CAMBODIA: In the spring a few years ago, 17-year-old Vanny was at home with her mother, in their village in Cambodia, when a woman offered Vanny a job as a domestic worker in Thailand, earning the equivalent of $75 a month. Because of their poverty, the girl and her mother quickly signed the contract. Three days later, Vanny and twenty-six other children from the village departed for Thailand. Vanny was sold to a brothel in Bangkok and was forced to receive clients on a daily basis. She was raped and abused and spent the next months in desperate circumstances. Finally she managed to send a letter to her mother, who, shocked at the news, traveled to Bangkok and was forced to pay $1,000 for her daughter's release. Upon their return to Cambodia, the case was reported to the local police, who were able to locate and arrest the perpetrator, who was sent to prison.¹

The 2005 US State Department Trafficking in Persons (TIP) Report estimates that between 600,000 and 800,000 men, women, and children are trafficked across international borders every year. This number is dwarfed by the several million that are estimated to be trafficked within their home countries. TIP includes the buying and selling of humans for various purposes including forced labor, forced organ donation, bondage within rebel militias, and, most commonly, sexual exploitation. President Bush has called human trafficking "a special kind of evil in the abuse and exploitation of the most innocent and vulnerable."

The TIP report also estimates that between 14,500-17,500 persons are trafficked into the United States each year. The U.S. Department of Health and Human Services (HHS) calculates that the profits from human trafficking make it the second most lucrative criminal industry in the world after drug dealing, and the fastest growing criminal industry in the world. Over half of those trafficked internationally are women and children-for purposes of sexual exploitation-which poses an even more insidious threat than other forms of prostitution in spreading AIDS and other diseases.

While TIP for sex was once thought to be a problem beyond America's borders, the FBI and the Justice Department are now focusing intently on the issue-and what they've found is shocking. Thousands of young girls and boys are falling victim to violent pimps, who move them from state to state, which makes it a federal matter. The younger they are, the more they're worth on the street. "There is a greater and greater demand for younger and younger kids," said Ernie Allen, president of the National Center for Missing and Exploited Children, in an article in U.S. News and World Report: "America doesn't look. People are shocked and horrified when they hear these girls' stories. They say, 'That doesn't happen here. It happens in Thailand. Or the Philippines.' But once you start shining a light on it, you find it everywhere."²

LOS ANGELES-Kristie was 13 when she met the first of her four "daddies." She had run away from home in the Southwest, and friends introduced her to a tall, good-looking man, who said the red-haired teenager was sexy and had potential. Pretty soon, he had her prostituting herself on the streets of Las Vegas-then Los Angeles, Atlanta, and Phoenix. She and her "wifies," the other girls working under the same pimp, most of whom were also in their teens, would be brought to a city, work from 7 p.m. until sunrise, then move on. Kristie stopped only after she was arrested in July. From the beginning of the year until then, she estimates, she had had over 100 sex partners-but she had long ago stopped counting.³

Who are sexually trafficked victims?

Most TIP victims are women or teen girls who come from impoverished and desperate families. Socially isolated and/or ignorant and without access to information about life, their health, and their rights, they are easily manipulated and frightened into accepting sex work. Their situation is compounded if they have been trafficked across international borders and do not know the local language. They often lack coping skills, are poorly equipped to deal with TIP-associated health risks, and enter prostitution without any preparation. Seen by their pimps as reusable and inexpensive, these young girls are in high demand, both as virgins and because they are less likely to be HIV-positive. As a result, they earn more for those who have trafficked them. Once infected with HIV or STIs, they cannot readily own up to the source of infection, and may not be able to pay for healthcare. Their care may be complicated if they have been exposed to drugs to make sex work more acceptable. Their exploitation includes bar work (and often sex work); domestic and corporate work, and domination by their employer.

Where are healthcare providers likely to encounter TIP victims?

These women and teens seek care in emergency departments, urgent care centers, free clinics, community health centers, migrant healthcare clinics - any place where they can be anonymous and where they (or their pimps) can pay out of pocket. The most common medical conditions likely to bring these victims into the healthcare system are those relating to trauma, abuse (physical and substance/drug), and the sequelae of sexually transmitted infections (including HIV/AIDS). Some victims in addition may suffer from unwanted pregnancies, post-abortion complications, malnutrition, and communicable diseases seen in unsanitary and crowded living conditions (e.g., TB, scabies). While it is commonly stated that these victims are "hidden in plain sight," the carefully observant healthcare provider should be able to pick up clues that the patient they are dealing with may in fact be trafficked. A fearful or depressed female patient who does not speak English and presents with signs and symptoms of sexually transmitted infections, especially when accompanied by a controlling "guardian," should immediately raise strong suspicions of being a trafficking victim. This patient should not be released from the medical encounter until she has been separated from her "guardian" and questioned regarding her personal freedom. Often these patients are fearful of authorities and of being exported back to their country of origin; therefore, in spite of their captivity, they are frequently hesitant to speak up regarding their predicament.

What is being done about trafficking in Persons?

Several US federal agencies and NGO (Non-Governmental Organization) partners, such as International Justice Mission, work together to investigate suspected cases of
trafficking, to rescue and restore TIP victims, and to track, apprehend, and prosecute their perpetrators. In 2000 the US Congress passed the Trafficking Victims Protection Act of 2000 (TVPA). Internationally, the Department of State and the US Agency for International Development collaborate to do similar work abroad, including the submission of an annual "TIP Report" whose results have serious consequences for governments that fail to take action against trafficking.

CMDA has been working with the White House and several of the agencies mentioned above on TIP, both domestically and globally. CMDA is working to increase awareness in the medical community; develop protocols for physicians; explore funding for anti-trafficking projects; support the implementation of anti-prostitution standards in government grant awards; encourage research on the linkage between TIP, prostitution, AIDS and other communicable diseases; and, explore the development of a national treatment, research, and education center.

What should a healthcare provider do if he/she suspects a patient is trafficked?

• Isolate the patient from any accompanying persons, even if they claim to be family (such persons may actually be traffickers)
• Assure the patient of confidentiality
• Use interpreters if needed
• If the patient is under 18 years old, use a social services specialist if available
• Ask some of these questions:

Can you leave your job or situation if you want?
Can you come and go as you please?
Have you been threatened if you try to leave?
Have you been physically harmed in any way?
Have you ever been deprived of food, water, sleep, or medical care?
Do you have to ask permission to eat, sleep, or go to the bathroom?
Are there locks on your doors and windows so you cannot get out?
Has anyone threatened your family?
Has your identification or documentation been taken from you?
Is anyone forcing you to do anything that you do not want to do?

What should a healthcare provider do if a patient is probably trafficked?

• If sexual abuse has occurred, screen for sexually transmitted infections
• Conduct a complete physical examination to document all evidence of physical trauma
• Treat any medical problems as necessary
• Secure the safety of the patient to the custody of a shelter, law enforcement, or admission to hospital
• Report the incident

What can Christian healthcare providers do about TIP?

First, PRAY:

• Pray for the breakdown of the sex industry, which fuels sexual trafficking and commercial sexual exploitation
• Pray for the reduction of demand for commercial sex and prostitution; pray for conviction of hearts of all involved to turn to Christ
• Pray for the rescue and restoration of countless victims of sexual trafficking and that the Gospel message may reach them and be received
• Pray for world leaders, for heads of state, especially in impoverished countries or where government may be illegitimate or ineffective
• Pray for the church, as a whole as well as its individual members, to be responsive to this global problem, to the plight of its victims, and to the need for deep transformation of its perpetrators

Secondly, become involved, through your community and your medical practice:

• Help with awareness raising, training, and launching of public awareness campaigns; educate your church members. Write letters to editors and articles (such as this one). Copy the article and circulate it among staff and colleagues
• Talk to teens (and their families) and help them develop self-confidence, TIP awareness, better lifestyle choices, and higher education
• Know the law enforcement regulations and officers in your area
• Learn where you can send TIP victims for restoration, legal aid, shelter, counseling, or medical assistance; help establish aftercare and referral networks
• Support the efforts of NGOs working with TIP victims
• If working in a PEPFAR country (President's Emergency Plan For AIDS Relief), talk to USAID staff about TIP and HIV links; see if you can identify or be engaged in projects that work in this area
• Help to collect data and document the extent and nature of the trafficking problem
• Remember that your involvement fulfills Isaiah 58:6: "Is this not the kind of fasting I have chosen: to loose the chains of injustice and untie the cords of the yoke, to set the oppressed free and break every yoke?"

Signs raising suspicions that a person is trafficked:

(While any single sign by itself does not necessarily evidence trafficking, the probability rises when multiple signs are observed)

• Evidence of being controlled, such as a person insisting on remaining with the patient during the examination
• Bruises or other signs of physical abuse
• Severe emotional stress
• Origin in a foreign country
• Foreign language
• Lack of passport, immigration, or identification documentation
• Evidence of inability to leave or change jobs
• Evidence of sexual abuse
• Evidence of isolation from the public or family
• Unwarranted fear
• Frequent or unusual STIs

How to Access Victim Services or to Report Suspected TIP:

• To access victim services in the US-see: http://www.ojp.usdoj.gov/ovc/ or http://www.acf.hhs.gov/programs/orr/.
• To report trafficking crimes-in the US, call HHS Trafficking Information and Referral Hotline 1-888-373-7888, or the Trafficking in Persons and Worker Exploitation Task Force Complaint Line at 1-888-428-7581 (voice and TTY), or contact the FBI field office nearest you. If the patient is under age 18, call local law enforcement. Outside the US, contact the US Embassy by telephone, fax, or in person, depending upon circumstance, safety, and other concerns.

Bibliography

¹ Story taken from TIPinAsia at: http://www.tipinasia.info/KH/case-info.php?sub=no&l=en&id=31.

² US News and World Report, Oct 24, 2005.

³ Ibid.