You can help human trafficking victims
EDITOR’S NOTE: Trisha Sheridan, DNP, MSN, RN, WHNP-BC, SANE-A, CFN, has more than 15 years of experience in healthcare with seven years as a board certified women’s health nurse practitioner. She is board certified as a sexual assault nurse examiner for adults, adolescents, and pediatrics through the International Association of Forensic Nurses, serves as director-at-large on the IAFN board, and is an assistant professor at Emory University’s Nell Hodgson School of Nursing, where she is the women’s health nurse practitioner program coordinator.
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?

Human trafficking is a widespread form of slavery that exists today, even in the U.S.1,2 Victims can be any sex, gender, nationality, and race. While modern slavery includes sex trafficking, as well as domestic, industrial, and farm labor, in the U.S., 75% to 85% of victims are involved in the sex trade.3 For many, an opportunity to seek help comes when they see a healthcare professional. More than 25% reported being seen by a medical professional but were not identified as trafficking victims.4 Human trafficking is defined as: “ … recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability, or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude or the removal of organs.”1 Human trafficking is a low-risk, high-reward industry for the traffickers. There are more than 20 million victims worldwide; globally, more than 67% of victims are trapped in forced labor, and more than 25% are children.3 The human trafficking/forced labor industry has an economic impact of more than $150 billion worldwide, and sex trafficking in the U.S. ranges from $39.9 million in Denver, Colo., to more than $290 million in Atlanta, Ga.5,6 (Level B)
While modern slavery includes sex trafficking, as well as domestic, industrial, and farm labor, in the U.S., 75% to 85% of victims are involved in the sex trade.

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. Both Sally and Joe may be victims of human trafficking. The use of universal safety screening (such as questions about possible abuse or violence recommended by the Centers for Disease Control and Prevention and included in the electronic health record) and knowing what red flags to be aware of are critical when assessing these patients.

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.
Labor trafficking
Reality of trafficking

Sally’s mom tells us that Sally’s dad died of a heart attack last year, and she hasn’t been the same since. Before her father’s death, Sally was a healthy, happy student who played on her school’s volleyball team and maintained good grades. Recently, Sally has been withdrawn and has started hanging out with an older boy, Carl. Her grades are failing, and she has missed school days. Her mother noticed that Sally has new clothes. Sally explains she has been babysitting Carl’s little sister for extra money. Joe speaks limited English and reveals to the medical assistant who is fluent in Joe’s native language that he is working at a farm for extra money to send to his family. He doesn’t have health insurance and has no official forms of identification with him. 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 Labor trafficking-specific indicators 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 Sex trafficking-specific indicators 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. Sally’s mother is asked to leave the room, and the healthcare provider performs an exam, including an anogenital exam. The provider notices a tattoo of the letter C on Sally’s thigh. The “rash” on Joe’s foot is cellulitis. During the exam, the nurse notices that his boots appear well worn and threadbare, and his socks have holes.
Clinical vignette
Scenario:
Clarisse, an 18-year-old white female, presents to the ED. She is triaged by a nurse, whom she tells she has some burning “down there.” Clarisse is wearing a form-fitting top and an extremely short skirt, and she isaccompanied by an older female, “Auntie.” Clarisse says she ran away from home becauseher mother is a drug user and her stepfather made sexual advances toward her. As the nurse asks more questions, Clarisse begins seeking approval from Auntie before answering. The nurse is concerned there may be something more to Clarisse’s situation when Auntie refuses the nurse’s request to wait in the lobby of the ED. In giving report to the NP, the nurse shares some warning signs that need to be considered more closely. The NP escorts Clarisse into the exam room with Auntie close behind. As the NP begins to collect Clarisse’s health history, Auntie responds with answers, not Clarisse. Before the physical exam, Auntie is asked to leave the room, but she declines and stays.
Next
Next
Previous
What at risk factors lead to a suspicion of trafficking?
1
Patient’s complaint
Patient’s ethnicity
Patient’s personal and family history
a.
b.
c.
d.
Patient’s manner of speech and dress
What factor is MOST indicative that Clarisse is a victim of sex trafficking?
2
a.
Risqué clothing
b.
Family history
c.
Age
d.
Frequency of STIs
Previous
Next
What is a red flag indicator/behavior that healthcare providers have witnessed?
3
a.
Auntie being on the phone
b.
Clarisse not mentioning her biological father
c.
Clarisse speaking Spanish
d.
Auntie refusing to leave the exam room when asked
Previous
Next
Why is it essential that all members of the healthcare team are informed about how to recognize, treat, and collaborate with one another regarding victims of human trafficking?
4
a.
It’s easier to report when there are multiple witnesses.
b.
It allows for recognition of multiple trafficking indicators as well as helps create a safe environment where patient needs can be met.
c.
To ensure no one is at fault if trafficking is missed.
d.
It’s not essential as only physicians are responsible for recognizing and reporting human trafficking.
Previous
Answers
ANSWERS:
1
c.
Poverty, lack of education, and abusive family history are primary risk factors for becoming a victim of sex trafficking.
d.
Victims of sex trafficking (or labor and sex trafficking) may present with a history of frequent (and/or forced) abortion, frequent pregnancies, frequent STIs, and/or repeated relocations.
d.
Human trafficking red flags include a companion who refuses to leave or insists on providing translation, delayed presentation for care, deliberately overstating age compared to appearance, discrepancies between stated history and clinical presentation or injury pattern, torture evidence, failure to care for previously identified medical condition, reluctance (or inability) to speak for themselves, and the companion answering for the patient.
b.
Disclosure happens after rapport with a healthcare provider is established and only when providers are sensitive, empathetic, culturally and socially aware, and nonjudgmental. In addition, working as a team allows multiple red flags to be discussed and identified.
2
3
4
Previous
During the exam, Auntie’s phone rings, and she steps outside to answer. The NP notes that Clarisse has bruising to her inner thighs, a mucopurulent vaginal discharge, and her cervix appears friable (bleeds easily without provocation). During the exam, Clarisse asks if she has to “get another shot again.” The NP finishes the exam and steps out of the room. She begins to review Clarisse’s record, which reveals that she has been positive for both chlamydia and gonorrhea several times in less than a year. The NP then notes in the record “suspected human trafficking.” The NP discusses her concerns with the ED medical director, and they agree she’ll presumptively treat Clarisse for the sexually transmitted infections, and consult with the social worker. The medical director recommends alerting the nurse who will be administering the medication and discharge instructions to wait until the social worker sees Clarisse. The social worker is consulted, and she reviews Clarisse’s chart and agrees with the preliminary suspicion of human trafficking. While Auntie is distracted by phone calls, the social worker begins to interview the patient gently to determine if Clarisse is, in fact, a victim of human trafficking. The next steps depend on what, if anything, Clarisse discloses, and how receptive she is to help.
Start questions
Previous

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 NHTRC or the Polaris Project.
How to earn continuing education
THIS COURSE IS 1 CONTACT HOUR
Read the Continuing Education article.
1.
2.
3.
If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer.
4.
Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test.
All users must complete the evaluation process to complete the course. You will be able to view a certificate on screen and print or save it for your records.
Go online to https://www.nurse.com/ce/human-trafficking-identification-and-assessment-of-victims-essential to take the test for $12. If you are an Unlimited CE subscriber, you can take this test at no additional charge. You can sign up for an Unlimited CE membership at Nurse.com/UnlimitedCE for $49.95 per year.
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In support of improving patient care, OnCourse Learning (a Relias LLC Company) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

OnCourse Learning is also an approved provider by the Florida Board of Nursing, the District of Columbia Board of Nursing, and the South Carolina Board of Nursing (provider # 50-1489). OnCourse Learning’s continuing education courses are accepted by the Georgia Board of Nursing. Relias LLC is approved by the California Board of Registered Nursing, provider # CEP13791.
You can take this test online or select from the list of courses available. Prices subject to change.
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Human Trafficking: Identification and Assessment of Victims Essential
By Trisha Sheridan, DNP, MSN, RN, WHNP-BC, SANE-A, CFN
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This course is 1 contact hour
Course must be completed by Dec. 29, 2019
Goals and objectives: The goal of this human trafficking continuing education program is to provide healthcare professionals with information, tools, and resources to identify, assess, and treat human trafficking victims, as well as providing referral resources for legal and social services. After studying the information presented here, you will be able to:
  1. Describe the types of, risk factors for, and extent of human trafficking in the U.S.
  2. Discuss the role and responsibilities of the interprofessional healthcare team in the recognition, assessment, and treatment for the victim of trafficking, including management of medical records, patient safety, and referral sources
  3. Identify reporting and referral resources for victims of human trafficking
Nurse.com educational activities are provided by OnCourse Learning, a Relias LLC Company. For further information and accreditation statements, please visit Nurse.com/Accreditation. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. Relias LLC guarantees this educational activity is free from bias. See “How to Earn Continuing Education” to learn how to earn CE credit for this module or visit http://ce.nurse.com/instructions.aspx.
Sex trafficking
Indicators of trafficking victim status
Recommendations for assessments

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 Using the case of Sally, an example of IP collaboration would include the nurse who takes her vital signs and a basic health history, notes the thigh tattoo, and senses something is “not right.” The nurse alerts the medical provider that Sally’s history and demeanor seem concerning. Then, when the provider examines Sally, the provider is alert for injuries or other red flags that might suggest something other than routine abdominal pain. The provider asks questions that may allow disclosure and consults with the social worker (or forensic nurse) to discuss resources and information that can help Sally. 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)
Management and collection of trafficking victim medical records

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 During the sexual health history, Sally is asked if anyone has forced her or tricked her into doing anything or if she ever felt pressure to have sex or engage in sexual activities. She says Carl had taken a video without her knowledge while they were having sex. A social worker talks to Joe to give him options on how to obtain the medicine he needs. When asked about his living and working conditions, the social worker learns that Joe and several others were recruited to a local farm with the promise of room, board, and cash wages for 40 hours/week work for 12 weeks. However, he lives in a tent with the others and was told they would get paid only at the end of the contract after expenses for room and board were subtracted. 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
Assessment tools

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 Vera Institute of Justice. 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
Patient questions: Strong predictors of sex and labor trafficking15
Labor trafficking
Have you ever worked without getting the payment you thought you would get?
Have you ever worked in a place where the work was different from what you were promised or told it would be?
Did anyone at your workplace make you feel scared or unsafe?
Did anyone at your workplace ever harm or threaten to harm you?
Have you ever felt you could not leave the place where you worked or lived?
Sex trafficking
Did anyone you worked for or lived with trick or force you into doing anything you did not want to do?
Did anyone ever pressure you to touch another person or have any unwanted physical or sexual contact with another person?
Mandatory reporting

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 database 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.
When a patient discloses trafficking16
Legal and social services
Final outcomes

Was either Sally or Joe a victim of trafficking? We may never know, because we see too many patients, like Sally and Joe, who may present once and never return. But they leave a nagging suspicion and lingering mystery. Given the abuses the victims face, it is unsurprising that many are seen by healthcare providers repeatedly without asking for (or receiving) help.4,12 Providers must be sensitive, empathetic, culturally and socially aware, and nonjudgmental to form a relationship to allow victims to disclose and become survivors.14,17

Read the full module online.
Resources
It is important to have resources readily available to help assist these patients.
Trafficking in Persons and Worker Exploitation Task Force (TPWETF)
Direct hotline to federal law enforcement (9 a.m. to 5 p.m. EST weekdays): 888-428-7581
NHTRC
Hotline (24 hours a day, seven days a week): 888-373-7888 or text to BeFree (233733) NHTRC provides tips about potential trafficking victims, and can provide urgent and non-urgent referrals, as well as technical assistance for victims and healthcare professionals.
Designed to provide quick access to critical emergency, transitional, and long-term social services for victims and survivors of human trafficking. The directory also connects individuals with training and technical assistance and opportunities to get involved in their communities.
Hotline: 800-843-5678 Provides services, resources, and assistance to child victims.
Other resources
Complete course and take the test
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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.
The human trafficking/forced labor industry has an economic impact of more than $150 billion worldwide.
Earn 1 credit hour with this continuing education course
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