Unmasking Cancer as a Consequence of Human Trafficking: A Multidisciplinary Challenge
By Barbara Moynihan, Ph.D., A.P.R.N., B.C., A.F.N., F.A.A.N., and Katherine Olive M.H.S.A., B.S.N., R.N.
Cancer InCytes Magazine - Volume 3, Issue 2, Winter 2014
Managing Editor: Matt Kaku, M.S.
This article will focus on the development of cancer as a potential consequence of human trafficking. Various subtle sequelae of trafficking, such as the insidious development of cancer, may not be seen until well after the victim has been freed. There are a myriad of factors that contribute to missed or inadequate health care for victims and survivors of human trafficking. These health care needs (both medical as well as mental health) may be overlooked until many months or years post-trafficking.
We will address the risk factors consistent with human trafficking that should be considered by health care professionals who are caring for identified victims or survivors of trafficking. Screening for cancer of the rectum, uterus, lungs, throat, blood or immune system might not be routinely conducted or considered by the medical provider. Rigorous, focused assessment and screening need to be performed once consent to a physical examination has been obtained.
Trafficking victims may have been exposed to noxious or addictive substances in order to reduce their resistance. Other health issues that can also contribute to the development of cancer are forced abortions, dental injuries, genital trauma as well as predicted suppression of the immune system rendering the victim unable to resist or overcome these conditions.
The authors hope to achieve two essential outcomes: raising the reader’s consciousness considering cancer as a potential consequence of human trafficking; and developing appropriate screening tools to identify immediate and long-term effects of this egregious human rights violation.
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The focus of this article is to consider the development of cancer as a result of human trafficking. The magnitude of the risk for cancer is enormous. The “mule” transporting drugs or other dangerous substances is at risk for infection, unintended ingestion or absorption, and death. The female victim is at risk for a sexually transmitted disease (e.g., HPV) that is known to cause cervical cancer. The risk of contracting HIV/AIDS is ever present, either via sexual contact or intravenous drug use. The labor trafficking victim may be exposed to dangerous chemicals, pesticides or unhealthy living conditions.
This article addresses some of the risk factors inherent in human trafficking that may lead to the development of cancer in the trafficking victim. According to the medical encyclopedia in the U.S. National Library of Medicine (1), cancer is “the uncontrolled growth of abnormal cells in the body. Cancerous cells are also called malignant cells.”
The Federal Trafficking Victims Protection Act (TVPA) defines the crime of trafficking as: The recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act where such an act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age.
The Polaris Project website (2) offers the following broader description of human trafficking:
Human trafficking is a form of modern-day slavery where people profit from the control and exploitation of others. As defined under U.S. federal law, victims of human trafficking include children involved in the sex trade, adults age 18 or over who are coerced or deceived into commercial sex acts, and anyone forced into different forms of "labor or services," such as domestic workers held in a home, or farm-workers forced to labor against their will. The factors that each of these situations have in common are elements of force, fraud, or coercion that are used to control people. Then, that control is tied to inducing someone into commercial sex acts, or labor or services.
Regardless of specific details, an individual unfortunate enough to fall victim to a predator who then exploits their vulnerability has their life either interrupted or stolen. Due to the covert nature of trafficking, it is difficult to determine the number of victims (sex trafficking, labor trafficking, even organ trafficking). Drug trafficking will not be specifically addressed in this article, though if we were to look at the health risks when individuals are forced to transport drugs in their body cavities as “mules,” the potential consequences are enormous. Free the Slaves (3) estimates 21-30 million slaves are in the world today.
Once held captive, a person’s human rights are disregarded. Victims of human trafficking are denied fair wages, health care, education and basic needs for food, rest, clothing, shelter and social interaction. Exposure to diseases, infections, fatigue, torture, restraint and isolation become their way of life (6,8).
The human cost of trafficking is as difficult to calculate as the prevalence of trafficking. Victims are “hidden.” Labor trafficking is often ignored by society and sex trafficking in the form of sex tourism is fostered by society. Victims are conditioned to remain silent through fear, fraud and coercion. The conditioning can be brutal in every way. Victims are “initiated” by beatings, sexual assaults, deprivation of basic needs (food, sleep) and forced ingestion of drugs and alcohol. The threat of being killed is ever present. Trafficking in all forms succeeds by depriving the victim of any hope for rescue, as well as by fostering the psychological adaptation consistent with learned helplessness and surrender to the perceived lack of any rescue as in the Stockholm Syndrome (4). Any attempts at escape bring dire consequences to the victim. Threats to a victim’s family members, along with actual victimization of other captives, provide horrific evidence of the consequences of “running”(5).
The sexual exploitation of children is especially egregious and carries with it similar mental health and physical consequences that may continue for years with little or no intervention. When the victim of human trafficking is a child, it is essential to consider the victim’s culture, poverty status and stage of growth and development. The exposure to early and unwanted pregnancies is a continuous risk, whether a child or adult victim, as the use of contraception is rarely allowed. Illegal abortions, with serious consequences including sepsis and a ruptured uterus, may occur. Frequent sexual partners increase the risk of sexually transmitted infections in both male and female victims, as well as the risk for development of rectal or cervical cancer (6).
There is generally a total lack of any concern for a victim regarding disease prevention. Inadequate hygiene and an unhealthy, restrictive environment prevent recommended health promotion measures. A victim may ignore any signs of illness or trauma since he or she has learned to disregard oneself as important and deserving of care. Medical care may be unavailable until the victim is rescued or, if still held captive, until the progression of a disease is such that it is a question of obtaining health care intervention or dealing with a victim’s death.
The prevailing climate of fear and terror results in suppression of the immune system and increased inability to fight infection and disease (9,10). It is beyond the scope of this article to discuss in depth the trauma that the victim is exposed to (i.e., initial period of victimization related to direct maltreatment by the perpetrator and ongoing trauma experienced as a result of the daily fear, coercion, and forced hard labor or sexual encounters). Labor trafficking is as damaging to the health of the victim as is sex trafficking, due to the use of noxious substances and long and enduring work. The “mask” that trafficking victims must wear to hide their forced situation, to please a customer or employer, to appear seductive and participative during sexual acts, takes a toll and increases the risk of mental health disorders and ultimately the development of acute and chronic diseases (e.g., cancer).
The development of cancer as related to human trafficking may not be an immediate consideration post-rescue or when a victim is allowed to seek medical care. Therefore, the responsibility of the health care provider is more important then ever. Diagnosing cancer can be a tedious and painstaking task. In addition, cancer is a terrifying diagnosis for the patient and may reactivate loss-of-control feelings similar to those experienced while being trafficked. Often, the assessment and diagnosis of cancer are avoided by those who have never been victims of human trafficking; imagine the additional factors involved when working with a victim or survivor of human trafficking!
The initial assessment must include in-depth interviewing, which can be challenging. The first contact with a victim of human trafficking can open (or shut) the door for meaningful assessment in future health care encounters. The provider needs to determine if his or her patient is or was a victim of human trafficking. As stated by Issac, Solak and Giardino and referred to in the Arizona State University School of Social Work–Office of Sex Trafficking Intervention Research publication (7), health care providers may be one of the few professionals who interact with victims while they are still under the control of their abuser or the person profiting from their abuse.
The following are essential considerations:
Victim status (Is he/she still a captive or “free of the life?”)
Follow-up visits (Be sure to schedule regardless of victim status)
Future access to health care (transportation, control of time, freedom, etc.)
Victims have no reason to trust “the system” as any system can be a ploy to gain trust and then destroy that trust in one fell swoop. Thinking of a survivor of human trafficking as a person who is now “free” is inaccurate and can cloud assessment—it is in the aftermath that the full impact of one’s captivity may be experienced and the survivor may become very symptomatic. Perhaps we need to think of rescue as simply a first step toward recovery rather than the final outcome of all the diligent efforts exerted to liberate that person.
The following notes are a result of our review of data regarding the health consequences of human trafficking (11, 12, 13).
1. We found no data or studies that specifically link cancer with human trafficking. However, long-term sequelae of human trafficking may result in increased risk for developing cancer either during or post-trafficking:
Substance abuse (stomach, liver, colon and oral/throat cancer)
Abortions (cervical and uterine cancer)
First pregnancy after age 33 (breast cancer)
Undiagnosed or untreated infections (multiple types of cancer)
Oral abuse and poor dental care (oral and throat cancer)
Anal abuse (colorectal cancer)
2. We recognize that there are “two roads to cancer development” for victims of human trafficking:
Childhood trafficking resulting in the development of adulthood cancer
Adulthood trafficking resulting in the development of adulthood cancer
3. Health care providers need to address the link between cancer and human trafficking by:
Understanding that adverse childhood experiences (specifically sex and labor trafficking) can lead to an adult diagnosis of cancer.
Keeping in mind that the cause of cancer is usually multifactorial and that cancer growth or progression is often insidious and slow.
Acknowledging that adult cancer could result from either:
i.Childhood human trafficking; or
ii.Unhealthy behaviors in adulthood in response to being trafficked as a child
Recognizing there are other adulthood mediating factors – unrelated to a history of being trafficked – that may contribute to the development of cancer.
4. Further vigorous research is needed to address these unknowns related to the development of cancer in patients who were trafficked as children:
Potentially confounding variables in the development of cancer.
Possible culture-specific differences in the development of cancer as linked to history of human trafficking.
Which came first as the cause of cancer?
i.Childhood human trafficking
ii.Adult unhealthy (cancer-related) behaviors as a result of childhood human trafficking
In our search of the literature as well as through interviews with medical colleagues (primary care, obstetrics and gynecology, pediatricians), we found no broad, in-depth assessment for the possibility of cancer as a direct result of human trafficking, regardless of whether it was sex or labor trafficking. There seems to be no routine index of suspicion for a history of human trafficking on the part of health care providers when confronted with signs and symptoms related to impaired mental health, substance abuse (including alcoholism), HIV or other sexually-transmitted diseases, abortions – whether or not legally obtained – and associated infections, or dental and oral/throat conditions.
Health care professionals may be the first contact as well as the first ray of hope for rescue. Violence-related injuries might be the only focus for the acute-care examiner, and serious illness or injury may blur the need for cancer screening. If the person is still not free and the reason for the health care visit is seen as acute care only, additional screening may not occur. Although no data was found that specifically linked the development of cancer and human trafficking, we strongly suggest that the development of extensive, specific and comprehensive medical protocols needs to be seen as a priority.
“We will invest in helping trafficking victims rebuild their lives.”
–U.S. President Barack Obama, December 31, 2012
The caged bird sings
with a fearful trill
of things unknown
but longed for still
and his tune is heard
on the distant hill
for the caged bird
sings of freedom.
–Maya Angelou, “Caged Bird”, 1983
About the Authors
Barbara Moynihan, Ph.D., A.P.R.N., B.C., A.F.N., F.A.A.N. is a Professor Emerita of Nursing of Quinnipiac University in Hamden, Connecticut.
Dr. Moynihan is one of the pioneers of forensic nursing. She collaborated with a core group of expert nurses to develop the domains and performance measures that led to the designation of forensic nursing as a stand-alone area of specialization. Through her efforts over the past several decades, Dr. Moynihan has solidified the nurse’s critical role in identifying and addressing significant gaps in services and resources available to victims of Interpersonal Violence (IPV).
While working as the Nursing Director of the Emergency Department at Yale New Haven Hospital, Dr. Moynihan developed the first hospital-based rape counseling unit in Connecticut. She also served on the task force that drafted the Connecticut Technical Guidelines for Health Care Response to Victims of Sexual Assault. This document remains the “gold standard” for interventions with sexual assault victims in Connecticut.
Dr. Moynihan co-authored Forensic Nursing: A Handbook for Practice, now in its second printing and endorsed by Vice President Joseph Biden. Most recently, she has partnered with health officials in Nicaragua and Barbados to expand services to victims of interpersonal violence and human trafficking. Dr. Moynihan is also working with a multidisciplinary group of professionals from the U.S. and abroad to centralize resources on human trafficking.
Currently, Dr. Moynihan serves as a Practitioner in Residence for the Department of Forensic Science at the University of New Haven in West Haven, Connecticut. She is also the founder and director of The STARfish Project, a grassroots organization dedicated to fighting human trafficking and educating health care professionals on the issue of modern-day slavery.
Dr. Moynihan received her R.N. from Worcester City Hospital School of Nursing, her B.S. and M.S.N. degrees from Southern Connecticut State University, and her Ph.D. from the University of Connecticut.
Katherine Olive, M.H.S.A., B.S.N., R.N. is the director of clinical services at Kliman Laboratories at Yale University in New Haven, Connecticut and an adjunct clinical faculty member at Quinnipiac University in Hamden, Connecticut. Ms. Olive has worked as a nurse in various areas of health care, including geriatric, maternal-child, community and home care. She is the assistant director of The STARfish Project, a grassroots organization dedicated to fighting human trafficking and educating health care professionals on the issue of modern-day slavery.
Ms. Olive received her R.N. from Evanston Hospital School of Nursing, B.S.N. from Northwestern University, and M.H.S.A. from the University of Arkansas - Little Rock.
[1.] U.S. National Library of Medicine. Retrieved August 2014 from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002267/]
[2.] Polaris Project. Retrieved July 2014, from http://www.polarisproject.org/human-trafficking/overview
[3.] Free the Slaves. Retrieved August 2014 from https://www.freetheslaves.net
[4.] "Stockholm Syndrome." Merriam-Webster.com. Merriam-Webster, n.d. Web. 17 Aug. 2014. http://www.merriam-webster.com/dictionary/Stockholmsyndrome
[5.] Federal Strategic Action Plan on Services for Victims of Human Trafficking in the United States 2013-2017. Developed by the U.S. Departments of Justice, Health and Human Services, and Homeland Security. January 2014.
[6.] The Health Risks and Consequences of Trafficking in Women and Adolescents–Findings from a European Study. London School of Hygiene & Tropical Medicine. 2003. Available from https://www.lshtm.ac.uk
[7.] Training Tool for Health Care Providers. Arizona State University School of Social Work–Office of Sex Trafficking Intervention Research. 2013.Training Manual To Fight Trafficking In Children For Labour, Sexual And Other Forms Of Exploitation. UNICEF. 2009
[8.] Trafficking in Persons as a Human Right Issue. Federal Ministry for Economic Cooperation and Development. June 2008. Available from www.gtz.de/gender
[9.] Sabella, D. (2012). Health Issues and Interactions With Adult Survivors In Mary De Chesnay (Ed.), Sex Trafficking: A Clinical Guide for Nurses (pp. 3–21). New York, NY: Springer Publishing Company.
[10.] Dhabhar, F.S. (2008). Enhancing versus Suppressive Effects of Stress on Immune Function: Implications for Immunoprotection versus Immunopathology. Allergy Asthma Clinical Immunology, 4(1): 2–11. PMC2869337
[11.] Lederer, Laura J. and Wetzel, Christopher A.: The Health Consequences of Sex Trafficking and Their Implications for identifying Victims in Health care Facilities. Annals of Health Law, Loyola University. Chicago, IL. Winter 2014 23(1): 61.
[12.] Kelly-Irving et al.: Childhood adversity as a risk for cancer: findings from the 1958 British birth cohort study. BMC Public Health 2013 13:767.
[13.] Brown MJ, Thacker LR, Cohen SA (2013) Association between Adverse Childhood Experiences and Diagnosis of Cancer. PLoS ONE 8(6): e65524. doi:10.1371/journal.pone.0065524
National Human Trafficking Resource Center 1-888-3737-888
National Center for Missing and Exploited Children 1-800-THE-LOST (1-800-843-5678)