Modern Slavery In Healthcare Settings: Indicators and Recommendations

An estimated 49.6 million people live in conditions of modern-day slavery, the most common forms of which are forced labour, domestic servitude, forced sexual exploitation of adults and commercial sexual exploitation of children, forced criminal exploitation, and forced marriage.

The best estimate for the number of victims in the UK is 122,000, though the nature of the crime means that far fewer people are actually identified and supported each year. For example, in 2022, the last full year with available statistics, 16,938 potential victims of modern slavery were identified and reported via the UK Government’s ‘National Referral Mechanism’ system (547 of them in Northern Ireland). This was a 33% rise on the previous year’s figure, continuing a nearly uninterrupted trend of annual rises since the current system launched in 2009. There were also 4,580 potential victims in 2022 referred via the separate ‘Duty to Notify’ process.

Under the UK’s Modern Slavery Act 2015, modern slavery is an umbrella term encompassing the offences of slavery, servitude and forced or compulsory labour, and human trafficking. In practical terms, it means a person being controlled by another, usually through threats, violence, manipulation, deception and/or coercion. The exploiter’s aim is usually financial profit, but it may also include sexual gratification or acting in line with a perceived cultural belief.

Human trafficking is distinct from people smuggling. While the terms are sometimes used interchangeably by journalists and politicians, they are not synonymous. Human trafficking is when someone is moved within a country or across a border specifically for the purposes of exploitation, and is a crime against a person, not the state.

Interaction With Health Systems

The nature of modern slavery means that victims are kept far away from the authorities and possible support systems. They may not present as (nor think of themselves as) ‘victims’ and will often feel an obligation towards their trafficker or appear completely dependent on them. As such, healthcare practitioners can be among the professionals most likely to come into contact with victims. They should therefore be trained in, and familiar with, the common indicators.

This means being aware of a vulnerable patient’s presenting health condition, underlying health conditions, the impact of trauma, socio-economic background, and a possibly fragile conversation shaped by their experiences.

The vulnerable patient may only be present for a single episode of care and may fear reprisals from the trafficker and have a misplaced fear of the authorities and professionals. They may have been told they are a criminal (or have been forced to commit a crime and be being blackmailed) or told they will be deported. Some traffickers tell their victims that the authorities are corrupt and not to be trusted.

Victims of modern slavery will often lack access to their own documentation and connections to other services. A common scenario is that a victim is accompanied by a ‘helpful’ companion who will claim to be a friend or family member or intimate partner and will speak for them or claim to be interpreting. They will try to prevent the victim having time on their own with any professionals. They will have a scripted story or will have given the victim one to share, disguising the true cause.

Signs And Indicators

These are summarised in table 1. Victims often present as unkempt with untreated conditions and evidence of long-term multiple injuries, especially in the case of forced labour.

Selected physical symptoms associated with modern slavery victims

Other signs potentially indicative of modern slavery victims

• Sexually transmitted infections • Disordered eating or poor nutrition • Self-harm • Dental pain • Fatigue • Back pain • Stomach pain • Skin problems • Headaches and dizzy spells • Pelvic inflammation

• Not speaking the local language • Sound as if they have been coached, or someone speaking on their behalf • Inconsistencies with names, dates, addresses; vague medical history • Poor quality or ripped/torn clothing, general unkempt appearance • No registration with local services • Moving town or country frequently • Delaying seeking treatment • Little knowledge about the UK or their community • Tattoos or marks indicating ownership

There can be indications of mental, physical and sexual trauma, sexually transmitted infections, disordered eating or poor nutrition, and evidence of self-harm, dental pain or fatigue. Back pain, stomach pain, skin problems, headaches and dizzy spells are all common, as are generalised fear, anxiety and depression.

Systemic indicators include not speaking the local language; inconsistencies with names, dates, addresses and similar; no registration with local services; moving town or country frequently; delaying seeking treatment; and giving vague answers on medical history. While a reluctance to share personal details is more common, other victims may be emotional and raise concerns about their family or dependents. This is because many trafficking situations begin with an attempt to provide for family either in the UK or home country, and sometimes threats against family members are used by traffickers as a form of control.

The patient may have a lack of knowledge about the UK or the community where they now live. They often do not know their rights, and if they are not a British national, they may be vague about their immigration status or background. If they are alone, they may speak as if they have been coached on what to say.

Less common indicators include tattoos or other marks indicating ownership by exploiters.

For female victims who have been subject to sexual exploitation, common indicators include STIs, urinary or vaginal infections, pelvic inflammation, pregnancy or a recent forced termination. Indicators specific to pregnant woman can include late booking, non-attendance at appointments, poor preparation for the impending birth, presenting with non-specific symptoms, no GP, poor or no antenatal care and few personal effects.

One systematic review found that 63% of female victims of human trafficking had more than 10 concurrent health problems, and 39% had suicidal thoughts.

Trauma

Consider too the symptoms of complex trauma, which might come from a combination of their modern slavery experience and a pre-existing vulnerability or condition. This can include distrust or hostility, disproportionate responses, survival compliance, self-blame or shame, lack of recall of some incidents, and providing inconsistent information.

Trauma can also be induced by factors that are more likely to be experienced by trafficking victims compared to the general population, including injuries sustained through violence; exposure to infectious diseases; prolonged and repetitive physical, sexual and/or psychological abuse; chronic deprivation of food, sleep, medicine and safe shelter; and prolonged exposure to workplace hazards like poor ventilation and sanitation, chemicals, bacterial airborne contaminants, dangerous machinery, or a lack of protective equipment. Closely monitor the impact of your questions and be sensitive to indications like hypervigilance, mistrust, anxiety, numbing, or a dissociative state.

One study found that 78% of women and 40% of men who had been trafficked experienced high levels of depression, anxiety and post-traumatic stress symptoms. A US study found similar results: 71% of people trafficked had high rates of depression and 61% had Complex PTSD.

Also note that the vulnerable patient’s worldview may inhibit engagement, due to their socio-economic background, experience of war, poverty or political unrest, or cultural motivators, shame or other beliefs. Traffickers twist these views with their toxic input, causing a traumatic clash for the victim, signified by avoidance of certain thoughts, a heightened sense of threat, and a loss of regulating emotion. When a person is distressed, confused, and distrustful of efforts to help, this can obstruct constructive engagement with authorities or support services, and complicate responses.

Other Barriers To Disclosure

The victim may be unwilling to disclose details of their experience for other reasons too, mostly centred on lack of awareness or agreement that they are in fact a victim.

Examples include dependency or ‘Stockholm syndrome’ with a false emotional or psychological attachment. Some may tolerate their situation because they see it as a stepping stone to a better future and compare it favourably to imagined alternatives or a chaotic/neglected upbringing. They may see their situation as a temporary ‘bad job’ rather than long-term exploitative trap. Others believe their traffickers’ lies about the help they have been given and feel a real sense of obligation to repay them, financially and in other ways. Children may feel they are responsible for earning money for their family – they may see an exploitative situation as a sacrifice they are choosing to make.

Less commonly, some victims may believe they are under control through juju or witchcraft.

Methods Of Control

Members of the public first learning about victims of modern slavery often ask: ‘If they are not locked up, why do they not run away?’ This question is worth answering.

Traffickers gain and exert control using psychological and emotional manipulation, sometimes coupled with physical abuse and (rarely) locks and restraints.

Common methods include threats, beatings, violence, and sometimes death threats and threats against family members. Sometimes violence is meted out ‘for show’ against one victim in a household or group, as an example to the others of what could happen to them. Alternatively, small amounts of money and power can be given to certain victims in a group who are told they are ‘soldiers’ or ‘alphas’ tasked with controlling and reporting on the others, fostering paranoia and compliance.

Playing on a victim’s sense of shame is a frequent method of control, for example threatening to reveal the truth of their situation to family members, especially but not solely in the case of sexual exploitation. It is common that victims will want to hide the truth of their powerlessness from their families.

Financial control is extremely common. Grand promises are made and transport and accommodation are often provided for free or at a large discount at first, but as the exploitation deepens, the victim is told this was a debt all along, often alongside a finder’s fee for the employment. This is usually a spurious debt that only ever grows (known as ‘debt bondage’). The trafficker will control what and how the victim is paid, if anything, whether cash-in-hand or by controlling the address and cards associated with a bank account. This functions as another way to exert dominance, by offering occasional small sums of money from what should be a victim’s own account.

Addiction is used as a tool, with the trafficker becoming the main source of a victim’s alcohol, drugs or tobacco to fuel their habit and keep them compliant.

In rarer cases (in a UK context) debt bondage may have been passed down multiple generations, or a victim may feel ‘bound’ to their trafficker through the use of a ritual oath.

Recommendations For The Healthcare Professional

If you recognise indicators of modern slavery or believe a patient may have been trafficked, you should seek to maximise the encounter, offering as much care as possible – including other services. Respond in a non-judgmental way, be reassuring and make clear that it is safe for them to speak. The victim may find it difficult to remember details or make decisions, so allow them time to share their experiences.

Try to find out more about the situation and speak to the person in private without anyone who accompanied them. Keep your questions broad and open-ended, as these can encourage the potential victim to go off-script and bring up inconsistencies or warning signs. Examples of questions that have helped lead to a victim being identified are listed in table “ and include:

Suggested questions for healthcare professionals to use during a consultation with someone displaying indicators of modern slavery:

• “Please describe how much you are in control of your choices.”

• “You look very pale, can you tell me about your diet? What have you eaten over the last week?”

• “Can you tell me about your home and bedroom? Are you sharing with others?”

• “Can you tell me more about your work and the place where you were injured?”

• “Is this the first time or do you have other injuries?”

• “You are coughing a lot. I need to know about your home situation.”

• “Can you leave your job or situation if you want to? Please describe what could happen to you if you left.”

“Please describe how much you are in control of your choices.”

“You look very pale, can you tell me about your diet? What have you eaten over the last week?”

“Can you tell me about your home and bedroom? Are you sharing with others?”

“Can you tell me more about your work and the place where you were injured?”

“Is this the first time or do you have other injuries?”

“You are coughing a lot. I need to know about your home situation.”

“Can you leave your job or situation if you want? Please describe what could happen to you if you left.”

Treat any immediate physical or medical conditions and ascertain whether the patient wishes to report to the police. Self-referral for a forensic medical examination without having to report to the police allows victims to have forensic evidence stored, in case they wish to report at a later date. Avoid calling the police or immigration services unless you have the informed consent of the patient or where the threat of danger to the patient or others is such that you need to do so. Do not make promises you cannot keep about what will happen next.

Limit invasive examination and assess the need for further testing in the case of STIs and/or pregnancy.

Offer as much information as possible about their health condition and treatment. Ensure they know they can access health services freely and provide information on support services. Be discreet if necessary, for example by offering helpline numbers on small slips of paper that can be hidden in clothing, rather than leaflets or brochures. If applicable and possible, provide a complete regime of prescribed medication in that single encounter, on the assumption they will not return for follow-up treatment and assessment.

Some victims or traffickers may imply that something about their situation is a cultural practice or something that a UK healthcare professional would not understand or be familiar with. Do not let this prevent you from making an informed assessment about their safety and what to do next.

Speak to your manager, colleagues or local safeguarding leads for support and advice.

Wider recommendations include pushing for modern slavery and human trafficking training at your organisation, seeking collaborations with partner organisations on this issue (statutory or non-governmental organisations) or joining a regional Anti-Slavery Partnership if one exists.

Case Study.

Kambili (name changed) was tricked into leaving his home country in West Africa by two men who made false promises and pretended they wanted to help him. Kambili was at a vulnerable point, having become separated from his wife and three children during conflict and fighting.

The traffickers promised Kambili safety and work in the UK and to pay for his transport, so he accepted. But when he arrived, they took away his ID, housed him in a crowded room and left him for five days without food. He was then subjected to forced labour for seven years, working on farms, often for 14 hours a day, and receiving no pay. He was trafficked internally all around the UK, and regularly threatened or beaten by his abusers. Kambili was also sexually abused.

When Kambili was injured at work, the situation was impossible to ignore and the trafficker took him to get medical attention. The medical worker recognised several indicators of modern-day slavery and managed to speak to Kambili alone without the trafficker. He was safeguarded and later entered into the National Referral Mechanism, with help from anti-trafficking charity Hope for Justice.

For Advice Or To Report A Concern

Modern Slavery Helpline (24/7) 0800 012 1700 help@hopeforjustice.org

About Hope For Justice

Hope for Justice is an anti-trafficking charity that was founded in the UK in 2008, and which now works internationally. Its programmes reach approximately 200,000 people each year, across four pillars of work: preventing exploitation, rescuing victims, restoring lives and reforming society. Hope for Justice has a wholly owned social enterprise, Slave-Free Alliance, which provides services to companies and public bodies seeking to protect their operations and supply chains against the risks of modern slavery and labour exploitation.