This article focuses on the health consequences of children that have been primarily trafficked for the purpose of sexual exploitation. It begins by providing a definition of trafficking, and making a distinction between trafficking and smuggling. It then overviews the main health consequences faced by children who are victims of trafficking, followed by a review of studies which compare health outcomes for child trafficking victims, to those who have not been through such an experience. The article ends by providing some guidance for health practitioners when dealing with child victims of human trafficking.
The majority of studies found through a review of the literature draw on data in regard to trafficked children for the purpose of sexual exploitation in the US. However, a note of caution in regard to the literature found on commercial sexual exploitation of children (CSEC) and sex trafficking of children (both terms are often used intermittently), in particular in regard to US based studies. Literature considers CSEC and sex trafficking of children to have occurred when sexual exploitation of a child for the purpose of profit happens. Thus, cases where the migration element is lacking are also included in these bodies of work, and it is often not distinguished between cases of trafficking where the element of migration is present, and where it is not.
According to the UN Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, introduced in 2000, human trafficking is:
“the recruitment, transportation, transfer, harbouring 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. Exploitation includes, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs.” (UNODC, 2003, p. 2)
Article 3 of the Protocol states that when the person trafficked is a child, which is defined as any person below the age of 18, the means by which the person is smuggled—e.g., threat or use of force, of abduction, of deception—are not necessary conditions to recognize the person as a victim of trafficking . Thus, a child is considered a victim of trafficking when only two elements of the above provided definition are present: 1) an “action” (recruitment, transportation, transfer, harbouring or receipt of persons) and 2) “purpose” (exploitation).
In the same Protocol, a distinction is made between trafficking and smuggling, where smuggling is defined as “the procurement, in order to obtain, directly or indirectly, a financial or other material benefit, of the illegal entry of a person into a State Party of which the person is not a national or a permanent resident”. The main distinction, at least on paper between trafficking and smuggling is that the former is seen as forced, coerced, occurs through deception, while the latter is ‘voluntary’. However, in practice this is less clear, as a person who enters a country through human smuggling, may later become vulnerable to exploitation, due to their residence status not being secure.
According to the Global Report on Trafficking in Persons 2018, published by UNODC, of all detected victims of trafficking, 23% are girls, 7% are boys (21% men, 49% women). Detected girl victims are primarily trafficked for the purpose of sexual exploitation, while detected boy victims are primarily trafficked for the purpose of labor exploitation. Trafficking for the purpose of forced labor is most frequently detected in Southern, East and West Africa, and the Middle East (UNODC, 2018). South and Central Asia detect trafficking for the purpose of labor and sexual exploitation in equal proportions. While trafficking for the purpose of sexual exploitation is most frequently detected in Europe, North, Central America, Caribbean, East Asia, Pacific (UNODC, 2018). Children comprised 55% of all trafficking victims identified in sub-Saharan Africa (UNODC, 2018).
The health issues faced by children who are victims of trafficking are numerous, and one group of research studies focus on these. A systematic literature review of studies of trafficked children identified in the US (Phuong That D. Le et al., 2018) reported several themes covered in the research of health issues faced by children who were trafficked: 1) substance use and abuse, 2) mental health (depression, PTSD, suicidal behaviour), and 3) STIs (such as genital warts, genital herpes, chlamydia, gonorrhoea, pelvic inflammatory disease, HIV/AIDS). The study points out that what is missing in the literature is focus on physical health and physical health consequences of children who have been trafficked (Phuong That D. Le et al., 2018). A study drawing from a sample of 184 case files of children who were identified as trafficked in Los Angeles found that 76% of the children reported mental health problems, while 62% reported multiple health problems (Cook et al., 2018). It is notable that of the entire group, 43% had been hospitalised for a mental health problem prior to being identified as trafficked, while up to 89% reported having received some kind of counselling throughout their lifetime (Cook et al., 2018). Stanley et al., (2016) conducted interviews with 29 young victims of trafficking in the UK and found that victims had faced “physical violence, threats, restrictions of liberty, deprivation”, as well as a history of physical and sexual violence prior to the trafficking experience (p.100). Victims also reported pregnancies as well as psychological distress such as PTSD and suicidal thinking (Stanley et al., 2016). Based on a survey of 387 child victims of trafficking in the Greater Mekong Subregion, most of which (82%) were female, Kiss et al., (2015) found that 56% were depressed, 33% had an anxiety disorder, and 26% PTSD. Abuse in the household was reported by 20% of the sample, as well as physical (more prevalence among boys) and sexual violence (more prevalent among girls) (Kiss et al., 2015). The study also found that physical violence was associated with depression, anxiety and suicidal ideation, while sexual violence was associated with depression and suicidal ideation (Kiss et al., 2015). A study of commercially sexually exploited children (CSEC) identified in a pediatric hospital in the US found that the trafficked children had histories of mental health diagnosis, STIs, and drug or alcohol use predating the trafficking event, which may suggest that pre-existing mental health vulnerabilities may increase susceptibility to trafficking (Hornor et al., 2018, p.257).
Other studies have compared the health outcomes of children who have been trafficked to those who have no prior trafficking experience, or who have been sexually abused in non-trafficking situations. Significant differences between the various groups have been found. Ottisova et al., (2018a, 2018b) draw their sample from children who have been in contact with mental health services in England, and matched 51 trafficked children with 191 non-trafficked children. Trafficked children exhibited signs of PTSD (22% of trafficked children exhibited signs of PTSD), adjustment disorders (14%), affective disorders (22%) and danger of self-harm (33%). However, the study did not find any significant differences “with regard to trafficked children’s likelihood to have adverse pathways into mental health care when compare to matched controls”, although a “significant clinical difference that emerged was that trafficked children compared to non-trafficked children had a longer total duration of contact with mental health services” (Ottisova et al., 2018a, p. 11). Drawing from the same sample, another paper by the same authors compared the sample of trafficked children with complex PTSD, with non-trafficked children who experienced a single trauma and non-trafficked children who have experienced multiple traumas (Ottisova et al., 2018b). The study found that “compared to non-trafficked children with exposure to a single trauma, trafficked children were more likely to endorse more domains of complex PTSD”, “non-trafficked children exposed to multiple trauma were more likely to endorse more symptoms of complex PTSD compared to non-trafficked children exposed to a single trauma” and finally, “did not find evidence for similar differences between trafficked children and non-trafficked children that were exposed to multiple traumas” (Ottisova et al., 2018b, p. 238).
Several studies have compared the health outcomes of children who have and have not been trafficked, the majority of which have been conducted among children identified as victims of trafficking in the United States. Reid et al., (2018) compared a sample of 913 trafficked youth from Florida with a matched sample of 901 adolescents who were involved with juvenile justice systems but not trafficked. Child maltreatment, as well as higher levels of self-harming and health risk behaviours (alcohol and drug use and abuse) were found among the group of trafficked adolescents (p. 7). In another study conducted in Florida, Shaw et al., (2017) compared trafficked girls to girls who experienced sexual abuse and found that girls who were trafficked were more likely to be in foster care, to have been under arrest and school suspension, to abuse drugs, to have social and school challenges, to show symptoms of depression, to be aggressive and break rules, and to have a mood or conduct disorder diagnosis (Shaw et al., 2017, p. 325). Greenbaum et al., (2018) also compared children who have been trafficked (25) with those who have been sexually abused (83) in Atlanta, USA, and found that the following health challenges were more prevalent among trafficked children: “any type of tattoo; lifetime history of fractures, significant wounds, or traumatic loss of consciousness, either accidental or inflicted; history of sexual activity; history of violence at the hands of parents/caregivers and at the hands of others; history of drug use and of multiple drug use; history of running away from home; and history of involvement with law enforcement or with child protective services” (p.34). In addition, trafficked children had had more sexual partners, had been sexually active longer, and may have had an STI or pregnancy in their past (Greenbaum et al., 2018, p. 34). Cole et al., (2016) compared a sample of sexually exploited children (43) with a sample of children who have been sexually abused (172) from the US and found that 60.9% of children who have been trafficked were diagnosed with “sexualised behavior”, whereas for the sexually abused children that percentage was only 29.2% (Cole et al., 2016, p. 137).
Consistent with findings in regard to adult victims of trafficking, studies focusing on trafficked children also reveal a high likelihood that children would visit a health professional while being in a situation of trafficking. Research by Greenbaum et al., (2018a) studied 810 paediatric patients from 16 different locations in the US, and found that 13.2% of emergency patients, 6.3% of patients from child advocacy centres and 16.4% of patients of teen clinics were victims of trafficking. Hornor et al., (2018) find that ‘nearly all CSEC victims received health care at the paediatric hospital within the year of identification as a CSEC victim” (p. 257).
Nonetheless, studies also find that education among health care professionals on how to identify, approach and treat child victims of trafficking is lacking. Some research has however focused on good experiences child trafficking victims may have in their interactions with physicians. Stanley et al., (2016), for example, identified feedback from child trafficking victims in regard to positive exchanges with staff in maternity services (p. 106).
A final area of research on health and child victims of trafficking is dedicated to 1) identifying recommended practices for health professionals when dealing with child trafficking victims, as well as 2) identifying questions that would help health practitioners identify victims of child trafficking. Some researchers found that particular emphasis should be placed on providing trauma-informed care to patients who are potential victims of trafficking (Ijadi- Maghsoodi et al., 2016; Rafferty, 2018). In addition, Greenbaum et al. (2015) give the following guidelines to paediatricians: 1) trafficking victims have numerous needs, thus a team of doctors may be necessary in addressing them adequately 2); ‘self-identification’ by victims is rare, so it is doctors that should look for indicators 3) many tests may be necessary for a full medical evaluation and finally 4) all suspicious cases of trafficked children should be reported to the authorities. Greenbaum et al., (2018) also provide a 6 item screening questionnaire for physicians (p. 36).
This brief article has given an overview of the main health challenges of children who are victims of trafficking. They were found to exhibit higher levels of mental health problems, PTSD, overall physical health challenges as well as higher danger of self harm. Research also finds that there is high likelihood that trafficked children may seek medical help while in a trafficking situation, or following trafficking. However, research is lacking as to how these children are treated by health care professionals, and more information is needed on whether any guidelines exist for health care professionals, when encountering child victims of trafficking.
About the Autor
Biljana Meshkovska is a postdoctoral fellow at the Department of Nutrition, Faculty of Medicine, Oslo University. She is currently working on an implementation and impact evaluation of a public health intervention. In addition, her topics of interest are human trafficking, sex work and recovery and (re) integration processes of trafficked persons. Her previous research has focused on women who have been trafficked for the purpose of sexual exploitation in Europe. Through her research she has looked at issues such as the influence of criminal trials against traffickers on the (re) integration processes of survivors, as well as the stigmatisation of sex work, sex workers and trafficked persons. She has also worked on a mapping study of the Afghan diaspora in Europe. She has been a lecturer on the topic of human trafficking, as well as a tutor for online courses: ‘Introduction to Governance in Theory and Practice’ and ‘Introduction to Political Science’.
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 This is the case because of the way these cases are often legally prosecuted, as cases of child prostitution are considered as child trafficking
 Child sex trafficking (CST) “involves engagement of a minor (<18 years old) in any commercialized sexual activity (e.g., prostitution, production of sexual material, and performance in sexually oriented businesses) in exchange for something of perceived value, including money, drugs, food, luxury items, or shelter”. (Greenbaum et al., 2018, p. 746)
 Trauma-informed care means that the care which is provided takes into consideration the sexual exploitation which the patient has experienced, and the possible psychological and physical consequences of the same
 The guidelines have been developed and presented by the American Academy of Pediatrics
 Is there a previous history of drug and/or alcohol use? | Has the youth ever run away from home? | Has the youth ever been involved with law enforcement? | Has the youth ever broken a bone, had traumatic loss of consciousness, or sustained a significant wound? | Has the youth ever had a sexually transmitted infection? | Does the youth have a history of sexual activity with more than 5 partners?