It cannot be said too often that effective training for all healthcare personnel is necessary for the protection and identification of human trafficking victims. Without proper training for all healthcare providers, many victims will fall through the cracks as they are seen in by medical professionals. Victims are reluctant to seek help because they have been taught by the abuser that if they attempt to escape or find help, no one will believe them or they will be treated like a criminal or prostitute (Roe-Sepowitz et al., 2013).
There are many similarities seen between domestic partner violence and sex trafficking. Victims may feel shame, self-blame and feelings of unworthiness. Or they may not see themselves as a victim at all (Roe-Sepowitz et al., 2013). It is important for us to realize that effective communication is imperative when screening patients in identifying possible victims. Because they are fearful, we must try to cultivate trust and a feeling of safety if they are to open up about their situation.
Because medical professionals are on the front lines for these victims, proper training is the most important thing we can do to prepare for these patients. There is nothing more valuable to the rescue of our trafficking victims than prompt screening. Being able to screen them in private, when safe and away from their abuser or “family member,” is the priority. Safety of the staff, facility, and victim is essential before intervention can begin.
The Department of Justice suggests basic warning signs that we must be trained to identify:
- A youth that has been verified to be under 18 and is in any way involved in the commercial sex industry, or has a record of prior arrest for prostitution or related charges
- Having an explicitly sexual online profile
- Excessive frequenting of internet chat rooms or classified sites
- Depicting elements of sexual exploitation in drawing, poetry, or other modes of creative expression
- Frequent of multiple sexually transmitted diseases or pregnancies
- Lying about or not being aware of their true age
- Having no knowledge of personal data, such as but not limited to: age, name, and/or date of birth
- Having no identification
- Wearing sexually provocative clothing
- Wearing new clothes of any style, getting hair and/or nails done with no financial means
- Having secrecy about whereabouts
- Having late nights or unusual hours
- Having a tattoo that he or she is reluctant to explain
- Being in a controlling or dominating relationship
- Not having control of own finances
- Exhibiting hyper-vigilance or paranoid behaviors
- Expressing interest in, or in relationships with, much older men or women (DOJ, 2016)
The most common healthcare areas that attract trafficking victims are EDs, urgent care or primary care clinics, obstetrician/gynecologist clinics, school nurses offices, community health centers, mobile clinics, planned parenthood clinics, and dental clinics (Roe-Sepowitz et al., 2013). When encountering a potential victim, it is important for clinicians to remember that victims may not be comfortable coming forward.
Healthcare providers must be trained in identifying possible trafficking victims by knowledge of key questions to ask during patient visits. Multiple characteristics can be assessed when clinicians screen to determine if intervention for a potential victim is necessary and safe. Practitioners must be careful in assessment and identification not to lead the victim into future harm.
It is important for any organization to become a resource for human trafficking victims when staff are trained to recognize that it is possible for victims to be right in front them without their knowledge. If you believe you have identified a trafficking victim, but any intervention may place the victim or facility at risk of the abuser, you may need to step back to avoid violence.
Facilities need to ensure that they have appropriate resources to make assistance available to the victims. Ideally, they will assist in their rehabilitation back into society after the traumatic experiences that may have occurred.
Most victims are in need of immediate medical care. They may present to a clinic for the first time when giving birth, or with a child who is in need of medical care (Eccleston, 2013). Nursing staff must be trained with the screening tools and interventions beginning with increased knowledge about asking the right questions to avoid further exploitation and abuse (Roe-Sepowitz et al., 2013).
The best question to ask a possible victim would be “What has happened to you?” Not “What’s wrong with you” or “Why are you doing this?” (Roe-Sepowitz et al., 2013). Open-ended questions encourage discussion and allow the victim to disclose as much information they are comfortable sharing. Victims need to feel safe with you before they will begin to open up about their situation and their needs.
Signs of Abuse
In a medical clinic you may be confronted with multiple signs of abuse. These include but are not limited to evidence of sexual trauma, fractures, cigarette burns, bruises or contusions, tattoos on the body that may serve as a “brand” of their trafficker, respiratory infections, dental issues, drug-related issues (hepatitis, skin infections), malnutrition, dehydration, unexplained scars, injuries to head and mouth, temporal mandibular joint problems from oral sex, bite marks, stab or gunshot wounds, hearing loss from head trauma, bald patches from having hair pulled, tension headaches, traumatic brain injury, bladder damage, other injury or infection (Roe-Sepowitz et al., 2013).
Other Behavioral Characteristics
When assessing a patient in a medical setting, look for other behavioral characteristics such an inconsistent past medical history; patient making no eye contact; an unwillingness to share answers; resistance to gynecologic exams; being accompanied by an individual who does not let the patient speak; whether the patient is unable to provide an address or is unaware of location or date/time. Victims can often act fearful and nervous, especially if the abuser is present (Roe-Sepowitz et al., 2013).
Psychological effects of torture include helplessness, shame and humiliation, shock, denial and disbelief, disorientation and confusion, phobias, and panic attacks (OTIP, 2017).
Victims of labor trafficking can present with chronic back and visual or respiratory problems from working in agriculture, construction, or manufacturing under dangerous conditions (OTIP, 2017).
Screening questions for healthcare staff to ask, ideally in private, without the abuser present:
- Are you free to come and go as you please?
- Have you or your family been threatened if you try to leave?
- Have you been physically harmed in any way?
- What are your working and living conditions like?
- Where do you eat and sleep?
- Do you sleep in a bed, on a cot, or on the floor?
- Have you ever been deprived of food, water, sleep, or medical care?
- Do you have to ask permission to eat, sleep, or go to the bathroom?
- Are there locks on your doors and windows so you cannot get out?
- Has your identification or documentation been taking from you?
- Is anyone forcing you to do anything that you do not want to do? (Resendez, 2012)
It has been found that questions asked about migration, work, and living conditions are good predictors of trafficking after taking demographics into account (NHTH, 2017). Practitioners who are culturally competent may have an easier time building a trusting environment with victims who do not speak English or are unfamiliar with American customs (Hodge, 2014). It is best to utilize a professional hospital translator during the assessment when there is a language barrier. If the abuser is present, the value of questions is doubtful.
Victims are often terrified, fearing to open up to healthcare providers because they have suffered from terrible physical and psychological abuse (Eccleston, 2013). Victims are also reluctant to open up to healthcare providers because of the stigma, fear of corrupt law enforcement, and fear of retaliation from their abuser (Gorman & Hatkevich, 2016).
When patients find they trust you enough to speak about their situation and risk possible consequences from their abuser, the process of exiting trafficking can begin (Hodge, 2014). They are moving from “victims” to “survivors.” Once a survivor is comfortable with you and in a safe environment, you can begin asking questions. The World Health Organization (WHO) has a guideline for interviewing potential trafficking victims.
First, and most important, do no harm. Assess the risk associated with each case before beginning the interview. This is for the safety of the patient as well as yourself and the staff. Next prepare referral information in the survivor’s language about appropriate legal, health, shelter, and security services. Select interpreters, if needed, and enlist coworkers who have the proper training in screening methods.
Protect patient identity and confidentiality at all times during the interview process. Ensure that patients understand how the interview information will be used and that they have given informed consent. Provide a non-judgmental environment and listen and respect the patient’s concerns.
Avoid asking questions that might provoke an emotional response or re-traumatize the survivor. Always have an emergency plan if survivors say they are in imminent danger. Finally, use the information in a way that will benefit the patient and help develop policies and procedures in the future to assist and identify other trafficking victims (Clause & Lawler, 2013).
(National Human Trafficking Resource Center, 2016)
Maribel, a young woman, comes to the ED with severe abdominal pain. A man identifies himself as her father-in-law and offers to translate for her. He explains she has had stomach problems recently, but she has not been to a doctor because she doesn’t have insurance. The patient does not make eye contact with staff or her father-in-law.
A nurse explains to the father-in-law that she needs to examine each patient privately, and the father-in-law says something harsh to the patient, speaking in Spanish. A professional hospital interpreter is present and the patient informs the nurse she helps clean her father-in-law’s house and provides child care for various family members. While she loves the children, she states she is very stressed because she works over 12 hours every day. Her father-in-law monitors all of her phone calls and conversations.
A physician diagnoses the patient with a stomach ulcer and gives her a prescription. Maya is visibly troubled. She tells the nurse she has been to another ED and given the same diagnosis. She stopped taking the medicine because she did not have enough money saved to pay for it and she cannot go to a pharmacy unless her father-in-law drives her there.
What questions could be asked to determine if this is a human trafficking situation? Consider the following.
- Maya, stress can make stomach ulcers worse and you seem to work a lot of hours. Do you have days off or get out of the house to do something for yourself? Why, or why not?
- Do you get adequate breaks during the day, eat all your meals or get enough sleep every day when you are working for your family?
- If you wanted to stop working for your father-in-law to get a different job, would you be able to leave?
- Is there someone else who can help you with your healthcare when needed?
- Your father-in-law seemed to speak harshly to you earlier. Does he speak to you like that often? Has he ever harmed or threatened to harm you?
Questions should be as neutral as possible and never accusatory. The goal is to establish trust with the patient and to assist them as they wish. It is also important that healthcare providers let potential trafficking victims know of any mandatory reporting obligations before questioning the individual (NHTRC, 2016). Reporting obligations vary from state to state.
Survivors need a great deal of support, beginning with the most basic needs, once they are able to escape their captive. Nurses are one of the few professional groups that interact with victims while they are still under control of their abuser (Roe-Sepowitz et al., 2013). Resources that are available depend on the degree to which the facility’s approach is proactive in appropriate interventions and proper staff training. If an organization has not trained the staff or identified the necessary resources to assist with trafficking victims, it greatly limits the possibility for assisting them safely.
National Human Trafficking Resource Center
The National Human Trafficking Resource Center (NHTRC) offers a database of service providers who deal with human trafficking throughout the United States. They help healthcare agencies to connect with existing resources in their area as they begin developing a response protocol for victims of human trafficking. The NHTRC has a referral network for anti-trafficking organizations, legal service providers, shelters, law enforcement, and local social service agencies to assist victims of human trafficking. Facilities can also turn to the NHTRC for extensive training on a variety of topics related to trafficking.
In addition, the NHTRC offers confidential 24-hour access to anyone wanting to report tips, seek services, or just ask for help. Access is provided in more than 200 languages through a tele-interpreting service. All communications with the NHTRC are strictly confidential to the extent permitted by law.
The NHTRC offers guidelines for clinical assessment of a potential victim. These include allowing patients to decide if they feel more comfortable with a male or female and, if the patient requires interpretation, always utilizing professional interpreters who are unrelated to the patient or situation. They suggest that you find a time and place, and take the time, to speak with the patient privately if they are accompanied by others; it is important to build rapport with potential victims and ensure that the patient understands confidentiality policies and practices, including mandatory reporting laws.
Lack of training can mean that many victims are overlooked who pass through various medical facilities; those who are identified may suffer further simply because of a lack of resources. More facilities are working to teach who to contact when identifying a possible victim. Resources available to victims may be limited based on state, area, or community in which they are being identified.
The NHTRC will be covered in more depth in Module 6.
Hospitals and Other Healthcare Agencies
Many healthcare organizations are also beginning to collaborate with outside resources to assist in recovery and healing for human trafficking survivors. Hospital organizations can form partnerships with resources in their area such as police departments, schools, shelters, and clinics (Stempniak, 2017). Each facility that begins to build local resources can play a positive and reliable role in facilitating a new life for the survivors.
Once the survivors are rescued from the abuse of their trafficker, they will need not only services to meet basic physical needs but also to meet any mental health problems that have developed due to the trauma that occurred during their trafficking. Resources will need to assist in finding housing, food, and clothing, in addressing medical and legal issues, and support to avoid turning back to the abusers (Clause & Lawler, 2013).
Hospital social workers and case managers can initiate identifying the patients’ physical, emotional, and spiritual needs, but there will be a need for ongoing assessment and support. It is mandatory under both state and federal law to report the sexual exploitation of children (Roe-Sepowitz et al., 2013). You must contact the local police as well as Child Protective Services. Child protective workers, therapists, victim advocates, school counselors, and juvenile justice professionals can be early points of contact as they can conduct assessments for maltreated youth (Reid et al., 2017).
Hospitals should have trained their staff to speak with possible victims as well as designated trauma interviewers. Many facilities are still at the beginning stages of training this specialized resource; however, a sexual assault nurse examiner (SANE) will provide adequate support. SANE trained professionals are taught to look for red flags for sexual violence, domestic violence, and human trafficking (Schwarz et al., 2016).
Physical needs and medical attention are the first concerns. However, the (Hodge, 2014). Survivors often suffer from depression, anxiety, insomnia, alienation, substance abuse, post traumatic stress disorder, hostility, suicidal thoughts, or self-harm (Hodge, 2014). Mental health challenges may continue to occur throughout the healing process; some of these wounds may never completely heal.
Once the basic physical needs are met and mental health treatment has been begun, victims will also benefit from family counseling and life and job skill training, which can be offered by counselors, psychologists, and social workers. Another valuable resource beginning to be recognized in assisting trafficking survivors available in hospital facilities is occupational therapy (OT). These practitioners offer therapy to assist the survivor in performance skills and patterns to promote wellness and improved quality of life (Gorman & Hatkevich, 2016).
Encouraging survivors to engage in meaningful occupations offers a distraction from negative thoughts and emotions and promotes feelings of confidence and control. Depending on the length of time survivors were trafficked, they may not have experienced feelings of control or confidence in many years (Gorman & Hatkevich, 2016).
Refer to existing institutional protocols for victims of abuse. Many anti-trafficking resources can be utilized by telephone or online and contact information can be posted in facilities to assist in finding appropriate resources or to report a tip.
USDHS Blue Campaign
To report suspected human trafficking:
866 347 2423
To get help from the National Human Trafficking Hotline:
888 373 7888
The U.S. Department of Homeland Security offers a website resource under its Blue Campaign to work toward ending human trafficking (DHS, 2022). The website recognizes the key indicators of victims of human trafficking as the first step in identifying victims. This site contains lots of general information for the public as well as tips and resources for contacting law enforcement and assistance if there is a suspected victim of human trafficking. Many of the graphics in this course are taken from the Blue Campaign website.
The U.S. Department of Health and Human Services offers training to clinicians through the SOAR to Health and Wellness Program:
S = Stop
O = Observe
A = Ask
R = Respond to human trafficking
Source: DHHS, 2022.
This program uses a public health approach by building communities that can identify and respond to the complex needs of victims and survivors of human trafficking. The program understand the root causes that make individuals, families, and communities vulnerable to trafficking and educates healthcare providers and the public.
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While many websites, organizations and resources are available that provide basic knowledge for the public on reporting human trafficking and identifying possible victims, there is still a great deal of work to be done in the healthcare sector. Assessment and screening tools have been developed but there is still little evidence-based research to support a specific tool.
Human trafficking cannot be solved with one approach. Intervention and screening tools vary based on location and available resources in the area as well as training and knowledge community staff have received. Human trafficking is complex and victims undergo various—and perhaps multiple—forms of trauma. Every case is different and every victim requires different resources and support.
Clinicians need to support each other, collaborating with multidisciplinary teams to build a screening and intervention tool for staff to give the victim best opportunity for escape. Human trafficking not only deprives victims of their right to freedom but is also a huge global health problem (Clause & Lawler, 2013). This is not a one-size-fits-all answer. Nurses and healthcare providers must work together for each individual to turn a victim into a survivor.
Source: DHS, 2022.