A FORM OF MODERN-DAY SLAVERY, human trafficking affects more than 20 million victims globally, including more than five million children.1 It's defined as the act of recruiting, harboring, transporting, providing, or obtaining a person for compelled labor or commercial sex acts through the use of fraud, force, or coercion. Not all victims of trafficking have been moved from other countries; some were born into a state of servitude or are being exploited in their own home town.2
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Human trafficking is the fastest growing industry in the world; globally, 1.2 million children are sexually exploited each year, with over 200,000 minors from the United States at risk for being victimized. An estimated 199,000 youths are lured into human trafficking every year, with the average age of entry being 12 to 14 years.3 Every day, people are being bought, sold, and smuggled like slaves, often beaten, starved, and forced to work as prostitutes or to take jobs as migrant, domestic, restaurant, or factory workers with little or no pay.4 Human trafficking brings an estimated $25 to $30 billion to traffickers each year, with the United States being a main point of destination.3
Because up to 80% of victims are seen by a healthcare provider while under the control of their trafficker, nurses are uniquely positioned to intervene.5-7 This article explores how human trafficking is perpetrated and what nurses can do to identify and help victims.
Kidnapping, coercion, and more
Traffickers use various methods to lure their victims, including kidnapping, seduction, coercion, and false advertisements for "dancing," "acting," or "modeling." They also contact potential victims via web-based chatrooms.8 Once under the trafficker's control, victims are forced to work long hours in unsafe working conditions that lack essential safety measures to protect them from harm. Many are forced into labor to repay debts that are essentially impossible to repay due to their lack of compensation and the cost of transportation, housing, food, and other expenses that are constantly added to the loan amount.9
Sexual exploitation involves the use of money, valuables, or other material objects in exchange for sex. The average age of victims forced into prostitution, stripping, pornography, and sex tourism is 12 to 14. Women and children may be forced to "serve" up to 15 men per day, earning an estimated $124,000 each year, per victim, for the trafficker.9
Healthcare visits are frequently triggered by an illness that interferes with the victim's ability to perform household duties, recurring sexually transmitted infections (STIs), pregnancy tests, and abortions.5 Victims may be seen by clinicians in any healthcare setting with disorders affecting nearly every organ system.9
Unfortunately, nurses who encounter victims of human trafficking often don't realize it, and an opportunity to intervene is lost.10 Although no single indicator can reveal whether someone is being trafficked, nurses and other clinicians should be alert for telltale signs and know how to follow up by asking questions to assess the patient's work and living conditions, mental health, and freedom of movement (see Questions to ask about living/work conditions).10,11
Victims of human trafficking often experience posttraumatic stress disorder, paranoia, fear, suicidal thoughts, and mood swings.8 They may appear frightened, depressed, or anxious. Other signs include angry outbursts, intense shame, self-blame, self-loathing, substance abuse, and hypersexualization. Their account of their job or how they arrived in the country may be inconsistent or not make sense. They may report sleep disturbance, nightmares, and wanting to die as a means of escape.8
Physical signs of human trafficking can be subtle or nonspecific, such as myalgia, headaches, dizziness, back pain, or STIs. More overt signs include repeated abortions, bald patches where hair has been pulled out, ecchymoses, burns, bite marks, vaginal/rectal trauma, malnourishment, lack of healthcare, jaw problems from being forced to repeatedly perform oral copulation, and head injuries. In addition, the patient may appear alert and oriented but may not know where he or she truly is.3,8,10 Note unusual tattoos or branding-type marks as well, as traffickers often brand victims as a sign of ownership.10
Barriers to communication
Victims of human trafficking have very little control over their own lives. They may not manage their own money or have ID documents, and they may have very few personal possessions. Commonly traffickers won't allow victims to speak for themselves and may prepare dishonest answers for questions that they expect healthcare providers to ask.5
Victims have minimal opportunity for disclosure when their trafficker insists on speaking for them. Victims fear for their lives and for the lives of their families if they speak up or attempt to escape. Traffickers often "test" their victims to see if they're loyal to them when questioned.10
Language is another common barrier to communication. Many victims are trafficked into the United States from other countries and don't speak English, requiring the use of interpreters during assessments as mandated by federal law.
Healthcare professional may miss opportunities to identify victims because they don't ask appropriate questions. For example, many victims aren't asked about personal safety or history of abuse.5
Some victims are completely unaware they are being trafficked. Those who were born into servitude may believe this lifestyle is normal.5 Others choose not to disclose their enslavement due to shame, and may be shunned by their families for no longer being virgins.10 They also fear imprisonment or deportation.
One of the best things nurses can do is establish trust with their patients by ensuring confidentiality during the patient interview. To promote honest answers, interview the patient in private. If the trafficker insists on interpreting for the victim, nurses must decline and reinforce that hospital policy must be followed to use certified medical interpreters.12 In addition, screen the interpreter to verify he or she doesn't know the victim or trafficker and have a conflict of interest.13
Exhibiting cultural competence is another vital component to establishing trust and rapport with the potential victim, who may be unfamiliar with certain customs or legal options based on his or her country of origin.14 Utilizing an empathetic, understanding, and accepting approach has the potential to elicit more honest responses that may become more detailed as the victim's sense of safety increases. If a language barrier exists, a trained professional interpreter is essential and mandated.
Nurses who suspect that a patient is a victim of trafficking must be mindful of the best way to approach the patient. Many victims don't realize they're being trafficked and are often accompanied by a captor, so don't ask a patient directly if he or she is a trafficking victim.12
Separating the victim from the trafficker is the most important action a nurse can take to ensure patient safety and encourage the patient to speak openly. To remove the trafficker, the nurse could state that facility policy requires nurses to complete a physical assessment in private or move the patient to a separate location for a diagnostic procedure, such as an X-ray. A call to security may be necessary if the trafficker won't cooperate.
Due to shame, hopelessness, and fear, the patient may resist help and want to leave. Or, if the trafficker senses suspicion, he or she may attempt to force the patient to leave. Ensure that a staff member stays with the patient at all times to provide support and encourage the patient to stay.12
Following a comprehensive evaluation, victim-centered services should be offered to the patient. Services may include medical, psychological, social, and vocational support, with an emphasis on promoting empowerment, community, and safety.15
Any suspicion of human trafficking should be reported to the National Human Trafficking Resource Center (see Where to report suspicions of human trafficking).16 Check with the current regulations in your state, and contact local law enforcement or protective services. As mandated reporters, nurses have a legal obligation to report child victims of abuse.
Also check your facility's current policy regarding the reporting of minor and adult victims of human trafficking. Making referrals to agencies such as law enforcement, social services, and mental health providers may be difficult without an established policy. Consider adapting protocols for intimate partner violence or child abuse in the absence of sex trafficking protocols.17
Federal statutes, such as Victims of Trafficking and Violence Protection Act of 2000, can give victims access to T Nonimmigrant Status (T-visa), which allows them to legally reside in the United States with access to mental health and health services.14,18 After 3 years, residents with a T visa may apply for permanent residence.19
After a survivor's basic needs for safety, shelter, and medical care are met, he or she must deal with psychological damage inflicted while under the trafficker's control. Unless psychological damage is recognized and addressed, victims are likely to face victimization again.15 Collaborating with law enforcement and social workers, nurses can ensure appropriate assessments are conducted and referrals are made to address both short and long-term physical and psychological injuries in order to avoid revictimization.
Modern-day slavery is a reality
Human trafficking affects millions of people, both worldwide and in our own backyard. By identifying victims, conducting thorough assessments, asking the right questions, and collaborating with a multidisciplinary team, nurses can help some of the most vulnerable people in the world escape from this modern-day form of slavery.
Questions to ask about living/work conditions10,20
"Are you free to come and go in your home as you please?"
"Have you ever worked without receiving the payment you thought you would get?"
"Have you ever worked in a place that was different from what you were promised or told it would be?"
"Does anyone at your work make you feel scared or unsafe?"
"Did anyone at your workplace threaten to harm you?"
"Have you ever felt you couldn't leave the place you work/live?"
"Do you live with your employer?"
"How many hours do you work in a week?"
"Do you owe your employer money?"
"Does your home have bars on windows, windows you can't see through, or security cameras?"
Where to report suspicions of human trafficking
* The National Human Trafficking Resource Center: (888) 373-7888
* Your local authorities
* For more information and resources, visit http://www.humantraffickinghotline.org.