Imagine, for example, the heroin user in a local motel room. The motel manager calls the police because of complaints of suspected drug use from occupants in neighboring rooms, and police respond to encounter an eighteen-year-old female on heroin in the room of a motel that happens to be located in a high-prostitution area of town, with a male hurriedly exiting upon their arrival. Quite possibly, the officers who have responded are either the patrol unit on duty or vice and narcotics officers who were called because of complaints of drug use. In either case, the likelihood that these officers have completed a human trafficking training (although growing), is relatively slim, and the likelihood is slimmer still that they have received training specifically delineating the intersection between sex trafficking and heroin use.
—She Leads a Lonely Life: When Sex Trafficking and Drug Addiction Collide6
Out of the wake of the war on drugs has risen the Opioid Epidemic which has swept Americans of all ages and demographics. There has been a marketed increase in prescription drug which in some drugs has been by as much as 500% since 1999.1 This has changed the way in which we approach drug use, and has informed how drug use in seen in the sphere of public health. We can see a carrying over of a belief that drug is an issue of criminal justice, rather than an issue of public health. The pathologizing of drug use has directly impacted the ways in which health care professionals treat drug users often seeing them as criminals first, and patients second. These attitudes directly inform how health care professionals treat their patients, and how they evaluate diagnoses. It is with this backdrop that we examine Human Trafficking, and the ways in which the opioid epidemic has influenced the ways in which healthcare providers identify survivors of human trafficking.
Why the Opioid Epidemic?
The rise of the Opioid epidemic in the United States has been a significant deviation from the ‘norms’ of drug use in the past fifty years. We can see tangibly this differential in the number of cases, and the ways in which women identified individuals have engage in drug use as a demographic. Tammy Anderson notes that women in particular have seen a dramatic increase in their use of drugs like methamphetamine in particular.5 A rise Anderson credits to a shift in women as a primary household provider, with women using ‘uppers’ as means to keep up with demands of both the workplace and motherhood.5 We see this pressure to perform within the idea of the ‘second shift’ where women are demanded not only to work, but to do all household work and childcare as well. This has a laundry list of implications for the livelihood of many women, with many states having especially harsh penalties for those found to be using in the presence of children.5 Policies such as this directly contribute to the precarity of women who are already likely to be in financial strife by placing them under social scrutiny. By running these women through the criminal justice system, women and their families are made even more susceptible to human trafficking as they are unable to work due to their record. This creates a vicious cycle which does not even effectively address the struggles that many individuals have with addiction long term. This simply separates individuals from the drugs without considering the larger contributors to drug abuse such as social and economic stressors and/or isolation.5 Individuals who go through the criminal justice system are left with little options other then to engage in work such as survival sex work to keep themselves and their family afloat. This speaks to a dangerous trend that Lindsey Roberson of the Wake Forest Law Review identifies in her analysis of addiction and sex trafficking:
The study also found that 22% of respondents had been arrested for a drug-related offense. While these numbers indicate the prevalence of drug use among youths entering the sex trade, other statistics point to another, related, trend: pimps and traffickers using drugs to control victims’ behavior for profit6
From here we can pinpoint the intersections between addiction and risk factors that are tangibly associated with ones likelihood of being trafficked, such as survival sex work. As individuals are placed in more and more precarious circumstances, their chances of falling victim to the promises that often accompany trafficking increase. This intersection leads us to our second question, as we explore how addiction more directly effects human trafficking.
How Does Drug Use Affect Human Trafficking?
The issues that face those who are survivors of human trafficking become more magnified by the compulsive dynamics of addiction. The war on drugs started during the Reagan administration has contributed significantly to the criminalizing of survivors before they may even be identified. These survivors are viewed by prosecutors as drug addicts first and survivors second, a trend which further conceals an already ‘hidden crime’ from law enforcement. Hanni Stokloska brings to light this entanglement in their analysis of the intersections of addition, mental health, and human trafficking:
Addiction has a complex relationship with human trafficking: it can exacerbate a trafficked person’s vulnerability, be part of a captor’s means of coercing a captive person to submit, be part of a captor’s means of incentivizing a captive person to remain captive, and be used by the captive person as a mechanism of coping with the physical and mental traumas of being trafficked.3
This is not even taking into consideration the rate at which drug use affects survivors of human trafficking, with studies showing as high as 84% of survivors using drugs at some point.6 Drug use affects survivor of human trafficking, and sex trafficking survivors in particular at rates vastly higher than the average United States demographic. This is likely due to the ability of opioids to dull both physical and emotional pain often associated with trafficking work.6 This combined with the intensity of withdrawal symptoms exposes individuals both to initial trafficking and to power dynamics that can be exploited by traffickers. It has been the case that traffickers have used the threat of withdrawal symptoms to coerce survivors into working, and to punish survivors who do not cooperate. This dynamic complicates the already intense situations of trafficking, a fact that has not gone unnoticed by the United States courts. As was the case in the 2014 case of the United States v. Guidry where the use of drug addiction as means of coercion led to harsher sentencing for the trafficker which later upheld in a 2016 appeal.6 The success of this case was due in large part to the inclusion of health care professionals who identified addiction as a compelling force, which brings us to ideas explored in our final question.
What Can Health Professionals Do?
There comes a point when an issue becomes salient enough in a society that its treatment must become standardized, it is my belief that we have reached this threshold for human trafficking. With the increase in ‘awareness’ around trafficking must come more policy action around the issue, and with the backdrop of the opioid epidemic this policy change must be centered in public health. As PhuongThao Le of the Policy Studies Organization points out there are some policies are already in place for many states:
Article 6 of the Palermo Protocol states that in addition to the obligation to provide trafficking survivors with health and social services, governments must also ensure coordination among various stakeholders (UN, 2000). Multi-sectoral collaboration is an important component of the public health approach and is just as critical in anti-trafficking programs and policies.2
Even with the technical inclusion of public health centered policies, many states need to go further to tangibly alter the experiences of survivors positively. There is a need to get health care professionals involved as conscious stake holders in the identification and treatment of human trafficking survivors. For many survivors they are their first point of contact with individuals outside of their trafficking ring as they seek treatment for work related injuries and infections.4 These providers must be trained in not only how to identify survivors but how to best approach survivors, given the complex psychological and physical implications of trafficking. Here is the necessity for the establishment of a survivor centered and preferably survivor led protocol to be established for health care professionals. As Stokloska argues this protocol should focus on developing communication skills when talking to survivors to avoid reinforcing “power dynamics and avoiding retraumatization”.3 By focusing on the experiences and needs of survivors providers can effectively care for their survivor patients without exasperating disorders associated with social exclusion such as drug abuse. Further it is of utmost importance that clinicians be cognizant of their own implicit biases that they may have about both human trafficking survivors and drug users. These biases may manifest in the phenomena of diagnostic overshadowing where a provider can be lead to ignore overarching health concerns in favor of diagnoses that align with their bias.3 This phenomena can have devastating consequences consequences for both general patients and survivors. If providers express bias towards drug using survivors could be written off as ‘just’ drug abusers, which has the two-fold effect of reducing the likelihood of identification and disclosure to providers. There must be an established trust between provider and survivor to facilitate investigation and encourage survivors to reach out for help in the first place. In the context of a crime that is most often identified by the disclosure or help from those who are trafficked, the perception of survivors can directly effect their likelihood to receive help. If there is going to be change it stands that health care providers must invest in education and training around human trafficking. The implementation is needed to give health care providers the tools necessary approach survivors in a way that fosters the trust that providers will not harm them like many people in their lives already have. There must be a movement for health care providers to take responsibility for their patients from all demographics, not just those patients that fit their narratives.
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