Victim Recognition and Intervention for Healthcare Professionals
Online Continuing Education Course
Human trafficking is a growing trend across the United States. Take our training to understand the types of trafficking and to learn how to recognize warning signs. Identify potential child and adult victims and the requirements and resources for intervening and reporting.
Course Price: $24.00
Contact Hours: 3
Course updated on
February 16, 2021
"The information answered many of my questions regarding trafficking adults verses minors as well as prevalent issues to be aware of while practicing." - Lisa, PT in California
"Thank you for offering a course that I could print out and work on at home. I have limited English skills, and I would otherwise not be able to do this type of course online." - Jing, OT in Ohio
"Very good information. Clear and concise." - Jeannine, RN in Kentucky
"I have attended AWHONN programs about this topic, however I found your article more informative and helpful with the explanations of visas, social work, etc. Thank you." - Terry, RN in Delaware
Accreditation / Approval Information
FLORIDA: Take the FL version of this course.
MICHIGAN: Take the MI version of this course.
TEXAS: Take the TX version of this course.
Victim Recognition and Intervention for Healthcare Professionals
Copyright © 2021 Wild Iris Medical Education, Inc. All Rights Reserved.
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 factors that place persons at risk for human trafficking victimization.
- Articulate the extent to which human trafficking occurs.
- Describe assessment tools for and indicators of human trafficking.
- 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.
- Identify the mechanisms for reporting suspected human trafficking.
TABLE OF CONTENTS
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. 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/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).
Healthcare workers are in a unique position to aid in prevention and protection of human trafficking victims. Education of healthcare professionals about human trafficking allows them to identify victims of human trafficking and intervene effectively. Human trafficking is associated with complex physical and psychological health consequences that include communicable diseases, substance dependency, and mental illness. A history of abuse, neglect, and exploitation can influence the experience of the victim of trafficking. Healthcare providers must learn to recognize potentially trafficked persons, consider their wishes and vulnerabilities along with their healthcare needs, and be cognizant of pertinent resources that may be offered (Macias-Konstantopoulos, 2017).
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 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.
SAFE HARBOR LAWS AND SEX TRAFFICKING OF MINORS
A minor is defined as being under the age of 18 years, but the age for consent for lawful intercourse in some states is as low as 16, and the majority of states still criminalize child prostitution. Therefore, some youth between the ages of 16 and 18 remain vulnerable to arrest for prostitution even though the TVPA defines the commercial sexual activity of minors as victimization as opposed to criminal behavior regardless of whether the child’s activity appears to be voluntary (Finklea et al., 2015).
The arrest and criminalization of trafficked youth for commercial sexual activity typically compounds their trauma. Placement in the juvenile justice system also exposes trafficking victims to other youth detained for criminal acts.
To address this issue, a few states have passed “Safe Harbor” laws in order to ensure that minors are not criminalized for prostitution and so that they will receive services for sexually exploited you. However, many states do not have such laws protecting minors from arrest (Human Trafficking Search, 2020).
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 (Polaris, 2016).
The following definitions can be found in federal laws:
- Threats of serious harm to or physical restraint against a person; any scheme, plan, or pattern intended to cause a person to believe that a failure to perform an act would result in serious harm to or physical restraint against any person; or the abuse or threatened abuse of the legal process
- Commercial sex act
- Any sex act on account of which anything of value is given to or received by any person
- Debt bondage
- The status or condition of a debtor arising from a pledge by the debtor of his or her personal services or of those of a person under his or her control as a security for debt, if the value of those services as reasonably assessed is not applied toward the liquidation of the debt or the length and nature of those services are not respectively limited and defined
- Physical restraint or harm, sexual assault, battery, or control by confinement or monitoring
- False promises and hopes given to the victim; deceptions concerning employment, wages, the type of job that is offered, love, marriage, or a better life
- Involuntary servitude
- A condition of servitude induced by means of any scheme, plan, or pattern intended to cause a person to believe that, if the person did not enter into or continue in such condition, that person or another person would suffer serious harm or physical restraint; or the abuse or threatened abuse of the legal process
(22 USC § 7102; U.S. DHHS, 2017)
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.
|(Polaris Project, 2020)|
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 (U.S. DOS, 2017a).
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.).
Human Trafficking Venues
Labor trafficking occurs most often in the agriculture and hospitality industries, landscaping, and traveling sales. The exploiters frequently target immigrants and economically marginalized persons. As one example, young victims may be recruited to participate in “begging rings,” which are organized groups that sell trinkets and magazines and are only paid enough money to barely cover their food and personal items (Polaris, 2016; NHTH, n.d.-c).
Sex trafficking venues are often related to commercial sex, which may occur in:
- On the street or in outdoor areas such as truck stops
- Hotels or casinos
- Escort services
- Massage parlors
Sex trafficking may also occur in venues related to pornography, sex tourism, exotic dancing, stripping, and “mail-order” brides (U.S. DHHS, 2018).
|Traveling sales crews||107|
|Illicit massage/spa business||1,247|
|Residence-based commercial sex||592|
|Online ad/venue unknown||452|
TRUCKERS AGAINST TRAFFICKING
Truckers Against Trafficking is a national nonprofit organization that acknowledges truckers as valuable in recognizing and reporting victims of trafficking. This group has partnered with law enforcement and government agencies, and they provide a website for members of the trucking industry to educate and empower themselves in combatting trafficking. A training video created by Empathize, an organization that focuses on prevention of and education about crimes against children, is available to view on their website (Truckers Against Trafficking, 2020).
Dynamics of Human Trafficking
Once a trafficking victim becomes entrapped by the exploiter, leaving may be difficult because the victim may fear threats of physical abuse or be subjected to false promises. They may be manipulated into thinking that they are indebted to or protected by the exploiter. Victims may become isolated from family and friends, feel ashamed, be controlled by drugs, or develop a type of traumatic bond with the exploiter (CDC, 2017).
The dynamics of the relationship between an exploiter and a trafficking victim share similarities with the dynamics of the relationships associated with domestic violence. In both cases, the victim may have difficulty leaving the relationship emotionally, physically, and financially, or may fear the repercussions of leaving. Trafficking victims and domestic violence victims may both develop feelings of trust or affection toward their abuser or captor (sometimes referred to as Stockholm syndrome) and suffer from shame, self-blame, and posttraumatic stress (U.S. DHHS, 2017).
Exploiters can operate as individuals, small businesses, or in large, organized criminal networks. Traffickers and victims frequently share similar backgrounds and ethnicities, which gives exploiters an advantage to manipulate victims whom they somewhat understand. Some exploiters are the same age as the victims and work as peer recruiters.
Traffickers may be owners of brothels or massage businesses or own businesses that employ domestic servants or agricultural workers. Traffickers may be family members, intimate partners, or friends of the victim. They may own factories or corporations, and trafficking may exist within a legitimate business.
Traffickers frequently exploit industries such as advertising or airlines. They may also exploit buses and other forms of travel. Trafficking may be associated with landlords, passport service businesses, labor brokers, and the hotel industry. Although these businesses can be used for criminal trafficking activity, legitimate business owners should be aware of exploiters and report trafficking situations (NHTH, n.d.-b.).
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 vulnerability 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 vulnerability factors include but are not limited to:
- Family violence
- Loss or abandonment
- Peer or family exploitation
Community vulnerability 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 vulnerability 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).
“I had just graduated from high school and was accepted to an out-of-state college on a sports scholarship. I was a good student and was really excited to go away to college. Although I had just broken up with someone, I never really had what you would call a serious romantic relationship.
“One evening I was walking outdoors with some friends, and we ran into a group of guys. That is how I met Michael. His cousin introduced us, and we started dating. Michael treated me well. He bought me nice things, took me on trips, and made me feel special. He was charming and so good-looking. I would see him with a whole group of women, and I felt so good because he had picked me.
“At the end of the summer, Michael took me on a trip to Las Vegas. Once we checked in to the hotel, everything changed. He brought a series of buyers into the room and forced me to have sex with them. He became violent when I resisted, and I had no choice but to comply. I didn’t know anything about people like that. No one ever told me.”
* The “Survivor Voice” statements presented in this course were made to the author during personal interviews with a survivor of human trafficking.
EXTENT OF HUMAN TRAFFICKING
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. Children (defined as under 18 years of age) are frequently recruited as runaways, with the likelihood that an estimated 1 in 6 U.S. children who ran away from home in 2014 were victims of sex trafficking (Polaris, 2017b). Thirty-three percent of the sex trafficking cases in the United States that were identified in 2015 involved children (U.S. DHHS, 2016).
While it is difficult to know for sure how many people are victims of human trafficking, the National Human Trafficking Hotline gathers data from calls made to their hotline (see tables below).
|Sex and labor||505|
MALE TRAFFICKING VICTIMS
Although most published statistics portray victims of trafficking as predominantly female, that information may not be accurate. 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.
Initially, male victims may not self-identify as victims. Social values reinforce their perception because society continues to view males as less vulnerable than females. Male victims are at risk for deportation or being charged as criminals rather than being treated as exploited persons. Recovery is much more difficult for male victims, since shelters or recovery programs may not accept men. Clearly, male victims need the same assistance that females receive, including housing, therapy, legal aid, and medical care (U.S. DOS, 2017b).
Male Sex Trafficking
One summer, Kevin, age 14, met a man called Ray, who took an interest in him. Ray soon asked Kevin if he would like to meet some young friends his own age. Ray gave him a ride and dropped him off to meet the boys in another part of town. Kevin sat outdoors with two new friends and watched a middle-aged man walk past them and into a public restroom. One of the boys followed the man into the restroom and motioned for Kevin to come, too. Kevin watched while his friend orally copulated the man and then was paid $25.00 cash. Eventually Kevin began to exchange sex acts for money, too.
(Adapted from Kline & Maurer, 2015.)
Human trafficking impacts the health of its victims. Most epidemiological studies on human trafficking have focused on women and children who have been sexually exploited. These studies have historically concentrated on HIV, sexually transmitted infections (STIs), chronic health problems, and mental health issues. It is known that victims of trafficking are abused physically, psychologically, and sexually.
In healthcare settings, individuals may present with chronic health conditions such as diabetes, chronic pain, chemical dependency, HIV, or depression that have gone untreated because they have been unable to access healthcare. Adolescents may not be up to date on their immunizations or suffer from vitamin deficiency, developmental issues, or other malnutrition and toxic stress.
Physical symptoms that are commonly reported include:
- Stomach problems
- Significant weight loss
- Back pain
- Chronic pain
- Chemical dependency
- Dental problems
- Neglect of chronic health conditions such as diabetes or HIV
Reproductive and sexual health concerns and procedures may include:
- Sexually transmitted infections, including HIV
- Abnormal PAP, cervical dysplasia
- HPV testing
- LEEP (loop electrical excision procedure for cervical dysplasia)
- Contraception evaluation and management
- Pregnancy termination procedures
- Prenatal care
- Labor and delivery
“Some girls got STIs or got pregnant. When they couldn’t meet their quota, they would go without a condom because buyers would pay more for doing it that way. Some traffickers would get girls pregnant to trap them.”
Mental health issues have also been identified and found to persist longer than physical symptoms. These include:
- Addiction (especially opioid)
- Complex trauma resulting in psychosis
- Suicide attempts
- Posttraumatic stress disorder (PTSD)
When one considers the extensive psychological trauma that an adult or child experiences in response to a single sexual assault, it is not surprising that victims of sex trafficking, who experience multiple assaults, would suffer from significant behavioral health issues such as depression, anxiety, posttraumatic stress disorder, and substance abuse (Greenbaum & Crawford-Jakubiak, 2015).
Due to the clandestine nature of the crime of human trafficking, it is difficult to conduct long-term research. The literature suggests that the lifespan of trafficked victims is significantly shortened due to the lifestyle that is associated with this type of victimization, but few studies have been done to substantiate the claim.
One of the few pertinent epidemiological studies that evaluated cause-specific mortality in a cohort of “prostituted women” used 30 years of continuous surveillance in Colorado to generate statistics. The investigators identified 1,969 women for the study. Most of the women worked on the streets, and a few worked in massage parlors as well as on the street. The study acknowledges the increased violence, drug use, infection, suicide, and homicide risks in the cohort, which also occur in the lives of victims of sex trafficking.
The standardized mortality ratio was 5.9 for the study group, which was three times higher than the ratio of 1.9 found in the general population. Few women died of natural causes, and 19% died as a result of homicide, 18% due to drug ingestion, 12% accidents, 9% alcohol-related, and 8% from complications of HIV infection. The authors concluded that trafficked women are living and working in the most dangerous environment in the United States and are vulnerable to murder and drug overdose in particular (Potterat et al., 2004).
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 suffer from 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.
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).
Human trafficking may be indicated by numerous possible signs. Clinicians may note one or more of the following “red flags” in a healthcare setting.
- 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
- 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 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.
“I was taken to the hospital about 80 times for injuries and sometimes to check for STIs, but I never told the truth about what happened. The nurse always just accepted what I said. For example, one time I said that I fell even though it was obvious I didn’t just fall. I had a broken nose so bad that I had to have reconstruction. I came in with sore ribs, and I had teeth knocked out from one side of my jaw. I didn’t go back to the same hospital because I was trafficked across several states.”
“We always dressed in nice clothes and we wore heels. I carried a cell phone and a Louis Vuitton bag. Our nails and our hair were always done, and we only rode in a new SUV. We got food, so I didn’t have malnutrition or anything, but I know some girls who did. I had bad scars on my legs from being dragged from a car, but no one ever asked me about them.”
- 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
“There was a new girl, and I was taking her around. She was really young, and she couldn’t take it. She shot herself.”
- 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
“I couldn’t ever go to the hospital alone. One of the girls always came with me and never left the room. She was there to make sure I didn’t tell the hospital staff the truth. I think one nurse knew, but all she did was give me a phone number. I never could call it because as soon as we left, the girl who came with me took it away. I would have been too afraid to call it anyway because it would have been dangerous to do that. [The trafficker] controlled our phones.”
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.”
It is important to note that 1 in 6 runaways is likely to be trafficked within 48 hours of leaving home and may become sexually exploited in exchange for food, a place to stay, or cash. This is sometimes referred to as “survival sex” and is another form of commercial sexual exploitation. The youth may also disclose a history of involvement in the foster care or juvenile justice system. Although children who have run away and are on the street are particularly vulnerable to traffickers, youth who live at home with parents or who are in foster care homes or group homes are also vulnerable to exploiters and may become victims of trafficking or CSEC when approached at malls, schools, parks, youth groups, and online.
Haley was 14 years old and wanted to be a dancer or a chef when she grew up. One day she met a young man at the mall who told her she was beautiful. They exchanged phone numbers and began talking on a regular basis. He gave her gifts, and Haley thought she was in love. Haley was being “groomed,” one of the ways that exploiters gain trust and control over victims.
Haley’s new “boyfriend” soon asked her to have sex with other men, something she said she did not want to do but did anyway because she wanted to please him. Haley also had a history of physical, emotional, and sexual abuse in the home, which made her particularly vulnerable to the methods of exploiters because the cycle of abuse was familiar to her. Because Haley had endured years of sexual abuse in her home, she already felt dirty and ashamed in relation to sex.
Haley’s situation progressed to being sold to another exploiter, who beat her if she did not make any money and took all of her money when she was paid. She lived in a locked basement and slept on a mattress on the floor, with only a bucket to use as a toilet. Devoid of job skills, money, and fearing further abuse if she returned to her home, Haley felt trapped and that she had no way out.
Haley’s exploiter took her for frequent STI testing at various free clinics to avoid suspicion. Chandra, a nurse practitioner who volunteered at several of the clinics, began to recognize Haley. At the insistence of her exploiter, Haley always registered as an 18-year-old whenever she requested services, but Chandra suspected that Haley was probably younger. Before asking Haley her true age, Chandra made an effort to gain Haley’s trust, and Haley confided in her that she was only 14. This confirmed Chandra’s suspicions that Haley was probably a minor victim of trafficking, and so she followed the state protocol to report suspected child abuse.
Haley was taken to an emergency receiving center, and because her parents had never filed a missing person report or made an attempt to find her, she was placed in protective custody. Later, Haley was placed in a residential recovery facility for trafficking survivors. Haley was given a safe place to live, extensive treatment for her trauma, a high school education, and eventually, culinary training. Haley works as a cook now.
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, 2017).
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 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 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, 2017).
“I knew a girl who went to the hospital with her trafficker. He was in the room, but she slipped the nurse a note by shaking her hand. The note said, “I am not okay, and I need help.” The nurse left the room. When she came back, she told the trafficker that she had to take the girl to get an X-ray. As soon as they were alone, the girl told the nurse that the trafficker had a gun on him, and she asked the nurse to call the police for her.”
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, 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 (HEALTrafficking.org, 2017). 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 and/or skills in these areas:
- Resources for human trafficking survivors
- Mandatory and nonmandatory reporting of human trafficking
- Means of separation from the trafficker
- Survivor empowerment, follow up, and monitoring
- “Red flags” for human trafficking
- Skilled collaboration and assessment
- 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-Strake et al., 2020)
“Nurses should look at the behavior of the patient and any person accompanying them. They should talk to the patient one to one. If just one nurse could have taken me somewhere private, I would have told them what was happening and asked them to call the police.”
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 (U.S. DOS, 2017). Research identifies multiple contributing factors to the lack of recognition of male commercially sexually exploited children, even though half of children who are involved in commercial sex may be male, and why they are not offered services:
- 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.
- 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.
- There is a general belief that boys are not trafficked but are willing participants, and this fallacy obscures the need for services for male victims.
(Youth Collaboratory, 2018)
Several assessment tools have been developed to assist professionals in identifying victims of trafficking. These tools require training and are available online at no cost.
The Commercial Sexual Exploitation Identification Tool (CSE-IT) was developed by West Coast Children’s Clinic for social workers to screen at-risk youth who are 10 years of age and up for commercial sexual exploitation. The evidence-based and validated CSE-IT tool uses a weighted scoring system to evaluate observations made by the professional rather than answers given on a questionnaire to the youth. A 3-hour training in a classroom setting is required for child welfare workers prior to using the CSE-IT (WCCC, 2017a & 2017b).
The Vera Institute of Justice’s Trafficking Victim Identification Tool (TVIT) is validated and can 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 (Vera Institute for Justice, 2014).
New York State’s Covenant House developed the Human Trafficking Interview and Assessment Measure (HTIAM-14) to assess youth for trafficking. It is similar to the other screening tools, with the child welfare professional scoring responses to quantify risk.
A more recent tool, Quick Youth Indicators for Trafficking (QYIT), evaluates for both labor and sex trafficking among homeless young adults. The QYIT is validated, brief to administer, and does not require a human trafficking expert to evaluate the results (Chisolm-Straker et al., 2020).
Additional tools have been developed by individual states, and professionals should familiarize themselves with protocols within their own jurisdictions.
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. Victims of trauma become overwhelmed with stressful stimuli, and this interferes with their ability to function or cope effectively (NHTRC, 2016). Victims of trauma may feel ashamed and see themselves as helpless, powerless, or worthless. They may trust no one and feel that no one can protect them. Victims who view life through a traumatic lens will respond accordingly when working with healthcare practitioners or 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. The core principles of a trauma-informed system of care integrate safety, trustworthiness, choice, collaboration, and empowerment into all client services.
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 client feels safe, believed, and empowered. No victim should be made to feel like a witness for his or her own crime.
Professional training in trauma-informed care is strongly encouraged for anyone who works directly with victims. Such training will help prevent retraumatization of victims and help the professional to recognize and mitigate adverse responses when victims begin to feel out of control or threatened, experience unexpected change, or feel vulnerable or ashamed (U.S. DOJ, n.d.).
Approaches to Screening
Promising practices that implement a trauma-informed approach to screening include:
- First meet the basic needs of the individual who is seeking care. Basic needs include food, water, clothing, and shelter. Medication may also be a basic need for individuals who are diabetic or have a major behavioral health issue or other conditions that are mitigated by medication.
- Reassure the individual that they are safe. Victims of human trafficking need to understand that they are not in trouble and that they are safe. They may fear arrest, deportation, or retaliation from their abuser.
- Build trust. A nonjudgmental attitude, kindness, and good listening skills will help to build rapport with the individual. Abusers teach victims to trust no one, especially people who have positions of authority.
- Language is important. Mirror the language that the individual uses to be sure that they understand what you are saying. Ask open-ended questions and avoid any derogatory inferences.
- Be aware of power dynamics. It is important that the individual understands that a disclosure is not required to receive treatment.
- Do no harm. Avoid retraumatization by having a conversation with the individual rather than an interrogation. The presence of an advocate who is trained in human trafficking can be very helpful.
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” 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 acknowledge the victim’s trauma and ask, “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 ask, “What were you feeling?” or “What was your thought process during this experience?” instead of “Why did you do that?”
- The six senses can be employed, and the interviewer can ask, “What are you able to remember about smell, sound, sight, taste, touch, and body sensations?”
- Interviewers ask how the experience affected the victim, what was the most difficult part of the experience, and if there is anything the victim cannot forget about the experience.
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).
A young woman, Teresa, presents to the emergency department with a chief complaint of abdominal pain. She is accompanied by a young man who answers every question for her because she is monolingual Spanish-speaking. He offers to pay in cash because she has no insurance.
As part of the exam, Teresa will require an ultrasound. The nurse, Patty, explains to the man accompanying Teresa that she will take Teresa to the X-ray department and asks him to wait in the waiting room. He reluctantly agrees and says something harsh to Teresa as she leaves the exam room that makes her cringe. While in the X-ray area, an interpreter is called, and Patty learns that Teresa has no “papers” because she came on a “caravan” into the United States. She says that the man who brought her to the hospital is a distant cousin and that he promised her a job, but now he is angry that she is “weak” and won’t be able to work.
Because Patty and Teresa are now in a safe, private place, Patty can begin applying the principles of trauma-informed care, in a modified form when indicated. Because Teresa’s pain is still being evaluated, Patty knows that she cannot offer Teresa food or water to drink. Instead, she offers a tiny amount of tepid water in a small cup for oral rinsing and mouth care swabs and covers her with a warm blanket. She also tells Teresa that once the doctor says that food or drinks are allowed, she will ask if Teresa wants something to eat or drink.
Patty reassures Teresa that she will not be in trouble with the police because she came here on a caravan, and she visibly relaxes. Patty sits beside the patient while she waits and asks her about her abdominal pain. Teresa says that she had an ulcer before and can’t afford the medicine, and now the pain has returned. Patty states that stress can contribute to ulcers.
Patty also states that she noticed the cousin had said something harsh as he left and asks if Teresa is comfortable talking about that. Teresa says that she has just met the cousin, and he immediately warned her that if she were too weak to work in the fields, then she would owe him a lot of money for the caravan trip and would have to pay him back another way. Remaining nonjudgmental, Patty asks her about her thoughts about working somewhere else, but Teresa says she does not think she would be able to do that without papers. Patty then asks her if she is comfortable sharing how much money she will be paid, and Teresa replies that she does not know and that the money all goes to her cousin until she has paid her debt for the caravan he sponsored.
Being mindful of power dynamics, Patty informs Teresa that she does not have to owe her cousin for this hospital visit and that other arrangements can be made for her bill. Patty then tells her that she will bring in an advocate who can talk to her about her situation and her options. Patty also reassures Teresa that she will receive treatment for her abdominal pain no matter what she chooses to do about her work situation.
SHARING INFORMATION WITH PATIENTS
Healthcare professionals are on the frontlines 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 (HEALTrafficking.org, 2017).
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 (Cox, 2019).
The following recommendations for institutions can augment the quality of the information-sharing experience between the provider and the client:
- Develop treatment plans based on available resources and ensure that these plans are patient-centered
- Utilize “warm hand-offs” for referrals when possible (call the party to which one is referring the patient in front of the patient or introduce the other party in person)
- Employ survivor advocates
- Develop a personalized safety plan (the National HT Hotline can assist)
- Provide guidance on prevention of sexually transmitted infections, pregnancy, and HIV
- Provide resources verbally as well as through discreet messaging, bearing in mind that it may not be safe for patients to leave with written information. Good examples include placing a business card in a sanitary napkin or writing a hotline number on a prescription pad and labeling it “X-ray.”
- Ask the patient the safest way to communicate if a follow-up is possible
(Baldwin et al., 2017)
If the patient does not request immediate help, the information-sharing should include a treatment plan with referrals to comprehensive care services that are unique to the patient’s needs and sensitive to the patient’s circumstances. The goal of the provider is to treat the patient and offer information and support (HEALTrafficking.org, 2017).
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 assistance should be accessible for all victims of human trafficking, and advocacy is available to help navigate a complex system. Victims need to understand their rights so that they can receive services to help 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 (see box below).
Local resources can be identified easily by calling or accessing the National Human Trafficking Hotline website. The National Human Trafficking Hotline website offers an interactive map and search tool to locate specific types of resources in regions throughout the United States. This tool may be accessed by the healthcare provider in the presence of the patient or the patient may use it independently. The website has an escape key to protect victims from repercussions should they be at risk from the trafficker discovering that the visited the website. The National Human Trafficking Hotline can also be accessed by text.
HEAL Trafficking (Health, Education, Advocacy, Linkage) is another resource that can be shared with victims of human trafficking. This organization is 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.
(See “Resources” at the end of this course.)
U VISA and T VISA
The U visa is a unique visa for undocumented victims of crimes who have suffered 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.
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. DHS, 2016).
The number of petitioners for the U visa has diminished from a total of 58,991 in 2018 to 47,225 in 2019 (U.S. CIS, 2020). This decrease in applications is attributed to Immigration and Customs Enforcement (ICE) Directive 11005.1, which allows ICE to deport pending U visa applicants at their discretion (U.S. ICE, 2019).
Celia entered the United States from the Philippines. Desperate for work to support her three children after her husband suffered a stroke, Celia had been recruited by an organization in Manila that represented itself as an employment agency for catering and hospitality jobs in the United States. When she first arrived in the United States, she owed the recruiter $3,000 for an H-2B visa, airfare, and interest for a loan that had been suggested by the recruiter.
Although her contract stated she would work 40 hours per week for $8.50 per hour, Celia was never paid that much per hour and was never given that number of hours. Her work visa was specific to her contract with a certain hotel, and she was unable to secure additional hours elsewhere to make ends meet. Her rent, which was an inflated amount, and her bus fare were deducted from her paycheck, leaving her about $50 per week to repay her loan, buy food, and send money home to the Philippines to support her children.
Although Celia’s visa status qualified her for Medicaid, she was not aware of this and was reluctant to seek healthcare or establish a professional relationship of trust with a primary care provider or dentist. When she got sick, she relied on home remedies until she became seriously ill, at which point she was forced to visit the local hospital emergency department.
In the emergency department, Celia was diagnosed with bronchitis. As part of a simple screening process, the nurse asked Celia about her living situation and elicited Celia’s response about being forced to share a single room with five other hotel coworkers because that is all she could afford. Through the nurse’s empathetic response, Celia felt encouraged to share more about how she had been promised a well-paying job but instead made $50 a week and was unable to repay her debt to the company that brought her to the United States from the Philippines.
Suspecting that Celia was a victim of labor trafficking, the nurse referred her to a local agency that could help free her from her servitude. Celia learned of her rights, received legal assistance, and obtained a T visa for trafficking victims. Today she works as a nanny and earns enough money to send some to her children.
(Adapted from Schwartz, 2017.)
REPORTING HUMAN TRAFFICKING
Each state has its own laws and reporting protocols pertaining to human trafficking. Healthcare professionals must be familiar with, understand, and comply with the relevant laws in their state.
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. Suspicion of such crimes must be reported according to pertinent state laws. The same is true with suspicion of trafficking among vulnerable adults, such as those who are unable to provide for their own care or protection due to disability or aging. In cases where a minor or vulnerable adult may be in imminent danger, the healthcare professional must call the police.
Reporting Trafficking in Competent Adults
Depending on the jurisdiction, there may be no specific reporting statutes for domestic violence or sexual assault that might be applied to competent adult victims of human trafficking due to the assumption that competent adults have the right to privacy and agency. In some jurisdictions, licensed professionals may not report domestic violence or sexual assault without the victim’s consent, and to do so without their specific consent could lead to civil action against the reporter.
However, healthcare professionals 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 (see box below).
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, n.d.-d).
The crime of human trafficking creates a ripple effect of trauma that originates with victims and expands steadily in circles that encompass families, communities, and professionals who assist victims. 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 victims; and prosecutors must hold offenders accountable.
Blue Campaign (U.S. Department of Homeland Security)
To report suspected human trafficking: 866-347-2423
Commercial Sexual Exploitation—Identification Tool (CSE-IT)
National Human Trafficking Hotline
Text “BeFree” to 233733
Victim Assistance Program (U.S. Immigration and Customs Enforcement)
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course.
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