Clinical and Advocacy Implications of the Dobbs vs. Jackson Women's Health Organization Ruling on Trafficked Persons

Abstract

The United States Supreme Court decision on the case of Dobbs vs. Jackson Women's Health Organization abolished federal protections of abortion, leaving abortion legislation at the discretion of individual states. Trafficked persons are a population especially vulnerable to the impacts of this ruling. Because there is no existing literature describing the effects of restrictive abortion legislation on this group, we described some of the potential consequences of restrictive abortion laws for sex and labor trafficked persons, based on real case examples. We describe steps that should be taken to sufficiently protect and support pregnant trafficked women in relation to the Dobbs law.

Keywords

human trafficking sex trafficking abortion restrictive abortion laws

Introduction

In June of 2022, the United States Supreme Court issued a ruling on the case of Dobbs vs. Jackson Women's Health Organization, eliminating the federal constitutional right to abortion (Supreme Court of the United States, 2022). This judgment reversed the landmark 1973 case of Roe vs. Wade, which had previously protected pregnant persons’ fundamental, individual liberty to terminate a pregnancy with the supervision of a physician. The ramifications of this decision were immediate and far-reaching, freeing states to enforce unrepealed pre-Roe bans, implement previously unenforceable trigger bans, and enact legislation criminalizing, restricting, or outright banning abortions. In the aftermath of this decision, 12 states definitively banned abortion, and select states have banned abortion after specific gestational ages, ranging from 6 to 22 weeks (Guttmacher Institute, 2023a). Notably, 10 of the most highly restrictive states make no exceptions in their abortion bans for rape, incest, or forced pregnancy, placing victims of sexual violence in a harrowing position. Their plight draws focus to a distinctly vulnerable population in the post-Dobbs era: survivors of human trafficking.

Human trafficking refers to the “recruitment, transportation, transfer, harboring or receipt of people through force, fraud or deception with the aim of exploiting them for profit” (United Nations, 2022). Women and girls are disproportionately trafficked for sexual exploitation, accounting for 99% of sex-trafficked persons and 71% of total trafficked persons globally (International Labor Organization, 2017). Female trafficked persons are frequently subjected to disproportionate violence, sexual abuse, psychological, and reproductive coercion (Baldwin et al., 2015; Reid, 2016). Risk of unwanted pregnancy is heightened in this population, with many survivors citing limited control over contraception use in combination with numerous sexual partners (Bick et al., 2017; Kelly et al., 2019; Lederer & Wetzel, 2014), up to 35 a day in one report (Freedom Network USA, 2015).

Because of these factors, we set out to describe some of the potential implications of restrictive abortion laws, now more prevalent post-Dobbs, for trafficked persons. To this end, we briefly present six cases, based on the experiences of patients in our own human trafficking program as illustrative of potential clinical challenges post-Dobbs. We describe the roles of physicians, healthcare providers, and medical organizations as advocates for this vulnerable population.

Methods

The authors reviewed approximately 100 cases of trafficked patients identified by our institution's anti-human trafficking program since the passing of Senate Bill 8 and the Dobbs ruling. The patients were based in the state of Texas, which passed Senate Bill 8 in advance of the Dobbs ruling, prohibiting abortion after documentation of a fetal heartbeat and imposing statutory damages on those who perform or induce an abortion (Texas Health and Safety Code, 2021). Broad criteria for case selection included individuals who identified as female who had been trafficked for sex or labor, who experienced an unwanted pregnancy, and who were denied abortion or were restricted in their access to abortions during pregnancy. The cases were selected to represent the variety of types of clinical challenges that providers may encounter when working with trafficked persons. Three of the authors selected the convenience sample and all three agreed that six cases met the inclusion criteria. All patients’ demographic details have been altered in order to anonymize them.

Case Examples

Case 1

A 19-year-old pregnant White female was brought into the emergency room with uterine bleeding and hemodynamic instability (lack of adequate blood flow required to perfuse the body's organs). On a gynecological examination, she was found to have a septic abortion (a spontaneous or induced abortion complicated by infection of the uterus) with endometritis (inflammation of the inner lining of the uterus) and retained products of conception. The patient was sex trafficked for 2 years and prohibited from using contraception. She recently became pregnant and was reproductively coerced by her trafficker to undergo abortion. With no access to a safe abortion in the state, he conducted an unsterile, forced, out-of-hospital abortion on her.

This case illustrates an issue that may increasingly come into play in restricted abortion states following the Dobbs vs. Jackson ruling. Many survivors of human trafficking report that they did not freely choose to undergo abortion, reinforcing their sense of loss over bodily autonomy (Freedom Network USA, 2015; Lederer & Wetzel, 2014). For traffickers, forced abortions function as both a physical and psychological control mechanism, as well as a means to maximize profits and to continue exploiting women's bodies for sex and labor (Reid, 2016). Survivors have reported that forced illicit abortions ranged from verbal coercion to medically induced abortions, to traumatic, physically induced abortions by the trafficker (Freedom Network USA, 2015; Lederer & Wetzel, 2014). Complications of self-managed abortions are severe, including sepsis, hemodynamic instability, sterility, and death (Haddad & Nour, 2009).

Case 2

A 25-year-old, pregnant, Vietnamese female presented to an outpatient clinic seeking an abortion. The patient was brought to the United States by her traffickers from Vietnam and forced into domestic servitude. She was physically, sexually, and emotionally abused by her employer, resulting in impregnation. Her employer denied her access to an abortion, insisting that she remains pregnant. She escaped from the home and was denied a legal abortion under state law.

Case 3

A 21-year-old, pregnant, undocumented female from Mexico presented to an outpatient clinic seeking an abortion. The patient was forced into sex work by the individual she paid to help her cross the border. She was arrested twice for prostitution and then released on probation. She became pregnant by an unknown individual and was denied a legal abortion by state law. Her trafficker was in possession of all of her finances and identification documents, so she was unable to leave the state. She was legally prohibited from leaving the region as a condition of her probation.

Cases two and three illustrate the impact of restrictive abortion laws on populations who are already limited in their freedom of movement. Trafficked persons may be trapped physically and psychologically in their circumstances, through a variety of exploitative tactics (Baldwin et al., 2015; Reid, 2016). These include abusive measures such as violence, intimidation, social isolation, emotional manipulation, intermittent reinforcement, and control over finances or identification papers. In this way, traffickers methodically establish a trauma bond, defined as “a form of coercive control in which the perpetrator instills in the victim fear as well as gratitude for being allowed to live” (Reid, 2010).

Case two portrays the entrapment tactic of reproductive coercion via forced birth. Traffickers may rape or intentionally impregnate a woman in order to use pregnancy as a form of control. They may threaten pregnant women with the loss of their fetus or child in order to further exploit them or promote compliance (Reid, 2016). Traffickers may derive profit from individuals who seek intercourse with a pregnant woman. Alternatively, traffickers may have exploitative motives for the neonate, aiming to sell the infant on the black market or to large-scale infant trafficking schemes (Makinde, 2015; Shen et al., 2013).

Case three demonstrates the tactic of rendering trafficked persons complicit in crime. They may be deemed offenders and arrested for crimes related to exploitation, diminishing their trust in law enforcement and creating legal hurdles (Reid, 2016). Obtaining the finances to pay bond may place them further indebted to their trafficker, and harsh probation regulations may restrict their movement regionally (Halter, 2010). These effects are intensified in undocumented trafficked persons, who may fear deportation, face language barriers, or be unaware of labor, employment, and healthcare protections to which they are entitled. Consequently, enabling access to services, including abortion services in a timely fashion, even by assisting women to cross state lines to receive those services when legally permissible, is very challenging.

Case 4

A 12-year-old, pregnant, Honduran female presented to the hospital seeking an abortion. She was kidnapped from her family at age 11 by a local drug cartel. She was brought to the United States against her will and forced to marry an older gentleman. She was raped by several unknown men during this time. As a minor, state law prohibited her from getting an abortion.

This case highlights the vulnerabilities of trafficked persons special to their minor status under restrictive abortion laws. Increased sexual encounters from a young age place trafficked girls at further risk of unwanted pregnancy (Barnert et al., 2017, 2020). Currently, 36 states require parental involvement in a minor's decision to have an abortion (Guttmacher Institute, 2023a, 2023b). For trafficked minors, social isolation by the trafficker may hinder contact with a parent, conservator, or guardian who is legally capable of consenting to abortion. Alternatively, the minor's parent or guardian may be their trafficker (Greenbaum, 2022; U.S. Department of State, 2021).

Currently, 35 states offer minors a judicial bypass procedure to permit a court-approved abortion (Guttmacher Institute, 2023b). However, as pregnant, trafficked minors turn to the legal process for an abortion, they face further obstacles. Lengthy legal processes may delay essential reproductive care and cause patients to present outside their state's gestational timeframe for abortion. Submitting court testimony in cases of sexual abuse may aggravate these patients’ existing trauma via “secondary victimization” by court proceedings (Campbell & Raja, 1999). After all, it is very difficult for well-resourced women to navigate court processes, let alone especially vulnerable and poorly supported populations such as pregnant trafficked minors.

Case 5

An 18-year-old, pregnant, Indonesian female presented to the hospital with severe pelvic pain, cramping, and uterine bleeding. She was found to have an inevitable spontaneous abortion (miscarriage, or loss of a pregnancy before 20 weeks gestational age). She was sold by her family in Indonesia to a trafficker and brought to the United States 3 years prior. She was forced into sex labor and underwent severe physical and sexual abuse. After discovering her pregnancy, she was required to keep working for fear of her life. Ongoing violence during her pregnancy precipitated a spontaneous abortion. Her state's abortion ban required loss of viability prior to intervention, preventing her from getting a surgical evacuation on initial evaluation.

Existing abortion bans contain varying exceptions in cases of endangerment to a patient's physical health or life (Guttmacher Institute, 2023a). Following implementation of restrictive abortion bans, medical providers have been placed in complex legal quandaries as they fulfill their ethical duty to protect high-risk pregnant patients while facing risk of fines, loss of licensure, or prison (Nambiar et al., 2022). Due to ongoing physical and sexual violence, pregnant trafficked persons are at heightened risk for trauma-induced obstetric complications, with many survivors reporting miscarriage or stillbirth (Johri et al., 2011; Lederer & Wetzel, 2014; Silverman et al., 2007; Stöckl et al., 2012). Labor trafficking may further increase risk of pregnancy complications, with patients forced to exert physical energy for rigorous hours without relief. Under restrictive abortion laws, trafficked patients with obstetric complications may frequently encounter risky delays in care, placing them at increased risk of maternal mortality (Arey et al., 2022; McGovern, 2022).

Case 6

A 32-year-old pregnant Black homeless female with untreated schizophrenia presented to the psychiatric emergency room. She was distressed by auditory hallucinations originating, via her perception, from the fetus. She was also experiencing withdrawal symptoms from an unknown substance. One year ago, she was found on the street by a trafficker and forced into prostitution. Her traffickers used sedating and hallucinogenic drugs to induce submission, establishing a substance use dependency and worsening her primary psychotic symptoms. She became pregnant while forced into prostitution and did not receive any maternal or mental health care. She was denied an abortion by State law.

This case draws attention to the impact of restrictive abortion laws on trafficked patients with preexisting major mental disorders. Reduced decision-making capacity, impaired social support, risk of homelessness, and substance abuse place those with mental illness in a particularly vulnerable position to sexual violence (Coverdale et al., 2022). Forced substance use is an additional control tactic used by traffickers to induce submission, drug dependency, or reliance on the trafficker (Meshelmiah et al., 2018). Both substance abuse and psychotic disorders place pregnant patients at high risk of adverse health outcomes (Pinto et al., 2010).

Trafficked persons with major mental illness and cognitive disabilities face added challenges in accessing essential reproductive care. They may lack the executive functioning to gather their resources and initiate the planning required to access out-of-state care (Gordon et al., 2022). They may experience barriers to communication in a forensic setting or lack the necessary cognitive skills to report sexual violence or initiate a legal bypass procedure (Coverdale et al., 2020).

Discussion

Patients who are trafficked and coerced into unwanted pregnancies or who are repeatedly raped, especially when they are unable to avail themselves of safe abortion services, will evoke strong emotional responses in physicians and other healthcare providers. These emotions can inhibit sound clinical judgment and action. The professional virtues, especially the professional virtue of compassion, are key to managing these emotions, to protecting patients, and to driving action by promoting their interests and needs (McCullough et al., 2022). We call upon physicians and healthcare providers to develop the requisite services to effectively identify and assist trafficked patients in managing their reproductive needs, including access to abortion care services and assistance with the aftermath of denied abortions.

In the first instance, efforts should be undertaken to prevent persons from becoming trafficked. These include early identification of empirical risk factors, such as childhood abuse or neglect, LGBTQ status, homelessness, migrant or refugee status, substance abuse, and family poverty (Greenbaum et al., 2018). Collecting a detailed bio-psycho-social history can enable identification of at-risk patients, who require tailored sexual education and anticipatory guidance regarding relationship safety, trafficking recruitment, and resistance tactics (North Carolina Coalition Against Sexual Assault, 2009; Senn et al., 2015). Interdisciplinary collaboration with social, legal, and community health workers is essential in alleviating contributing stressors such as unstable housing, unemployment, mental illness, or substance use disorders (Coverdale et al., 2022).

Secondary prevention strategies are intended to identify trafficked persons and mitigate resultant adverse health effects (Greenbaum et al., 2018) including those health effects related to restrictive abortion laws. Screening for trafficking can be facilitated by a variety of clinical tools, such as the Polaris Project Medical Assessment Tool (Bespalova et al., 2016). A thorough sexual and reproductive history is indicated for all trafficked persons, which must elicit information surrounding contraceptive usage, forced sexual encounters, sexually transmitted infections, and reproductive coercion (Coverdale et al., 2022; Lederer & Wetzel, 2014). Trafficked persons require additional logistical support when accessing reproductive care, such as financial assistance, transportation, or legal assistance. Tailored counseling and integrated reproductive mental health care are essential for those with concomitant mental illness, substance use disorders, or cognitive disabilities (Coverdale et al., 2020, 2022). Research initiatives must assess the effects of new restrictive abortion legislation on trafficked persons, in order to guide effective interventions for this population.

Supportive measures for trafficked patients must further address the aftermath of denied abortions. Mental health support is indicated, as denial of abortion is associated with psychological distress that is worsened in populations with a history of trauma, abuse, mental health conditions, or lack of social support (Biggs & Rocca, 2022). Following unwanted pregnancies, legal support, housing, and safe sanctuaries must be established to protect the trafficked person and neonate from perpetuation or exacerbation of potentially violent trafficking circumstances (Roberts et al., 2014). Adoption services, parenting classes, employment opportunities, and affordable daycare can help support trafficked persons as they manage the economic burdens of childcare. One of our cases illustrates the compounded vulnerabilities of trafficked minors, who must be supported emotionally, legally, and financially as they face magnified challenges in accessing abortion or raising a child. All providers should adopt trauma-informed models of care when supporting trafficked patients, recognize the violent or traumatic circumstances that may have precipitated a pregnancy, and address the psychological consequences of such violence (American College of Obstetricians and Gynecologists, 2021; Owens et al., 2022).

Conclusions

In the era following the Dobbs ruling, a pregnant person's access to abortion is determined by the jurisdiction of their state. The profound impact of this ruling will have unique repercussions on trafficked persons, who are highly susceptible to unwanted pregnancy. In addition to limited mobility between states, pregnant trafficked persons as adults or girls can be subject to disproportionate violence or have comorbid conditions that further restrict access to care. Inequities in care for these patients will have detrimental effects on their physical, maternal, reproductive, and psychological health. We are obligated therefore to work within laws to improve their access to abortion services, in light of their own decisions on the management of their pregnancies, to overturn restrictive laws, and to protect their safety. Physicians and healthcare providers will also need to educate themselves about relevant state laws as well as about specialized services to assist trafficked persons, including services that provide information and support for safe abortion care.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Ila Gautham

Author Biographies

Ila Gautham, MD, is a psychiatry resident at Harbor UCLA Medical Center. Ila received her BA in Psychology with a minor in Global Health from Emory University prior to completing her MD at Baylor College of Medicine. Broadly, she is interested in forensic psychiatry, global mental health, emergency psychiatry, and management of psychotic spectrum disorders. She is passionate about working with refugees, asylum seekers, survivors of trafficking, and marginalized migrant populations.

John Coverdale, MD, is an academic psychiatrist, educator, and editor. He earned an MB ChB as well as an MD from the University of Otago and he is a fellow of the Royal College of Australia and New Zealand Psychiatrists. He is currently a tenured professor of psychiatry, behavioral sciences, and medical ethics at Baylor College of Medicine and co-directs the Baylor College of Medicine Anti-Human Trafficking Program. He is a senior editor at the Journals Academic Medicine and Academic Psychiatry and has published more than 300 papers in peer-reviewed journals on psychiatry in obstetrics and gynecology, human trafficking, stigma, professionalism, and medical education. He is the recipient of the Vestermark Award for excellence, leadership, and creativity in the field of psychiatric education and an AOA Robert J. Glaser Distinguished Teacher.

Phuong T. Nguyen, PhD, is currently the training director of the Ben Taub Hospital/BCM Psychology Postdoctoral Fellowship Program, as well as the director of Psychology Services at Ben Taub Hospital. He earned his PhD in Psychology from the University of Massachusetts prior to completing advanced training at Massachusetts General Hospital. He is an active contributor to literature that advocates for survivors of human trafficking and is an active member of Baylor College of Medicine's Anti-Human Trafficking Program.

Mollie R. Gordon, MD, is an associate professor in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. She completed medical school and residency at Barnes Jewish Hospital at Washington University in St. Louis. She is the co-director of the Inpatient Psychiatric Unit at Ben Taub Hospital, co-director of the Baylor College of Medicine Anti-Human Trafficking Program, co-chair of the American Medical Women's Association-Physicians against the Trafficking of Humans, and founder of the Baylor College of Medicine Division of Global Mental Health. She actively contributes to literature that advocates for marginalized populations, survivors of torture and trafficking, and vulnerable populations with chronic mental illnesses.

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