March, 2018. When we hear the term “human trafficking” we may automatically think of it as a terrible and inhumane business that occurs in faraway, unfamiliar places—places less “civilized” than our own. Not so fast! Yes, it does occur in many faraway places, but it occurs right under our noses, in our own back yards. The US Department of Homeland Security1 has this to say:
Human trafficking is modern-day slavery and involves the use of force, fraud, or coercion to obtain some type of labor or commercial sex act. Human trafficking is a hidden crime as victims rarely come forward to seek help because of language barriers, fear of the traffickers, and/or fear of law enforcement. Traffickers use force, fraud, or coercion to lure their victims and force them into labor or commercial sexual exploitation. They look for people who are susceptible for a variety of reasons, including psychological or emotional vulnerability, economic hardship, lack of a social safety net, natural disasters, or political instability. The trauma caused by the traffickers can be so great that many may not identify themselves as victims or ask for help, even in highly public settings.
It has become increasingly recognized that this “hidden crime” is far more prevalent in the United States than has been apparent, and there is no shortage of factors that make some of us susceptible, as described above (eg, economic hardship, natural disasters, political instability). Although extreme abuse virtually defines the business of human trafficking, I would argue that there is a spectrum of abusive behavior ranging from this trafficking extreme to other forms of abuse that may not involve “modern-day slavery,” but which can be morally unacceptable and psychologically and emotionally damaging. And which also, quoting from the above, involve “the use of force, fraud, or coercion.” Just pick one example: the #MeToo movement has dominated recent headlines, revealing long ignored sexual harassment of junior employees by powerful and morally corrupt bosses.
In this issue of the Journal, 2 separate papers call our attention to the daunting challenges involved in identifying and helping victims of human trafficking. Gordon and colleagues make the case for an integrated care approach—a persuasive recommendation particularly apt for this population, given the broad range of physical and psychological damage that is often involved. The authors emphasize the need to implement provider training, to be proactively alert to the possibility that patients in emergency departments could be victims of trafficking, and to provide skilled psychiatric interventions in both acute care and reintegration settings.
In the second paper on the topic, Salami and colleagues focus on the psychological problems secondary to trauma in trafficking victims. Although the literature is sparse regarding evidence-based treatment for this particular population, valuable published clinical wisdom provides much needed guidance. The authors recommend the use of cognitive approaches, such as Cognitive Processing Therapy, to target maladaptive cognitions, but they emphasize the importance of individualizing the treatment approach for each patient, given the wide range of types of trauma experienced by these individuals.
On these editorial pages, if you’re a regular reader, you know that I often stress the importance of “mentalizing” as a powerful method to connect with and respond to our patients. One shorthand description of mentalization is to see yourself from the outside and to see your patient from the inside—that is, to put yourself in the patient’s shoes and imagine how you would see the world if you had lived the life of the patient. It is not easy. And I find it particularly hard to do when considering victims of human trafficking. The truly inhuman cruelty inflicted on these sufferers can be almost unimaginable. But we have to keep trying and not let ourselves look away. That’s what these 2 useful papers help us do.
John M. Oldham, MD Editor