The Public Health Response to Human Trafficking: A Look Back and a Step Forward

By Jordan Greenbaum, Ginny Sprang and Hanni Stoklosa

To counter and eventually eliminate human trafficking (HT) requires not only a strong response from the criminal justice system, but also a comprehensive, rigorous public health response. We’ve come a long way in the past 20 years, broadening our view of HT to include the public health perspective and increasingly, public health strategies are driving human trafficking research. Examples include investigations using sophisticated methods of prevalence estimation, the design and validation of screening tools, and the use of sentinel surveillance to detect trends in human trafficking. While much research focuses on identifying risks and vulnerabilities at the individual and relationship levels, there is an increasing focus on studying cultural factors that influence human trafficking at the societal level, including systemic racism and other beliefs and attitudes that foster the marginalization of large groups (eg, homophobia, transphobia).

We need to acknowledge that public health research on human trafficking is still in a formative stage of development. It is strongly affected by history, politics, international trends, and other sociocultural, legal, and environmental conditions. All of these influence research priorities, funding, and even key definitions.

Valid criticisms exist regarding the scope of past and current trafficking research. First, most research has focused on sex trafficking despite indications that labor trafficking may be underrepresented in prevalence estimates and that it is associated with significant health and mental health adversity. There is relatively little peer-reviewed published research on labor trafficking globally and only a handful of studies published in the US. The lack of research on labor trafficking is consistent with historical inequities seen throughout the history of the United States related to the devaluing of people of color, including immigrants of color. Unfortunately, the disproportionate focus on sex trafficking is evident in our supplemental issue, signaling the need for continued efforts to raise awareness of forced labor as an important area of research and to advocate for funding to support this work. This was an important lesion I learned in my work on this supplement.

Trafficking research has focused heavily on the experiences of cisgender women and girls, to the detriment of individuals with other gender identities and varied sexual orientations. A heavy emphasis on sex trafficking and the strong influence of machismo gender roles partially account for the lack of data on male exploitation, as cultural stigma and discrimination partially explain the paucity of data on transgender and nonbinary populations. These make for serious gaps in our knowledge of risks, vulnerabilities, protective factors, and service needs of large numbers of individuals, many of whom are at especially high risk of trafficking and exploitation.

A third criticism of existing research on HT highlights the paucity of studies that

· disaggregate data by sex and gender

· that compare characteristics of sex versus labor trafficking,

· that examine the interaction of sex and labor trafficking since we know that many individuals experience both types of exploitation.

These gaps in research may lead to false assumptions (for example, The belief that “Boys cannot be commercially sexually exploited” leads us to ignore potential signs of risk and vulnerability among males. We don’t see what we aren’t looking for, so we conclude there are few males experiencing sexual exploitation, which reinforces our original false assumption.), The gaps in research also may lead to inappropriate generalizations (such as, “All individuals experiencing HT have the same risk factors”), which in turn can lead to ineffective prevention and intervention efforts. That is, we may build our programs on false assumptions and erroneous conclusions.

As we look forward to the next generation of antitrafficking public health research, we have an opportunity and responsibility to reflect on, and learn from the past. As mentioned, US public health research has a history of contributing to inequities. Our antitrafficking response, including research funding mechanisms, trafficking data, and even the interest of researchers, has been shaped by the forces of structural racism and xenophobia. As a team of co-editors who are White, cisgender, US-born women in academia without a lived experience of trafficking, we acknowledge the inherent privilege and biases we bring to our analysis of the state of the public health trafficking research.

Bearing this in mind, we make these recommendations.

1. Future research should be based on equity-grounded theories that address trauma, interpersonal violence, and social determinants of health. We need to thoughtfully consider how we determine our hypotheses, how we design our studies, and how we address potential confounders and biases. Our research should be critically appraised for its rigor, objectivity, its accuracy in interpretation of results, and its consideration of societal and historical contexts.

2. Research should be designed and implemented with the input of affected communities, including those with lived experiences of trafficking and those from at-risk, vulnerable populations. We need to use established community-based participatory research methods. Every effort should be made to center the voices of those at the margins of US society.

3. Balance measures, used to assess for unintended consequences, may be developed in partnership with people affected by trafficking-specific interventions, such as adults engaged in commercial sex and undocumented migrant workers. We need to be acutely aware of negative unintended consequences of our prevention and intervention efforts.

4. Research agendas should be shaped by diverse stakeholders including academic researchers, public health practitioners, policy makers, and advocacy organizations.

Public health research, if conducted rigorously and with a focus on equity, has the power to change the systems and structures that allow human trafficking to persist and propagate. We need to reflect on limitations of prior research and learn from those with lived experience to shape the future of our work.

This supplement, “The Public Health Response to Human Trafficking: A Look Back and a Step Forward,” aims to build the evidence base for human trafficking prevention and intervention and elevate the importance of a strong public health response to HT. As guest editors, Drs. Sprang, Stoklosa and I sought to highlight innovative strategies for human trafficking research, prevention, and service delivery. We looked for research that will lift the field to the next level. The studies in this supplement clarify important research questions and encourage new strategies for identifying and serving those who have experienced human trafficking. They cover a broad range of topics, including a comparison of public health methods for estimating the prevalence of hard-to-reach populations; a look at the relationships between commercial sexual exploitation during adolescence and health during adolescence and adulthood; and the design and implementation of a Collaborative Multidisciplinary City-Wide Victim Services Model that focuses on healthcare for those who have experienced HT. Read the supplement here.

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Supplement details:

The Public Health Response to Human Trafficking: A Look Back and a Step Forward
Guest Editors: Jordan Greenbaum, Ginny Sprang and Hanni Stoklosa
July/August 2022
Public Health Reports

About the Authors:

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Jordan Greenbaum, MD is a physician in Atlanta, GA. She is the medical director of the International Centre for Missing and Exploited Children, and past medical director of the Stephanie Blank Center for Safe and Healthy Children at Children’s Healthcare of Atlanta. She has worked in the field of child maltreatment for over 20 years. Dr. Greenbaum is a board member of the International Society on the Prevention of Child Abuse and Neglect (ISPCAN) and a past president of the American Professional Society on the Abuse of Children. She has provided training and technical assistance to health professionals globally to improve the health sector response to child abuse, exploitation and trafficking.

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Ginny Sprang, Ph.D., is a professor in the College of Medicine, Department of Psychiatry at the University of Kentucky, and executive director of the UK Center on Trauma and Children. Dr. Sprang is one of two principal investigators of a CDC funded randomized control trial to prevent child sex trafficking in middle schools. She is the Principal Investigator of the SAMHSA funded Category II Secondary Traumatic Stress Innovations and Solutions Center, the Category III Child and Adolescent Trauma Treatment and Training Institute, and Chair Emeritus of the Secondary Traumatic Stress Collaborative group. She is member of the College of Medicine’s executive committee, and serves as a member of the Appointment, Promotion and Tenure Council for the Department of Psychiatry. Dr. Sprang has published extensively on topics such as child trauma, trauma informed care, the commercial sexual exploitation of minors, implementation and sustainability, disaster response and secondary traumatic stress. Her work involves the creation of translational tools, and the development, testing and implementation of evidence-based treatments and practices to treat those exposed to these traumatic experiences.

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Hanni Stoklosa, MD, MPH, is the Founding CEO of HEAL Trafficking, an emergency physician at Brigham and Women's Hospital (BWH) with appointments at Harvard Medical School and the Harvard Humanitarian Initiative. Dr. Stoklosa is an internationally-recognized expert, advocate, researcher, and speaker on the wellbeing of trafficking survivors in the U.S. and internationally through a public health lens. She has advised the United Nations, International Organization for Migration, U.S. Department of Health and Human Services, U.S. Department of Labor, U.S. Department of State, and the National Academy of Medicine on issues of human trafficking and testified as an expert witness multiple times before the U.S. Congress. Moreover, she has conducted research on trafficking and persons facing the most significant social, economic, and health challenges in a diversity of settings including Australia, China, Egypt, Guatemala, India, Liberia, Nepal, Kazakhstan, the Philippines, South Sudan, Taiwan, and Thailand. Among other accolades, Dr. Stoklosa has been honored with the U.S. Department of Health and Human Services Office of Women's Health Emerging Leader award, the Harvard Medical School Dean's Faculty Community Service award, has been named as an Aspen Health Innovator and National Academy of Medicine Emerging Leader. Her anti-trafficking work has been featured by CNN, the New York Times, National Public Radio, Fortune, Glamour, Canadian Broadcasting Corporation, STAT News, and Marketplace. Dr. Stoklosa published the first textbook addressing the public health response to trafficking, "Human Trafficking Is a Public Health Issue, A Paradigm Expansion in the United States."