Human trafficking: Oral health can tell a story that victims cannot

As the stories of Jeffrey Epstein and R. Kelly proliferate in mainstream media, the atrocity against humanity with the increase of human trafficking cases is fast becoming one of the greatest crimes against morality. Even though most believe that human trafficking is a “sex crime,” there are also cases of forced labor and public servitude where victims become trapped by their circumstances. Some believe that human smuggling is the same as human trafficking, but they are two separate crimes. Human trafficking is defined as “the act of recruiting, harboring, transporting, providing, or obtaining a person for compelled labor or commercial sex acts through fraud, force, or coercion.”¹ Human smuggling “involves the provision of a service—typically, transportation or fraudulent documents—to an individual who voluntarily seeks to gain illegal entry into a foreign country.”²

As the fastest growing commerce in the world, the $150 billion criminal industry of human trafficking is ranked third behind drug sales and drug dealing. Unless this crime is eradicated, the rank of third may move to number one as those involved in human trafficking find it more lucrative than drugs. You can sell a kilo of heroin only once, but you can sell a young girl 20 times a night, 365 days a year.

Figure 1: Human trafficking cases reported by state

Human trafficking is a crime in every state (figure 1), and in 2000, the first comprehensive federal law to address trafficking in persons—The Trafficking Victims Act—was implemented. This law identifies three elements that must be present to identify these crimes as trafficking: force, fraud, and/or coercion. Without these three elements, the person is a victim of exploitation, not trafficking. Traffickers utilize these three elements to compel victims into the world of human trafficking by promises of things such as: job opportunities, safety, stability, love, affection, a sense of belonging, drugs, or modeling careers. Traffickers typically identify someone who is vulnerable or comes from persistent current and historical inequities in our society and economy…people who have a need. These situations occur most often within populations of people of color, indigenous communities, immigrants, and the LGBTQ+ community. Traffickers initially come across as friendly and attentive, but that is a tactic to gain trust, learn more about potential victims, and uncover their vulnerabilities to fill the victim’s need by showering them with attention, gifts, false promises, anything to hook them. Traffickers isolate the victim and then the abuse begins. They demand sex or forced labor as repayment and will use the three elements of fraud, force, or coercion to assert control.

How to report the unthinkable—child sexual abuse

The impact of adverse childhood experiences on oral health

As the numbers of suspected cases grow, many states are initiating mandated courses for various professions for training on the recognition of the signs of HT. The Polaris Project is a nonprofit, nongovernmental organization that works to combat and prevent sex and labor trafficking in North America. The Polaris Project collects data on and works to combat human trafficking, in addition to maintaining the US National Human Trafficking Hotline.³

In a survey conducted by the Polaris Project,⁴ 75% of human trafficking survivors reported they came into contact with hotels at some point during their trafficking situation. Because of this high percentage, Virginia Delegate Shelly A. Simonds of Newport News proposed legislation that would authorize the Department of Criminal Justice Services to create a mandatory online course to help hotel employees better recognize and report human trafficking. The bill would require employees to complete the training within six months of employment and become recertified every two years. House Bill 258 (defined as Department of Criminal Justice Services; hotels; human trafficking training) “directs the Department of Criminal Justice Services, under the direction of the Criminal Justice Services Board, to develop an online course to train hotel proprietors and their employees, as defined in the bill, to recognize and report instances of suspected human trafficking. The bill provides that such online course shall be provided at no cost to the hotel proprietors and their employees. The bill requires that every hotel proprietor require its employees to complete such human trafficking training course developed by the Department or an alternative online or in-person training course approved by the Department within six months of being employed by a hotel and thereafter at least once every two years, for as long as the employee is employed by the hotel.” The bill was passed unanimously.

On October 5, 2018, President Trump signed public Law 115-254, the FAA Reauthorization Act of 201, Section 408 of the Act, Training on Human Trafficking for Certain Staff. This new section was implemented for the airline industry to mandate human trafficking training for all employees.

How does this affect dental professionals?

As of 2016, only 13 states required health-care professionals to participate in human trafficking training. As states work to implement training to identify potential victims, only three states have implemented mandatory training as of 2022: Texas, Michigan, and Florida. The American Dental Association has a Principles of Ethics and Code of Professional Conduct whereby the dentist is “obliged to become familiar with the signs of abuse and neglect and to report suspected cases to the proper authorities consistent with state laws.” Human trafficking falls into this responsibility. A nationwide requirement for every dental professional to be trained in recognizing and reporting suspicions of human trafficking would increase the number of vigilant professionals by more than 650,000. See resources in Table 1.

A survey of US-based survivors of human trafficking shows that while being trafficked, 26.5% were seen by a dentist, along with other health-care providers, but few victims were identified by these clinicians.⁵ While oral issues may cause the trafficker to seek dental care for the victim, it is not out of concern for the victim but more out of concern for lost job time. Some traffickers may even seek cosmetic dentistry to make victims more attractive so they can bring in more money. Education is needed so that health-care providers can recognize the signs of human trafficking, feel confident approaching the subject, and assist in reporting suspected cases.

Since many of the injuries that may occur to these victims are visible in the head and neck region, dental professionals are in a prime position to identify abuse, recognize trafficking situations, and take the appropriate measures to assist victims in getting help.

Clinically evident oral signs may include:

Tooth decay due to poor oral hygiene and a high rate of malnutrition
Injuries such as burns, lacerations, bruises, displaced teeth, and tooth- or bone-related trauma from when a victim is force-fed or gagged
Erythema and petechiae of the hard and soft palates and the floor of the mouth
Signs of oral sexually transmitted infections, including HPV

Other signs that may become evident during a clinical exam could include:

Victims may display markings or tattoos on their bodies, especially on the face or neck, often with the name or sign of the trafficker.
Due to trauma, trafficking victims may have difficulty with certain exam positions or having items in their mouth or may feel a lack of control.

Other indicators that may be evident and identified by nonclinical dental professionals include:

Controlling dynamics. Victims may seem to be in fear or under the control of persons who may bring them to the office. They may look at their traffickers for guidance on what to say or do or may not be allowed to speak for themselves.
Inconsistent or vague details. Victims may be reluctant to share personal information and have vague or conflicting stories. They may not be aware of the city they’re in, or they may appear to have lost a sense of time or have stories that sound scripted.

Signs for the entire staff to be aware of:

Fearful, anxious, depressed, or nervous (often looking around before talking)
Startles easily
Emotionless and/or withdrawn
Constant supervision by the trafficker
No personal belongings

Even though this is not an exhaustive list, there are obvious indicators dental professionals need to be vigilant in identifying. It is also important to note that patients over the age of 18 have autonomy in the decision-making process associated with themselves. These patients should be screened utilizing a patient questionnaire (a link to a framework for identification is listed at the end of this article). Adults should never be pressured into reporting. If an adult does not wish for help but is in a precarious situation, health-care professionals can discretely relay resource information (such as the hotline number), or the word “help” can be texted to BeFREE, which is a direct link to the hotline.

Trauma-informed approach

As health-care providers, dental professionals have legal obligations and must be trained on the specifics of assisting and possibly reporting suspected human trafficking victims.

Each facility should have a plan of action with detailed responsibilities assigned to each staff member.
The National Human Trafficking Hotline Number should be kept on file.
If the suspected victim is over age 18, they must be allowed to decide whether to report.
If the child is under 18 and involved in commercial sex trade, it is mandatory to report and does not require evidence of threat, force, fraud, or coercion for the prosecution of the traffickers.
Well-written and thorough treatment notes can benefit the patient in the future.
A follow-up appointment may allow the clinician to gain the patient’s trust or the patient may decide to report as a victim.

Even as the global industry of human trafficking grows exponentially, the adoption of universal standards in required training modules is lacking in many states, leaving a wide degree of variability in content.⁶ Failure to adopt content and design standards leaves a gap in the process between the training of professionals and the identification of potential victims. Until mandated training is standardized and required, the Polaris Project and the resources listed in table 1 can provide a multitude of resources that can be utilized to develop an office trauma-informed approach protocol for individual facilities.

Editor's note: This article appeared in the October 2022 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

Helpful resources

Trafficking red flags: rdhmag.com/humantrafficking.hotline
Framework for a human trafficking protocol in health-care settings: rdhmag.com/humantrafficking.protocol

References

Byrne M, Parish B, Ghilian C. Victims of human trafficking: hiding in plain sight. Nursing. 2017;47(3):48-52. doi:10.1097/01.NURSE.0000512876.06634.c4
Human trafficking vs human smuggling. The Cornerstone Report. US Immigration and Customs Enforcement. https://www.ice.gov/sites/default/files/documents/Report/2017/CSReport-13-1.pdf
Dodson J. Hotel workers in Virginia will complete training to combat human trafficking. WKKR.com. March 31, 2022. https://www.wtkr.com/news/hotel-workers-in-virginia-will-complete-training-to-combat-human-trafficking
On-ramps, intersections, and exit routes: a roadmap for systems and industries to prevent and disrupt human trafficking. The Polaris Project. July 2018. https://polarisproject.org/wp-content/uploads/2018/08/A-Roadmap-for-Systems-and-Industries-to-Prevent-and-Disrupt-Human-Trafficking-Hotels-and-Motels.pdf
Dentistry’s responsibility in human trafficking. Academy of Minimally Invasive Implantology. AMIItv.org. October 29, 2020. https://www.amiitv.org/blog/dentistry-s-responsibility-in-human-trafficking
Peck JL, Greenbaum J, Stoklosa H. Mandated continuing education requirements for health care professional state licensure: the Texas model. J Human Trafficking. 2021. doi:10.1080/23322705.2021.1981708