A form of modern-day slavery, human trafficking is a serious public health emergency affecting 12 to 30 million people, including more than 5 million children.1-4 Defined as the act of recruiting, harboring, transporting, providing, or obtaining a person through the use of fraud, force, or coercion for compelled labor or commercial sex acts, victims of human trafficking can be any age, race, sexual orientation, or socioeconomic level, and from urban or rural areas.5 Trafficked individuals are bought, sold, and smuggled, often beaten, starved, and forced to work as prostitutes or take jobs as migrant, domestic, restaurant, or factory workers with little or no pay.6 Sometimes, victims may be completely unaware that they're being trafficked; they may even believe this lifestyle is normal.7 Other victims choose not to disclose their enslavement due to shame, especially when those forced into sex work are shunned from their families for no longer being virgins, despite the element of coercion.8 Individuals who are trafficked fear for their lives and the lives of their family members if they speak up and are often threatened with imprisonment, deportation, or harm if they attempt to escape.8
Caring for a victim of human trafficking can be traumatic, so nurse leaders must ensure that staff members are educated on how to identify and report human trafficking and connect patients with services and support systems. With proper training and support, staff members can rise to this challenging, and often difficult, facet of practice.
The facts
Human trafficking is the fastest growing industry in the world.8,9 It's estimated that 800,000 people are trafficked in the US each year, with 1 million children being exploited and coerced into the commercial sex trade annually. Within 48 hours of running away from home, it's likely that a child will be approached to participate in prostitution or some form of commercial sex exploitation.5 The National Center for Missing and Exploited Children estimates that one in six children will be victims of human trafficking.10
Traffickers often use social media and the internet to lure their victims with false advertisements for "dancing," "acting," or "modeling," and then kidnap, seduce, or coerce them.11 The average age of individuals forced into prostitution, stripping, pornography, and sex tourism is 12 to 14.1,12 Although victims of human trafficking are perceived as young, female, and foreign-born, 44% of individuals who are sex trafficked in the US are citizens.13 Risk factors for youth victims of sex trafficking include a history of abuse and neglect, involvement with child protective services or the juvenile justice system, and identifying as lesbian/gay/bisexual/transgender/queer. Young people who've run away or are homeless are at high risk, as are those with mental health issues or a history of substance misuse.
Once under the trafficker's control, individuals are forced to work long hours in unsafe working conditions lacking essential safety measures to protect them from harm.12 Many are forced into labor due to debts that are impossible to repay due to the lack of compensation for transportation, housing, food, and other expenses, which are added to the initial loan amount.12 Others find themselves facing sexual exploitation, which includes the use of money, valuables, or other material objects in exchange for sex.12 It's estimated that human trafficking brings in $25 to $30 billion for traffickers each year, with the US being a main point of destination.3
The nurse's role
Fifty to 80% of trafficked individuals are seen by a healthcare provider while under the control of their trafficker.5,14-16 Healthcare visits are frequently triggered by an illness that prevents the ability to work, recurring sexually transmitted infections (STIs), positive pregnancy tests, or abortions.7 Although there isn't a single indicator of whether someone is being trafficked, there are several signs that nurses should be aware of and questions that can be asked.17
Recognize
Victims of human trafficking often experience posttraumatic stress disorder, paranoia, fear, suicidal ideation, and mood swings.11,18 The patient may appear frightened, depressed, or anxious. Other behavioral signs include outbursts of anger, intense shame, self-blame, self-loathing, hypersexualization, sleep disturbances/nightmares, and addiction.11 The story of the patient's job, lifestyle, or how he or she arrived in the country may be inconsistent, or simply not make sense.
Physical signs may be subtle, such as muscle strain, headaches, dizziness, back pain, or STIs. More significant signs include repeated abortions, bald patches where hair has been pulled out, bruises, burns, bite marks, vaginal/rectal trauma, malnourishment, lack of healthcare, jaw problems, and brain damage.3,8,11 Unusual tattoos or branding marks, which may signify that the patient belongs to a certain trafficker, should be noted.19
Assess
Human trafficking victims have very little control over their own lives. They may not be in control of their own money, may lack identification documents, and may have very few personal possessions. Frequently, they aren't allowed to speak for themselves. With the trafficker insisting on speaking for the patient, there's minimal opportunity for disclosure and traffickers often prepare dishonest answers to questions that healthcare providers may ask.7
Establishing trust is imperative; the nurse should interview the patient in private to promote honest, open answers. Language may be a barrier to communication; many victims are trafficked into the US from other countries and don't speak English, requiring the use of an interpreter. By avoiding interruptions, leading questions, and continuous direct questions without pauses, the nurse can create a safe, nonjudgmental environment. The nurse can ask questions to assess the patient's living and working conditions, lack of control over his or her life, mental health status, physical health, and possible sex trafficking.
Questions to ask about living/working conditions include:8,19
* 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 workplace 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?20
Nurses serving patients in high-risk populations need to be vigilant about considering the possibility of sex trafficking. Spontaneous disclosure of sex trafficking is rare, so nurses should ask questions about risk factors and discuss concerns of sex trafficking with patients. The Joint Commission recommends the following screening questions:20
* Where do you sleep and eat?
* Do you live there with other people?
* Is your family there or nearby?
* Are the doors and windows locked so you can't get out?
* Have you been denied food, water, or medical care?
* Has your ID or documentation been taken away from you?
* Have you been threatened if you try to leave?
* Has anyone threatened your family?
* Have you been physically harmed in any way?
* Are you being forced to do anything you don't want to do?
When a child is suspected of being trafficked, the nurse can observe the adult who's with the child. Other considerations include:19
* How do the child and adult interact?
* Does the child seem well nourished, clean, and appropriately dressed?
* Is the history provided consistent with the chief concern?
* Is an older child able to provide a home address and state his or her current location, date, and time?
* Does the child hesitate or is he or she unwilling to answer questions related to the chief concern?
* Does the adult interpret the child's statements or answer for him or her?
* Does a working-age child have wages withheld?
* Does the child have tattoos saying "Daddy," "$," "for sale," or "property of"?
* Has an adolescent/young adult had multiple STIs, pregnancies, or abortions?
* Does the child use slang or terminology common in the sex industry?
The nurse should sit or get down to the child's eye level to build rapport. The patient's physical needs should be met first and a qualified interpreter used if needed. Avoiding terms such as sex worker, pimp, escort, and call girl, the nurse can ask the child:19,21,22
* Who takes care of you?
* Where do you live?
* Who lives with you?
* Do you feel trapped?
* Has your family been threatened?
* Can you tell me about your tattoos?
* Is anyone making you do things you don't want to do?
* Have you been denied food/water/medical care/sleep/access to your family?
Intervene
Priority nursing care must include basic needs for safety, shelter, and medical care. Nurses can utilize community resources and emergency housing to ensure safety. Social workers have a critical role in developing a patient safety plan and providing appropriate referrals to comprehensively meet the patient's physical and psychosocial needs. Often, patients aren't ready or don't feel safe to take resource materials, so nurses can encourage them to memorize the National Human Trafficking Hotline number (1-888-373-7888) for protection.20 Because every situation is unique, promote the use of a patient-centered response.20
Nurses should be knowledgeable about community organizations that serve individuals with risk factors for human trafficking, such as mental health agencies, shelters, and substance abuse clinics. Keep in mind that victims are often recruited based on a promise of love, money, shelter, food, or employment. Nurses can provide risk-specific resources for patients who lack familial support, housing, stability, and basic needs to reduce vulnerability to recruitment.16 Once physically stable and safe, survivors need support to address the repeated psychological damage inflicted while under their trafficker's control. Left unaddressed, these individuals are likely to face victimization again.23
Objective documentation is essential and includes findings, patient responses, and direct quotes, as well as observations of nonverbal cues.5 If it's suspected that a patient may be a victim of trafficking, nurses can call the National Human Trafficking Hotline.9 Nurses should check current state regulations and contact local authorities if required. Staff members are legally required to contact child protective services if the victim is under age 18.4 Adult victims can't be forced to report their situation but should receive information about how to safely do so.20
Federal statutes, such as the Victims of Trafficking and Violence Protection Act of 2000, provide victims with a T visa, allowing survivors of human trafficking to legally reside in the US with access to mental health and healthcare services.24
Nurse manager considerations
Nurse managers can provide their staff members with information on how to identify victims of human trafficking to ensure patient safety.20 Recently, training and screening tools to help identify victims of human trafficking have been developed. Based on actual cases, these victim-centered, trauma-informed programs provide educational modules and victim response procedures that engage nurses, healthcare providers, first responders, and the community to build a strong network to prevent exploitation, support trafficked individuals, and empower survivors.25 However, not all states provide protection for victims. Given the inconsistencies between and across federal and state legislation and regulations, healthcare professionals are often unaware of which protections apply in their practice areas. For this reason, provide nurses with informational posters, brochures, videos, websites, and social media resources to supplement education.26 (See Educational resources.)
Work to develop policies and protocols within your organization to streamline screening, assessment, and response to ensure a systematic approach to human trafficking identification and intervention, as well as promote community health and wellness, child welfare, gender equality, and violence prevention.16 Take advantage of resources to build your staff members' knowledge base about human trafficking, then teach others. Consider approaches beyond direct education in the clinical setting. In professional organizations, initiate discussions about human trafficking risk factors, prevention strategies, and resources. Within the community, work to combat social/cultural norms, such as gender-based discrimination and violence and intolerance of sexual minorities that may contribute to human trafficking.16
Reducing vulnerability
Human trafficking is a reality that affects millions of people worldwide. As a key stakeholder group, nurses are positioned to engage in prevention efforts that target patient populations across the risk continuum and seek to mitigate multilevel contributors to human trafficking. By increasing nurses' ability to identify victims, conduct thorough assessments, ask the right questions, and collaborate within multidisciplinary teams, we can aid our most vulnerable patients.
Educational resources
American Nurses Association
* Position Statement: The Nurse's Role in Ethics and Human Rights: Protecting and Promoting Individual Worth, Dignity, and Human Rights in Practice Settings http://www.nursingworld.org/~4ad4a8/globalassets/docs/ana/nursesrole-ethicshuman
Emergency Nurses Association/International Association of Forensic Nurses
* Joint Position Statement: Human Trafficking Awareness in the Emergency Care Setting http://www.ena.org/docs/default-source/resource-library/practice-resources/posit
HEAL Trafficking and Hope for Justice
* Protocol Toolkit for Developing a Response to Victims of Human Trafficking in Health Care Settings https://healtrafficking.org/2017/06/new-heal-trafficking-and-hope-for-justices-p
Massachusetts General Hospital
* Human Trafficking: Guidebook on Identification, Assessment, and Response in the Health Care Setting http://www.massmed.org/Patient-Care/Health-Topics/Violence-Prevention-and-Interv
National Human Trafficking Hotline
* Framework for a Human Trafficking Protocol in Healthcare Settings https://humantraffickinghotline.org/resources/framework-human-trafficking-protoc
* Human Trafficking Awareness for Mental Health Professionals https://humantraffickinghotline.org/resources/human-trafficking-awareness-mental
* Identifying Victims of Human Trafficking: What to Look for in a Healthcare Setting https://humantraffickinghotline.org/sites/default/files/WhattoLookforduringaMedi
* National Human Trafficking Referral Directory https://humantraffickinghotline.org/training-resources/referral-directory
* Recognizing and Responding to Human Trafficking in a Healthcare Context https://humantraffickinghotline.org/resources/recognizing-and-responding-human-t
US Department of Health and Human Services, Administration for Children and Families, Office on Trafficking in Persons (OTIP)
* Adult Human Trafficking Screening Tool and Guide http://www.acf.hhs.gov/sites/default/files/otip/adult_human_trafficking_screenin
* OTIP Resources http://www.acf.hhs.gov/otip/resource-library/search?tag=6306
* SOAR Online http://www.acf.hhs.gov/otip/training/soar-to-health-and-wellness-training/soar-o
US Department of Homeland Security
* Blue Campaign http://www.dhs.gov/bluecampaign
INSTRUCTIONS Human trafficking: Impact, identification, and intervention
TEST INSTRUCTIONS
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PROVIDER ACCREDITATION
Lippincott Professional Development will award 1.0 contact hour for this continuing nursing education activity.
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This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 1.0 contact hour, and the District of Columbia, Georgia, and Florida CE Broker #50-1223.
Payment: The registration fee for this test is $12.95
REFERENCES