1. Sabella, Donna PhD, RN


Overview: Human trafficking, also called modern slavery, happens worldwide-and the United States is no exception. Within our borders, thousands of foreign nationals and U.S. citizens, many of them children, are forced or coerced into sex work or various forms of labor every year. Nurses and other health care providers who encounter victims of trafficking often don't realize it, and opportunities to intervene are lost. Although no one sign can demonstrate with certainty when someone is being trafficked, there are several indicators that clinicians should know. This article provides an overview of human trafficking, describes how to recognize signs that a person is being trafficked and how to safely intervene, and offers an extensive resource list.


Keywords: debt bondage, human trafficking, labor trafficking, modern slavery, sex trafficking, trafficking in persons


Article Content

Mimi could feel the blood start to run through her hair and down the side of her face. Her head ached where her customer had grabbed a handful of her hair and pounded her face into the gravel-strewn alley, where they'd gone so no one could see them. Now Mimi wished she hadn't chosen such a private spot. She told herself she'd be more careful next time-if she lived through this time. As she lay on the ground, her assailant kicked her several times in the stomach, then took all the money she'd made that night and ran off. Scared that she'd been badly hurt, Mimi struggled to her feet and made her way toward the street, where another man was waiting for her. In the light of a street lamp, he could see that she needed medical attention. He drove Mimi to a hospital ED, where she was seen by well-intentioned physicians and nurses who treated her injuries; but what didn't happen at the hospital was almost as harmful as the beating Mimi had suffered. No one questioned why such a young-looking girl was out late on an unusually cold night, underdressed and wearing too much makeup. And no one thought to separate Mimi from the man accompanying her in order to find out more about what had happened.

Figure. Nigerian nat... - Click to enlarge in new windowFigure. Nigerian native Beatrice O. Okezie, 30, shown here in her Bronx, New York, neighborhood, was 13 years old when she was brought to the United States and forced to work as a household servant for nine years. Photo by Ozier Muhammad /

If they had, they might have learned that "Mimi" wasn't her real name; it was Elis. (This patient's names and other identifying details have been changed to protect her anonymity.) She was an 18-year-old girl from Brazil who'd been trafficked to Las Vegas and forced to work as a prostitute by the man who'd brought her to the hospital-her trafficker. But the ED clinicians who treated her injuries didn't recognize the situation for what it was, and released her back to a man whose actions were arguably worse than those of her assailant that night. If even one nurse had realized what was going on, Elis might have been spared further physical and emotional suffering.



While Elis's case might seem unusual for someone living in the United States, it's not. Although precise numbers are impossible to determine, it's estimated that between 600,000 and 800,000 adults and children worldwide are trafficked across international borders annually and made to work under brutal and inhumane conditions.1,2 Human trafficking has been broadly defined as "activities involved when one person obtains or holds another person in compelled service"; categories include sex trafficking, labor trafficking (including debt bondage, forced labor, and indentured servitude), and trafficking in child soldiers.3


Sex trafficking is defined by law as "the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act"-and it's considered "severe" when such an act is "induced by force, fraud, or coercion, or . . . the person induced to perform such act has not attained 18 years of age."4 In other words, regardless of the degree of force or coercion used, all sex trafficking in minors is considered a severe form. Victims can be found working in brothels, massage parlors, truck stops, strip clubs, private houses, or as escorts. Similarly, labor trafficking is defined by law as "the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery" and is also considered severe.4 Victims can be found working in various domestic and commercial capacities, including as nannies, housekeepers, farmworkers, janitorial and restaurant staff, and factory and construction workers. They are forced to work long hours, often receive no pay and little food, and are threatened with bodily harm or death should they resist or try to escape. Debt bondage occurs when a victim is required to work off some form of debt, incurred either by the victim or by a member of the victim's family. Often the debt includes expenses the trafficker incurred in getting the victim to her or his destination.5


Trafficking of children includes forced child labor, child soldiering, and child sex trafficking.6,7 A particularly heinous form of child sex trafficking is "sex tourism," in which adult men travel to another country in order to have sex with children.8,9 Many sex tourists are citizens of the United States and other developed nations; destination countries are typically less developed ones, such as Cambodia, Thailand, and the Dominican Republic.10 Sex tourism is a crime; any American citizen who engages in the practice risks conviction and up to 30 years' jail time.10,11


Where does it happen? Human trafficking occurs everywhere. A country can be a source, transit, or destination country, or any combination thereof. Human trafficking is an extremely profitable endeavor; it's believed to be the fastest growing industry in the world, and after drug dealing it is tied with illegal arms dealing as the second-largest criminal industry.5 While many Americans might be inclined to say that "this sort of thing doesn't happen here," the data show that it does. Our own Department of State characterizes the United States as a source, transit, and destination country.3 It's estimated that from 14,500 to 17,500 people are trafficked into this country annually.1 Within U.S. borders, sex trafficking is the most prevalent form of trafficking in U.S. citizens, while labor trafficking is the most prevalent form in foreign nationals.3 Indeed, after Germany, the United States is reportedly the second- largest market for women and children trafficked into sex work.12


Who gets trafficked? Although trafficking victims include people of all ages and both sexes, the majority are women and girls.3 More than half of all victims trafficked into the United States from other countries are children, according to the Center for Problem-Oriented Policing.13 Trafficking victims in the United States come from all over the world, including Africa, Asia, India, South America, Eastern Europe, Russia, and Canada.13 And not all of those trafficked in the United States are foreign nationals; an unknown number are domestic victims, born and raised here and trafficked within U.S. borders. One need not cross an international border to be trafficked. A majority of known domestic victims are children involved in prostitution.3 Many are runaways. But some are not. One such case is that of Theresa Flores, a 15-year-old American teenager who was trafficked while living with her middle-class family in Detroit.14 She was drugged and raped by a classmate, who then forced her into sexual slavery by threatening to harm her and her family if she didn't comply. She was trafficked on a regular basis for two years, without her parents or school officials realizing that it was happening, until her family's move freed her. Flores told one interviewer, "The point I will always make is that it [being trafficked] can happen to anyone."15


Why does trafficking occur? There are numerous causes; as the authors of one report for Congress put it, "the criminal business feeds on poverty, despair, war, crisis, and ignorance."16 They cite the breakdown of Communism in the former Soviet Union and parts of Eastern Europe as a major factor, because it led to widespread economic hardships, creating more opportunities for organized crime and weakening law enforcement,16 a view supported by other experts as well.17 Other factors include the subordination of women in many societies, which leads to viewing women and girls as economic burdens; a high worldwide demand for cheap labor; and the disinterest of many governments in combating trafficking.16,17

Figure. Brianna, 18,... - Click to enlarge in new windowFigure. Brianna, 18, of La Center, Washington, whose last name is concealed to protect her identity, was lured into a Seattle sex trafficking ring, narrowly escaping with the help of her friends and family. Photo by Zachary Kaufman, Associated Press /

Although many victims are kidnapped or otherwise forced into being trafficked, some are lured into what seems to be willing participation, at first by promises of a better life for themselves and their families. Desperate people need a way to support themselves and their families, if only to survive from day to day. Anywhere there is poverty, a lack of employment opportunities, an increase in population, mistreatment of women and children, political or civil unrest, armed conflict, or natural disaster, people are vulnerable to being trafficked. But they are victims nonetheless. Such was the case for Elis, whose traffickers initially promised her a job as a babysitter for a wealthy American family and the opportunity to go to school. But the babysitting job never existed; instead, when she arrived from Brazil, Elis was taken to a brothel and threatened with injury to her and her family if she didn't cooperate.


Government and organizational assistance for trafficking victims. Before 2000, traffickers met with few legal consequences for their activities in this country, and victims who managed to escape often found little support for rebuilding their lives. This changed in October 2000, when the Victims of Trafficking and Violence Protection Act of 2000 (also known as the Trafficking Victims Protection Act, or TVPA) was signed into law; it's since been reauthorized several times, most recently in 2008. The TVPA takes steps to prevent human trafficking, protect its victims, and prosecute those who engage in trafficking.4 It also provides victims of severe forms of human trafficking, regardless of their immigration status, with numerous benefits and services. (As noted earlier, sex and labor trafficking involving force, fraud, or coercion, and all sex trafficking involving minors, are considered severe forms.)


To prevent trafficking, the original law called for programs that raise public awareness of trafficking, especially among potential victims, and that promote international initiatives to improve their economic opportunities. To help protect victims of severe trafficking, the law created a new visa category, the "T" visa, which grants temporary residency with the possibility of permanent residency after three years.4,18 It also made victims eligible for the Federal Witness Protection Program and for other benefits typically extended to refugees, including health care, shelter, job training, legal representation, and even translation services. And it established that trafficking in persons is a federal crime and that perpetrators can be prosecuted and ordered to pay restitution to the victims.4,19 The subsequent reauthorization acts have expanded on these measures. For example, the 2008 reauthorization act calls for the creation of an integrated database on human trafficking using data from all U.S. federal agencies, authorizes a new assistance program for domestic victims, and increases the criminal liability of traffickers.19,20


During the last decade or so, there's also been an increase in the number of nongovernmental organizations (NGOs) that address various issues related to trafficking. Some, such as the Coalition Against Trafficking in Women, Free the Slaves, and Polaris Project, were established specifically to do so. Others, such as Amnesty International, work on a variety of human rights issues, including human trafficking. (For a list of NGOs and other agencies, see Resources.) Typing "human trafficking" into any Internet search engine is also likely to yield many sources of useful information. Yet despite increasing public awareness and the availability of such information, many people-including many health care professionals-still aren't well informed.



My experience. I was working as a mental health nurse in Philadelphia for an agency that staffed community health drop-in centers, when I realized that some of my clients were involved in prostitution and had been brought into the city to sell sex. Although I was meeting with these women to address their mental health issues, I was struck by the physical problems they presented with, which included black eyes and bald spots on their scalps where hair had been torn out; one woman had been branded with her pimp's initials. To find out more about such women and the services available to them, in 2006 I spent time doing research at a residential program for prostituted and trafficked women run by Catholic Charities Community Services in Phoenix. The program, known as Developing Individual Growth and New Independence Through Yourself (DIGNITY), is one of only a few such programs in the United States. When I returned to Philadelphia, I used what I'd learned to establish Project Phoenix (, an outreach program for prostituted and trafficked women in Philadelphia. Both my own nursing education and my experience in teaching nursing students have shown me that nurses often aren't well informed about human trafficking, particularly with regard to recognizing potential victims and knowing how to intervene effectively. Because the one and only time a nurse might encounter a trafficking victim is when she or he presents with a health problem, it's important that nurses be knowledgeable and prepared to offer appropriate help.


Common health problems. There have been few studies regarding the health issues of trafficking victims. That said, it's known that physical and psychological health problems are common in this population.21-23 In addition to the adverse effects of trafficking, many victims have preexisting health concerns; for example, those who are poor are likely to have had little or no access to health care and insurance. Trafficking victims typically receive health care only when their condition becomes serious, as seeking health care for a victim can be risky for the trafficker.21,24 Preventive care is rarely, if ever, provided.

Figure. The tissue d... - Click to enlarge in new windowFigure. The tissue damage behind the ear of a woman identified as Samirah is shown in an undated photograph taken at Nassau University Medical Center in East Meadow, New York. Samirah and another woman were hired as housekeepers and then enslaved and brutalized in a Long Island, New York, mansion. Associated Press / U.S. Attorney's Office.

Physical health problems seen among people trafficked into prostitution or sexual slavery include sexually transmitted diseases, vaginal and rectal trauma, unintended pregnancies, infertility, and urinary tract infections.25 One European study of women trafficked into sex work found that 95% had experienced physical or sexual violence in relation to that work, including being kicked while pregnant, burned, punched, thrown against a wall or floor, hit with bats or other objects, and dragged by the hair.23 Victims might present with bald patches where their hair was pulled out, lacerations, bruises, scars, burns, and bite marks. Similarly, people trafficked for their labor can suffer from various physical problems, including chronic back pain, muscle strains and sprains, and cardiovascular and respiratory conditions.26 Trafficking victims may suffer from malnutrition, dehydration, exhaustion, and dental and visual problems if they've been deprived of adequate food, water, light, and sleep.27 Diseases and conditions such as diabetes, cancer, and hypertension may go undetected or untreated. Infectious diseases such as tuberculosis are also a frequent consequence for trafficking victims.21,25,26


The role of trafficking in the spread of HIV and AIDS is of particular concern. Trafficked and prostituted women often report that their customers don't want to use condoms and will pay more for unprotected sex. Of the women I have worked with, most say that they've learned to put a condom on a male customer without his knowledge; but the effort isn't always successful, and a woman being held captive might not have access to condoms. Most are afraid of contracting HIV and of being abandoned or killed by their traffickers if they can't work.


Common psychological problems of trafficking victims include depression, anxiety, suicidal ideation, posttraumatic stress disorder (PTSD), and addiction.28,29 In a study on prostitution and trafficking in nine countries, Farley and colleagues found that 68% of the interviewed participants met the criteria for PTSD.30 Other emotional problems reported by participants and characterized by the researchers as "severe" were mood swings, anxiety, terror, depression, and wanting to die as a means of escape.


Many victims feel intense shame, a fact that traffickers use to keep the victims in line.31 In many countries, a girl who loses her virginity outside of marriage, even as the result of rape, is ostracized by her family and community. One report on women from Southeast Asia who've been trafficked for sex work states that, even if permitted to return home, such women "may face harsh social and family censure for having been prostitutes despite their victimization."32


My experience in working with sex trafficking victims corroborates these findings; I've seen all of these physical and psychological problems and more. Many women present with jaw and neck problems from repeatedly being forced to perform oral sex. Back problems are common in those made to spend hours walking the street in high heels in order to attract customers. I worked with one woman whose trafficker had run over her legs three times with his car to teach her a lesson; one of her legs was deformed as a result. Some women have been branded by a pimp to show ownership, much as cattle are branded; some have marks from having been beaten with a "pimp stick"-a wire hanger that has been straightened and then folded back on itself several times. Some women have pulled up their shirts to show me where they've been stabbed or burned with cigarettes, either by their traffickers or by customers; others have removed partial dentures to reveal where their teeth had been knocked or kicked out. Many are supplied with drugs as a way to maintain control over them. One woman suffered from severe malnourishment. Her trafficker had permitted her to eat only during three 10-minute daily intervals; she had to wear a dog collar, and whatever she couldn't finish in the allotted time was thrown away. Despite suffering often severe physical damage, the majority of the women I've worked with tell me they feel that this can be overcome; it's the emotional and psychological damage they find more devastating.


How to recognize a victim of trafficking. In this country, nurses and other clinicians who encounter a person who's being trafficked probably won't realize it. There are several reasons for this. Trafficking victims are in no position to step forward, identify themselves as such, and ask for help. Many don't speak English, are unfamiliar with American culture, and have no idea where to seek help. They're threatened with physical or sexual violence (or both) if they fail to comply with the demands of their traffickers; in fact, it's likely they've already suffered such harm. Their families and loved ones may also have been threatened or harmed. Many are captives, prevented from going out on their own; they're told that if they try to escape, they'll face imprisonment, deportation, or worse. Some traffickers "test" victims by having someone in league with the trafficker pretend to offer a way out, severely punishing those who accept the bogus offer. Such was the case for Jill Leighton, a teenage runaway forced into prostitution by a man who picked her up from the streets and held her captive.33 A customer offered to help her leave; but the customer was working for her trafficker, and she was beaten and gang-raped for trying to escape. (She eventually gained her freedom when her trafficker was arrested on unrelated charges.)


Although no one sign can demonstrate with certainty that someone is being trafficked, there are several indicators that nurses and other clinicians should be aware of. The presence of one or more of the following should prompt further investigation34,35:


* The person doesn't speak English and someone else is speaking for her or him.


* The person speaks some English, but someone else is speaking for her or him.


* The person doesn't seem to know where she or he is.


* The person doesn't have any identification or travel documents, or someone else is holding the documents.


* The person has no spending money.


* The person appears to be under the control and supervision of someone who never leaves the person alone.


* There are signs of malnutrition, dehydration, drug use or addiction, poor general health, or poor personal hygiene.


* There are signs of physical abuse or neglect, such as scars, bruises, burns, unusual bald patches, tattoos that raise suspicion (for example, "Property of-" or gang-like symbols), or untreated medical problems.


* The person appears depressed, frightened, anxious, or otherwise distressed.


* The person's story about what she or he is doing in this country or on the job doesn't make sense.


* The person lives with an employer or at the place of business and can't give you an address.


* Those who brought the person in for treatment are resistant to letting you speak with the person alone.




If you suspect that someone might be a victim of human trafficking, consider asking some questions that could help you to determine whether this is the case. But it's important to realize that asking the person directly whether she or he is a trafficking victim usually isn't helpful. Many victims are unfamiliar with the term or don't know that trafficking is illegal in the United States; some even blame themselves for their predicament. Many, not knowing whom to trust, are wary of strangers. Some have a general fear and mistrust of authority figures, including law enforcement and health care personnel and government workers-and traffickers often play on such fears, telling victims they themselves could be jailed or deported for their "crimes." Some victims will decline offers of assistance out of concern for the safety of their family and friends. In such cases the victim's wishes should be respected. (However, if the suspected victim is under the age of 18, the case must be reported as suspected child abuse.)


When trying to discern whether someone is a trafficking victim, it's essential to talk with the person alone, in a place where no one else can overhear the conversation. Asking a suspected victim questions in the presence of her or his trafficker is unproductive and could make matters worse. When I worked as a crisis intervention specialist in an ED, I routinely told patients assigned to me for assessment that hospital policy required me to question everyone individually, a practice that worked well. If the person doesn't speak English and a translator is brought in, it's important to ensure that the translator has no connection to the suspected traffickers.


Some questions the nurse might ask a possible victim include the following36:


* Where are you from?


* What brings you to the United States?


* How did you get here?


* What type of work do you do? Do you have a set schedule?


* Are you paid for your work? How much do you earn?


* Have you been threatened with violence or harm if you decide you want to leave your job?


* Do you have identification (ID) on you? If not, why not? Who has your ID or other documents?


* Do you have to ask permission to eat, sleep, go to the bathroom, or talk with others?


* Are you being forced to do what you're doing?


* Are you allowed to go out on your own?


* Where and with whom do you live? Are there locks on the doors and windows so that you can't get out?



It can be painful and even traumatic for trafficking victims to describe to a stranger what they've been through. Some might deny some of the details or refuse to talk at all. It's important for anyone questioning a suspected victim to have patience-and to understand that getting the entire story isn't the point at this time. That is a task best left to someone experienced in working with trafficking and trauma victims. Indeed, the World Health Organization has published a manual on how to interview trafficked women to ensure that they aren't further traumatized (many of the recommendations are also applicable to men).37 Moreover, it's not up to the nurse or to anyone else in the health care setting to prove that trafficking is occurring. If you suspect that someone is a trafficking victim and are unsure how to proceed, call the National Human Trafficking Resource Center (NHTRC) hotline at 1-888-3737-888 or visit Once that call is made, possible ways to handle the situation can be discussed and an investigation can begin.



As nurses, we're in a position to help make a difference in the lives of trafficking victims at several points, from the initial encounter and identification to their rescue and restoration to health. Yet often such opportunities are missed, as at least one study confirms. In a study of 21 survivors of human trafficking in the San Francisco, Los Angeles, and Atlanta areas, researchers found that although 28% had come into contact with health care providers during their captivity, the providers didn't realize their patients were being trafficked.31 It's also worth noting that clinicians in a variety of settings-not just hospital EDs-could potentially encounter people who are being trafficked. For example, in the aforementioned study, some of the victims were brought to dentists' or physicians' offices.


Regardless of the setting and the suspected victim's place of birth, much of what we need to know in order to approach and intervene effectively is the same. The clinician's primary concerns must be to prioritize and treat the person's health problems and to ensure her or his safety. Once these needs have been met, if trafficking is suspected, the nurse and others on the health care team can then proceed to assess the situation.


It's never too soon to start thinking about how you and your facility will handle a potential trafficking situation. Encourage your facility's administration to address the issue of human trafficking by providing education and training to nursing and medical staff and establishing policies and procedures for cases in which trafficking is suspected or known. Other things that you can do include the following:


* Stay informed by reading about human trafficking and learning more about local and national efforts to address the issue. Provide trafficking literature to others on staff.


* Explore the sites listed in Resources. A good starting point: the toolkits created by the U.S. Department of Health and Human Services' Campaign to Rescue and Restore Victims of Human Trafficking.


* Don't be afraid to ask questions if your patient has one or more indicators of trafficking or if something doesn't seem quite right to you. Remember to speak with the person alone; if a translator is needed, make sure she or he has no connection to the traffickers.


* Post the NHTRC's toll-free hotline number: 1-888-3737-888. They answer calls around the clock, 365 days a year.


* Prepare small palm-sized cards with instructions in several languages for calling the NHTRC hotline number and local law enforcement that you can give to suspected victims. Hang posters with such information in places victims might see them, such as outpatient clinics, EDs, and facility bathrooms.


* Think beyond the clinical setting; notice what's going on in your community. Are there children who never seem to go to school? Are there men coming and going at all hours at a nearby residence?


* For your safety, never confront a suspected trafficker directly. Instead, contact local authorities and call the NHTRC hotline number.


* Reach out to professionals in other disciplines at your facility. Talk with people involved in antitrafficking efforts in your community, as well as with local law enforcement personnel. Find out what's going on in your state.



Despite increasing awareness of human trafficking and the provisions of the TVPA and subsequent reauthorization acts, there's still much work to be done, both in the United States and abroad. There is a lack of direct services for trafficking victims; in this country, for example, more residential treatment facilities and better mental health services are needed. No single program addresses all of a victim's needs; a trained professional must spend time piecing together services from various sources, which may or may not be available locally. Nurses can help by advocating more direct services for trafficking victims, offered at centralized locations where victims have access to the full range of such services. For example, you can write or call your local and state representatives to find out what they're doing in this regard.


If you're a nurse educator, consider adding a course on human trafficking as an elective or incorporating a lecture on the subject into a course you're already teaching. You might invite a local expert to speak on the subject at your school, or show a film on human trafficking to your class. When I taught at Kutztown University of Pennsylvania, I offered an online course for undergraduate nursing students (and other interested students) on the role of health care and service providers in identifying and helping trafficking victims. Students gained the knowledge and the tools they needed in order to recognize potential victims and intervene effectively, and were encouraged to share what they learned with colleagues in the workplace. I'm now teaching at Drexel University and hope to offer a similar course there.


Elis: an update. If even one clinician had known how to recognize indications of human trafficking, Elis's suffering might have ended sooner. On that night, she was allowed to leave the ED with the man who was her trafficker, and her ordeal continued for another six months. Eventually Elis managed to escape on her own with just enough money for a cross-country bus ticket, allowing her to return to the East Coast, where she had family. She went to a shelter and was referred to an agency that provided services for runaways; the agency in turn found her a social worker, who contacted me. The social worker helped Elis to obtain permission to stay in the United States and to find a part-time job while she was in counseling. Elis continues to recover and rebuild her life.

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For 17 additional continuing nursing education articles on ethical/legal issues, go to