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chronic exploitation and, thus, face multiple obstacles and unmet complex needs that contribute to the difficulty they have in leaving exploitive environments (Center for Court Innovation, 2015). Ideally, measuring both services offered and provided will give a clearer understanding of effective interventions. In order to respond effectively and sensitively to these difficult cases, all involved 130 H. G. ATKINSON ET AL. stakeholders, including physicians and other health care providers as mandatory reporters, need to be prepared for the high rates of relapse and continued exploitation after “intervention,” so that their expectations about case outcomes are reasonable. It is important to note, however, that increasing awareness about human trafficking is stimulating an increase in services offered. For example, trafficking victims who escape their traffickers are often in need of legal advice on a variety of issues. Over recent years, an increasing number of pro bono lawyers from the nation’s big law firms have volunteers to fill this need, working collaboratively with law enforcement, nonprofit organizations, and health care providers. Nevertheless, if health care providers anticipate that appropriate policies, procedures, and resources are not in place to provide for the safety of and services to trafficking victims, then they may decide not to report, despite their obligation to do so. One of the core bioethical principles, non-maleficence, demands that physicians “first do no harm.” The four-decades-long experience with child abuse and neglect gives insight into the ethical and practical dilemmas that physicians face with mandatory-reporting laws. Lessons learned from child abuse and neglect laws In response to clinical reports of battered children, all 50 states and the District of Columbia passed laws between the years 1963 and 1967 that required health care providers to report suspected cases of child abuse and neglect to appropriate state agencies (Flaherty et al., 2008). Several states also passed laws that mandated training about child maltreatment. In the ensuing 40 years, numerous ongoing reports in the medical literature document that physicians nevertheless underreport suspected child abuse (Pietrantonio et al., 2013). Investigators have documented that health care providers perceive numerous barriers to reporting. The barriers fall into two major areas: (a) lack of knowledge and failure to identify the underlying abuse and (b) consciously deciding not to report suspected abuse to state authorities due to concerns about the impact on themselves, as well as the children and their families (Sege & Flaherty, 2008). Specific barriers include lack of adequate training, unfamiliarity with the details of mandatory-reporting requirements, ambiguity about the meaning of the term “suspicious” in the statutes, lack of certainty about whether abuse caused the injury, concern over losing trust or disrupting the professional relationship with the child and family, fear of physical or legal reprisal, and stress about the time and effort it takes to report, to cooperate with authorities, and perhaps to testify in court (Sege & Flaherty, 2008). Importantly, clinicians have repeatedly indicated that both skepticism regarding the overall utility of making reports and previous negative experiences with child protective services negatively influence their decision to report. Qualitative studies that focused on assessing the factors that influenced reporting have found that such doubts about the benefits of reporting played a significant role in clinicians’ decision making. Clinicians conjectured about how child protective services (CPS) would respond to a report, and, if they felt that either CPS would dismiss the case without investigation or that the outcome would not be beneficial to the child and family, then the clinicians sought alternative ways to deal with the situation (Jones et al., 2008). Lack of feedback from CPS about case outcomes may also contribute to low expectations among clinicians and reinforce their skepticism regarding the utility of filing a report. Clinicians give considerable weight to expected outcomes and need to feel comfortable that reporting will not result in further harm. It is important for mandated reporters to know that there is, in fact, a benefit: not only appropriate law-enforcement intervention but also critical services for the trafficking victim. Barriers to reporting trafficking cases It is reasonable to expect similar barriers will impede the willingness of physicians and other health care providers to report suspected or confirmed cases of trafficking. Some barriers may even be greater in cases of trafficking. For example, clinicians’ fear of physical or legal reprisal by traffickers is a real consideration, given the brutality often used by traffickers to keep victims compliant. JOURNAL OF HUMAN TRAFFICKING 131 Reprisals against the victim are a concern as well. In addition, as these laws proliferate and gain traction, traffickers may stop taking exploited children and adolescents to emergency rooms and other health care facilities, thus limiting even further their access to much-needed health care. Health care providers may also find themselves in ethical dilemmas, obliged on the one hand to keep a minor’s medical history related to sexual health confidential, as required by law, and, on the other, to report a situation should certain kinds of information come to their attention while taking a history from an adolescent patient. Numerous studies have documented that adolescents place a premium on confidentiality when seeking sexual and reproductive health services; it significantly increases their willingness to engage with providers (Bender & Fulbright, 2013; Reddy, Fleming, & Swain, 2002). If victims know that health care providers are mandated to report to the state, they may not divulge critical aspects of their history, or they may themselves avoid seeking medical care (National Health Collaborative on Violence and Abuse, 2015). Furthermore, reporting procedures must reflect the reality of trafficking situations, and child-welfare and law-enforcement systems need to better understand trafficking and how it differs from other forms of child abuse and child abuse reporting. For example, required reporting of the victim’s parental names and addresses may not be feasible and may create an obstacle to reporting. Many reporters will have contact only with the minor, not the parents, when a third party (nonfamily) exploiter is involved. Parents may be unavailable or out of state, or the child may be involved in the child-welfare system or homeless. It is not yet clear that mandatory reporting will improve how physicians and other health care professionals address human trafficking as they encounter it in their practices. The IOM/NRC report “cautions that adopting a universal reporting requirement without ensuring the adequate preparation of child welfare agencies may have unintended consequences that are harmful to the vulnerable children that the laws are designed to assist” (2013, p. 182). As state legislatures consider amending their mandatory reporting laws to include human trafficking, they should take the opportunity to address the known barriers to reporting and make specific provisions, when possible, to lessen their effects. For example, Massachusetts has an anti-retaliation provision to protect reporters and has also directed CPS to notify a reporter within 30 days about any follow-up on a reported case.78 States should also couple mandatory reporting laws with more protective safe harbor laws in recognition that minors who are trafficked should not be considered or treated as criminals. Conclusion Seventeen states have enacted training and/or mandatory reporting laws regarding human trafficking that affect health care providers and other professionals. Clearly laudable in purpose, these laws raise the question of how their effectiveness will be measured. We need to understand which approaches to education are most effective in improving health care providers’ awareness about trafficking and in increasing their competency to address it. And we need to understand whether mandatory reporting laws actually advance the goals of identifying, protecting, and assisting victims of trafficking. Currently, there is a lack of reliable and comprehensive data on all aspects of trafficking—prevention, prosecution, and protection—and a concerted effort is necessary to fill this gap. Presently, data sets are not standardized within or across states nor are data collected or shared systematically. Steps should be taken to identify specific data needs, to standardize data sets, to systematically collect data and disseminate data, and to provide useful platforms for key stakeholders,