Human Trafficking

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Human trafficking is a significant humanitarian issue in the United States and the world that has continued to grow in the past several years despite government and public efforts to combat it. With increasing news coverage of high-profile human and sex trafficking cases, the problem was recently brought into the American public’s eye. However, the results published by the Polaris Project make it evident that human trafficking is not just a problem of the elite or occurring in poorer areas. It is within our own neighborhoods and workplaces.

For healthcare workers in the United States, the war on human trafficking will be won through: gaining the knowledge to recognize the warning signs and specific characteristics of a potential trafficking victim; the most effective ways to intervene, which will enable the victims to gain access to help; and where to garner additional support in addressing the issue.

Prevalence and Definition

The Polaris Project estimates that collectively there are over 25 million victims of human trafficking worldwide. These are individuals that have been forced into sexual or labor servitude. Of those, approximately 48,326 were related to individual trafficking contacts in the United States (7).   These numbers exemplify the number of potential victims that are not reaching out for help.

Often, when human trafficking is discussed, a common misconception is that it is simply the transporting of humans. Human trafficking covers a much broader scope than this. It is this a modern age form of slavery and involves the exploitation of individuals for monetary or sexual gain. As stated by the Department of Homeland Security, “Human trafficking involves the use of force, fraud, or coercion to obtain some type of labor or commercial sex act”(3).

As defined by U.S. law, there are three categories of human trafficking (all from 1):

• Children under the age of 18 induced into commercial sex
• Adults (age 18 or over) induced into commercial sex through force, fraud, or coercion
• Children and adults induced to perform labor or services through force, fraud, or coercion

The majority of trafficking in the United States involves sex crimes, followed by labor (4). These crimes may be occurring simultaneously to the same victim. Types of trafficking can include forced sex work, pornography, strip dancing, criminal enterprise and bonded labor in domestic servitude or migrant work. Outside of street sex work, sex trafficking is most likely to be occurring in venues such as strip clubs, massage parlors, or other fictitious business fronts. A major difference with sex trafficking of minors is that, unlike adults, force, coercion, or fraud does not need to be present for prosecution (6). As there are a number of different avenues for and types of human trafficking, recognition can be challenging.

Risk Factors

The profile of the human trafficking victim is not easy to define. Victims of human trafficking come from varied backgrounds that may or may not be what is expected or stereotypical. Victims may come from any race, socioeconomic status, color, religion, age, gender, sexual orientation or gender identity. The main commonality is that there is a layer of deception whereby the human trafficker is targeting a vulnerability in the victim. As stated by the Department of Justice, trafficking victims are deceived with “. . . false promises of love, a good job, or a stable life and are lured into situations where they are made to work in deplorable conditions with little or no pay” (5). There are some trends noted that do make certain populations more at risk, but keep in mind that this does not encompass all potential victims and vigilance should be taken to avoid assumptions.

The risk factors for human trafficking are just as varied and dependent upon the type of trafficking and method by which the abuser is able to hold the victim indentured or captive. This figurative prison may be physically, emotionally, or monetarily induced. The Center for Disease Control and Prevention (CDC) lists the following characteristics and factors:

• Many victims are women and girls, though men and boys are also impacted.
• Victims include all races, ethnicities, sexual orientations, gender identifies, citizens, non-citizens, and income levels.
• Victims are trapped and controlled through assault, threat, false promises, perceived sense of protection, isolation, shaming, and debt.

Several higher risk populations have been identified through the data gathered from the Polaris Project. It was found that children who were or had been within the foster care system or runaway homeless youth were more likely to encounter sexual victimization. Other factors include substance abuse, recent relocation or migration, unstable housing situations, and underlying mental health disorders (7).

As a population that is often overlooked, shamed, or lacks resources, members of the lesbian, gay, bisexual, transgender, queer, plus (LGBTQ+) community are more vulnerable to being subject to human trafficking. Up to 40% of homeless youth are part of the LGBTQ+ community and may not seek assistance for fear of being shunned (8).

Illegal and sponsored immigration remains at a higher risk of trafficking and exploitation. The NHRTC reports a significant number of calls that reference foreign nationals (2). Individuals wishing to become American citizens are lured with the promise of freedom in exchange for large fees that are made impossible to be worked off. Although there are laws in place to prevent this, this type of servant bondage is forced upon the victims who are in a new country and often lack resources or are unable to seek assistance due to cultural, language, and accessibility barriers. Further, cases have been reported where the employer or trafficker withhold visas or identification barriers in order promote compliance and essentially are holding the victim hostage (9).

Mandatory Reporting

Mandatory reporting of human trafficking by health care professionals is incorporated into the law in a growing number of locations in the United States. Health care professionals are already mandated reporters through previous existing laws that require reporting of child abuse, domestic violence, as well as knife and gunshot wounds (11)

The following states the criminal and civil liability of failing to follow the law as a mandatory reporter in some states:

In a civil action, the mandated reporter may be held liable for all damages that any person suffers due to the mandated reporters’ failure to file a report. In a criminal action, the mandated reporter may be found guilty of a misdemeanor punishable by imprisonment for up to 93 days and a fine of $500.

Reporting of suspected adult human trafficking is not as clear in regard to mandatory reporting. However, vulnerable adults suspected of being abused, exploited, or victimized fall under the same guidelines and are reported to the Centralized Intake (CI) at the Department of Health and Human Services in the same manner as above.

Recruitment Techniques

A major tactic of the perpetrators of these crimes is to prey on vulnerable individuals with a lack of resources. Thus, a primary ploy used is a layer of deception whereby the human trafficker is targeting the needs or wants of the victim.

Traffickers are often individuals that the victim has come to trust. This may be a girlfriend or boyfriend, intimate partner, spouse, or other family member. Victims are also commonly sold to outside parties.

In cases of sexual trafficking, typically young women and men are groomed and given preferential treatment, gifts, and drugs until they become reliant upon the “John”. In other cases, individuals are tempted with the promise of a better life, or in the case of immigration, the sponsorship for a visa (9).

Federal Laws

Today, there are 39 states that have committed to the crusade of establishing a statute banning human trafficking.

A specific U.S. Federal law addressing trafficking crimes was first enacted with the Trafficking Victims Protection Act of 2000. The bill has since been revised several times; however, the fundamental of it is to provide guidance and authorization for their “three-pronged approach that includes prevention, protection, and prosecution” and covers both sex and labor trafficking (12).

Preventing Sex Trafficking and Strengthening Families Act of 2014 and The Justice for Victims of Trafficking Act of 2015 are both aimed at providing victims increased protection for exploitation and increased resources specifically aimed at prevention and support for child and youth sex trafficking crimes (12).

The Customs and Facilitations and Trade Enforcement Reauthorization Act of 2009 is aimed towards prohibiting the importation of goods made by victims of human trafficking (12).

Recognizing Signs of Human Trafficking

According to the Department of Health and Human Services, close to 90% of human trafficking victims visit a health care facility at least once while in servitude and are not identified as such by health care providers (14). This is due to a lack of education, lack of consistent use of identification and screening tools, and time constraints within the current health care system. As a mandatory reporter and healthcare team member, it is imperative to use best practice in recognizing the signs and symptoms as well as the tools that are available.

Signs and Symptoms

Human trafficking victims may present to a healthcare setting with primary or underlying signs that may be related to physical or mental abuse. These signs and symptoms may be related to the reason that they are seeking treatment or may be identified by the healthcare provider during a thorough assessment. The following physical and psychological sequelae may be noted during an assessment as potential evidence of victimization (all derived from 9, 15):

Physical

• Unexplained or implausible injuries
• Bruising
• Wounds and Cuts
• Missing or broken teeth
• Closed head injuries
• Blunt force trauma

Neurological

• Headaches
• Migraines
• Memory loss or difficulty concentrating
• Vertigo
• Insomnia
• Brain trauma

Gastrointestinal

• Diarrhea
• Constipation

Dietary

• Malnutrition
• Anorexia
• Severe weight loss

Cardiovascular and Respiratory

• Tachyarrhythmias
• Hypertension
• Respiratory distress

Reproductive System

• Sexually transmitted disease
• Vaginal and/or anal fissures
• Previous Abortions

Psychological

• Depression
• Suicidal Ideation
• Anxiety
• Self-harm including cutting or branding
• Drug and alcohol abuse
• PTSD symptoms
• Regression
• Anger
• Dissociative and depersonalization tendencies

Red Flags and Indicators

There are several characteristics that should be kept in mind as red flags during the interview and assessment that may indicate potential trafficking. These include, but are not limited to (all derived from 9, 15, 16):

• Tattoos that indicate ownership, a number, or tracking system or are out of character/obscene
• Inappropriate clothing for climate
• Workplace violence or abuse
• Unsanitary living conditions
• Multiple families or people sharing a living space that is too small
• Shares living space with employer
• Is not in control of financial assets
• Refusal to speak alone with health professionals
• Accompanied by individual that refuses to allow patient to speak for themselves or be alone
• Sex work under age 18
• Answers are scripted
• Answers are implausible or contraindicated
• Appears younger or older than stated age

Interview Tools and Techniques

Check with your facilities protocol for specific guidance on assessment and examination protocols for suspected abuse victims. There are also many scripted interviewing tools available online that assist with asking targeted questions. First and foremost, it is important to establish the patient’s safety and to gain trust.

Gaining trust can be difficult and conducting assessments and interviews should be completed in a non-threatening environment with an unbiased and non-judgmental tone. Creating a space that is quiet and will not be interrupted is important. This will ensure that the potential victim feels safe communicating and is not concerned that they will be overheard. Present your demeanor in a non-threatening manner, at eye level, and focus on being attentive with observant listening. Maintain respectful eye contact to convey interest and reflective listening. If taking notes during the interview is required, explain to the patient what will be documented and what it will be utilized for (17).

The National Human Trafficking Resource Center (NHTRC) offers a plethora of resources and scripted questions. The following are general questions on assessing if the individual is being forced into a situation and can be applied to any of the specific types of human trafficking (all from 17):

“Did someone control, supervise or monitor your work/your actions?”

“Was your communication ever restricted or monitored?”

“Were you able to access medical care?”

“Were you ever allowed to leave the place that you were living/working? Under what conditions?”

“Was your movement outside of your residence/workplace ever monitored or controlled?”

“What did you think would have happened if you left the situation? Was there ever a time when you wanted to leave, but felt that you couldn’t? What do you think would have happened if you left without telling anyone?”

“Did you feel that it was your only option to stay in the situation?”

“Did anyone ever force you to do something physically or sexually that you didn’t feel comfortable doing?”

“Were you ever physically abused (shoved, slapped, hit, kicked, scratched, punched, burned, etc.) by anyone?”

“Were you ever sexually abused (sexual assault/unwanted touching, rape, sexual exploitation, etc.) by anyone?”

“Did anyone ever introduce you to drugs, medications as a method of control?”

While screening tools provide a base for asking difficult questions, the NHTRC advises “Before screening, users should also be prepared to draw upon the expertise of local legal and medical staff and to refer identified trafficking victims to appropriate housing, health, and social services in their area . . . the tool is a complement to, not a substitute for, specialized training in human trafficking, good professional practice and victim-centered service” (17).

The NHTRC also provides a 24-hour national hotline that is able to guide health professionals through completing assessments and determining the next best steps to intervene or offer the victim assistance. This is a very beneficial resource; however, it must be understood that calling NHTRC does not fulfill the mandatory reporting requirement for certain states and the Centralized Intake (CI) at the Department of Health and Human Services is the only means of legally fulfilling the reporting obligation.

Interventions and Collaboration

When presented with a suspected human trafficking victim, it is likely that the individual will not be alone. Maintaining safety and support for the patient may require separation from the suspected trafficker. While this may not be possible, an attempt should be made to bring the patient to a room or examination area unaccompanied.

Be conscious of any cultural preferences that may affect the patient. If there are language barriers preventing meaningful communication, enlist the assistance of a professional interpreter. This is especially vital in cases where the accompanying visitor or family is attempting to interpret for the patient and may be filtering the victim’s responses.

For patients that seek healthcare related to sexual abuse, a SANE assessment and rape kit should be obtained per facility protocol. With permission, patients should be tested for sexually transmitted infections including HIV, gonorrhea, UTIs, syphilis, and pubic lice, as well as a pregnancy test for females. Forced and coerced abortions are frequent among minor females in the sex industry (18).

Thorough documentation of the patient’s reported reason for visit, physical and neurological assessment including any trauma, bruising, wounds, affect, and pertinent statements should be noted in the patient’s electronic medical record.

Educate yourself on local resources and be able to provide assistance with finding access to healthcare, mental health, and rehabilitative resources that are available in the community. Victims may not want to take pamphlets with them that may be found, so providing locations or addresses of shelters or clinics with operating times may be a safer option.

Collaborate with the healthcare team, law enforcement, and social work for suspected child or vulnerable adult trafficking.

Mandatory reporting of suspected cases of child abuse or trafficking is not encumbered by HIPAA disclosure when reporting to authorities; however, when reporting suspected adult trafficking, disclosure and permission must be granted unless there is an imminent threat to the safety of the patient, or the patient has been identified as a vulnerable population. Thoroughly assess if the individual meets criteria as a vulnerable adult and proceed accordingly. If the adult does not meet criteria, permission must be gained to report.

If a competent adult does disclose that they are a trafficking victim, determine if the patient is in immediate, life-threatening danger. If so, follow facility protocol and encourage and support the patient in reporting to a law enforcement agency. If there is no immediate danger, supportive care and assistance should be provided. The patient should be informed of the options available for social services, reporting, and resources. Creation of a safety plan is highly recommended (15).

Prevention

Prevention of human trafficking requires public education, awareness, and knowing how to properly respond when faced with suspicions. The Blue Campaign is a strategy from the Department of Homeland Security to bring national awareness to the issue and provide specialized training to law enforcement and federal employees. Blue Campaign pamphlets and other materials are available at their website, www.dhs.gov/blue-campaign, for distribution.

The Center for Disease Control takes the stance that sex trafficking is preventable via community awareness and acknowledging exploitation when it does occur. They state “Strategies based on the best available evidence exist to prevent related forms of violence, and they may also reduce sex trafficking. States and communities can implement and evaluate efforts that:

• Encourage health behaviors in relationships
• Foster safe homes and neighborhoods
• Identify and address vulnerabilities during health care visits
• Reduce demand for commercial sex
• End business profits from trafficking-related transactions” (6).

One of the largest barriers to prevention in the healthcare system is the inability to recognize signs and symptoms. As cited above, a significant number of human trafficking victims have filtered in and out of healthcare systems without being recognized. These are missed opportunities to connect, provide resources, and offer further assistance. The NHTRC provides many resources for training within healthcare facilities and standardized forms and interviewing questions that may be tailored to individual situations and facility needs.

Resources

National Human Trafficking Resource Center

Phone: 1-888-373-7888

SMS Text: 233733 (Befree) – Text “HELP” OR “INFO”

Online chat: https://humantraffickinghotline.org/chat

This network provides healthcare facilities and individuals with information and connections to over 3,200 referral contacts that will assist human trafficking victims. These contacts include low or no-cost legal services, law enforcement agencies, social services, and anti-trafficking organizations. Communication is enhanced as dialect is available in English, Spanish, and 200 other languages.

HEAL (Health, Education, Advocacy, Linkage) Trafficking

Website: www.Healtrafficking.org  

The HEAL Trafficking Direct Service Committee works to improve the clinical care for trafficked persons by providing opportunities for service providers to connect, access support, share information and promising practices, identify best practices, and expand the referral network.

National Center for Missing & Exploited Children

Address:

333 John Carlyle Suite 125

Alexandria, VA   22314-3175

Phone: 1-800-THE LOST (1-800-843-5678) 24-Hour Call Center

Website: http://www.missingkids.org/theissues/trafficking

Provides specialized technical assistance, analysis, and recovery services on cases involving child sex trafficking.

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