Organization
(8) assess the effectiveness of of Diseases codes to report the for Migration or End Child
psychosocial and mental health types of human trafficking and Prostitution, Child Pornography
interventions. Researchers should distinguish them from other and Trafficking of Children for
focus not only on heterosexual types of violence and exploitation. Sexual Purposes);
female victims but also male and Tracking cases of human
LGBTQ victims and give priority trafficking is critical to monitoring 2. Advocate for the inclusion of
to the study of labor as well as sex its incidence and recurrence, health care professionals as
trafficking; determining short- and long- vital members of community
2. Advocate for development of term adverse effects on children multidisciplinary teams
intervention strategies and and adults, assessing treatment combatting human trafficking.
rigorous empirical evaluation of modalities, and estimating cost To best serve victims, they need
their impact on child health and of care. Such data are central to to become active members
well-being. Conduct longitudinal public health efforts to prevent of a community response to
and comparative studies on and eradicate this severe form of human trafficking, building
integration and reintegration exploitation. relationships with local providers
to assess which factors within and investigators. Health care
programs providing services to professionals can educate team
Collaboration
victims are most effective and members on the health needs of
whether significant differences 1. Advocate for health care survivors and facilitate services
exist between needs and professionals in larger health care that will improve the physical
outcomes of groups of survivors facilities to identify victim service and mental health of trafficked
(eg, boys versus girls, LGBTQ providers and organizations in persons. Health care professionals
versus heterosexual youth, their communities (including can also learn from other team
domestic versus transnational homeless or runaway shelters, members and use this information

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8 FROM THE AMERICAN ACADEMY OF PEDIATRICS
to improve their interactions with 5. Promote outreach and awareness SECTION ON INTERNATIONAL CHILD HEALTH
and support of survivors; at the community, state, national, EXECUTIVE COMMITTEE, 2016–2017
3. Advocate for development of and international levels. Parminder S. Suchdev, MD, MPH, FAAP,
Chairperson
clinic and hospital protocols LEAD AUTHORS Kevin Joseph Chan, MD, MPH, FAAP
outlining processes to help Cynthia Ruth Howard, MD, MPH, FAAP
Jordan Greenbaum, MD
recognize and respond to child Nia Bodrick, MD, MPH, FAAP Patrick T. McGann, MD, FAAP
trafficking of all types as well as Nicole Erin St. Clair, MD, FAAP
trafficking involving caregivers. COMMITTEE ON CHILD ABUSE AND Katherine Yun, MD, MHS, FAAP
These processes should NEGLECT, 2016–2017
FORMER EXECUTIVE COMMITTEE MEMBER
include specific information Emalee G. Flaherty, MD, FAAP, Chairperson
on reporting requirements Sheila M. Idzerda, MD, FAAP Linda Arnold, MD, FAAP
Antoinette “Toni” Laskey, MD, MPH, MBA, FAAP
and processes for making
Lori Anne Legano, MD, FAAP
reports to authorities as well as John M. Leventhal, MD, FAAP LIAISIONS
supported referral mechanisms CAPT Amy R. Gavril, MD, FAAP Swati Antala, MD – Section on Pediatric Trainees
to facilitate communication with Mirzada Pasic Kurbasic, MD, MSc, FAAP –
LIAISIONS American Pediatric Association
health care professionals of
varying subspecialties and with Beverly Fortson, PhD – Centers for Disease
Control and Prevention
community partners; Harriet MacMillan, MD, FRCPC – American ABBREVIATIONS
4. Advocate for easily accessible, Academy of Child and Adolescent Psychiatry
Elaine Stedt, MSW – Office on Child Abuse and Neglect, AAP: American Academy of
victim-centered, culturally
Administration for Children, Youth and Families Pediatrics
appropriate medical homes for
LGBTQ: lesbian, gay, bisexual,
trafficked persons in the United STAFF
transgender, or queer
States and other countries; and Tammy Piazza Hurley

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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12 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Global Human Trafficking and Child Victimization
Jordan Greenbaum, Nia Bodrick, COMMITTEE ON CHILD ABUSE AND
NEGLECT and SECTION ON INTERNATIONAL CHILD HEALTH
Pediatrics 2017;140;
DOI: 10.1542/peds.2017-3138 originally published online November 27, 2017;

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Global Human Trafficking and Child Victimization
Jordan Greenbaum, Nia Bodrick, COMMITTEE ON CHILD ABUSE AND
NEGLECT and SECTION ON INTERNATIONAL CHILD HEALTH
Pediatrics 2017;140;
DOI: 10.1542/peds.2017-3138 originally published online November 27, 2017;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/140/6/e20173138

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2017 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
1073-0397.

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