The advents of child abuse and human trafficking in their various forms represent a serious crime and affects virtually every country in the world, where they not only represent an issue of the violation of the basic human rights and dignity of those persons affected but also impacts their families and loved ones who may be inadvertently left behind. While most instances of human trafficking have traditionally involved humans being coercively forced to enter into areas of sex and labor violations, the emerging area of illegal organ trafficking to support a growing need for organ transplantation procedures can now be included.

While children and younger adults are the most commonly affected segments of the population for some categories of trafficking, globally human trafficking may impact victims of diverse backgrounds of any age, gender, race, ethnicity, culture, or persuasion, and may present in the clinic accompanied or unaccompanied for urgent care. When presenting, a patient may exhibit cardinal signs, symptoms and clinical stigmata that may be of a suspicious nature and be indicative of further investigation to include reporting the issues to competent authorities especially when the victim is an infant or considered a minor, less than 18 years of age in most countries. Since the health care professional is often in a position to become the first point of contact where symptoms and stigmata of human trafficking, child abuse, and other signs indicative of abuse are apparent, additional modules in health care forensics would be a welcome addition to medical curricula and public health perspectives for physicians and other members of the healthcare team.

Thus, the purpose of the present paper was to review the characteristics of human trafficking and abuse, to summarize key areas of legal, medical, and administrative responsibility in order to ensure availability of optimal and appropriate patient-centered care of victims, and to emphasize the need for inclusion of modules in forensic medical education in medical curricula.

Keywords: human trafficking, medical education, child abuse, forensic stigmata

The human trafficking and abuse of children and adults is a serious crime that affects virtually every country in the world. Since it is an issue of the dignity that violates the wellness and basic human rights of each person who may become a victim in addition to their families who may have been left behind, and who also becomes impacted by the crime, it becomes an important topic in the curricula at all levels of medical education.^1–6

While it largely involves perpetuation of violence against women and children, adults of any age, gender or ethnicity may be affected, of whom may display a broad spectrum of clinical signs and symptoms ranging from the obvious superficial lesions to deeper psychological issues. Issues of human trafficking and child abuse remain a significant issue of public health in the United States and globally and should be addressed as such, including the inclusion of forensic diagnostic modules that focus on the topic. Trafficking may often be considered to be a form of contemporary slavery also known as “trafficking in persons” rather than other forms of goods or services.⁷ The United Nations has defined human trafficking as "the recruitment, transport, transfer, harboring or receipt of a person by such means as threat or use of force or other forms of coercion, abduction, fraud or deception for the purpose of exploitation”.⁶

Human trafficking is usually divided into two major categories In the United States, focusing on a) sex trafficking, and b) labor trafficking. There is also a third category affecting global human health, that of organ trafficking of human organs intended to be used in organ transplant procedures that may be located remote from the site of organ harvesting.³

The victims of sex and labor trafficking victims are typically derived from extremely diverse backgrounds and often vary greatly in terms of their individual ages, gender, cultural origin, race and ethnicity, unknown immigration status, and socioeconomic background.⁸ Since health care professionals are often the first responders in the healthcare chain to make contact with the suspected victims, the identification, diagnosis, treatment, and referral of the potential victims of human trafficking to safe environments becomes important. Thus, it is imperative to include education and training in this area of medical surveillance into their training and educational programs regarding issues of suspected abuse in children and adults.^4,5,9,10

Human trafficking victims may often may go unrecognized upon first entry to a health care setting.¹⁰ It is deemed important for the medical professionals in the direct line of care to be able to discern that any individual who presents to their facility has the potential to have been a possible victim of human trafficking, and to be able to make note and clinical record of the time and presence of cardinal signs noted.^9–12 Health care professionals who may encounter a potential victim of human trafficking or child abuse in a health care setting should be guided by ethical principles while at the same time recognizing their professional obligations under Human Rights Law. In addition, they must maintain their obligations to maintain the requisite standard of care that the patient may need.¹⁰

These standards and other perspectives become essential elements to guide the health care professional in their decision-making actions and treatment processes. The must recognize that they may encounter many of society’s most vulnerable victims of human trafficking and abuse on any given day, and thus key topics are suggested as emerging areas for inclusion in the medical education curricula to assist providers and their front-line supporting staff in early detection of possible victims. The treatment protocols should include proper identification of the patient to the extent possible, ethical considerations in designing their clinical treatment plan, the potential beneficial aspects of the proposed treatments, patient confidentiality and autonomy, and finally, careful, and accurate reporting to superiors and health care authorities when and where deemed appropriate should medical findings be indicative of abuse or trafficking or child abuse. In most Westernized countries reporting of suspected abuse of children and minors under the age of 18 is deemed mandatory.^12-16

While most published reviews consider the plight of the victims of human trafficking, little research has been done to determine the plight of the family and loved ones whom they may have forcibly left behind upon becoming a victim of human trafficking.^17,18 While not always the case, communication with those inadvertently left behind is often nonexistent, as it could not only expose the culprits who have orchestrated the trafficking and place them at risk of discovery, with subsequent further retaliative harm to the victim, but the trafficked individual may be denied the opportunity to make such calls.

There are three broad categories: a) Those who are inadvertently taken into trafficking without their advance knowledge or perception, b) Those who may entrust an agent to ‘safely ferry them across a border’ or some other destination for a predetermined financial commitment, only to fall prey and become a victim after entering into the agreement, and c) Those who may inadvertently fall prey to organizations engaged in organ harvesting for export, and who may not always survive the harvesting procedures which are sometimes reportedly performed under austere conditions.

In all considerations, the families and loved ones left behind as well as those whom the victim had planned to rendezvous with upon a safe arrival at their intended destination, now suffer the loss of their family member and of any commitment, pledges or best wishes they may have made to their families. For the more fortunate organ harvesting victims, he or she may be able to recover and rejoin society albeit with some likely limitations depending on the organ or organs that may have been harvested.^17,18 The pain and human losses may be felt by many unintended persons at multiple levels back home and abroad. The principal areas of consideration in human trafficking of adults and children are summarized below:

Obtaining an authentic identification of the suspected victim

The gender and estimated age of the victim may be estimated from the physical examination of the patient and should be noted in the clinical record, independently of the reported age and gender by the victim themselves or with the assistance of his/her accompanying adult or adults if present.¹⁹ In cases where languages differ, an interpreter familiar with pertinent medical terminology may be necessary both to assist the interviewer and to extract necessary pertinent details from the patient. The typical profile of a potential victim may limit the provider’s ability to determine the true identity of victims of human trafficking, however. The situation and timing may dictate the provider to limit the support and care that may be deemed to be needed to include care that may be essential for the immediate wellbeing of the patient.

Based on the above, there are numerous criteria that may enhance an individual's likely susceptibility to incur trafficking or physical abuse. Factors include the patient’s age, a previous history of abuse as a child, a previous history of being homeless, of being a member of a social minority population, a physical or cognitive disability, status as a migrant worker of low socioeconomic status, and racial or ethnic minority status.^8,14

For the younger child, the age by itself because of their complete dependency on the adult in their life to provide life’s essentials, tends to place the child in a most vulnerable position than an older child or adult may experience. Given the variety of environments health care professionals may be obliged to work within, they are ultimately often in the “front line” and along with their immediate professional and administrative staff, may be among the first to encounter and identify victims of human trafficking. Physicians and other members of the health care team are often on the alert for common red flag indicators, symptoms, and persona that a patient may present with and that may indicate that they are or may have been a recent victim of human trafficking. Some estimates indicate that over 80 percent of human trafficking victims have interacted with a member of the health care team at some point in their life or during their period of captivity, further emphasizing the need for inclusion of key hallmarks of human trafficking and child abuse in their professional training and preparation for clinical practice.⁸

Physicians and other health care professionals may sense an uncertainty during the initial observations, and sometimes may have missed those early opportunities for intervention. A provider being vigilant for indicators, the identification and documentation of relevant signs, symptoms and other physical and psychological criterion are essential elements in the clinical documentation and further actions the provider may deem necessary. Mora²⁰ has reviewed some of the signs that a victim of abuse or trafficking may exhibit, and which may signal that he or she may be a victim of trafficking upon becoming a patient have also been summarized by O’ Callaghan⁷ and include but are not limited to the following items:

1. The age of the patient, especially If the patient is considered a minor. A minor is younger than 18 years in most countries and if they are a suspected commercial sex worker or subject of child abuse the clinical record should be properly annotated to reflect the discovery of such findings or suspicions. Note that the true age of such a patient may not always be readily disclosed and the patient’s appearance may not be consistent with their true chronological age.
2. Does the patient have an accompanying guardian or alleged caregiver, especially if the patient is an adult who displays an outwardly controlling behavior? The patient may be accompanied by a person who exhibits controlling behavior over the patient, may not accurately reflect the true nature of the visit. The accompanying escort of the patient may pretend to be a spouse or significant other, a friend, an employer, a parent or other relative. The accompanying person may insist on staying with the patient and translating for him or her during the medical interview, evaluation, and treatment procedures, sometimes offering suggestions for desired treatments they may wish to see accomplished. Thus, obtaining sufficiently reliable information one may need to establish a valid diagnosis and treatment plan may pose a challenge.
3. The patient, especially if an infant or young child, may present with a history of multiple emergency room admissions to different medical facilities, sometimes citing history of a rare or possibly unknown disorder, but without establishment of a definitive diagnosis or treatment plan. Signs of possible recent trauma should be documented and attended to.
4. The patient may not have any easily recognizable form of identification. Most patients commonly can present believable identification documents to confirm their identity such as a driver’s license, passport, or other valid form of ID. Alternatively, if these documents are available, the person accompanying the patient may not wish to allow anyone else to inspect them and thus may prevent the provider from viewing or recording information from such documents.
5. What are the signs and symptoms observed or reported to the physician? The patient may exhibit symptoms of neglect or abuse, including nutritional stigmata including malnutrition, evidence of physical injury including cigarette burns on the arms or other forms of physical abuse, especially if the patient is an infant or child, but the typical stigmata of abuse may also be present in adults of any age.^4,5
6. The signs do not match the symptoms, or in lay terms, “the cuffs don’t match the collar.” Any discrepancies in clinical signs and symptoms observed should be noted and recorded where discrepancies occur between the medical history provided and the physical and clinical findings discovered.
7. When the patient is an infant or child, is the accompanying adult a known parent or authorized guardian? What is the proposed relationship between the patient and the accompanying adult, if any? Parents are responsible for the care given their children by themselves or designated caregivers, and any excursions from the normal chain of responsibility should be noted in the clinical record, and corrective actions taken to notify authorities when and where warranted.
8. What is the patient’s psychological state of mind? Does the patient make eye contact with the clinician or the accompanying person? Does the patient become unusually apprehensive, fearful, or submissive? How do they interact and address the person who accompanied them to the clinic? These behavior attributes and may suggest give away cues that may merit further investigation.⁸
9. Where has the patient resided prior to the admission and how long have they been in the present country? Has the patient recently entered the United States recently from Asia, Eastern Europe, or Latin America, and if so, do they have documentation of their entry status? Absence of such information may signal an illegal entry, or the illness itself may simply be consistent with the fulmination stage of a pre-existing illness or infectious disease the patient or victim may have contracted prior to departure, progressed during transit, and not known to be prevalent or endemic in the current location. Have others in the community who may have travelled with the patient experienced similar symptoms?
10. Are there any other notable signs not summarized above that may stand out in the patient’s manner and presentation including such items as atypical apparel, grooming, personal hygiene, or other indicators of selfcare suggestive of abuse or neglect that may not appear appropriate for the time and place? When such are evident, an explanatory note should be entered and annotated as necessary in the patient’s clinical record, and where significant reported to local authorities when the patient is an infant, child or under the age of adulthood, an age of 18 years in most jurisdictions.¹²

While there is no single indicator or a combination of indicators that can automatically confirm a patient to be a victim of trafficking or abuse, certain factors may trigger suspicions during initial or follow-up visits to healthcare facilities. The clinician and the healthcare team should be adequately prepared and trained to accommodate such incidents in a professional and patient-centered manner. These indicators may include maladies such as sexually transmitted diseases, requests for pregnancy testing early abortion procedures, evidence of malnutrition, dehydration, alcohol and drug addiction, chronic pain, depression, anxiety, fear, and indicators of abrasions burns and unexplained bruises and unexplained physical injuries.

The health care team working in the front lines are strategically positioned to be among the first in the chain of events to recognize the victims of human trafficking and child abuse and should have some level of competence in making such assessments. While the role of healthcare professionals in addressing the explicit needs of victims of human trafficking and child abuse are complex and staff may sometimes be reluctant to release personal information for fear of repercussions. Their apprehensions may be warranted especially if their suspicions do not turn out to have been confirmed. In the presence of authority figures, the challenges of successful interviewing of the victim may prove to be difficult to achieve at any desired level of satisfaction, and thus may leave the clinician with unanswered questions.

The initial steps in a successful patient encounter are often critical in achieving a successful clinical outcome

Dovydaitis¹¹ outlined the first steps to a successful encounter as including: a) isolating the client from their captors if possible, and in the presence of a neutral medical assistant. Since victims of trafficking and abuse are often accompanied by another person, separating them from their captors may prove difficult; b) identifying an acceptable interpreter knowledgeable in medical terminology if necessary, and c) building a trusting rapport to instill confidence with the client just as one would likely attempt to accomplish with any patient. The client may be most unlikely to identify himself or herself as a trafficking victim or victim of abuse, the physician or other health care professional needs to pay careful attention to subtle and nonverbal cues such as the patient’s affect, body language, and attitude in addition to any obvious clinical stigmata.

Direct inquiry to ascertain if a patient is a victim of human trafficking or abuse is unlikely to result in a successful outcome, as the patient is not likely to come forward and volunteer such information especially when in the presence of their captor or guardian due to a myriad of factors including fear of physical or other forms of retaliation by the perpetrator.⁹ Many victims may be unaware that human trafficking and abuse of a child in their care is illegal in the United States and other countries and thus may make unfounded assumptions accordingly regarding their apparent fate should they be discovered. Some victims may actually decline to get the help they most needed because of anticipated consequences and presumed worse outcomes of attempting to escape or reveal their captor if caught doing so. A victim’s family may also be threatened by some traffickers should their person try or become successful in escaping their captivity and seek out authorities for assistance.^6,14

The promotion of a safe environment may not further the immediate endangerment of the victim during treatment and is a minimum standard of care delivery that is applicable to all physicians and other health care professionals and requires preclinical exposure and clinical experience in discerning reliable telltale signs when they become evident. A multifaceted approach and patient-centered plan of healthcare is essential for managing victims of human trafficking and child abuse. It is important for the provider to provide a safe place with a neutral environment for interaction for the potential victims and to address points about the details of their trafficking history. An integrative care approach facilitates consultation with appropriate medical, surgical, gynecological, and psychiatric disciplines when and where indicated. Above all it is incumbent to ensure that human trafficking victims have adequate access to quality and appropriate health care, including substance abuse treatment options and support from social services including availability of early childcare when indicted.

Ethical principles must be applied in patient centered patient care

Ethical principles of delivering quality healthcare should be adhered to, while simultaneously recognizing that the standards and other perspectives that may be needed to guide their decision-making and subsequent actions for those encounters with potential victims of human trafficking and child abuse in the health care setting must be maintained.¹² According to Macias-Konstantopoulos¹⁴, the overarching principles governing physician- patient relationships are beneficence (Beneficence is the obligation to prevent harm and promote good to the patient), non-maleficence (non-malfeasance is the obligation to do no harm to your patient), justice (Justice is the obligation to provide others with whatever they are owed or deserve), and autonomy (autonomy is defined as the obligation to respect the self-determination of other persons). These four principles when applied will provide as a fundamental guide for providers to form the foundation of effective responses and serve as important directives for delivery of patient-centered healthcare and should be applied by those health care professionals who may be in a position to encounter victims of human trafficking and child abuse in a healthcare setting.

Health care professionals should do no harm and always strive to act in the best interest of their patient

The added attributes of beneficence and non-maleficence are also important discriminators of patient -centered healthcare. Health care professionals have a first obligation to intentionally do no harm to their patient (non-maleficence), either through acts of omission or commission, and to always act in the best interests of their patients (beneficence)¹⁴ Macias-Konstantopoulos stated that the patients’ needs, wishes, priorities, and vulnerabilities and their risks, must be reviewed by the health care provider to gain a better understanding of the complexity of their patient in order to best carry out these duties and incorporate them into an effective and realistic plan of care. The attributes of beneficence and non-maleficence in healthcare options indicate a necessity to incorporate the application of a trauma-informed approach that is sensitive to the patient’s needs and past experiences with the health care system and with societal concerns. A trauma-informed approach to care may optimize healing and recovery while minimizing the risk of repeat traumatization.¹⁰

However, the principle of non-maleficence cautions against generating patients’ admission or disclosure such that they are being trafficked as a primary goal of the patient-clinician interaction. Victims are typically highly unlikely to disclose that they are being trafficked when accessing health care. Aggressive attempts by a health care professional to address a potential victim should be avoided. To outwardly confirm a suspicion and obtaining an admission or disclosure from a victim may become psychologically harmful for the individual and may potentially trigger a significant sense of fear, stress, and additional anxiety that may compromise the treatment options.

They may also cause the patient to reject the treatment options out of fear of discovery and thus abandon the clinical facility prematurely and thereby requiring an additional explanatory note in the clinical record. Equally, it can be retraumatizing, and the patient may experience sensations that may provoke psychological and physical distress as incidents of past trauma become re-experienced.

Justice requires fair and equitable care for all patients

Justice is an overarching factor that demands the health care professionals to individually distribute services fairly and equitably to the extent necessary and possible for each patient’s unique case.¹² This principle may sometimes be a challenge for the provider due to the often concealed and controlling nature of the potential of an alleged crime. The victims of human trafficking may be considered to be in an adverse situation and may more commonly prefer to focus on smaller issues of their day-to-day survival over preservation of activities for their overall longer-term well-being. This may occur even though they may have access to appropriate primary care and follow-up care at the moment of their clinic visit. This is one of the justifications for supporting a greater utilization of urgent care centers, emergency departments, and retail clinics rather than long-term comprehensive primary care services. Regardless of the type of facility, the incorporation of adequate, focused training in areas of forensic health in their preclinical curricula and clinical experiences becomes important. Patient non-adherence of patient centered standards of care during primary care appointments can be problematic for both patient and provider.

For example, if a suspected victim presents with sexually transmitted infection, a point of care treatment that is equally effective is preferable than recurring multi-dose treatment options which can carry potential risks for non-adherence should a patient fail to return for subsequent appointments to complete the desired therapeutic protocol. Should the patient fail to report for the intended additional scheduled follow-up appointments, they may seek additional treatment options elsewhere should they feel challenged or otherwise threatened with inadvertent discovery and its consequences. The fair allocation of services and ongoing assessment and follow-up among the victims and survivors of human trafficking is likely to be challenging at best but rewarding when resolution is obtained.

Telehealth and telemedicine options may not be the best option for patient victims of abuse or trafficking

The recent increases in options for telehealth visitations subsequent to the covid-19 pandemic have now emerged and become an accepted practice option in the delivery of routine management of health care. In telehealth visitations, the option may be delivered via telephonic, or computer assisted technology.²⁰ As such, the clinician may not have the decided benefit of direct visualization or examination of the patient or their visual signs, symptoms, and environment. While the telehealth option may offer an economy of resource utilization in health care economics, they pose a particular issue where the provider may not have a pre-existing relationship with the patient and thus bypasses the opportunities for direct observation and clinical assessment during the interview of the patient and their immediate surroundings, and thereby compromise the clinician’s ability to fully discern the often subtle indicators of suspected abuse or trafficking that a patient may present with. Further compromising this aspect of currently available health care options is the opportunity presented by potential patients to receive healthcare options and opinions across state lines or international boundaries, which may pose potential risks of an inaccurate diagnosis for both the patient and the clinician. While is always most desirable to have the patient appear in person in the presence of the clinic and its professional staff, in the absence of such possibility a sincere referral to an active facility that is more immediately available to the proposed patient is preferable. The telehealth provider should always note the record accordingly with the best information that may be available to him or her at the time and point of delivery.

Autonomy is important in the delivery of quality patient-centered health care

The psychological aspects of trafficking and abuse are often substantial. The victims may blame themselves for their transgressions and seemingly dire situations. They may experience general feelings of shame, guilt, humiliation, and ultimate helplessness including the loss of their individual sense of autonomy.^12,19 Those who engage in trafficking often adopt and apply elements of psychological manipulation to gain and maintain total control of their victims. It is important for health care professionals to recognize the common stigmata of trafficking and to develop a sense and clinical perception to determine when likely victims of trafficking or abuse may need help to heal their wounds or to facilitate rescue from their abusive situation.

Macias-Konstantopoulos  highlighted a belief that promotes a view of a victim of trafficking as being totally helpless in their current situation, and thus may be harmful to themselves because they may perceive the conceptions of trafficking agents as moral agents who can retain or regain capacities for self-determination and decision making of their subjects.¹⁴ While the need to facilitate trafficking survivors’ growth in improving their sense of self a supporting agency may give careful attention to linguistic movement, with a supporting premise that trafficked persons may lose agency and autonomy, and psychological support may improve their prospects for recovery from the traumatic events of their victimization. In all respects the process may become static and flawed without a comprehensive approach including careful attention to the details of the patient’s experience. For example, a victim can actively gauge the trustworthiness of a health care personnel with whom they interact with and thus make decisions about whether to disclose or hide their situation, or whether to decline or accept the assistance offered at the moment or some later date.

Also, the victim may decide to just obey the trafficker in order to avoid future confrontation or possible retribution for any such disclosure, especially when the captor remains physically present. A victim may decide to obey the trafficker, perhaps to a fault in order to gain trust and the opportunity to conduct a successful escape attempt at a later time. The victims of human trafficking often display clinical markers of autonomy in variable degrees that health care providers should become aware of, and which perception may be enhanced with prior training, experience, and attention to facets of healthcare forensics.

Confidentiality is paramount in patient centered medical care

The requirements to maintain rules of patient confidentiality in health care settings are essential. It may also be desirable to create additional space and physical separation between the victims as patients and their captors, abusers and traffickers.²¹ The degree of confidentiality established may in turn improve the probability that one might discover the nature and extent of the suspected trafficking of their victims will be forthcoming, their illness properly identified, diagnosed, treated appropriately and to be fully documented in the clinical record of the episode. Like any patient encounter, trafficked and abused persons are fully deserving of the same magnitude, sense of security and extent of a dignified, respectful level of professional health care to meet and accomplish their needs.

Mandatory reporting and legal issues is an essential aspect when treating victims of abuse, neglect, and trafficking

The mandatory reporting of incidents of trafficking and abuse has the potential to bring victims and survivors of abuse, neglect, and trafficking to the attention of social service and law enforcement agencies but may discourage trafficked persons in particular from seeking needed medical help and assistance so as to avoid possible retribution by their abusers and traffickers. Thus, this factor may impede the ability of health care providers to fully establish the essential trust desired and to be able to more effectively provide needed care.¹³

Once plan of care has been determined and implemented for a victim, the health care provider should be aware of the following potential outcomes: a) the provider cannot coerce the victim to report the crime should they not desire to do so, and b) the reporting of the crime to authorities may place the victim and/or the victim’s family and next of kin at risk for considerable harm for reporting of the incident.¹¹ The clinician is not mandated by law to call anyone including either a victim referral line or law enforcement agency unless the victim is considered a minor or child and is not of legal age. The provider is however under legal obligation to phone child protective services where the suspected victim is a minor and under 18 years of age. While the clinician may call the referral line anonymously without the client’s permission, it is not advisable to make an official report without the client’s consent. The provider can give the client a phone, the phone number, and a safe space in which the victim may or may not choose to make the call himself or herself. Of interest, this remains a ‘gray area’ for discussion and that each clinician will have to make his or her own moral decision regarding the reporting of suspected trafficking and abuse, and which may depend in part on the magnitude of the physical findings uncovered during the patient visit. In any case, the encounter should be duly recorded in the clinical record with the best information available, to include the offers to seek legal assistance from relevant authorities.

The National Human Trafficking Resource Center (NHTRC) is an available resource on a 24/7 basis.^18,21 This agency provides a toll-free referral line that can assist in finding local resources that may be useful or essential for the victim and can facilitate the discovery of resources and in the development of an individualized safety plan that is deemed acceptable to the client. In some jurisdictions, the filing of an anonymous tip regarding an adult patient who is a suspected victim of abuse, neglect, or trafficking and who has previously refused rescue assistance might pose a potential legal risk for the health care professional or the victim’s family whereas in other jurisdictions, filing a such a report may be required by a local statute.

For example, most US states require that a health care professional report suspected abuse and/or neglect when treating a patient with an injury resulting from use of a firearm or another dangerous weapon including a knife, bludgeon, or other implement. Therefore, each health care professional or provider must decide on the merits of reporting on a case-by-case basis what proper course of action should be considered and how best to achieve it. In all aspects, there is no definitive rule that would guide all providers in all instances. It is imperative to respect the patient’s right to self-determination, assuming preservation of life and limb is not of immediate danger and to the extent deemed most rewarding to the patient and their desired outcome.

Human rights law guarantees individuals the right to security, liberty, and freedom from unusual cruel and inhumane treatment

Human rights violations may occur as a consequence of abuse and trafficking of individuals and can impact people of any age, gender, or geographic location. The particular human rights violations which occur in cases of trafficking (UNHROHC, 2014)^2,6,19 include the right for one to enjoy the exercise of liberty and security; the right of an individual to not be submitted to physical or mental abuse, to be free of slavery, servitude, and forced or bonded labor; the right to not be subjected to torture, punishment, or cruel, inhumane, or degrading treatment; the right to be free from gendered violence; the right to freedom of movement; the right to the highest attainable standard of physical and mental health that they may enjoy; and the right of infants, children and minors to special protection. It is clear beyond any reasonable doubt that human rights law prohibits global human trafficking given that slavery violates provisions and standards of customary international law.²⁰

Compensation: monetary or good for the heart and soul? should physicians and other downstream providers in the health care chain receive monetary compensation for treating victims of neglect, abuse, and trafficking, considering the humanitarian nature of the care that they may provide? 

Historically physicians take an oath (The Hippocratic Oath, derived from the most widely known and celebrated original Greek texts and implored by a number of healing gods, to uphold specific ethical standards) during their preparation for progressing into postgraduate training and future employment as a physician.²¹ In the Oath the physician pledges to only provide treatments that will be beneficial to the patient, and to refrain from causing injury or hurt, prescribed according to his or her ability and best medical judgement but it doesn’t fully describe the manner in which the physician may receive his or her reward.

The physician’s reward for adhering to the terms of the Oath could be interpreted to imply that the physician may develop a manner and process so as to enjoy an exemplary personal and professional life, but it fails to disclose how such enjoyment might be achieved, whether it be monetary or satisfaction and warmth to the heart and soul for having done a good deed in providing deserved treatment often to an underserved segment of the population when and where needed. It has often been considered that it is a physician’s privilege to be able to give back to the community that provided his or her rewards. Thus, it becomes an individual decision to determine where to draw the line and how the rewards might best be delivered, whether to the heart and soul of the physician or to another entity in some other form of remuneration. In reality, there is always a business side to a medical practice which cannot be ignored but the dividing line may sometimes be only vaguely apparent and troublesome to discern.

A clinician provider who desires to assist vulnerable victims is deemed explicable at the same time, in that concerns of the victim’s condition and wellbeing may become worsened if primary patient centered medical care was not offered or provided. The prevailing question of Todres¹⁹ remains: “When and to what extent should a physician participate in or accept compensation for aiding a scheme that involves the abuse or sexual exploitation of seemingly helpless victims?” There are other options in this scenario, not least of which is that the physician can ensure the incident is reported to law enforcement authorities so that the incident may be investigated for the best interest of the alleged and future victims of the scheme and facilitate the arrangement of appropriate medical care in the process.

All physicians are entitled to withdraw their treatment of a patient or to decline to treat a patient in certain circumstances baring emergency life threatening situations that fall within their personal level of expertise and ability, and when absent of treatment a patient’s life and survival may hang in the balance. In such desperate circumstances the physician must exort every effort to facilitate the proper medical treatment for the patient in a timely manner, even if it might require relocation to another facility where the needed resources for the instant case may be found.

Human trafficking, medical neglect, and abuse of people of all ages from infancy to later adulthood remains a worldwide concern of human health that affects the individuals, their communities, and the global society at large. From both ethical and legal perspectives, the role of physicians and other health care providers include a responsibility for the proper identification of suspected victims, the needs, priorities, wishes, goals, risks, vulnerabilities, and delivery of responsible health care options, and where resource allocation and mandatory reporting may be properly addressed. Although readily accessible point of care services such as the emergency department, urgent care centers, and retail clinics can often become a safe haven for victims of abuse and human trafficking, susceptible victims may still often go unrecognized or untreated and may appear to just slip through the cracks of the system where such discrepancies could exist. It is imperative that medical professionals at all levels develop a sense of the urgency is applying the principles of clinical forensics when victims of neglect, abuse, and suspected trafficking may spontaneously appear seeking a reliable measure of patient centered care and treatment.

It is recognized that not all medical staff may have developed sufficient expertise or clinical experience in applications of forensic health care during their initial academic preparation to readily identify all such potential victims, leading to an emerging need for development of continuing medical education opportunities projected towards their roles and responsibilities in the health care team. Thus, it is important that during their primary training physicians, nurses, and other health care providers especially those who are positioned as front-line providers to maintain a constant state of vigilance and to remember that any individual or patient is a potential victim.

Given the complexity of the needs faced by trafficked and abused victims, providers are undeniably confronted with ethical and legal challenges. For this reason, working collaboratively with other health disciplines, social services, and law enforcement are deemed vital to the successful provision of comprehensive patient-centered services for those victims and hopefully will contribute to a resolution and pathway for victims to not only receive needed care but to facilitate their safe escape from trafficking and abuse. Second opinions are always welcomed and may be useful in not only recognition and confirming the status of potential victims, but also in establishing an appropriate patient-centered care plan that best meets the immediate needs of the patient, whether as a victim or otherwise. As summarized above, the individual efforts, responsibilities, and combined contributions of each member of the administrative and clinical team of the healthcare system are essential to provide this service to victims, in addition to alerting relevant authorities when evidence of trafficking and abuse becomes apparent.

Human trafficking and abuse continue to be a crime of significant global concern, despite coordinated efforts to interrupt the practice by local, regional, and international law enforcement activities. Thus, the need emerges for the inclusion of relevant educational modules in clinical forensics in multiple areas of medical education and administration, in an attempt to better recognize clinical forensic stigmata, to provide best available patient-centered treatment to the victims, and to assist cooperating enforcement agencies in their attempts to halt such traffic.

The authors thank Dr Athena Ivanoff for her critical prepublication review of this manuscript, and the University of Science Arts and Technology for providing resources for the completion of this manuscript.

The authors declare that there is no conflict of interest.

1. Europol. Legislation on trafficking in human beings and illegal immigrant smuggling. Europol Public Information.  2005.
2. Markovic N, Muratbegovic AA, Kobasliia S, et al. Knowledge and attitudes regarding child abuse and neglect. Mater Sociomed. 2015;27(6):372–375.
3. Clawson JH, Dutch N, Solomon A, et al. Human Trafficking into and Within the United States: A Review of Literature. United States Department of Human and Health Services. 2009.
4. Ivanoff A, Einstein George P,  Tulp Orien Lee. A Review for Medical Students and Student Doctors on Detecting and Reporting Suspected Child Abuse and Neglect (SCAN) from Clinical and Forensic Observations. Faseb J. 2020;34(S1):1–1.
5.  Ivanoff A, Tulp OL. The inclusion of medical curricula for greater training on the detection and reporting of child abuse and neglect. Emerging trends in disease and health research. 2022;6:24–26.
6. United Nations. About human rights and trafficking in persons. United Nations Human Rights Office of the High Commissioner.  2022.
7. O’Callaghan M. Human Trafficking and the Dental Professional. Journal of American Dental Association. 2012;143(5):498–504.
8. Nguyen PT, Coverdale JH, Gordon MR. Identifying, Treating, and Advocating for Human Trafficking Victims: A Key Role for Psychiatric Inpatient Units. General Hospital Psychiatry. 2017;46:41–43.
9. Sinay K. Human Trafficking: An Introduction to What Texas Nurse Needs to Know. Texas Board of Nursing Bulletin. 2017;48(3):4–6.
10. Rollins R, Gribble A, Barrett SE, et al. Who Is in Your Waiting Room? Health Care Professionals as Culturally Responsive and Trauma-Informed First Responders to Human Trafficking. American Journal of Ethics. 2017;19(1):63–71.
11. Dovydaitis T. Human Trafficking: The Role of the Health Care Provider. Journal of Midwifery & Women’s Health. 2010;55(5):462–467.
12. Chaet DH. The AMA Code of Medical Ethics’ Opinions Related to Human Trafficking. American Journal of Ethics. 2017;19(1):43–44.
13. English A. Mandatory Reporting of Human Trafficking: Potential Benefits and Risks of Harm. American Journal of Ethics. 2017;19(1):54–62.
14. Macias Konstantopoulos WL. Caring for the trafficked patient: Ethical challenges and recommendations for health care professionals. American Journal of Ethics. 2017;19(1):80–90.
15. Chance C. Medical and Ethical Issues in Medical Practice. BSC 785, USAT Montserrat, 2017-2022.
16. Public Health Emergency. Human Trafficking & Health Professionals: Questions and Answers.  2020.
17. National Human Trafficking Hotline. Human Trafficking Resource Center. 2022.
18. The Laboratory to Combat Human Trafficking. Human Trafficking: A Human Rights Violation.  2018.
19.  Todres J. Physician encounters with human trafficking: Legal consequences and ethical considerations. American Journal of Ethics. 2017;19(1):16–22.
20. Telemedicine ref Brian William Hasselfeld, M.D., Benefits of Telemedicine. Johns Hopkins Medicine, Johns Hopkins University, 2022.
21. Greek Medicine, from: History of Medicine, NIH History of Medicine Division, National Library of Medicine. National Institutes of Health.