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Author Contributions: Drs Hadland and Barocas were co—senior authors. Dr Bagley had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Critical revision of the manuscript for important intellectual content: Bagley, Gai, Earlywine, Schoenberger, Hadland. Administrative, technical, or material support: Bagley, Earlywine, Schoenberger, Hadland. King Trust Dr Barocas.

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Read terms. Victims of trafficking have been found in a wide range of legal and illegal business settings, and this frequently hidden population is most often exploited in the commercial sex industry, agriculture, factories, hotels, restaurants, as domestic workers, and by marriage brokers and some adoption firms. Obstetrician—gynecologists and other women's health care providers are well-situated to identify and assist victims of human trafficking. Many trafficked individuals present to outpatient obstetrics and gynecology clinics, community health centers, family planning clinics, urgent care centers, and adolescent medicine clinics, and one half of all female victims of sex trafficking have visited the Wives seeking real sex MA Boston 2109 department while involved in sex trafficking.

Obstetrician—gynecologists and other women's health care providers should be aware of human trafficking, recognize s of human trafficking, and be prepared to assist patients who are victims or who have been victims of human trafficking. This Committee Opinion has been updated to include screening questions and indicators to identify victims of human trafficking, additional information regarding reporting obligations for suspected human trafficking, and additional resources for survivors of human trafficking.

The American College of Obstetricians and Gynecologists makes the following recommendations to improve awareness of the s of human trafficking and to prepare obstetrician—gynecologists and other women's health care providers to take action: Recognize indicators of human trafficking, such as patients with s of abuse or neglect or those accompanied by an individual who does not let the patient speak for themselves, refuses to allow for privacy, or insists on interpreting for them in place of a professional.

Become well-informed about common health care issues faced by victims of human trafficking, including sexually transmitted infections, substance use disorders, mental health problems, and physical trauma. Evaluate a patient's medical and nonmedical needs while recognizing the importance of providing a safe and comfortable environment for the patient, using appropriate methods of communication, and acknowledging the dynamics involved in evaluating a patient who is subject to human trafficking.

Be aware of the laws in your jurisdiction regarding reporting obligations for suspected human trafficking, with specific attention to mandatory reporting requirements for child abuse. Provide resources for survivors of human trafficking, including brochures, pamphlets, and pocket cards displayed in examination rooms, waiting rooms, or, more discretely, in bathrooms in addition to contact information for organizations and resources that can support survivors.

Human Wives seeking real sex MA Boston 2109, or modern-day slavery, is a global problem with broad reach that is often underrecognized in the United States. The International Labor Organization estimates that 25 million individuals around the world are victims of modern slavery in the form of forced labor and sex trafficking 1. The United States is not immune, and the Global Slavery Index estimates that on any given day, more thanindividuals in the United States are living in conditions of modern slavery, a prevalence of 1.

The profit gained from human trafficking and the ability to evade law enforcement make human trafficking a difficult problem to address. It is important to note that these estimates for global and domestic human trafficking have been criticized and questioned, and that data regarding illegal activity is difficult to collect 4 5.

However, these estimates are widely used by government agencies and others to quantify the prevalence and effect of human trafficking 4 5. It takes the form of forced labor, bonded labor, debt bondage among migrant workers, involuntary domestic servitude, and sex trafficking.

Victims of trafficking have been found in a wide range of legal and illegal business settings, and this frequently hidden population is most often exploited in the commercial sex industry, agriculture, factories, hotels, restaurants, as domestic workers, and by marriage brokers and some adoption firms 7. Sex trafficking is a form of human trafficking in which a commercial sex act is induced by force, fraud, or coercion.

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Minors engaged in the commercial sex industry eg, online and street prostitution, pornography, stripping, escort services are considered victims of human trafficking regardless of the use of force, fraud, or coercion 6. Trafficking of children most commonly takes the form of forced child labor, child soldiers, and child sex trafficking.

Human trafficking and human smuggling are not the same and often are confused.

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Trafficking is based on exploitation of an individual whereas smuggling is the importation of individuals with deliberate evasion of immigration laws 8. However, individuals smuggled into the country are at risk of becoming victims of human trafficking because fear of deportation, economic hardship, and limited language proficiency can be used to exploit them.

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Individuals who are trafficked are diverse. No racial or ethnic group is spared, nor is any community immune to this problem. Vulnerable individuals, including those from politically or geographically unstable areas abroad or economically disadvantaged areas globally and within the United States, are at greater risk. Migrants, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and gender nonconforming individuals, those who are isolated from support networks, and survivors of violence and trauma are also at increased risk 2.

Trafficking may be perpetrated by organized crime, individuals, or both. Traffickers in the United States and abroad manipulate and exploit those who are vulnerable. Traffickers may make physical threats against the trafficked individual and their family, may pose as a loved one to gain initial trust, and may take away passports and other essential documentation from victims. As in other cases of abuse, it becomes very difficult to come forward and to escape trafficking once involved in this abusive relationship. Victims often experience self-blame and shame that prevent them from seeking help.

Traffickers manipulate and reinforce these feelings.

Isolation and internalized propaganda often make victims distrust law enforcement and other authorities 9. Understanding force, fraud, and coercion as management tools used by traffickers will help health care providers understand why so few victims escape, why they are difficult to identify, and why it is challenging to find evidence of force, fraud, or coercion. Methods of power and control include both abusive and threatening behavior. Used constantly and unexpectedly, the goal is to violate personhood and render the trafficked person powerless.

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Children and adolescents at particular risk for human trafficking have a history of sexual abuse, are homeless or runaways, are in foster care, or have been in the juvenile justice system One in three adolescents living on the street is recruited for sexual exploitation within 48 hours of becoming homeless Children are typically targeted at arcades, malls, or bus stations Several barriers prevent the identification of children and adolescents involved in human and sex trafficking.

They are less likely to understand that exploitation is abnormal, and may believe their victimization is their own fault. Children and adolescents separated from families because of trafficking or who are being trafficked by family members experience psychologic distress.

All victims, particularly children, have Wives seeking real sex MA Boston 2109 explaining and describing their experience to law enforcement. Reporting child abuse is mandatory. Many trafficked individuals present to outpatient obstetrics and gynecology clinics, community health centers, family planning clinics, urgent care centers, and adolescent medicine clinics, and one half of all female victims of sex trafficking have visited the emergency department while involved in sex trafficking 14 15 These visits to health care providers may be one of few opportunities for a victim of human trafficking to speak to outsiders and are an important chance to intervene.

The International Classification of Diseases, Tenth Revision codes on human trafficking released in help clinicians think about trafficking during clinical encounters, and they indicate that trafficking is a concrete medical diagnosis Recognition is the first step in helping victims. Obstetrician—gynecologists and other women's health care providers should become well-informed about common health care issues faced by victims of human trafficking, including sexually transmitted infections, substance use disorders, mental health problems, and physical trauma Organizations knowledgeable about human trafficking have gathered indicators to help health care providers recognize possible victims of human trafficking Box 1.

Obstetrician—gynecologists and other women's health care providers should recognize indicators of human trafficking, such as patients with s of abuse or neglect or those accompanied by an individual who does not let the patient speak for themselves, refuses to allow for privacy, or insists on interpreting for them in place of a professional.

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Also, obstetrician—gynecologists and other women's health care providers should be suspicious if patients are accompanied by someone who is controlling and insists on answering questions for them. These questions should be asked when the patient is alone, and suspicions should not be raised when attempting to isolate the victim from her potential abuser.

Suggested questions that help identify suspected human trafficking are listed in Box 2. Accompanied by an individual who does not let the patient speak for themselves, refuses to allow for privacy, or who insists on interpreting for them. Evidence of controlling or dominating relationships excessive concerns about pleasing a family member, romantic partner, or employer.

Modified from Office on Trafficking in Persons. Adult human trafficking screening toolkit and guide. Washington, DC: U. S Department of Health and Human Services; Have you ever experienced this, or are you in a situation where you think this could happen? Sometimes individuals make efforts to repay an individual who provided them with transportation, a place to stay, money, or something else they needed. The individual they owe money to may require them to do things if they have difficulty paying because of the debt.

Have you ever experienced this, or are you in a situation in which you think this could happen? Wives seeking real sex MA Boston 2109 individuals do unfair, unsafe, or even dangerous work or stay in a dangerous situation because if they don't, someone might hurt them or someone they love.

Sometimes individuals are not allowed to keep their own identification or travel documents. Sometimes individuals work for someone or spend time with someone who does not let them contact their family, spend time with their friends, or go where they want when they want.

Human trafficking

Sometimes individuals are told to lie about their situation, including the kind of work they do. Sometimes individuals are hurt or threatened, or threats are made to their family or loved ones, or they are forced to do things they do not want to do in order to make money for someone else or to pay off a debt to them.

In addition to awareness of potential s of trafficking, interviewing possible victims in private, maintaining cultural sensitivity, and building trust are all key in identification and counseling of victims. Obstetrician—gynecologists and other women's health care providers should evaluate Wives seeking real sex MA Boston 2109 patient's medical and nonmedical needs while recognizing the importance of providing a safe and comfortable environment for the patient, using appropriate methods of communication, and acknowledging the dynamics involved in evaluating a patient who is subject to human trafficking.

When assessingadolescent, or woman as a potential victim of human trafficking, it is important to conduct the assessment in a safe, calm, and comfortable environment using the following techniques 19 20 : Demonstrate approachable, relaxed body language. Health care providers may be uncomfortable asking patients about trafficking because they are not sure how to help.

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They can offer victims the necessary support, referrals, and resources to escape their situation see the For More Information section. Obstetrician—gynecologists and other women's health care providers should be aware of the resources available, both local and national, to assist in identifying patient needs, and provide referrals for support services They should never directly confront a trafficker or otherwise put themselves or staff in danger.

Obstetrician—gynecologists and other health care providers should provide resources for survivors of human trafficking, including brochures, pamphlets, and pocket cards displayed in examination rooms, waiting rooms, or, more discretely, in bathrooms in addition to contact information for organizations and resources that can support survivors. Laws on mandatory reporting vary by jurisdiction.