Trafficking of persons is a global public health problem with far-reaching consequences.¹ Under international law, child trafficking refers to the recruitment, transportation, transfer, harboring or receipt of a person under 18 years for purposes of exploitation, including sexual exploitation, slavery, forced labor, servitude or removal of organs.² Sexual exploitation may involve prostitution of a child, creating sexual exploitation materials (formerly referred to as “child pornography”), engaging a child in a sex-oriented business, child marriage, and the mail-order bride trade; it may or may not involve online activity. Trafficking may also include forced begging or engaging in criminal acts, forced participation in armed conflict, or illegal adoption. Forced labor involving children encompasses work or service by a child that is exploitative in nature or interferes with the child's education and healthy development.³ This may involve children performing a wide variety of activities, from domestic servitude to construction, from gold mining to brick-making; from restaurant work to farm work. In some labor sectors, children are recruited for specific purposes, for example, to dive and free snagged nets in the fishing industry. Children may be trafficked within their home country (domestic trafficking), moved across borders to neighboring countries or transported to destinations thousands of miles away (international or transnational trafficking).

At the national level, there is variation in interpretation of how “child trafficking” is defined, with some countries requiring movement/migration of an individual, and some excluding self-initiated commercial sexual transactions (often called, “survival sex”). Further, the age of consent varies across and within countries so that a child may be considered a victim of trafficking in one location, and a “sex worker” in another. These variations in interpretation contribute to problems determining the prevalence of child trafficking and may also hinder child trafficking survivors' access to services. Accurate measurements are further hindered by the illegal nature of the activity, the lack of a central database to track cases, under-recognition of victims, and reluctance of victims to report their status (due to shame, fear, lack of knowledge of their rights, or loyalty to a trafficker).^{Reference Greenbaum and Crawford-Jakubiak4} The International Labour Organization estimated that 5.5 million children are victims of forced labor globally.⁵ In one global study of approximately 40,000 identified human trafficking cases, 33% of victims were children (21% female; 12% male).⁶ The proportion of identified victims under 18 years varied with geographic region, from 18% in Europe/Central Asia to 62% in Africa/Middle East. In addition, geographic differences were demonstrated in the proportion of victims experiencing labor vs. sex trafficking. For example, 66% of those identified in Europe/Central Asia endured sexual exploitation and 26% forced labor, while in Africa/Middle East, the proportions were 53% and 37%, respectively. This geographic variation may reflect true differences in trafficking activities, but may also indicate variations in the focus of investigations and in levels of knowledge regarding different types of trafficking. Contributing to the difficulty in assessing the prevalence of child trafficking is the lack of understanding of the breadth and variation of trafficking experiences; efforts to describe “typical” victims often lead to overlooking trafficked children who do not fit that profile.

Children may become vulnerable to trafficking through a wide variety of factors at the individual, family, community and societal levels (see Table 1).⁷ In addition to these risk factors, children's youth — and their comparatively immature cognitive, emotional, and physical development — further heightens their vulnerability. Adolescents may be unable to conceptualize future negative consequences associated with current actions or develop adequate insight into the motivations of others.

Table 1

Some Common Risk Factors for Child Trafficking

The tremendous variation in “push/pull” factors affecting children emphasizes the need for an open mind when assessing risk and the possibility of exploitation and trafficking of an individual child. Some risk factors are especially relevant to the pediatric population: youth fleeing violent, gang-controlled communities may travel unaccompanied to another country, with few resources, limited experience and increased vulnerability. These conditions are exemplified in recent mass migration of unaccompanied children from Central American countries to the U.S..⁸ Female children are at increased risk for sex trafficking in some countries because of gender bias and the diminished value placed on girls. In addition, some countries have very high rates of HIV/AIDS and a common belief that having intercourse with a “virgin” will prevent or cure the disease.^{Reference Silverman, Decker, Gupta, Maheshwari, Willis and Raj9} Small size and small hands may favor children for certain forms of forced labor such as the fishing industry.^{Reference Hamenoo and Sottie10} Because of their roles in the family and in society, their limited skills and options, and their relative lack of rights compared to adults, children are particularly vulnerable to trafficking by adults whom they know, including in some cases family members and relatives.

The adverse health effects associated with sex and labor trafficking span cognitive, developmental, physical, social, and emotional domains.^{Reference Turner-Moss, Zimmerman, Howard and Oram11} Victims may experience traumatic injury from sexual and physical assault or work-related injury,^{Reference Silverman12} sexually and non-sexually transmitted infections (e.g. HIV, tuberculosis, N. gonorrhea, C. trachomatis),¹³ chronic untreated medical conditions related to work or living conditions (e.g. mercury exposure in gold mining, dust exposure in construction; pesticides in agriculture),^{Reference Buller, Svaca, Stoklosa, Borland and Zimmerman14} poor growth and malnutrition, pregnancy and related complications (many of which are more common among younger adolescents),^{Reference Greenbaum, Dodd and McCracken15} chronic pain, and complications of substance misuse.^{Reference Edinburgh, Pape-Blabolil, Harpin and Saewyc16} Heavy manual labor and repeated use may lead to musculoskeletal injuries, especially when experienced prior to skeletal maturity. Poor access to health care may result in preventable infectious diseases (through lack of immunization and crowded unhygienic conditions), lack of developmental screening with late diagnosis of delays, and other complications of poor primary care. Child victims may develop severe depression with suicide attempts, post-traumatic stress signs/symptoms, or other mental health conditions.^{Reference Kiss, Yun, Pocock and Zimmerman17} Very young children may experience attachment difficulties. And sex/labor trafficking victims of all ages may experience debilitating isolation, humiliation, and shame associated with stigma, discrimination, and marginalization.

Given the often multiple vulnerabilities leading to trafficking, the complex trauma experienced during (and sometimes before) the trafficking period, and the myriad adverse effects of exploitation, the needs of the child victim may be extensive and multi-faceted. Housing, food, medical care, crisis intervention, mental health counseling, immigration services, interpreter/language support, education and job skills training are often necessary.¹⁸ The healthcare professional providing for the victim is in no position to fulfill all of these needs alone so she or he must be prepared to work as part of a multidisciplinary team alongside community victim service providers, government agency representatives, investigators, attorneys, and others, acknowledging that the availability of multidisciplinary, allied services may be limited in some geographic areas. This outward focus on community partnerships represents a paradigm shift for healthcare professionals, who traditionally interact primarily with others in the health field. Such collaboration is best accomplished through proactive development of a hospital/clinic protocol for recognition of and response to human trafficking, active efforts to identify community partners and build effectual relationships, and a continuing commitment to maintaining cooperative arrangements that ensure prompt and effective referrals for services, while minimizing trauma to the victim. This may include healthcare professionals advocating for human trafficking services in the community and serving on multidisciplinary human trafficking teams and task forces.

Health professionals must also be familiar with state and national laws regarding reporting suspected child labor and sex trafficking,^{Reference Todres19} as well as requirements to be heeded when a pediatric patient's adult caregiver is the suspected victim, with or without concomitant child victimization. Even in jurisdictions where the law does not expressly require reporting of trafficking cases, such laws might still require reporting of harms to children that parallel symptoms of child trafficking and thus would require a health care professional to inquire further.²⁰ When children are not victimized and in no danger, the adult's privacy and confidentiality must be respected regarding their own victimization. However, resources may be offered to the victim, and reports/referrals made if permission is granted. Besides familiarity with the laws, professionals need to be aware of national resources, such as the U.S.'s National Human Trafficking Hotline (1-888-373-7888), which provides advice and information to professionals, victims, families, and the public.

While much may be learned about recognition of, and intervention in, human trafficking by examining models shown to be effective in addressing child abuse and neglect or intimate partner violence, it is important to acknowledge factors distinguishing global child trafficking. Typically, trafficked children have experienced chronic, complex trauma that involves many perpetrators, many types of trauma (physical and sexual assault, emotional manipulation and abuse, deprivation, separation from loved ones, witness to violence), an extended period of traumatization, and in many cases, significant pre-existing trauma that occurred prior to exploitation. They may have no supportive individuals available to them and be far from home. They may face significant cultural barriers and challenges, and stigma and discrimination from the public. Thus, mental health therapeutic strategies used with sexually abused children may need to be adjusted to adequately treat the complex trauma experienced by child trafficking victims. In addition, a child's cultural beliefs about health, mental health, and traditional healing methods are extremely important in guiding treatment. For cross-border trafficking cases, immigration issues must be addressed promptly and effectively to prevent deportation and promote family reunification, as appropriate. Trauma-sensitive interpreters are needed to assist during crisis intervention and throughout rehabilitation. With cases of child trafficking, specific challenges related to the victim's minor status need to be addressed. Protocols need to indicate appropriate actions to take when the caregiver/guardian is inaccessible and the child needs services and placement; or how to proceed when a child's age is not clear and services vary according to child vs. adult status.

The gross human rights violations of child trafficking as well as its extensive adverse effects and the substantial attendant needs of its victims have multiple policy implications. As physical and mental health problems are common and may be prolonged,²¹ access to trauma-sensitive, trauma-trained, culturally competent healthcare providers is critical, yet such access is relatively limited in low-, medium-, and even high-resource countries. Providers often lack training regarding human trafficking and may fail to recognize those at high risk for victimization, and/or they may show intolerant, stigmatizing, judgmental behavior when interacting with victims. Well-meaning providers may lack expertise in providing mental health therapy specific to chronically traumatized individuals. Healthcare professional training and institutional protocols are needed so that adequate care may be provided to trafficked persons and the latter spared re-traumatization associated with service provision. Considerable financial and social resources are needed to strengthen and improve the medical and mental health response to human trafficking. Such changes need to be systematic, well-organized, based on rigorous scientific research, and subjected to outcomes evaluations.

The multidisciplinary approach to prevention, recognition, and intervention requires that all professionals likely to contact victims receive appropriate training on trafficking and the victim-centered, trauma-informed approach. Services for victims typically involve a major role for child protective services. These agencies are often under-funded, under-staffed, and poorly resourced, which hinders their ability to meet the challenge of providing safe and supportive environments for child trafficking survivors. Additional funding, staff training, and resources are needed for social workers to have a positive impact. In the same vein, foster care services for children are often without adequate resources, and substantial funding is needed to help train and support safe adult caregivers who are familiar with the effects of human trafficking and capable of employing a trauma-sensitive, culturally-informed approach to child care. In regions where child victims of trafficking are more likely to be detained by immigration authorities (e.g., border control), staff training is also needed to ensure that child victims of trafficking will be appropriately identified.

To combat child trafficking, a country's legal code must prohibit all forms of child exploitation, including trafficking, forced labor, sexual exploitation, child marriage, and similar harms. Such laws need to be implemented and enforced effectively and consistently. To prevent further trauma and help ensure access to appropriate services, anti-trafficking law and related criminal law must clearly recognize trafficked children as victims and protect them from being charged with crimes associated with their trafficking experience. When a child is viewed as a perpetrator of crimes associated with trafficking (petty theft, begging, or prostitution, for example), they may be directed into the criminal justice system or deported, rather than being connected with services that will help them rebuild their lives (locally or in the home country). Laws and policies must also ensure comprehensive services are available to child trafficking survivors, including programs to address short-term needs as well as measures to support children's long-term rehabilitation and return to their communities.

Finally, laws and policies (with accompanying funding) are needed to prevent child trafficking. These include appropriate legal protections and services for children of heightened vulnerability, including unaccompanied migrant minors, abused and neglected children, and homeless/runaway/thrown away children. Prevention and eradication of human trafficking requires the legal, political, and social will to dedicate resources to addressing the root causes of exploitation. This involves law, policies, and programs that help strengthen families, reduce violence, especially gender-based violence, secure economic and social rights, especially health and education rights, increase the capacity of communities to provide for their residents, and build economies that foster individual self-sufficiency and success.