Sally, 18, who is brought to the family-planning clinic by her mother, is complaining of abdominal pain. Joe, 45, comes to the same-day clinic with a rash on his foot. Are these patients victims of human trafficking?

There is no official count of victims in the U.S., but cases have been reported to the National Human Trafficking Resource Center from all 50 states.^3,7 The number of cases reported to the NHTRC increases yearly.⁸ Although calls come in from rural and urban areas throughout the U.S., the majority of human trafficking reports come from large cities. In the U.S., human trafficking is outlawed under The Trafficking Victims Protection Act. Under U.S. law, victims of human trafficking can be described as:

• Children younger than 18 years induced into commercial sex
  
• Adults 18 years or older induced into commercial sex through force, fraud, or coercion
  
• Children and adults induced to perform labor or services through force, fraud, or coercion.

While victims represent all demographic groups, circumstances and vulnerabilities lead to some populations having higher susceptibilities to trafficking. Traffickers often target runaway and homeless youth, as well as victims of domestic violence, sexual assault, war or conflict, or social discrimination.⁹ Foreign nationals who have paid significant recruitment and travel fees often become highly indebted to traffickers, or “coyotes” (border smugglers), or other intermediaries.

Under U.S. federal law, anyone younger than 18 years induced into commercial sex is a victim of sex trafficking regardless of whether the trafficker used force, fraud, or coercion. Sex traffickers use violence, threats, lies, debt bondage, and other methods of coercion to compel adults and children to engage in commercial sex acts against their will. More than 80% of the victims are U.S. citizens.^{10 (Level B)} Poverty, lack of education, and an abusive family history are primary reasons for victimization. The National Center for Missing and Exploited Children estimates one out of six runaways are likely child sex trafficking victims; more than two-thirds were in the care of social services or foster care when they ran away.⁹ Many resort to “survival sex” for living expenses, drawing them to predators who offer kindness (albeit short term). For foreign nationals, mail-order bride or modeling services can be fronts for obtaining women or children from disadvantaged areas who can be sold for a lump-sum payment. The industry uses many venues for advertising and business, including fake massage businesses, online ads, escort services, the streets or truck stops, hotels and motels, commercial front brothels, or residential brothels.^3,11

Labor traffickers (i.e., recruiters, contractors, and employers) are involved in industries worldwide. In the U.S., labor trafficking includes domestic servants, farmworkers, and factory workers. It’s also been reported in door-to-door sales crews, restaurants, construction work, carnivals, and health and beauty services. In the U.S., most labor trafficking cases involve foreign nationals.¹⁰ Often, these workers have paid recruitment fees for U.S. “jobs;” more than 71% entered the U.S. on lawful visas and paid, on average, more than $6,100 in fees.² In one study, 31% of Spanish-speaking migrant workers in Southern California had experienced labor trafficking.¹² Often workers are in “debt bondage” working off a “debt” for transport or job “finding fees.” They continue to accrue interest, exorbitant “fees,” or rent, and it becomes difficult to retire the debt and escape.

Healthcare professionals must understand that some trafficking victims may not be aware they are victims, as traffickers use a variety of means to prey upon vulnerable or at-risk individuals.^13,14 Traffickers are typically charming and make promises about providing a job for a stable living for the victims or their families.

Traffickers control victims by leveraging the nonportability of many work visas and often confiscate identification documents and money. Sometimes, emotional, verbal, and physical violence are used. Coercive tactics include beating, tattooing, burning, forced drug use, starvation, threatening harm to a loved one, and/or torture, all of which instils fear and results in intimidation of the victim. In other cases, sexual violence and denigration are control tactics.¹⁵ Victims are moved often to prevent friendships, and communication with family and friends is restricted or prohibited. Some do not understand English, are unfamiliar with cultural and legal norms, and are afraid to ask for help. Many will distrust healthcare providers and others who wish to help. Others fear legal authorities — and the pressure to cooperate in a prosecution — more than their abusers out of fear of deportation or incarceration. In many ways, victims are in an extreme form of an “abusive relationship” (i.e., intimate partner violence) and may present similarly in a medical environment (e.g., defend the abuser, feel that they are being protected by the abuser, or believe they would be stalked by the abuser), and deny the abuses and fear they face.^3,7,16

While there are superficial similarities between victims of intimate partner violence and trafficking, they have different indicators (“red flags”).¹⁶ There may be a companion present who refuses to leave, or insists on translating, answering for the patient, or trying to control information during the examination. The patient may show reluctance or inability to speak, or responses may appear scripted/memorized. There may be discrepancies between the stated history and clinical presentation or injury pattern, evidence of torture, delayed presentation, or failure to care for a previously identified medical condition.

The patient may be unable to produce identification documents or documents are provided the companion. Ownership marks, brands, or insignia may be present or the patient may refuse to discuss a tattoo. The patient may deliberately overstate age compared to appearance, and seem submissive, hypervigilant, or fearful.^16,17 are highlighted by patients with injuries or ailments consistent with working without proper personal protective equipment, long work hours, labor without sufficient food or water (e.g., dehydration, exposure), or repetitive motion injuries (i.e., children in a sweatshop environment).^12,16 Because foreign nationals are more likely to be trafficked as labor, these indicators are especially noted in patients for whom English is not a first language (especially those of Latin-American origin).^12,16 include frequent pregnancies and/or forced abortions, frequent sexually transmitted infections (STIs), and repeated relocations.^4,11,16 In pediatric or teen/young adult cases, alerting features include an excessive number of sex partners, history of truancy or running away, expensive material possessions above the patient’s means, understanding of sexual terms/practices, or an unrelated/nonguardian adult.

Every case of human trafficking is unique. Not all victims will be ready to seek assistance from service providers, law enforcement, or medical providers. Healthcare providers should offer victims information and support through the process of connecting with advocates or service providers when they are ready to report their situation.¹⁸ Once a patient discloses that he or she is a victim of trafficking, contact and consult with a forensic nurse and/or social worker/mental health professional. In cases of immediate, life-threatening danger, follow institutional policies for reporting to law enforcement. Try to partner with the patient in making the decision to contact law enforcement. If the patient is a minor, follow mandatory state reporting laws and institutional policies for child abuse or serving unaccompanied youth. forensic nurses and social workers need to advocate for not placing victims in group homes for abused and neglected children, which may not be safe because these facilities might not provide adequate security to deter traffickers intent on coercing victims back into trafficking.^16,19 Provide the patient with options for services, reporting, and resources. Ensure that safety planning is included in discharge planning. Provide the patient with the NHTRC hotline number and encourage the patient to call for help or to talk to someone. If the patient feels it is dangerous to have the number on paper, ask them to memorize it.

Victims may seek assistance at local, state, and national levels. Healthcare providers initially provide assistance through the social services/social workers in the healthcare setting. Forensic nurses and SANEs can help patients navigate the medicolegal landscape. The availability of forensic nurses/SANEs varies between jurisdictions; however, resources are available from the or the

A plan for assessing trafficking victims should be in place. While many steps are similar to that of victims of intimate partner violence, care should be taken to ensure that patients maintain autonomy. Ideally, there should be a response process among ED residents, attending physicians, triage staff, nurses, forensic nurses, and social workers to work together in a timely fashion to provide care and guidance to suspected human trafficking victims.^16,18 Recognize that the goal of your interaction is not disclosure or rescue, but to create a safe, nonjudgmental place that will help you identify trafficking indicators and assist the patient.¹⁶ If the patient requires an interpreter, use professional interpreters. If the patient is not alone, find a time and place to speak with the patient privately. Building rapport with a potential victim takes time. Strong trauma bonding often occurs between victims and traffickers; victims may not view clinical interventions as help.¹⁹ Many feel their “entire lives are in the hands” of abusers, which may hinder the ability or willingness to trust the medicolegal system. Forensic nurses and social workers, along with mental health professionals,are skilled in motivational interviewing and stages of change that can be an effective way to build trust during the intervention phase of treatment.¹⁹ Ensure the patient understands confidentiality policies and practices, including mandatory reporting laws. Use multidisciplinary resources, such as social workers and hotlines, where available. Refer to institutional protocols for victims of abuse/sexual abuse.15-17,20 (

Level ML

)

The medical record of victims can be admissible in court and can substitute for or supplement a healthcare provider’s testimony. The patient’s medical history should be documented in an unbiased manner, and findings of “suspected human trafficking” should be noted, as well as unaltered direct quotes from the patient.²⁰ Ensure all information about injuries or treatment is documented accurately in the patient’s records. While documentation of abuse may help build a legal case against a trafficker, information can also be used against the victim in court. The availability of forensic nurses or sexual assault nurse examiners (SANEs) enhances the ability to collect and record evidence. They are educated to take a detailed and unbiased history, and to collect forensic evidence (evidentiary photos, including scale objects, or sketches of injury locations).²¹ It should be noted that patients have the right to refuse or restrict photographic documentation. Forensic nurses are expert at navigating the medicolegal landscape, facilitating postexposure prophylaxis (both HIV and contraceptive), and returning autonomy to the victims while directing them to community-based referrals. Forensic nurses also improve reporting to legal authorities and produce a greater conviction rate along with longer sentences for offenders.²¹ Social workers are a critical part of the IP team to help document care coordination, discharge instructions, and follow-up care.¹⁹ Social workers are often excluded from medical teams as “nonessential,” but in cases of human trafficking, the resources and steps in reassuring the victim that they provide are important.^16,19

It is estimated that only a fraction of U.S. trafficking victims offer disclosure or are identified. Current recommendations are that all women of childbearing age be screened for violence at periodic intervals, such as annual examinations and new patient visits. Visits for substance abuse, mental health problems, new STIs, or recurrent STIs warrant an assessment for violence. Screenings can be performed by a variety of medical professionals from medical assistants to nurses to physicians. However, this alone is not enough. A recent step in victim identification has been the development of validated assessment tools by the . This tool “gives legal, healthcare and social service providers, law enforcement, and other professionals the ability to bring trafficking victims out of the shadows and improve their legal and social outcomes.”¹⁵

Mandated reporting obligations can stem from multiple legal sources, such as state statutes, state regulations, case law, and attorney general opinions; however, legal requirements regarding mandatory reporting of human trafficking vary from state to state. Situations may require mandatory reporting under related state statutes even if the situation does not involve human trafficking per se (e.g., child abuse or domestic violence). While the U.S. Department of Health and Human Services maintains a of state-mandated child abuse reporting statutes, it may not reference additional state statutes necessary to understand reporting obligations, such as criminal codes, nor does it reference state regulations, case law, or other sources of reporting obligations. Refer to local or state requirements regarding mandatory reporting requirements. When a patient discloses his or her status as a victim of human trafficking,providers should ensure there is informed consent regarding institutional policies about sharing information with other team members, as well as gain permission before reporting, keeping HIPAA in mind. When contacting the NHTRC, local service providers, or community referrals, confidentiality obligations must be met.