What comes to mind when you hear human trafficking? Many think of sex slaves or forced prostitution. Public media has focused on sex trafficking, such as the movie Taken (Hoarau & Morel, 2009). This story depicted the actions of a former agent of the Central Intelligence Agency, intent on recovering his teen daughter from a criminal syndicate who kidnapped her to sell her as a sex slave. Although this movie brought sex slavery/trafficking to the attention of audiences worldwide, the plotline and actions undertaken by the lead character to save his daughter are more Hollywood fantasy than reality.
What, then, is the reality of human trafficking? Does human trafficking involve transporting people? The United Nations Protocol to Prevent, Suppress and Punish Trafficking in Persons (2000) defines human trafficking as:
[T]he 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. (p. 2)
Note that a commercial sex act is any sex act in which anything of value is given or received by any person, such as money, drugs, survival needs (food, shelter), or transportation. When a person is younger than 18, and they're induced to perform a commercial sex act, it's a crime regardless of whether there is any force, fraud, or coercion (U.S. Department of State [DOS], 2017).
REALITY OF THE PROBLEM
The realities of human trafficking require awareness and addressing misconceptions (Table 1). One pervasive misconception is that human trafficking and sex trafficking are synonymous. Although sex trafficking exists via commercial sex in brothels and street-based activities, it is only one form of human trafficking. The Federal Strategic Action Plan on Services to Victims of Human Trafficking in the U.S. (Office for Victims of Crime, 2014) indicates that human trafficking is a crime involving the exploitation of someone for compelled labor, or commercial sex. United Nations Secretary General Antoinio Guterres notes (U.S. DOS, 2017):
Global supply chains have transformed many lives for the better-but not always without costs. Clothes, food, smartphones, jewelry and other consumer goods may bear, wittingly or unwittingly, the traces of exploitation. Gleaming new skyscrapers may owe some of their shine to the sweat of bonded laborers. (p. 44)
The International Labour Organization (2012), estimates that 68% of all human trafficking is due to forced labor. Labor trafficking has been reported in business markets, such as nail salons, agricultural organizations, restaurants, hotels, manufacturing plants, and in domestic service.
The exploitation of persons via human trafficking includes three components: action/process, means, and purpose/goal. Each component has several possibilities to determine if trafficking exists (Figure 1). With adults, human trafficking includes at least one item from each component. The consent of adult victims to participate is irrelevant if any one of the means (i.e., force, fraud, etc.) is used to elicit participation. However, when the situation involves minors, the means is irrelevant, as only the act/process and the purpose/goal need to be demonstrated to determine trafficking.
Human trafficking exists in every country. Victims live in cities, towns, suburbs, and rural areas. A single profile to identify persons who are victims of trafficking is impossible to develop, as socioeconomic levels, educational status, and citizenship vary greatly. There are, however, situations and/or vulnerabilities that increase the risk of becoming a victim of human trafficking (Table 2).
Traffickers use targeted means to prey on their victims and are adept at using Maslow's Hierarchy of Needs. Maslow (1943) referred to the lower levels of the pyramid as deficiency needs because a person becomes anxious when these needs are not met. The longer needs are unmet, the more desperate the person becomes to meet those needs. Thus, it is easier to exploit someone who is experiencing physiologic needs (food, sleep, water, shelter), safety needs (employment, security, physiologic safety), or belonging needs (affiliation, acceptance, affection, friendship, love), than someone who is secure in these areas. Traffickers manipulate victims, making them feel it is their fault they are doing what they are doing. They might say, "You were the one who ran away from home," or, "You were the one who was flirting at the night club."
Trafficked persons frequently do not self-identify as victims. They feel helpless and hopeless, believing things will never change and there is no point in telling a healthcare provider about their situation. The victim may fear for others or for him- or herself. Victims will be uncomfortable disclosing their situation and not ready to seek assistance. Trafficking victims often have a prior relationship with their trafficker, such as romantic involvement or with an employer. One study of homeless youth found that 36% of minors were trafficked by parents or immediate family members (Covenant House New York, 2013). The appearance of consent does not mean someone is not being trafficked. Victims may believe that even though they are being beaten or forced to have nonconsensual sex, their situation is better than when they were not being trafficked. Illegal immigrants may think they have no rights.
NURSING ROLE AND RESPONSE
Multiple studies indicate that trafficking victims intersect with healthcare (Baldwin, Eisenman, Sayles, Ryan, & Chuang, 2011; Barrows & Finger, 2008; Lederer & Wetzel, 2014). In fact, 87.8% of victims report an encounter with healthcare workers (Lederer & Wetzel). The Coalition to Abolish Slavery and Trafficking (2017) found that of victims who had an encounter with healthcare providers while they were being exploited, nearly 97% reported they received no information or resources on human trafficking. Healthcare organizations are increasingly mandating training/education sessions to prepare providers to recognize patient signs and/or symptoms that may be indicative of human trafficking (McKinney, 2015). Nurses have an opportunity to recognize signs and become a first line of response for a trafficked person.
However, identification of human trafficking victims in healthcare environments remains problematic. Much stigma and prejudice is associated with sex trafficking. Providers report not knowing what to say and anxiety about identifying victims, in addition to fear of Health Insurance Portability and Accountability Act (HIPAA) violations. Nurses need to look and listen for clues that may indicate a patient could be a victim of human trafficking. Common health problems that may indicate a patient is a victim of human trafficking are found in Tables 3 and 4. The information offers a guide, as each situation and victim is different. Indicators of trafficking must be reviewed in context. The identification of one indicator does not mean the patient is a victim. However, a constellation of indicators warrants further investigation. A victim may experience the health problems listed or others not listed. Physical health problems and mental health issues may be intertwined, thus a thorough assessment needs to be conducted in a manner that provides safety for the patient, as well as for the provider (Zimmerman & Borland, 2009).
It is not a healthcare provider's responsibility to determine if a patient is a victim of human trafficking. Providers cannot resolve the issue of human trafficking as defined by law. Nurses' responsibilities are to understand what constitutes trafficking, be watchful for signs of trafficking, and respond appropriately using established procedures that are victim-centered and trauma-informed (Koetting, 2016). If red flags are identified, respond, educate, and empower patients to make choices toward seeking help.
WHEN YOU SEE RED FLAGS
When a nurse encounters a patient who may be a trafficking victim, be prepared to provide safe and nonthreatening care. The victim is a valuable commodity; therefore, the trafficker typically will accompany a victim to the healthcare facility. For the safety of the victim, as well as personnel, never confront the trafficker directly. When safety is a concern, contact security personnel and/or local law enforcement and allow them to confront the trafficker.
Regarding interacting with the patient who is a possible victim, Zimmerman and Borland (2009) state, "Providing good health care requires adopting approaches that consider, among other things, past or current risk of being subject to violence, post-trauma reactions, social or cultural differences, economic circumstances associated with debts and legal status" (p. 20). Ten guiding principles for ethical and safe interviewing of potential trafficking victims were developed by Zimmerman and Watts (2003) based on their work with trafficked females (Table 5). Patience must be demonstrated, as trafficked persons rarely identify themselves as such. In fact, they may not realize they are being trafficked. Many who are trafficked are taught to fear healthcare providers, law enforcement personnel, teachers, social workers, and others who could assist. Eliciting trafficking information will require trust. Nurses have a unique opportunity to provide victims with information and options, while supporting them through the process of connecting with advocates or service providers, if they are ready to report their situation.
An initial step in offering aid is to call the National Human Trafficking Hotline at 1-888-373-7888. This hotline is staffed 24/7 with advocates educated to assist healthcare personnel. Advocates are aware of confidentiality laws and will not ask for information that would violate HIPAA laws. Whenever possible, the advocates will speak with the patient, but only if the patient gives consent. Translators are available. The advocates will share reporting and available referral options and allow victims to make decisions on how to proceed. In addition, advocates coordinate with law enforcement personnel in urgent cases so that communications are correct and clear.
When you suspect trafficking, use a victim-centered response. View the person as one made in the image of God (Imago Dei) and treat him or her with dignity and respect. Foster honesty, trust, and respect with the suspected victim of any abuse, neglect, or violence. People are more vulnerable to being trafficked if they have been let down in the past, or if they reported something and got into trouble by the abuser. Use open-ended questions and practice reflective listening. Trust can help the trafficked person, or vulnerable person, respond to you or come back later. Incremental disclosure over time is how most cases unfold, so know that offering safety and support may be all that you can do for a victim in this encounter. The goal is to empower the patient, so avoid making decisions for this person (Office on Trafficking in Persons [OTIP], 2017a).
INTERVIEWING SUSPECTED VICTIMS
Beginning the initial interview with nonthreatening questions can help elicit trust, cultivate rapport, and create a safe, inviting physical environment and nonjudgmental space. It is difficult to build trust when an interviewer appears judgmental, presses too hard for disclosure, or fails to promote informed consent. Answers to screening questions are likely to provide a sense of whether the patient may be a possible victim of human trafficking. Suggested screening questions from the U.S. Department of Health and Human Services (DHHS, 2013) are in Table 6. These questions need not be asked in order, and wording should be adapted to meet patient needs.
Ask questions in a private setting. If someone is accompanying the patient, determine a way to separate that person from the patient in a manner that does not raise suspicions, such as the need to review insurance information, complete paperwork, get an x-ray, or accompany the patient to the bathroom for specimen collection. Before separating the patient from the companion, ensure someone is ready to conduct screening, as you may only have a few minutes to speak privately. Notify security as soon as you suspect someone is a victim; engage help as needed. Call law enforcement, if needed.
Trust is promoted when providers clarify their role in supporting the potential victim. Trust will help the patient become open or come back later. For example, saying, "You are not in trouble. What you tell me is confidential, unless I feel that you are in immediate danger. I'm not a police officer." Note nonverbal reactions, such as eye contact, closed posture, or fear of touch. Be careful with your nonverbal facial expressions and maintain an open posture; don't cross your arms.
Be ready to tell potential victims what you can or cannot do to assist. Emphasize that he or she is not guilty or at fault. State that you are worried about his or her safety and ask, "What concerns do you have right now?" Tell the patient, "If you need to leave, you are free to go" (OTIP, 2017a).
Note that if a patient has a phone or other electronic device, someone may be listening. Ask questions like, "Is it safe for you to talk with me right now? Do you feel you are in any kind of danger speaking with me? Is there anything that will help you to feel safer while we talk?" Ask if you can follow up with a phone call later.
When doing a safety check by phone, remind the person that he is free to hang up at any point. Ask if she is in a safe place and can state a location. Or, "Would you prefer to call me back?" Find out if the person is injured or would like you to call 911. If you believe that someone may be listening in, ask questions like, "How can we communicate if we get disconnected? How (or can) I call you back or leave a message? If someone comes on the line, what would you like me to do (hang up, identify myself as someone else, a certain person?" (OTIP, 2017a).
In person, ask patients if you can make a follow-up appointment to check infection, stitches, etc. Ask, "Is there anything I can do for you before you leave?" Tell the patient, "I can provide resources that may help," and offer aid other than contacting authorities. Build confidence by telling a suspected victim who is not ready to seek help, "You will make the right decision. Only you can know what is safe and what is not" (OTIP, 2017a). When you suspect, or assessment data indicate, that a patient may be trafficked, follow the established institutional protocol. If your institution does not have a protocol, resources for designing protocols are readily available (Health, Education, Advocacy, Linkage, n.d.) (Table 7).
A good protocol does not put responsibility on staff to gain disclosure or rescue victims. That is the job of law enforcement personnel and the legal process. Our job is to identify red flags. If we see red flags, get the person in a private space, build rapport, and educate on available resources. Investigate resources so you'll know what victims experience, if they reach out. Empower patients to think through what would help them.
Accurate documentation of interaction with the patient is necessary to provide optimal care. Documentation may be used to provide evidence if the the patient decides to pursue legal options to deal with the trafficking situation. Follow good documentation rules: be objective, accurate, specific, and clear. Use direct quotes of verbal disclosures. Document old injuries. State "suspected human trafficking victim" as a finding or potential problem in the medical record when appropriate (Alpert et al., 2014).
Identifying and responding to victims of human trafficking in healthcare environments is a challenge, as victims often are hidden in plain sight, and their complaints and presenting problems mimic those of other patients. Examine the case study (Sidebar: Is Thomas a Trafficking Victim?) and consider whether you'd suspect trafficking in this situation. Additionally, how might nurses identify trafficking victims in a beauty salon or a restaurant? Although awareness of human trafficking is increasing, there is still much work to be done.
PUBLIC HEALTH RESPONSES
Human trafficking affects more than individuals. Trafficking is a public health issue impacting families and communities. The primary, secondary, and tertiary public health approach to problems explores culturally specific prevention and intervention efforts, engages community stakeholders, and looks for ways to build community capacity. Seeing trafficking as a public health issue helps us examine systemic issues that make people vulnerable (primary), understand trafficking (secondary), and recognize how to help victims after trafficking (tertiary) (OTIP, 2017b).
Primary intervention focuses on prevent on by educating on the risks, as well as protective factors. It is crucial to identify social and economic determinants that lead to trafficking; increase public awareness about labor trafficking in domestic services, construction, and agriculture; and help people understand primary places of sex trafficking recruitment (schools, shopping malls, gangs).
Secondary intervention reduces the duration that victims are trafficked. How do you recognize a victim? What do you do if you suspect trafficking?
Tertiary intervention helps victims after trafficking. How do we prevent retraumatization through trauma-informed care? What services are needed to help with rehabilitation and recovery? What laws are needed, and what policies and procedures will help organizations tackle human trafficking?
In August 2017, the U.S. Administration for Children and Families Office on Trafficking in Persons offered the SOAR to Health and Wellness Program online (OTIP, 2017a). SOAR encourages providers to Stop and increase awareness and understanding of human trafficking. Observe patients and recognize the verbal and nonverbal indicators of trafficking. Ask good questions and interact with potential victims. Respond appropriately when you suspect that trafficking may be occurring. The SOAR webinar is available free online (see Web Resources).
NURSING EDUCATION IN ACTION
In 2011, Sabella challenged nurse educators to incorporate awareness of human trafficking in teaching/activities in nursing programs. One school in the Midwest responded. Students enrolled in the prelicensure baccalaureate nursing program are introduced, via the theory course, to information regarding human trafficking and the role of nurses in identifying and advocating for victims. An accompanying clinical simulation was developed in which the patient is a likely trafficking victim. This was determined to be the best method to provide students with a safe environment in which to practice the application of new concepts and the skills needed to identify a potential victim.
The scenario with the potential victim was integrated into an established clinical simulation day when students are required to participate in multiple simulations. Placed into groups of four, students take turns in the role of the providers or as observers (via streaming video). Prior to participating, all students review a brief patient report. Students in the provider roles enter the exam room to gather a health history and perform a physical assessment. Students in the observer roles critique their peers' performance and document clinically appropriate alternatives.
Faculty members observe student responses/behaviors during the clinical simulation. During debriefing, students connect with the reality of human trafficking through their ability to identify, assess, and potentially advocate for victims. Anecdotally, students voice this simulation increases their awareness of trafficking signs and perceive the simulation as a valuable learning experience.
Nurses can do much to increase their awareness of trafficking and fight to eradicate it. A first step may be to read web-based resources (see Web Resources). Nurses can advocate for antitrafficking education in the workplace, church, and school; and direct people to credible information. Become aware of antitrafficking legislation at the local, state, national, and international levels.
CONCLUSION
The fight against human trafficking requires a concerted effort from many disciplines. Faith communities can support prevention by addressing the root causes of trafficking, such as poverty, culture, gender inequality, and family relationships (National Human Trafficking Hotline, n.d., a). Often, nursing is at the forefront of these efforts of caring for the forgotten and the overlooked. As Christians, nursing is a service to God; the hands of the nurse represent the hands of Jesus. Jesus cared for the sick, the lonely, the outcasts, and the forgotten-a description of human trafficking victims. He would have reached out to the victims and assisted them to restoration. Can we, as Christian nurses, do anything less?
SIDEBAR: Is Thomas a Trafficking Victim?
Thomas, a 26-year-old male, comes to the minor emergency center (MEC) complaining of penile discharge. He reports working as a server at a restaurant and attending the local community college. He has no regular healthcare provider. Thomas makes poor eye contact and offers terse answers to your assessment questions.
While entering data in the medical record, you note Thomas has been to other MECs affiliated with where you work and diagnosed with sexually transmitted infections. The nurse practitioner (NP) performs a history and physical discovering Thomas is sensitive in the anal area and has sores in his mouth.
After the NP completes his assessment, you ask Thomas, "Are you okay? I'm a bit worried about you." Thomas relays to you that he is taking hormones to prepare for sex change surgery. He also asks about getting a prescription for Adderall(R), because he needs help concentrating. When you ask about stressors, he states he is "totally stressed out" about paying back a huge debt. You ask about his sex practices, and Thomas confides that he has multiple sexual partners.
Assessment suggests that Thomas has a chlamydial infection. A toxicology screen reveals the presence of opiates and tetrahydrocannabinol in his blood. At 5'11" tall (180 cm), he weighs 130 lbs (59 kg); his body mass index is 18.1.-JCN
* What are barriers for Thomas, and for you, in identifying him as a potential trafficking victim?
* What red flags do you see?
* What questions would you ask?
* What service providers would you suggest to Thomas?
* How would you encourage Thomas to return to the MEC for further care?
Web Resources
* National Human Trafficking Hotline-http://traffickingresourcecenter.org
* Trafficking in Persons Report-https://www.state.gov/j/tip/rls/tiprpt/2017/index.htm
* Office on Trafficking in Persons-https://www.acf.hhs.gov/otip
* SOAR to Health and Wellness Resources-https://www.acf.hhs.gov/otip/resource-library
* Coalition to Abolish Slavery and Trafficking-http://www.castla.org
* Christian Medical & Dental Association-https://cmda.org/resources/page/human-trafficking-continuing-education-modules
* International Justice Mission-https://www.ijm.org/
* Polaris Project-https://polarisproject.org/
* HEAL Trafficking-https://healtrafficking.org/
* Salvation Army International-http://www.salvationarmy.org/ihq/antitrafficking
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