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Human Trafficking Training for Florida Nurses
Identifying Victims of Human Trafficking

Online Continuing Education Course

Young human trafficking victim sits on the floor with hand raised up so that the face is shielded and Florida state outline

Course Description

Required for all FL Nurses. Discusses recognizing human trafficking, assessment tools, trauma-informed approach to screening, and reporting obligations for mandated reporters in Florida. Accepted by the Florida Board of Nursing.

Course Price: $20.00

Contact Hours: 2

Course updated on
December 19, 2023

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"Thank you for providing an online option to fulfill my licensing obligation. There are limited opportunities for a live seminar in my area." - Denise, RN in Florida

"Enjoyable reading. The course was well presented and easy to follow." - John, RN in Florida

"Excellent read. I already knew the basics, but knowing more will help me identify those minors in our community who may be at risk." - Jacqueline, LPN in Florida

"I preferred to read this article rather than watch a video on the topic. Having a PDF version will be a useful resource if I ever come across a potential victim. Thank you for the very useful information." - Karin, APRN in Florida

Accreditation / Approval Information

This course fulfills the requirement for human trafficking education for nurses. Accepted by the FL Board of Nursing. CE Broker Provider #50-2174.

Human Trafficking Prevention Training for Florida Nurses
Identifying Victims of Human Trafficking

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will have the current, evidence-based information and tools necessary to accurately recognize and intervene in suspected instances of human trafficking. Specific learning objectives to address potential knowledge gaps include:

  • Describe the different types of human trafficking.
  • Recognize risk factors for human trafficking.
  • Articulate the scope and extent of human trafficking.
  • Describe assessment tools and strategies that can be used in clinical settings to identify human trafficking victims.
  • Discuss the importance of using a trauma-informed approach when screening victims of human trafficking.
  • Explain procedures for sharing information with patients related to human trafficking.
  • Describe referral options for legal and social services that can assist victims of human trafficking.
  • Identify the use of hotlines and other mechanisms for reporting suspected human trafficking in Florida.

WHAT IS HUMAN TRAFFICKING?


Human trafficking is a crime involving the exploitation of someone through the use of force, fraud, or coercion for the purposes of compelled labor or a commercial sex act. Human trafficking affects individuals across the world, including in Florida. It affects people of all ages, genders, ethnicities, and socioeconomic backgrounds. Human trafficking robs individuals of their basic human rights and can occur across and within state and international borders.

Human trafficking steals freedom for profit. It is a multibillion-dollar criminal industry that victimizes an estimated 29.9 million people around the world. This crime occurs everywhere, and victims may be found in such industries as healthcare, childcare, agriculture, nail salons, trucking, and hotels or motels. All trafficking victims have a common experience: the loss of freedom (Polaris, 2020a).

Since the Thirteenth Amendment to the Constitution was ratified in 1865, involuntary servitude and slavery—such as human trafficking—have been prohibited in the United States (Interactive Constitution, 2020).

The Trafficking Victims Protection Act (TVPA) was first passed in 2000 and has since been amended and reauthorized many times by Congress. The TVPA provides the infrastructure for the federal response to human trafficking. A multi-agency approach is founded on a framework that focuses on the “3 Ps”: prevention, protection, and prosecution.

Federal agencies such as the U.S. Department of Homeland Security and the Federal Bureau of Investigation investigate human trafficking cases. The Justice Department prosecutes federal cases and funds the formation of state and local human trafficking task forces. The Department of Health and Human Services is involved in community education and awareness efforts, prevention, and funding the National Human Trafficking Hotline (Polaris, 2020b).

The U.S. Department of Health and Human Services has identified human trafficking as a public health issue. As such, healthcare professionals are key to responding to the problem. Access to healthcare is often difficult for trafficking survivors due to issues such as lack of identity documents, lack of finances or insurance, shame, and fear. Survivors often contend with health issues such as depression, trauma, sexually transmitted infections, chemical dependency, injuries, and poor nutrition. Survivors require both acute and long-term responses to their healthcare needs.

Because human trafficking is a hidden crime, it is easy to miss identifying a patient as a survivor unless the clinician understands risk factors and develops a rapport that will allow the survivor to disclose their needs. It is essential that healthcare professionals are educated on the recognition of human trafficking, referrals and resources, and the nuances of providing trauma-informed care. They can offer support to patients who disclose maltreatment or abuse, homelessness, and financial need. By listening carefully to the patient, healthcare professionals are in a position to help a patient leave a situation in which they are being exploited (Gardner, 2023).

HUMAN TRAFFICKING LEGISLATION IN FLORIDA

The Florida Department of Health has taken a public health approach to human trafficking. Recent legislation in Florida requires most licensed healthcare professionals to complete one unit of continuing education on the topic of human trafficking. In addition, Florida requires that massage businesses include a designated establishment manager (DEM) among their personnel to ensure that the establishment is operating in accordance with the law. Massage businesses and healthcare facilities must post information about human trafficking using a sign visible to the public in both English and Spanish (Florida Health, 2023).

Types of Human Trafficking

There are different types of human trafficking, also known as trafficking in persons. Human trafficking may predominantly involve commercial sex, it may be specific to labor, or it may include both sex and labor. Human trafficking can be domestic or international and does not require crossing international or state borders.

SEX TRAFFICKING

Sex trafficking encompasses many sex crimes. The victims may be adults or children of any gender and may be domestic or foreign residents.

According to the TVPA, sex trafficking is the recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purposes of a commercial sex act, in which the commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age. Under federal law, any minor under the age of 18 who is involved in commercial sex is considered to be a trafficking victim.

Force, fraud, or coercion are key elements used to identify trafficking, but they do not need to be present if the trafficking victim is under the age of 18. However, the use of force, fraud, or coercion on adults is what distinguishes sex trafficking from consensual commercial sex.

LABOR TRAFFICKING

According to U.S. federal law (22 USC § 7102), labor trafficking is the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, or coercion for the purposes of subjection to involuntary servitude, peonage, debt bondage, or slavery. As with sex trafficking, force, fraud, or coercion do not need to exist if the labor trafficking victim is under the age of 18.

Labor trafficking victims include adults and children of all genders. Labor trafficking is often achieved through the control mechanism of debt bondage. Traffickers offer persons outside the United States promises of legitimate jobs in exchange for a legal visa and travel expenses to this country. Once they have arrived, the victims of this scheme may be charged exorbitant fees for food, rent, and material needs and are unable to repay the debt, remaining under the control of the trafficker.

TRAFFICKING OF MINORS

Florida criminalizes sex trafficking of minors (those under the age of 18), and state law does not require proof of force, fraud, or coercion, as with trafficking in adults. Florida criminalizes human trafficking as a first-degree felony for both adult and minor victims. If convicted of commercial sex trafficking of “any child under the age of 18, or any person who is mentally incapacitated or defective,” the perpetrator may face a life sentence per Florida’s statute 787.06 (Online Sunshine, 2023).

The Action-Means-Purpose (AMP) model is one tool that can be used to assess whether a situation meets the federal definition of human trafficking. It asks whether a perpetrator has implemented any of the actions and used any of the means for the purposes of making the victim perform commercial sex acts, services, or labor. The presence of at least one item from each category determines possible human trafficking.

AMP MODEL TO ASSESS FOR TRAFFICKING
Action Means Purpose
(Polaris, 2020c)
  • Induces
  • Recruits
  • Harbors
  • Transports
  • Provides or obtains
  • Force
  • Fraud
  • Coercion
  • Commercial sex
  • Services
  • Labor

SMUGGLING

The crime of human smuggling is different from human trafficking, but it is frequently confused with human trafficking, and the two crimes are sometimes related. Unlike trafficking, the definition of smuggling includes transportation across international borders. Smuggling usually involves the consent of a person who is being transported. People who are smuggled generally pay to be transported across a border, but once they have arrived at their destination, they may become victims of trafficking (Polaris, 2021).

Smuggling is addressed in the Immigration and Nationality Act, Title 8, Section 1324 (a)(1), which provides criminal penalties for acts or attempts to bring unauthorized aliens to or into the United States, transport them within the United States, harbor unlawful aliens, encourage entry of illegal aliens, or conspire to commit these violations, knowingly or in reckless disregard of alien’s legal status (U.S. CIS, n.d.).

Risk Factors for Human Trafficking

Factors that are associated with increased risk for victimization may be viewed using a public health approach according to the socioecological model. This model describes individual, relationship, community, and societal factors that may result in vulnerability to human trafficking (Greenbaum, 2020).

Individual risk factors include:

  • History of exposure to homelessness
  • Running away from home
  • Physical, sexual, or other types of abuse
  • Involvement with Child Protective Services, the juvenile justice system, or foster care
  • Identification as lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+)
  • Being marginalized
  • Immigration status as an unaccompanied minor

Relationship risk factors include but are not limited to:

  • Poverty
  • Unemployment
  • Family violence
  • Loss or abandonment
  • Peer or family exploitation

Community risk factors are seen in areas where residents are involved in mass migration, corruption prevails, and exploitation is tolerated. Persons who live in a community that is exposed to violence and natural disasters are also vulnerable to human trafficking.

Societal risk factors are seen in groups that subscribe to cultural beliefs that support marginalization and inequality in matters of race, gender, and the rights of children. Individuals in societies that are without human trafficking laws or do not hold exploiters accountable are also at risk (Greenbaum, 2020).

EXTENT OF HUMAN TRAFFICKING

Statistics

The true prevalence of human trafficking in the United States is unknown because of the concealed nature of the crime. The unofficial estimate is hundreds of thousands when cases among adults, minors, sex, and labor trafficking are combined.

It is believed that more women and children are victims of sex trafficking and domestic servitude and that more boys and men are trafficked for other forms of labor, but it is not possible to present dependable statistics. Some researchers use reports of missing children to estimate statistics of trafficked children.

REPORTED CASES

Nationally, in fiscal year 2021, there was a 49% increase in the number of persons who were referred to U.S. attorneys for human trafficking. The number of referrals increased from 1,360 in 2011 to 2,027 in 2021, and the number of prosecutions more than doubled, rising from 729 to 1,672 over the same time period.

The National Human Trafficking Hotline gathers data from calls made to their hotline. Recent statistics for the state of Florida are described in the tables below.

REPORTED TRAFFICKING CASES IN FLORIDA BY TYPE, 2021
Type Number
*Total number of victims was 1,253 because cases may have multiple victims.
(NHTH, 2023b)
Sex 574
Labor 99
Sex and labor 37
Total cases 781*
REPORTED TRAFFICKING CASES IN FLORIA BY GENDER, 2021
Gender Number
(NHTH, 2023b)
Female 638
Male 115
Gender minorities 8
REPORTED TRAFFICKING CASES IN FLORIDA BY AGE, 2021
Age Number
(NHTH, 2023b)
Adult 579
Minor 151
MALE TRAFFICKING VICTIMS

Although most published statistics portray victims of trafficking as predominantly female, that information is misleading because labor trafficking of males occurs in almost every type of work, from mining and construction to fishing, hospitality, and healthcare. Sex trafficking of men and boys is underreported, and the sex trafficking industry may have nearly equal numbers of male and female victims. Boys who become sexually exploited often have certain vulnerabilities. These include substance dependency, child abuse, poor English-language skills, refugee status, homelessness, and identification as gay/bisexual/transgender.

Male survivors of trafficking face unique barriers. Initially, male survivors may not self-identify as victims. This is because society continues to view males as less vulnerable than females and offers a common portrayal of men as the perpetrators and females as the victims. Often males are fearful that they may be perceived as gay and then judged as “wanting it” because of societal stigma. Exiting a trafficking situation is likely to be more difficult for males than females because there are fewer resources for recovering male trafficking survivors, such as housing, therapy, legal aid, and medical care (Bykerk, 2022).

ASSESSMENT AND INDICATORS OF HUMAN TRAFFICKING IN CLINICAL SETTINGS

The goals of healthcare providers who wish to intervene and assist victims of human trafficking are in direct conflict with those of exploiters. Exploiters hope for the continued vulnerability of their victims and see their victims as merchandise. Exploiters use concealment and misdirection to confuse anyone who they view as a threat to their profits and manipulation, power, and control to discourage victims from disclosing their circumstances.

In order to develop a capacity to listen to patients who have a history of violence, healthcare workers must be willing to extend themselves into areas of malfeasance and human fallibility. Healthcare professionals’ best resource is knowledge. Being aware of warning signs and indicators of human trafficking can alert the clinician to possible victims.

Setting and Presentation

The media often portrays trafficking victims as women who are in chains or have a sign written on their hands that says, “Help Me.” However, this is not what most trafficking victims look like. When victims of human trafficking present in healthcare settings, it is uncommon for them to self-disclose that they are victims. They have significant trust issues, and even when asked directly, they are not likely to disclose that they are victims. The exploiter may also accompany victims, and as with victims of domestic violence, that presence will discourage victims from making any disclosures to a clinician.

A healthcare professional may encounter victims of sex trafficking in a clinic or emergency department setting who are requesting treatment or testing for pregnancy, abortion, sexually transmitted infections, and contraception. They may request a sexual assault forensic exam or treatment for substance abuse. Victims may experience broken bones or nonaccidental injury at the hands of exploiters or buyers.

Victims of labor trafficking may have physical injuries, pesticide poisoning, or salmonella from unclean water sources. If their illness or injury is severe, these patients may present in outpatient clinics or in the emergency department.

Behavioral health providers may encounter victims of trafficking who are depressed, cannot sleep, have anxiety, or are suicidal. Dentists may see these victims when dental problems become severe.

DOCUMENTATION

When conducting an exam of a patient who may be a victim of human trafficking, documentation should carefully record a written description of any findings, photographs, diagrams, and forensic evidence. It is important that documentation reflect the patient’s perspective and not the suppositions or biases of the clinician (HEALTrafficking.org, 2018).

Potential Indicators

Human trafficking may be indicated by numerous possible signs. Clinicians may note one or more of the following “red flags” in a healthcare setting.

PHYSICAL SIGNS

  • Signs or a history of deprivation of food, water, sleep, or medical care
  • Physical injuries typical of abuse, such as bruises, burns, cuts, scars, prolonged lack of health or dental care, or other signs of physical abuse
  • Brands, scars, clothing, jewelry, or tattoos indicating someone else’s “ownership”
  • Presence of sexually transmitted infections
  • Pregnancy
  • Possession of cell phones, jewelry, large amounts of cash, or other expensive items that appear inconsistent with the patient’s stated situation
  • Substance abuse or dependence signs and symptoms
  • Clothing that is inappropriate for the weather or emblematic of commercial sex
INDICATORS IN A VICTIM’S APPEARANCE

The patient’s appearance may include unusual tattoos that signify “branding,” such as “I belong to John,” “Team Zodiac,” “I cum for $,” or barcodes. The patient may dress incongruently for the weather, such as wearing long sleeves to cover bruises or other marks when it is warm, or in clothing that is sometimes emblematic of commercial sex, such as skimpy skirts and low-cut tops regardless of when the weather is cool. It is important to remember that the victim may also be dressed as a school child, appear to be very well-dressed, or may be male or transgender.

PSYCHOLOGICAL/EMOTIONAL SIGNS

  • Fear, anxiety, depression, nervousness, hostility, flashbacks, avoidance of eye contact
  • Restricted or controlled communication, or use of a third party to translate, with no indicator of inability to understand English
  • Inconsistencies in the history of the illness or injury
  • Denial of victimization
  • Attempted suicide, submissiveness, fearfulness, self-harm, or other signs of psychological abuse
  • Appearing to be controlled by a third party (e.g., looking for permission to speak, not being left alone)
  • Isolation from family or former friends
  • Fear of employer
  • Described or implied threats to self or family/friends
  • History of running away

ENVIRONMENTAL/SITUATIONAL SIGNS

  • Working and living in the same place
  • Lacking the freedom to leave their working or living conditions
  • Being escorted or kept under surveillance when they are taken somewhere
  • Not being in control of their own money
  • Having no, or few, personal possessions
  • Frequently lacking identifying documents, such as a driver’s license or passport
  • Indicators of being a minor in a relationship with a significantly older adult
  • Not knowing their own address
  • Being in possession of hotel keys
BARRIERS TO RECOGNIZING MALE VICTIMS

Evidence has shown that even those providers who are trained to identify human trafficking victims often miss identifying male victims when they encounter them. Research identifies multiple contributing factors to the lack of recognition of male commercially sexually exploited children, even though an estimated 31%–71% of youth who are involved in commercial sex may be male:

  • Boys are not likely to self-identify as sexually exploited due to feeling shame, stigmatization from their family or community, and in some cases concerns about being gay.
  • Boys may not disclose their status due to fear of criminalization for substance use or being undocumented.
  • Providers may defer to cultural norms that recognize girls as being vulnerable and needing protection but expecting boys to “tough it out.”
  • Providers may accept a social standard that assumes that boys who are involved with forced sex do so willingly in exchange for benefits, thereby believing they are not being trafficked but are willing participants.
  • If a girl has new clothes or a manicure from an unexplained source, providers may suspect it is because she has been sexually exploited. If a boy has new shoes, jewelry, etc., he may instead be suspected of theft or gang involvement.
  • If a girl is seen with an older man, providers will investigate, but if a boy is involved with an older man, providers might assume he is a willing participant in a same-sex relationship.
  • Western culture promotes the image of males as strong and self-reliant persons who actively pursue sex.
  • Anti-trafficking organizations offer limited outreach to areas that are known for male prostitution.
    (French Nafekh et al., 2023)

INDICATORS AMONG MINORS

Minor victims may present with the same physical findings as adult victims, but it is important to also take note of a youth’s belongings. Trafficked youth generally have a cell phone and may also have in their possession items that seem too costly for their age and occupation, such as expensive jewelry, purses, and large amounts of cash.

A careful social history may elicit that the child is “couch surfing” or “staying with a friend” and not attending school. Trafficked youth may have a chronic illness such as asthma or diabetes that is neglected. They may be accompanied by an older person whom they call “Daddy” or “Uncle” or refer to as their “boyfriend.”

Screening

Screening should take place in a quiet environment free from interruptions. Food, drink, and tissues should be available during the interview, and the interviewer should be prepared to offer clothing and referrals to medical care and other services as indicated. The screener should be sensitive to the fact that formal dress, suits, and uniforms may be emblematic of immigration or enforcement agencies and are not conducive to open communication.

(See also “Trauma-Informed Care” below.)

USE OF INTERPRETERS

If interpreters are needed, in-person services through accredited agencies are preferred. Interpreters should be screened for any conflict of interest, and they should utilize trauma-informed care practices. Patients should be given the option to request a different interpreter if they are uncomfortable. Some patients may prefer the anonymity of using a translator on the phone instead of in person. Trained interviewers are available in 200 languages through the National Human Trafficking Hotline (see “Resources” at the end of this course) (HEALTrafficking.org, 2020).

STRATEGIES TO INTERVIEW THE PATIENT ALONE

In order to provide an opportunity for the patient to communicate freely, the healthcare professional may need to implement a strategy to create privacy when the patient is accompanied by someone else. Strategies include: requesting that the patient leave the room with a clinician and without any accompanying person to undergo a procedure such as an X-ray, requesting that any accompanying person step out of the room due to hospital privacy policies, or asking an accompanying party to leave the room in order to provide assistance with registering the patient.

If the person who is accompanying the patient refuses to leave or to allow the patient to be separated, it may not be in the patient’s best interest for the healthcare professional to insist. If the trafficker feels threatened, there is a risk that the patient will not be allowed to receive treatment or be harmed after leaving the facility. The same is true for involving law enforcement or security. If the trafficker becomes suspicious, it may jeopardize the ability of the patient to return for needed treatment (HEALTrafficking.org, 2020).

SAFETY MEASURES

When working with human trafficking survivors, safety is a primary concern. Although many emergency departments have metal detectors to screen for weapons, it is important that all healthcare institutions have a response protocol in the event of violence. It is equally important that healthcare professionals are aware of how to keep their patients and themselves safe at work.

When working with crime victims and suspects in particular, the healthcare professional should pay attention to the environment and be prepared to act quickly. Because of the criminal nature of human trafficking, security should be alerted when a patient is suspected of being a human trafficking victim. Personnel should also be cognizant of prevention measures such as registering a high-risk patient under an alias, flagging their chart not to give information to the public, or placing the unit under lockdown if a direct threat occurs (Titler & Reynolds, 2020).

OVERCOMING SURVIVOR BARRIERS TO DISCLOSURE

The goal of the healthcare professional should not be to elicit a disclosure but to create a safe space where patients feel that they can be treated, learn more about their options, and receive support to make informed decisions (NHTTACenter, 2021). There are many barriers to disclosure by human trafficking survivors to healthcare workers:

  • Patients who are trafficked are frequently in the presence of their trafficker or another person who is watching what they say and are not free to discuss their situation.
  • They may be unable to communicate due to linguistic issues, illness, or trauma.
  • Patients do not have any reason to trust healthcare professionals, are fearful of their trafficker, and are concerned that they will not be believed or might be arrested.

Survivors who have experienced human trafficking are experts on this topic and understand what healthcare providers need to know in order to create a safe space for disclosure. According to survivors, it is important that healthcare workers have a working knowledge or skills in these areas:

  • Resources for human trafficking survivors
  • Mandatory and nonmandatory reporting of human trafficking
  • Trust-building
  • Means of separation from the trafficker
  • Survivor empowerment, follow up, and monitoring
  • “Red flags” for human trafficking
  • Skilled collaboration and assessment
  • Compassion
  • Advocacy
  • Respect
  • Trust
  • Patience
  • Gentleness
  • Sensitivity
  • Safety
  • Nonjudgmental attitude

Survivors also recommend that healthcare professionals:

  • Obtain informed consent for all treatments
  • Share accurate timeframes
  • Avoid touching the patient and, when clinically necessary, only do so after asking permission
  • Provide opportunities for the patient to be in control when possible
  • Listen and respond to the needs that patients verbalize
  • Include other survivors in the care team to reduce the possibility of shame
    (Chisolm-Straker et al., 2020)

SCREENING TOOLS

Florida’s Human Trafficking Screening Tool (HTST) is associated with a protocol that is specific to the Florida Department of Juvenile Justice (2023) and is designed to screen for indicators of human trafficking. Both the prescreening and HTST have been incorporated into the electronic case management system, and the process was revised in 2023. (See “Resources” at the end of this course for a link to the HTST.)

The Vera Institute of Justice’s (2014) Trafficking Victim Identification Tool (TVIT) is validated and continues to be used by health professionals, law enforcement officers, and other service providers to screen adult victims of trafficking. This tool consists of a 30-topic questionnaire and was developed over two years with a grant from the National Institute of Justice. The tool is available in both English and Spanish and comes in a full or abbreviated version. This tool requires about an hour to administer, and the results are evaluated by a human trafficking expert. The topics that are covered include background and demographics, migration into the United States, and working and living conditions. The total responses are evaluated, and needs such as safety, housing, social service, and employment are assessed. This tool works best with reliable referral networks so that victims can receive the services that they need from community partners (TX DHHS, 2023).

TRAUMA-INFORMED CARE

Trauma is an intense response to a stressful situation that can result in lasting negative effects on an individual that are averse to their health and well-being. Trauma impacts an individual’s worldview, identity, and relationships. These beliefs impact how the individual will respond to available services and the criminal justice system.

Therefore, whenever a clinician is interacting with a potential victim of human trafficking, trauma-informed care and interviewing techniques are important so that the individual is not inadvertently retraumatized. Providers should incorporate the “Four Rs” into their trauma-informed practice:

  1. Realize the prevalence of trauma
  2. Recognize that trauma affects how an individual responds to interactions with the organization or system
  3. Respond by putting knowledge into practice
  4. Resist retraumatization of individuals

Any service provider who interfaces with an individual who has a history of trauma—from the receptionist to the physician—should be educated about trauma-informed care and strive to create an environment in which the patient feels safe, believed, and empowered. Nobody should be made to feel like a witness to a crime for which they are the victim (OVC, 2023).

Principles of a Trauma-Informed Approach

Promising practices for a trauma-informed approach to screening rely on caring for each individual as if they have experienced a trauma and being mindful to avoid retraumatizing the patient. There is a focus on physical, psychological, and emotional safety and an emphasis on helping the patient achieve a sense of control, empowerment, and agency.

The six principles of a trauma-informed approach include:

  1. Safety. The provider ensures safety for the patient, both physical and emotional, and maximizes the patient’s control. The provider aims to meet the basic needs of the patient, including necessary medications.
  2. Trustworthiness and transparency. The provider spells out the limits of confidentiality and ensures that the patient is heard and understood.
  3. Peer support. The provider encourages the patient who has survived trauma to implement self-help.
  4. Collaboration and mutuality. The provider acknowledges the individual roles of the patient and staff and attempts to even out power discrepancies.
  5. Empowerment, voice, and choice. The provider supports the individual’s sense of agency and helps the survivor become empowered.
  6. Cultural, historical, and gender issues: The provider recognizes that there may be sources of trauma from cultural, racial, ethnicity, gender, and historical issues, including adverse childhood experiences (ACEs).
    (Human Trafficking Collaborative, UOM, n.d.)

Asking Difficult Questions

Sometimes it is difficult to frame questions in a way that will feel nonjudgmental to a victim. The ability to ask questions in a way that does not cast blame will provide the health professional with better information and is unlikely to cause harm to the patient.

  • An opening statement such as “I would like you to tell me everything that you are comfortable sharing” can be very helpful.
  • If immigration status might be an issue, it is best to not ask about this initially.
  • Asking, “What were you wearing?” could be interpreted by the patient as blaming them for the occurrence based on their dress. Instead, one might ask, “What are you able to remember about what you were wearing?”
  • It is important to avoid asking victims of human trafficking “why” questions about any of their actions or responses. Asking “why” may cause the victim to feel or believe that they did something wrong and is likely to negatively impact the interview.

Forensic Experiential Trauma Interview

Principles from the Forensic Experiential Trauma Interview (FETI), developed by Russell Strand, can be utilized by healthcare professionals who work with victims of trauma. The FETI is based on the neurobiology of trauma that entails a shutting down of the prefrontal cortex during the traumatic or stressful event. The prefrontal cortex, when operating efficiently, is the cognitive part of the brain that normally records the memory of an event (who, what, why, where, when, and how). During a traumatic event, less-advanced portions of the brain record the event. Stress and trauma interrupt how memories are stored and may lead to the victim expressing inconsistent or incorrect statements.

  • Interviewers make a sincere effort to establish safety, trust, and comfort for the victim. They acknowledge the victim’s trauma and ask nonleading questions such as, “What are you able to tell me about your experience?” or “I would like you to share with me everything that you are comfortable sharing.” Statements such as “Help me understand about the car ride” replace the use of “Why did you get in the car with him?”
  • Interviewers do not interrupt, and they pause to allow victims time to think through the question. They may ask, “What were you feeling?” or “What was your thought process during this experience?” instead of “Why did you do that?”
  • Interviewers express empathy and understanding and allow the victim to say they “don’t remember” rather than asking the victim to guess.
  • Interviewers acknowledge that the victim may remember more after some time has passed.
    (Lonsway & Archambault, 2021)

Forensic interviews of children and adolescents utilize a multidisciplinary team approach and generally take place in a child advocacy center. A certified interviewer conducts the interview while law enforcement, social services, behavioral health, and medical representatives observe from another room. These interviews are generally recorded using an audio-visual system, and observers document their observations according to each discipline’s requirements (Childsafe, 2020). Florida Statute 39.303(9) requires a task force to provide oversight to enhance the safety of children (Florida Senate, 2023).

SHARING INFORMATION WITH PATIENTS

Healthcare professionals are on the front lines of providing direct patient care to human trafficking survivors and are uniquely positioned to recognize and respond. The majority of survivors who are actively being exploited will encounter healthcare professionals. These individuals may be at risk of trafficking, involved but not ready to get out, involved and wanting help to get out, or have been previous victims.

The manner in which information is shared can be as important as the content itself. It is important to remain objective, provide privacy, and provide verbal and written information in a language that the patient can understand. Healthcare providers must also be mindful of maintaining a trauma and survivor-informed environment. Use of a harm-reduction model meets patients where they are and does not subject them to judgment or push them to disclose information if they are not ready to do so (WHO, 2023a).

The World Health Organization recommends that healthcare institutions implement the following:

  • Remove barriers to care, such as social and financial obstacles, to the degree possible and take measures to increase trafficking providers’ trust in the health care system.
  • Become involved in prevention efforts when possible, supporting programs such as “My Strength” and “My Life” that are offered in the United States.
  • Develop treatment plans based on available resources and ensure that these plans are patient-centered.
  • Use validated screening tools to universally screen all patients for trafficking.
  • Provide trauma-informed and compassionate care.
  • Promote staff education on human trafficking that can be standardized and easily accessed by staff, such as online training in order to provide better quality care to trafficking survivors.
  • Create policies and programs at local and state levels to address human trafficking
  • Encourage leadership among health professionals to provide education and intervention.
  • Become involved in research for evidence-based best practices.
    (WHO, 2023b)

When providing direct care for suspected human trafficking patients, the clinician should not focus on eliciting information from them about their trafficking situation. Instead, the clinician should offer comprehensive care services that are unique to the patient’s needs and sensitive to the patient’s circumstances. The aim of the provider is to establish a safe haven in the environment, treat the patient for their medical needs, and offer information and support. It is important that the patient gives consent for any procedures, and that the clinician maintains trauma-informed principles (Stoklosa & Beals, 2022).

Survivors who have experienced human trafficking are experts on this topic and understand what healthcare providers need to know in order to create a safe space to interact. According to survivors, it is important that healthcare workers have a working knowledge of resources and mandatory and nonmandatory reporting of human trafficking. When sharing information, healthcare workers should share accurate timeframes and respond to the needs that patients verbalize and provide opportunities for the patient to be in control when possible (Chisolm-Straker et al., 2020).

Legal and Social Services for Victims of Human Trafficking in Florida

Legal assistance should be accessible for all victims of human trafficking, and advocacy provided to help navigate a complex system. It is important for victims to understand their rights so that they can receive services to address their situation. Attorneys can help victims who have been detained, prevent them from being deported, and if they are not citizens of the United States, help them apply for a T visa. The T visa allows victims of trafficking to live and work in the United States and apply for permanent residency (see box below).

A variety of direct legal and social service providers are available to clients in Florida. Religious groups, government agencies, nongovernmental agencies, and community partners such as domestic violence shelters are part of a network of coordinated community care. The National Human Trafficking Hotline website, operated by the Polaris Project, is a robust resource. This website offers an interactive map and search feature to locate the type of service needed in each community of the United States. A provider or client can also inquire about local services by calling the telephone hotline (Baldwin et al., 2017). (See “Resources” at the end of this course.)

Other resources to consider sharing with human trafficking survivors include:

  • HEAL Trafficking (Health, Education, Advocacy, Linkage) is an organization composed of multidisciplinary professionals who support human trafficking survivors from a public health perspective. The organization provides an array of resources that are available on their website, including a Human Trafficking Protocol Toolkit, literature and publications, a speaker’s bureau, and links to a network of nonprofit groups and academic and government centers pertaining to human trafficking. The website also offers patient resources, information on child labor, COVID-19, and protocol consultancy.
  • South Florida Human Trafficking Task Force (SFHTTF), an antitrafficking coordination team, provides a unique model of addressing human trafficking that goes beyond the “3 Ps” (prevention, protection, and prosecution). Composed of law enforcement, nongovernmental organizations, private entities, clergy, and state-certified victim advocates, the task force responds in a collaborative manner to assist victims and address and disrupt organized crime that supports human trafficking. By providing victims with services while coordinating investigations, the SFHTTF promotes a victim-centered approach in which the needs of the victim are viewed as equally important as the apprehension and prosecution of the exploiters (SFHTTF, 2022).

(See “Resources” at the end of this course for website links/contact information.)

U VISA and T VISA

The U visa is a unique visa for undocumented victims of crimes who have experienced substantial mental or physical abuse and are willing to assist law enforcement in the investigation or prosecution of the criminal case. It was developed with the intent to strengthen the ability of law enforcement to investigate and prosecute certain types of cases. Victims who are granted a U visa are given temporary legal status and work eligibility in the United States for up to four years. This program helps law enforcement agencies assist many victims of crimes who would otherwise not be served (U.S. DHS, 2019). The number of petitioners for the U visa from 2009 to 2020 was 30,900, and USCIS approved 20,400 applications in that same time period (U.S. CIS, 2020b).

The T visa is similar and addresses victims of trafficking. These victims, along with approved family members, may reside in the United States for approximately four years if they comply with criminal justice system requests (U.S. CIS, 2020a). The number of petitioners for the U visa from 2009 to 2020 was 30,900, and USCIS approved 20,400 applications in that same time period (U.S. CIS, 2020b).

Three barriers have been identified that prevent victims from obtaining a T visa:

  • The process is not consolidated, and as a result, victims must tell multiple people and agencies what happened to them and relive the trauma each time.
  • Many victims do not speak English as a first language (if they speak it at all), but the visa application to be completed is in English.
  • The time to process the T visa is lengthy, ranging from 18 months to two and a half years. but the applicant is unable to legally work in the United States during that time.
    (Human Trafficking Search, 2021)

REPORTING HUMAN TRAFFICKING IN FLORIDA

Reporting Trafficking in Minors and Vulnerable Adults

Trafficking in minors (under the age of 18), including child sex or labor trafficking, is a form of child abuse and maltreatment, and any citizen who suspects child abuse must make a report to the Department of Children and Families (see “Making a Report” below). Reporters who feel that a child is in imminent danger should call the police first.

The legal definition of vulnerable adult in Florida is “a person age 18 years or older who has a disability or is suffering from the infirmities of aging.” These adults are unable to perform activities of daily living or provide for their own care or protection because they are impaired due to disability, brain damage, or infirmity. Any person who has a reasonable cause to suspect abuse of a vulnerable adult must make a report to the Florida Abuse Hotline (see “Making a Report” below). Reporters who feel that a vulnerable adult is in imminent danger should call the police first (FL DCF, 2023b).

PROFESSIONAL MANDATED REPORTERS

Professional mandated reporters in Florida who are required to give their name when they report include:

  • Physician, osteopathic physician, medical examiner, chiropractic physician, nurse, or hospital personnel engaged in the admission, examination, care, or treatment of persons
  • Health or mental health professional other than one listed above
  • Practitioner who relies solely on spiritual means for healing
  • School teacher or other school official or personnel
  • Social worker, day care center worker, or other professional childcare, foster care, residential, or institutional worker
  • Law enforcement officer
  • Judge

Mandated reporters should make a report immediately to the Department of Children and Families if they have a reasonable suspicion that a child or a vulnerable adult is experiencing abuse or neglect, including human trafficking. Although the mandated reporter is required to give their name, all reports are confidential.

Mandated reporters who knowingly and willfully fail to report abuse or neglect may be charged with a third-degree felony and may be sentenced up to five years in prison and fined up to $5,000. Educational institutions that fail to report child abuse related to institutional events may be fined up to $1 million for each failure to report abuse or neglect.

MAKING A REPORT

A report of suspected abuse of a child or vulnerable adult is made by immediately calling, faxing, or reporting online to the Florida Abuse Hotline. The hotline screens all reports and will initiate an investigation to determine risk to the victim (FL DCF, 2023a).

There are four ways to make a report of suspected human trafficking in Florida:

  • Telephone: 800-96-ABUSE (800-962-2873)
  • Fax: 800-914-0004
  • TDD: 800-955-8771
  • Internet: See “Florida Abuse Hotline” in the “Resources” section at the end of this course

The following information is included in a report of human trafficking for a child or vulnerable adult:

  • Name, occupation, agency, phone, and address of the reporting party (if the reporter is a professionally mandated reporter; all other reporters may choose to remain anonymous)
  • Name of the victim
  • Complete address and telephone number, including area code, of the victim
  • Estimated or actual date of birth of the victim
  • Gender, race, and social security number of the victim
  • Names and birthdates of other children in the home
  • Name, date of birth, gender, race, and social security number of a person suspected of abuse or exploitation
  • A brief description of the concern and any injuries sustained by the victim, including when and where the incident occurred, frequency of occurrence, and threat of harm
  • Names of others who might be aware of the abuse or exploitation of the victim and their relationship to the victim
  • The name and contact information of the victim’s parent or guardian, as well as other adults residing in the home
  • A brief description of the victim's disability or infirmity (required for vulnerable adults)
  • The relationship of the suspect to the victim
    (FL DCF, 2023c)

Reporting Trafficking in Competent Adults

In Florida, competent adult victims of human trafficking have the rights to privacy and agency. Mandated reporters may not report suspected human trafficking to law enforcement without a victim’s consent, and to do so without their specific consent could lead to civil action against the reporter.

Healthcare providers may counsel competent adult human trafficking victims and refer them to law enforcement and pertinent services. They may also make a confidential report to the National Human Trafficking Resource Center by calling the National Human Trafficking Hotline at 888-373-7888 (see box below).

(See also “Resources” at the end of this course.)

REPORTING TO THE NATIONAL HUMAN TRAFFICKING HOTLINE
  • Hotline number: 888-373-7888

This organization is not an investigative agency or affiliated with law enforcement. When a report is made to the National Human Trafficking Hotline, consent and safety are the most important elements that are considered. When a call is received, the following actions will occur:

  • A skilled advocate will assess the circumstances for potential labor or sex trafficking of a person of any age, nationality, race, or gender. Whenever possible, the hotline personnel will speak directly with victims in order to discuss reporting and referral options and receive consent to act on that person’s behalf.
  • If the victim is a child, the hotline advocate will immediately inform the appropriate authorities.
  • When the hotline advocate determines that the call concerns a potential case of human trafficking, a supervisor is immediately alerted to begin coordinating a response. Action steps frequently include:
    • A follow-up call to the caller (with their consent) for additional information
    • A report to the designated law enforcement agency
    • Coordination with service providers for emergency assistance or transfer to a service provider

Tips of suspected human trafficking may also be provided anonymously (NHTH, 2023a).

(See also “Resources” at the end of this course.)

CONCLUSION

The crime of human trafficking creates a ripple effect when the trauma of victims expands steadily in circles that encompass families, communities, and professionals who assist them. It is a crime associated with serious adverse mental and physical consequences and increased mortality in a cohort of individuals who may not define themselves as victims.

Change can only occur with a coordinated, multidisciplinary response and must include the efforts of professionals to learn to recognize the signs of human trafficking, take action in a trauma-informed manner when working with victims, and comply with mandated reporting laws.

In order to eradicate this form of human exploitation, legislators must continue to redefine our laws to protect the vulnerable; peace officers must enforce these laws; other members of society, such as healthcare practitioners, other mandated reporters, and citizens, must empathize with survivors; and prosecutors must hold offenders accountable.

RESOURCES

Blue Campaign (U.S. Department of Homeland Security)
To report suspected human trafficking: 866-347-2423

Florida Abuse Hotline (to report abuse)
800-96-ABUSE (800-962-2873) (phone)
800-955-8771 (TDD)
800-914-0004 (fax)

Florida Coalition against Human Trafficking

Florida Family Policy Council

HEAL Trafficking

Human Trafficking Screening Tool (HTST)

National Human Trafficking Hotline—Florida
TTY: 711
888-373-7888
Text “BeFree” to 233733

Polaris Project

Protective Response Model

Safe Horizon
24 Hour Hotline: 800-621-HOPE (4673)

Victim Assistance Program (U.S. Immigration and Customs Enforcement)

REFERENCES

NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course.

Baldwin SB, Barrows J, & Stoklosa H. (2017). Protocol toolkit for developing a response to victims of human trafficking. HEAL Trafficking and Hope for Justice. https://iowanaht.org

Bykerk E. (2022). The silenced minority: Sex trafficking of males. https://traffickinginstitute.org

Childsafe. (2020). The forensic interview. https://www.childsafe-sa.org

Chisolm-Straker M, Miller CL, Duke G, & Stoklosa H. (2020). A framework for the development of healthcare provider education programs on human trafficking, part two: Survivors. Journal of Human Trafficking, 6(4), 410–24. https://doi.org/10.1080/23322705.2019.1635333

Florida Department of Children and Families (FL DCF). (2023a). Abuse hotline. https://www.myflfamilies.com

Florida Department of Children and Families (FL DCF). (2023b). Adult protective services. https://www.myflfamilies.com

Florida Department of Children and Families (FL DCF). (2023c). Abuse hotline: What you need. https://www.myflfamilies.com

Florida Department of Juvenile Justice. (2023). Human trafficking screening tool. https://www.djj.state.fl.us/content/download/22467/file/human-trafficking-screening-tool.pdf

Florida Health. (2023). Human trafficking. https://flhealthsource.gov

Florida Senate. (2023). 2023 Florida Statutes. https://m.flsenate.gov

French Nafekh E, Ackerman-Brimberg M, Walker Brown K, Masciangelo J, Earl N, & Dickeson L. (2023). Understanding the commercial sexual exploitation of boys & young men: How service providers can break down biases & barriers to help boys & men thrive. National Center for Youth Law. https://youthlaw.org

Gardner A. (2023). Human trafficking is a public health issue. United Way. https://www.unitedway.org

Greenbaum J. (2020). The public health approach to human trafficking prevention. Georgia State University Law Review, 6(4), 1059–74. https://readingroom.law.gsu.edu

HEALTrafficking.org. (2020). Health education advocacy linkage. https://healtrafficking.org

HEALTrafficking.org. (2018). Introductory training on human trafficking for U.S. health care professionals. https://healtrafficking.org

Human Trafficking Collaborative, University of Michigan. (n.d.). Trauma-informed care. https://humantrafficking.umich.edu

Human Trafficking Search. (2021). T visas: Intent and reality—Immigration attorneys share challenges to ‘humanitarian’ approach. https://humantraffickingsearch.org

Interactive Constitution. (2020). The abolition of slavery. https://constitutioncenter.org

Lonsway KA & Archambault J. (2021). Effective victim interviewing: Helping victims retrieve and disclose memories of sexual assault. End Violence Against Women International. https://evawintl.org

National Center for Missing and Exploited Children. (2022). Child sex trafficking overview. https://www.missingkids.org

National Human Trafficking and Training Assistance Center (NHTTAC). (2021). Core competencies for human trafficking response in healthcare and behavioral health systems. https://nhttac.acf.hhs.gov

National Human Trafficking Hotline (NHTH). (2023a). Report trafficking. https://humantraffickinghotline.org

National Human Trafficking Hotline (NHTH). (2023b). Hotline statistics: Florida. https://humantraffickinghotline.org

Office for Victims of Crime (OVC), Training and Technical Assistance Center. (2023). Using a trauma-informed approach. https://www.ovcttac.gov

Online Sunshine. (2023). 2023 Florida Statutes: Statute 787.06. http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&URL=0700-0799/0787/Sections/0787.06.html

Polaris Project. (2021). Trafficking vs. smuggling: Understanding the difference. https://polarisproject.org

Polaris Project. (2020a). Human trafficking. https://polarisproject.org

Polaris Project. (2020b). Trafficking victims protection act. https://polarisproject.org

Polaris Project. (2020c). The AMP model. https://polarisproject.org

South Florida Human Trafficking Task Force (SFHTTF). (2022). Homepage. https://www.sfhumantraffickingtaskforce.org

Stoklosa H & Beals L. (2022). Human trafficking in the ED: What you need to know. ALiEM. https://www.aliem.com

Texas Department of Health and Human Services (TX DHHS). (2023). Texas human trafficking resource center. https://www.hhs.texas.gov

Titler J & Reynolds S. (2020). Human trafficking in the emergency department: Improving our response to a vulnerable population. Western Journal of Emergency Medicine, 21(3). https://westjem.com

U.S. Citizenship and Immigration Services (U.S. CIS). (n.d.) Unlawful employment of aliens. https://www.uscis.gov

U.S. Citizenship and Immigration Services (U.S. CIS). (2022). Characteristics of T nonimmigrant status (T visa) applicants fact sheet. https://www.uscis.gov

U.S. Citizenship and Immigration Services (U.S. CIS). (2020a). Questions and answers: Victims of human trafficking, T nonimmigrant status. https://www.uscis.gov

U.S. Citizenship and Immigration Services (U.S. CIS). (2020b). Number of form I-918, petition for U nonimmigrant status by fiscal year, quarter, and case status, fiscal years 2009–2020. https://www.uscis.gov

U.S. Department of Homeland Security (U.S. DHS). (2019). U visa law enforcement guide. https://www.dhs.gov

Vera Institute for Justice. (2014). Out of the shadows, a tool for the identification of victims of human trafficking. https://www.vera.org

World Health Organization (WHO). (2023a). “There was never one time that anyone asked me ‘Are you okay?’” https://www.who.int/europe/news/item/08-05-2023-there-was-never-one-time-that-anyone-ever-asked-me-are-you-okay

World Health Organization (WHO). (2023b). Addressing human trafficking through health systems. https://iris.who.int/bitstream/handle/10665/366280/9789289058827-eng.pdf?sequence=3

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