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: $18.00
Contact Hours: 2
Victim Recognition and Intervention for Healthcare Providers
Copyright © 2018 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 include:
- Understand the types, venues, and dynamics of human trafficking in the United States.
- Describe the impacts of human trafficking in the United States.
- Recognize risk factors, warning signs, and indicators of human trafficking that may be observed in adults and minors in healthcare settings.
- List assessment tools that can be used to identify human trafficking victims.
- Discuss the importance of using a trauma-informed approach when screening victims of human trafficking.
- Describe mandated reporter obligations for reporting suspected human trafficking.
- Identify resources for legal and social services available to victims of 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 socio-economic backgrounds. Human trafficking robs individuals of their basic human rights and can occur across and within state and international borders.
Human trafficking is a form of modern slavery—a multi-billion-dollar criminal industry that denies freedom to 20.9 million people around the world. And no matter where you live, chances are it’s happening nearby. From the girl forced into prostitution at a truck stop, to the man discovered in a restaurant kitchen, stripped of his passport and held against his will. All trafficking victims share one essential experience: the loss of freedom.
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 (Legal Information Institute, 2012).
In the United States, antitrafficking efforts have historically focused on the “3 Ps”: prevention, protection, and prosecution. Although the “3 Ps” should be weighted equally, they are frequently funded disproportionately, and prosecution tends to be emphasized above prevention and protection. The healthcare sector provides an opportunity to focus on prevention and protection by upholding the right to health services for all persons. Educating healthcare professionals about human trafficking allows them to identify victims of human trafficking and intervene effectively (Schwarz et al., 2016).
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.
According to U.S. federal law (22 USC § 7102), 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. Force, fraud, or coercion do not need to exist if the trafficking victim is under the age of 18.
Sex trafficking encompasses many sex crimes, and the victims may be adults or children of any gender, domestic or foreign.
COMMERCIAL SEXUAL EXPLOITATION OF CHILDREN
The commercial sexual exploitation of children (CSEC), which includes domestic sex trafficking of minors, is a form of sex trafficking. CSEC is defined as the exchange of goods or services that are paid to the individual or a third party in exchange for sex acts involving a minor. Examples of types of CSEC include child pornography, exotic dancing, and sex tourism.
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. Force, fraud, or coercion do not need to exist if the 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 any person; any scheme, plan, or pattern intended to cause a person to believe that 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 (U.S. DHHS, 2017a)
- 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, 2017a)
LEGISLATIVE EFFORTS TO ADDRESS HUMAN TRAFFICKING
State legislatures have demonstrated advocacy for survivors of human trafficking though the passage of various state laws. For example, laws in some states:
- Establish “Safe Harbor” provisions
- Create state commissions on human trafficking
- Require certain professionals to undergo training/education about commercial sexual exploitation and human trafficking
- Require the use of a screening instrument to identify sexually exploited children in certain professional environments
- Direct law enforcement officers to treat victims of human trafficking as victims rather than criminals
- Discontinue the prosecution of minors for prostitution, lewdness, etc.
- Allow expungement of criminal records of victims of human trafficking
- Allow trafficking victims to seek restitution from a trafficker in civil court
- Allow a person who rents a space (such as a motel) for use in sex crimes to be charged with a crime
- Allow human trafficking crimes (both labor and sex) to be prosecuted as racketeering offenses, with enhanced penalties
(Florida Senate, 2016; FCADV, 2016)
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 (National Institute of Justice, 2017).
Smuggling is addressed in the Immigration and Nationalization Act, Section 274(a)(1), (2), that provides for criminal penalties under Title 8, United States Code, Section 1324, 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 illegal status (U.S. Citizenship and Immigration Services, n.d.).
A recent tragedy illustrates why criminal penalties for smugglers are in place: In July 2017, the bodies of eight deceased persons were found in a tractor trailer that was parked behind a Walmart store in San Antonio, Texas. There were 30 additional people in the trailer who suffered from lack of air conditioning and water in 100-plus degree heat (Forsyth, 2017).
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 who 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 prostitution, which may occur in:
- On the street or places such as truck stops
- In 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, 2012).
|Source: National Human Trafficking Hotline, 2018.|
|Traveling sales crews||104|
|Source: National Human Trafficking Hotline, 2018.|
|Illicit massage/spa business||714|
|Online ad/venue unknown||519|
|Residence-based commercial sex||501|
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, 2016).
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 business, 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.)
VICTIMS OR CRIMINALS?
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. Therefore, in 2000, the Federal Victims of Violence and Trafficking Prevention Act redefined the commercial sexual activity of minors as victimization as opposed to criminal behavior regardless of whether the child’s activity appeared to be voluntary (Finklea et al., 2015).
But since a minor is defined as being under the age of 18 years and the age for consent for lawful intercourse in some states is as low as 16, some youth between the ages of 16 and 18 remain vulnerable to arrest in those states.
IMPACTS 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 boys and men are more frequently 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.
The National Human Trafficking Hotline gathers data from calls made to their hotline. Recent statistics are described in the tables below:
|Source: NHTH, 2018.|
|Sex and labor||377|
|Source: NHTH, 2018.|
|Source: NHTH, 2018.|
Buyers of domestic minor sex trafficking and CSEC (commercial sexual exploitation of children) are what drive the crime of human sex trafficking, because if there were no demand, there would be no gain to traffickers. A study done by the National Institute of Justice found that pimps and traffickers may take home as much as $32,833 a week in an underground sex economy of up to $290 million a year in major U.S. cities (Dank, 2014).
Shared Hope International’s demographics reveal that buyers were 54% white, and that number increases to 69% when the 15% of Hispanic buyers is included. Buyers were almost exclusively male, and the average age was 41. Victims received money in exchange for sex acts in 84% of the cases, goods in 14%, and drugs in 2%. The ages that appeared most frequently in the victim data were 15 through 17 years.
The profession of buyers, when identified, included 18.9% who had direct contact with minors, such as coaches, scout leaders, or teachers. Another 21.6% included positions of trust, such as attorneys, law enforcement officers, or military personnel. School employees comprised another 8.4%, first responders 5.2%, and 1.2% were faith leaders (Shared Hope International, 2014).
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).
Many youth who are victims of sex trafficking have been misidentified as criminals, and that may contribute to inaccurately low statistical data. It is estimated that 76% of transactions for sex with underage girls start on the Internet (Schuette, 2017).
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.
Physical symptoms that are commonly reported include:
- Sexual and reproductive health problems (e.g., STIs)
- Significant weight loss
- Back pain
- Substance use
- Suicide attempts
Psychological symptoms have also been identified and found to persist longer than physical symptoms. These include:
- Stockholm syndrome (psychological response in which hostages identify with their captors as a survival strategy)
- Memory loss
- 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).
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” (victims of sex trafficking) 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 standardized mortality ratio was 5.9 for the study group, which was three times higher than the ratio found in the general population of 1.9. 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% died from complications of HIV infection. The authors concluded that prostituted 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).
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.
As with girls, many boys become commercially sexually exploited in order to meet their basic needs for shelter, food, clothing, money, transportation, and substances. The mental and physical health of male victims is affected by abuse, malnutrition, threats of violence, loss of freedom, infections, and lack of sanitation.
Initially, male victims may view their situation as “bad luck” and 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, 2017; Estes & Weiner, 2001)
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 his two new friends and watched a middle-aged man walk past them and into a public restroom. One of the boys followed the man in to 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)
RECOGNIZING HUMAN TRAFFICKING IN HEALTHCARE 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 risk factors, warning signs, and indicators of human trafficking can alert the clinician to possible victims.
Risk factors for trafficking victims are best viewed through a social determinants of health lens. This model views the victimization of trafficking as part of a continuum of violence rather than as an isolated incident and considers many spheres of influence leading up to the victimization. The ecological model illustrates individual, relationship, community, and societal risk factors that contribute to victimization of commercial sexual exploitation of children (IoM & NRC, 2013).
Individual risk factors include a history of child abuse, neglect, or maltreatment and exposure to homelessness as a runaway or “throw-away child.” Lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth, and children who are of a racial minority are disproportionately represented in the CSEC population, and this may be due to their being marginalized. LGBTQ youth may feel a lack of acceptance by their families, which propels them to run away. More than 25% of LGBTQ children and nearly 50% of gay or bisexual boys have been commercially sexually exploited (Walker, n.d.). Exploiters look for vulnerable targets and manipulate people who are poor, have unstable housing, or yearn for a better life. This explains why youth who have been abused and neglected are particularly at risk (CDC, 2017).
Children who have been involved in the juvenile justice system or foster care are considered to be high risk as well. In the sphere of relationship risk factors, one should consider the child’s family, within which the child has experienced conflict, disruption, lack of acceptance, and dysfunction.
Community risk factors may include peer pressure, social norms, isolation, and gangs. One should evaluate how schools, neighborhoods, and community factors might influence a child.
Societal risk factors include a lack of awareness of sex trafficking or perhaps a willingness to look the other way. Society bears some responsibility for the normalization of sexual violence and sexualization of children and the failure to provide needed resources to address problems related to sex trafficking (IoM & NRC, 2013).
|Source: IoM & NRC, 2013.|
Warning Signs and Indicators
The media often portrays trafficking victims as women who are in chains or have a sign written on their hands that says, “Help Me.” But 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 the healthcare provider.
Therefore, it is up to the professional to assess the situation and work to develop the trust of this vulnerable population so that they feel safe to make a disclosure (NHTH, n.d.-a).
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.
POSSIBLE PATIENT INDICATORS
Human trafficking victims often exhibit one or more of the following when they appear in a clinical setting. Using the social determinants of health or ecological model, the healthcare provider needs to be alert to clues that indicate the possibility of victimization.
- 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
- Fear, anxiety, depression, nervousness, hostility, flashbacks, avoidance of eye contact
- Restricted or controlled communication, or use of a third party to translate for them, 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
- Isolation from family or former friends
- Fear of employer
- Described or implied threats to self or family/friends
- History of running away
- 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
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 inappropriately for the weather, wearing long sleeves to cover bruises or other marks when it is warm, or clothing that is emblematic of commercial sex such as skimpy skirts and low-cut tops regardless if 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.
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. Instead, she relied on home remedies until she became quite 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 (see below) for trafficking victims. Today she works as a nanny and earns enough money to send some to her children.
(Adapted from Schwartz, 2017)
POSSIBLE 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 runaway 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 train station 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 worked at one 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 her state protocols for reporting a case of 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.
RECOGNIZING MALE VICTIMS
Evidence has shown that even those trained to identify human trafficking victims often miss male victims when they encounter them (U.S. DOS, 2017). Research from ECPAT-USA (2013) identifies multiple contributing factors to the lack of recognition of male commercially sexually exploited children and why they are not offered services:
- Boys are not likely to self-identify as sexually exploited due to feeling shame or stigmatization from their family or community about being gay.
- Law enforcement officers and social workers do not screen boys because they are expecting victims to be female.
- Anti-trafficking organizations offer limited outreach to areas that are known for male prostitution.
- There is a general belief that boys are not pimped, and this fallacy obscures the need for services for male victims.
Several assessment tools have been developed to assist professionals in identifying victims of trafficking and are available online at no cost. It is important to remember that any screening should take place in a private and quiet environment, and when interpreters are used they should not be someone known to the person being interviewed. 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 (Florida Courts, n.d.).
The Commercial Sexual Assault 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. It is anticipated that the tool will be expanded for use by primary care providers in the healthcare setting. The evidenced-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. Like the CSE-IT, the professional who administers the tool does not read the questions to the person who is being screened.
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 (Bigelsen, 2013).
Additional tools have been developed by individual states, and professionals should familiarize themselves with protocols within their own jurisdictions.
SMARTPHONE APPS TO FIGHT HUMAN TRAFFICKING
A relatively new use of smartphone applications is directed toward fighting human trafficking. There are several apps available on both Google Play and iTunes that help citizens or professionals learn what to look for and what to do if they suspect human trafficking. Some apps integrate a camera feature for photo documentation. Apps that are currently available include the Stop App, Redlight Traffic, Lifeboat ACT Game, and TrafficCam (Women at Risk International, 2017).
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 service providers 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 he or she is 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 he or she understands what you are saying. Ask open-ended questions and avoid any derogatory inferences.
- Be aware of power dynamics. It is important that the individual understand that a disclosure is not required to receive treatment.
- Do no harm. Avoid retraumatization by having a conversation with the patient 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 on the victim 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 is an issue, it is best to not ask about immigration status 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 (FETI)
Principles from the Forensic Experiential Trauma Interview, 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.
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 he leaves that makes her cringe. While in the X-ray area, an interpreter is called and Patty learn 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.
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.
Most states mandate that certain professionals report all suspected child or vulnerable adult abuse. Examples of mandated reporters 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 child care, foster care, residential, or institutional worker
- Law enforcement officer
In some states, mandated reporters who knowingly and willfully fail to report abuse or neglect may be charged with a felony and may be sentenced to a prison term and/or fined.
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. Often, healthcare 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 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) (FL DCF, 2014).
(See also “Resources” at the end of this course.)
NATIONAL HUMAN TRAFFICKING HOTLINE
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 (National Human Trafficking Hotline, n.d.).
Removing victims from exploitation is only the first step, and recidivism among trafficked persons is common if they feel they have no alternative and are not given appropriate therapy for the trauma that they have experienced. In addition to behavioral health therapy for trauma, human trafficking victims may also need treatment for substance abuse issues. Victims of trafficking need psychotherapy, medical care, housing, job training, legal assistance, and career planning in order to maximize their recovery and prevent them from returning to trafficking (Hundertmark, 2016).
The average cost of a residential recovery program for a victim of human trafficking is $30,000 per person. There are limited residential recovery programs in the United States, with approximately only 680 beds that are dispersed throughout all regions of the country, with the majority of programs located in the West (Reichert & Sylwestrzak, 2013). Most of the programs are for youth and do not accept male victims.
U VISA and T VISA
The U visa is a nonimmigrant visa that was created in 2000 with the passage of the Victims of Trafficking and Violence Protection Act (including the Battered Immigrant Women’s Protection Act). It is a unique visa for 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 a similar plan in which qualifying victims of trafficking, along with approved family members, may reside in the U.S. for approximately four years if they comply with criminal justice system requests.
(U.S. DHS, 2016, 2014)
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 slavery, legislators must continue to redefine our laws to protect the vulnerable; peace officers must enforce these laws; other members of society, such as healthcare professionals, other mandated reporters, and citizens, must empathize with victims; and prosecutors must hold offenders accountable.
Human Trafficking Screening Tool (HTST) (sample from Florida Department of Juvenile Justice)
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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