This course fulfills the requirement for training in human trafficking for nurses and other healthcare professionals in Michigan. If you suspect that any child or adult is a victim, or is at risk of becoming a victim, call 855 444 3911 any time, day or night. If the individual is in imminent danger, immediately call 911.
Human trafficking (human slavery) is not only seen across the world but also in the United States. Healthcare professionals may be the only people to whom victims have access who can help them escape their captors and move from victimhood to survivor. This course presents risk factors for becoming a victim as well as ways to identify the person in a clinical setting. All health agencies must train staff how to proceed when trafficking is suspected. Screening and assessment tools are included.
The following information applies to occupational therapy professionals:
Criteria for Successful Completion
80% or higher on the post test, a completed evaluation form, and payment where required. No partial credit will be awarded.
Objectives: When you finish this course you will be able to:
Human trafficking is a global issue that affects every country around the world and all ages, races, genders, and cultures. Human trafficking is not a new issue. It has been occurring and will continue to occur unless it is spotlighted by increased education and identification of the victims. Human trafficking is often referred to as “modern human slavery” (Gorman & Hatkevich, 2016).
Human Trafficking Health Advisory Board
To combat human trafficking in Michigan, the Human Trafficking Health Advisory Board was created by Public Act 461 of 2014, signed into law by Governor Snyder as part of a package of 20 bills designed to bolster statewide efforts to combat human trafficking. The Board is part of the Department of Health and Human Services and is made up of 9 members, including healthcare providers, mental health professionals, department representatives, human trafficking prevention experts, and survivors of human trafficking.
Human trafficking is about profit. After drug dealing, human trafficking is tied with illegal arms trade as the second largest criminal enterprise in the world (Resendez, 2012) . Because human trafficking has been largely a hidden crime, the public has never been aroused to fight it; a lack of identification with the victims has impeded moves to intervention and to make governmental resources available to them. Healthcare providers, with the proper tools and training, can act as a critical resource in identifying and implementing escape from the victims’ abusers.
Source: DHS, 2017.
The 2016 Global Slavery Index estimates that, including U.S. citizens and immigrants, 57,700 people are victims of human trafficking (Wikipedia, 2017). The actual prevalence of human trafficking is unknown because most victims are too fearful to come forward (Eccleston, 2013).
Human trafficking is a concern of all hospitals in the country. Many states are now requiring nursing staff to have training in identifying possible victims of trafficking. Most important, we must have the proper training to identify when it is safe tocommunicate with the possible victim while keeping both the staff and the victim safe from retaliation. In addition, resources must be identified to the victim in advance then provided once desired.
Top priority is to protect the victim from potentially increased harm. Human traffickers are known to be very manipulative and they don’t hesitate to use violence on their victims. As healthcare providers, our goal is keep the victim safe and if possible, assist victims in escaping their abusers. This must be done with finesse and skill. There are several large hospital organizations across the country that are now dedicating clinics to victims of human trafficking (Stempniak, 2017).
Nearly 21 million people worldwide are trapped in a trafficking situation each year, according to the International Labor Organization. During 2017 the National Human Trafficking Hotline (NHTH) received 470 calls and 136 case reports related to human trafficking in Michigan. Of the 470 cases reported, 80% were related to sex trafficking while approximately12% were for labor trafficking. In addition:
Top venues for sex trafficking included illicit massage/spa businesses, hotel/motel based locations, residence-based commercial sex operations, escort services, and online ads. Top venues for labor trafficking included traveling sales crews, health and beauty businesses, housekeeping/cleaning services, hospitality businesses, and recreational facilities (NHTH, 2017).
Victims can be any age, race, or culture, and found in any country. The abusers prey on the weak and vulnerable. Youth especially at risk for being trafficked as are those from a lower socioeconomic status or privilege. These young people are at greater risk because they are looking for an escape from poverty or an abusive situation. The trafficker is precise and methodical in cultivating a friendship and what appears as a loving environment with the future victim.
Human trafficking has been reported in all 50 states with both U.S. citizens and foreign victims (Stempniak, 2017). Types of human trafficking can vary from community to community.
Source: DHS, 2017.
Human trafficking is not the same as human smuggling. Human smuggling is consensual, whereas trafficking is done against a person’s will (Rothman, 2017). There are three common types of human trafficking: the sex trade, forced labor, and domestic servitude. The economic sectors that profit most from human trafficking are agriculture, restaurants, manufacturing, domestic work, entertainment, hospitality, and the commercial sex industry. Trafficking can occur between countries or in areas within a country (Eccleston, 2013). It can happen to anyone of any gender, race, or age (NHTH, 2017).
Source: DHS, 2017.
Human trafficking will continue as long as there is demand for its victims. Healthcare providers may be one of the only channels through which a victim is identified. Proper staff training can lead to potential identification and intervention. Your ability to assess a victim and knowledge of the resources to assist a victim can turn a very bad situation into a positive outcome. Victims who are in a clinic or emergency department (ED) may rely on you to ask the right questions at the right time. It is possible a healthcare provider is the only other human contact they may experience in months or years, depending on their situation.
With the abuser pretending to act protective and caring, it can be easy for you to overlook a victim if you are not trained in what to look for, or if the abuser does not allow adequate time or conversation with the victim. Healthcare providers must be sensitive and methodical in approaching a victim if they suspect something is “off” about the situation. Having a screening tool, or training on appropriate questions to ask the victim and abuser, can open dialogue and uncover possible victimization.
Sex trafficking is the most prevalent form of human trafficking in the United States (Gorman & Hatkevich, 2016). Sex trafficking is a high profit and low risk business where the commodity—the human being’s body—can be sold repeatedly (Roe-Sepowitz et al., 2013). Unfortunately, sex trafficking is a problem in the United States because there is a high demand for child pornography and prostitution (Clause & Lawler, 2013). Commercial sexual exploitation includes prostitution, pornography, live sex shows, stripping, personal sexual servitude, escort services, mail order brides, military prostitution, and sex tourism (Gorman & Harkevich, 2016). Children and teenagers are at risk for any of these.
Recruitment of victims in the United States comes from shopping malls, junior high and high schools, foster homes, group homes, courthouses, restaurants and bars, bus stations, concerts, parks, libraries, and social networking websites (Gorman & Harkevich, 2016). Parents should be aware that one of the most common ways that traffickers access children is now through the use of social media sites like Facebook (Clause & Lawler, 2013).
Once the victims are found, they may be transported to where the trafficker has a high demand or they may stay close to the area where they were targeted. The use of internet advertising has taken the sex industry to a global operation (Clause & Lawler, 2013).
The Trafficking Victims Protection Act (TVPA) defines the crime of sex trafficking as the “recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act where such an act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age” (Roe-Sepowitz et al., 2013). Many people would not be able to recognize a sex slave even if living in the same community (Clause & Lawler, 2013). For this reason, proper training of healthcare workers is essential in reducing this crime.
Victims of sex trafficking will be “groomed” in stages by the abuser (see below). Traffickers look for victims who are vulnerable by using acts of kindness to groom them into submission (Clause & Lawler, 2013).
Source: Long, 2014.
There are two ways an abuser will pimp* a victim of sex trafficking. Finesse pimping uses kindness and psychological games to attract young vulnerable victims. Guerilla pimping involves the use of violence and intimidation to force the victim into submission. Finesse pimping is used more with children and guerilla pimping is used more against adults (Clause & Lawler, 2013).
*Pimping: the commodification of people, often against their will, for the purpose of sexual exploitation.
Vulnerable youth can be easily targeted by the abuser with the use of promises, psychological manipulation, provision of drugs and alcohol, or violence. The abuser will first try to establish a trusting environment by wooing the victim with what seems like a loving and caring relationship. Pimps will invest a lot of time and effort into forming a bond with their victim by initially buying gifts, showing affection, or providing a place to stay (Roe-Sepowitz et al., 2013).
With sex trafficking, the general public usually does not realize that the victims working the streets do not keep any of the money they receive for sex. All money, including tips, must be given to their pimp. Victims of sex trafficking may be forced to perform multiple sex acts with 10 to 20 customers every day (Hodge, 2014). Drugs play a large role in sex trafficking. Drugs are often used as a way for the victim to cope with the trauma; alternately, some victims enter this lifestyle to support a drug habit (Roe-Sepowitz et al., 2013).
Under Michigan law, any child who has been recruited, enticed, harbored, transported, provided, or obtained for commercial sexual activity, a sexually explicit performance, or the production of pornography, is a victim of sex trafficking. Although traffickers often use force, threats, violence, false promises, manipulation, lies, and other physical or psychological methods to control their victims, a child need only be sexually exploited to be considered a victim of sex trafficking in Michigan (HHS, 2017a).
There are times when traffickers of children take advantage of the parents’ extreme poverty. Parents may sell children to traffickers in order to pay off debts or gain income, or they may be deceived into thinking this will be a better life for their children (Wikipedia, 2017). Sadly, research has shown that 91% of domestic sex trafficking victims experienced some sort of abuse in their home (Gorman & Hatkevich, 2016). The internet and social media have made recruiting easier (Roe-Sepowitz et al., 2013). The average age at which a girl first becomes exploited into prostitution is 12 to 14 years, and boys make up almost half of the victim population (Roe-Sepowitz et al., 2013).
The MDHHS’ Human Trafficking of Children Protocol
(available from http://www.michigan.gov/documents/dhs/HumanTraffickingProtocol_440356_7.pdf)
was developed in consultation with state and local law enforcement, juvenile justice, healthcare providers, education agencies, and organizations with experience in dealing with at-risk youth. The protocol was developed to guide professionals in identifying and assisting children who are victims of human trafficking. The protocol focuses on the needs of victims, with the overriding intention of protecting the interests of children and maintaining their safety in the community.
All caseworkers and applicable contracted service providers must review the MDHHS Human Trafficking of Children Protocol and be aware of the signs/behaviors that indicate that a child may be a human trafficking victim.
Source: HHS, 2017a.
Because children are easier to exploit, Michigan law now offers them greater protections, effectively shielding them from prosecution for acts they committed while in the care of their traffickers. In January 2015, several changes in the law went into effect that impact how law enforcement, the court and the Michigan Department of Health and Human Services (MDHHS) respond to child trafficking cases. Perhaps most important, any child who is sexually exploited for commercial purposes is now recognized as a victim of human trafficking, regardless of his or her ability to prove the existence of force, fraud, or coercion. By creating a presumption of coercion in sex trafficking cases involving children, Michigan law shields these children from prosecution for committing commercial sex acts (HHS, 2017b).
Forced labor is another type of human trafficking. In the United States, the Trafficking Victims Protection Act of 2000 (TVPA) defines labor trafficking 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” (NHTRC, 2016). Peonage is the act of paying off debt through work (DHS, 2017a). Debt bondage is where the victim is forced in bonded labor to work to pay off a debt, loan, or other obligation (Eccleston, 2013).
Children as Victims of Labor Trafficking
Under Michigan law, any child who has been recruited, enticed, harbored, transported, provided or obtained for forced labor is a victim of labor trafficking. Labor trafficking can include, but is not limited to, domestic servitude, forced labor in restaurants or salons, forced agricultural labor or debt bondage. Michigan law includes a provision that allows the identification of child victims of labor trafficking, regardless of the presence of force, fraud or coercion, keeping these children in line with sex trafficking victims (HHS, 2017a).
Areas most prone to forced labor include domestic work, agriculture, construction, manufacturing, and hospitality (Eccleston, 2013). Forced labor is often difficult to detect. Forced labor in the private economy generates $150 billion in illegal profits per year, with migrant workers and indigenous people being particularly vulnerable (ILO, 2017). Illegal immigrants can become confined to forced labor if the abuser confiscates their passport or identification documents and uses the threat of their exposure as an illegal to the authorities (Eccleston, 2013).
Traffickers target those with low literacy and education levels and those living at or below the poverty line (Gorman & Hatkevich, 2016). Nearly 21 million people are victims of forced labor, with 11.4 million women and girls and 9.5 million men and boys (ILO, 2017). Women and children are highly trafficked in labor arenas because of their relative lack of power, social marginalization, and overall status as compared to men (OTIP, 2017).
Those at highest risk of any form of human trafficking are the vulnerable populations. As noted earlier, human trafficking is more common in people of low socioeconomic status or with children who experience abuse at home. While these are the most common, human trafficking does not discriminate. Red flags in spotting trafficking victims should be taught to all staff from the receptionist to the attending physicians to all ancillary departments. Everyone must be taught the signs of a potential victim the same way facilities train staff members to spot child and elder abuse.
Abuse can be emotional, physical, or sexual, and it can arise from emotional neglect, physical neglect, and family violence. All are prevalent among trafficked youths. Sexual abuse is the strongest predictor of human trafficking for both boys and girls. Those who have experienced sexual abuse in the home may be looking for a way to escape to a better life, only to find themselves manipulated into a trafficking situation.
Lack of caregiver protection from abuse in the home increases the likelihood of a child’s seeking protection from someone outside the home. Exposure to family violence is also an increased risk of human trafficking. Abusers will cultivate relationships with these young children or teens and they soon become victims. Trafficking of boys more commonly relies on emotional and sexual abuse (Reid et al., 2017).
According to the Department of Justice (2016), youth at risk for human trafficking include:
American Indian/Alaska Native Children
American Indian/Alaska Native children are subject to the Indian Child Welfare Act16 (ICWA) and Michigan Indian Family Preservation Act17 (MIFPA), which establish jurisdiction for state or tribal courts in child welfare matters. Native American Affairs policy and case management resources for the State of Michigan may be found on the Native American Affairs website at http://www.michigan.gov/americanindians. These resources address notice under ICWA and MIFPA, which is required for all American Indian/Alaska Native child custody proceedings in order to assist these families with culturally appropriate services and placement.
Source: HHS, 2017a.
Traffickers will specifically target runaway or “throwaway” teens who are having trouble at home. They are seen as easy targets because they are looking for shelter and may not be old enough to legally get a job. It is common for these teens to trade sex to meet basic survival needs of food, shelter, and clothes (Roe-Sepowitz et al, 2013).
Act 62 of 2016 (Human Trafficking Notification Act)
Act 62 requires the posting of certain notices relating to human trafficking. Notices required under Act 62 shall be posted in a conspicuous manner clearly visible to the public and employees within each facility open to use by the public and operated by an entity that is required to post human trafficking notices under Act 62.
Posters may be downloaded free of charge at the Wage and Hour Division website at www.michigan.gov/wagehour or by calling the Wage and Hour Division and asking that the posters be mailed to you.
Act 62 applies to the following entities:
Source: Department of Licensing and Regulatory Affairs (LARA), 2018.
For welfare children, the California Child Welfare Council found that 50% to 80% of victims of commercial sexual exploitation are or were formerly involved with the child welfare system (OTIP, 2017). Teens and children from the lesbian, gay, bisexual, or transgender community are at risk because of psychosocial vulnerabilities that have resulted from social alienation or maltreatment experiences (Gorman & Hatkevich, 2016). LGBT youth are disproportionately runaway and homeless and can be up to 5 times more likely than their heterosexual peers to be victims of human trafficking (OTIP, 2017).
The population at risk for labor trafficking often come from unstable and economically devastated places. Traffickers frequently identify vulnerable populations characterized by oppression, high rates of illiteracy, little social mobility, and few economic opportunities (OTIP, 2017).
Source: DHS, 2017.
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:
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.
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).
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:
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.
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.
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 NYTRC will be covered in more depth in Module 6.
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.
The U.S. Department of Homeland Security offers a website resource under its Blue Campaign to work toward ending human trafficking (DHS, 2017). 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.
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 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, 2017.
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.
* * *
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, 2017.
Nurses play an important role in keeping children safe from traffickers. Traffickers often identify themselves as a loving family member, boyfriend, or employer who is just trying to help, and their victims may be fearful of police or authority figures, which makes it difficult to intervene. Victims may be using drugs as a coping mechanism and worried they will be charged as a criminal for drug usage or possession. They may also be worried that their families will be put at risk by their abuser if they try to escape (Eccleston, 2013).
Many victims develop traumatic bonding, or “Stockholm syndrome,” which is a cognitive distortion wherein positive feelings develop between captors and their hostages. This bond is a survival mechanism and helps the victim cope with captivity (OTIP, 2017). Identification of victims is made more difficult by the fact that there is no single profile that identifies a trafficker.
Misidentification is an ongoing barrier to protecting these victims. The control exerted over children is rarely visible as the young victims appear to be independent. Even child sex trafficking victims who are controlled by violence and fear may appear to be acting on their own (Shared Hope International, 2017).
Traffickers and pimps may be identified by healthcare workers by the following behaviors: traffickers may be jealous, controlling, and violent; significantly older than female companions; promising things too good to be true; and encouraging victims to engage in illegal activities to achieve their dreams. They will buy expensive gifts or own expensive items and act vague about their source of income. The pimp will be pushy or demanding about sex and encourage inappropriate sexual behavior from the victim. Traffickers are usually open about financial matters but make victims feel responsible for their own financial stability (Shared Hope International, 2017).
These are all behaviors clinicians can recognize if the abuser is with the victim during a medical visit. It is crucial to understand that these behaviors indicate the level of control traffickers exert over victims (Department of Homeland Security, 2017).
Traffickers elude detection. The hidden nature of human trafficking requires law enforcement to be innovative and adaptive with investigative techniques. A person convicted of sex trafficking a minor faces serious federal penalties that include a mandatory minimum sentence of 10 years’ imprisonment. Law officers might decide to charge juvenile victims with delinquency in order to keep the child safe; however, this detention does not offer specialized services for the children and may not be safe. Many times, children return to the abuser when released because of the unique bonding that occurs between victims and their traffickers (Office On Trafficking in Persons, 2017).
Even though demand is the root cause of the commercial exploitation ofchildren, law enforcement frequently overlooks buyers in the crime of child sex trafficking (Shared Hope International, 2017). Keeping victims isolated is a tactic abusers use to keep them from getting help. Abusers will restrict activities and watch, escort, or guard the victims. When victims do come into contact with medical professionals or others, traffickers may give them scripted answers or a cover story (OTIP, 2017).
Sex Trafficking Case: Molly
National Human Trafficking Resource Center, 2017)
Molly comes to a clinic for an HIV screening. Her intake paperwork says she is 19 but the nurse mentions that she seems far younger. Molly explains to the nurse she is “mature for my age” and “very experienced.” She has a tattoo of the name Li’l G on one arm. During the exam she constantly receives texts on her cell phone. She answers a phone call and says “Daddy, don’t worry, I’ll be done soon.”
Molly tells the nurse that it was her boyfriend, who is worried about her. The nurse continues to believe that Molly is younger than she says due to her immature physical development and the discrepancy between her reported age and education level.
Why do you think a patient would lie about her age?
Her trafficker, presenting as her boyfriend, may have given her a scripted story to protect him from liability. Many victims try to protect themselves due to fear of their trafficker and lie to avoid triggering mandatory reporting to the state. According to the NHTRC:
State child welfare agencies are required to report instances of sex trafficking to law enforcement and provide information regarding sex trafficking victims or at-risk youth to the U.S. Department of Health and Human Services, who will in turn report these numbers to Congress. (NHTRC, 2017)
Studies estimate that between 30% and 88% of trafficked persons seek medical services at some point during their capture (Schwarz et al., 2016). When you suspect a patient may be the victim of trafficking, having staff properly trained with an assessment tool has the potential to rescue multiple lives.
Numerous universities and community organizations have developed and begun implementing human trafficking assessment tools for their facilities. Because small community hospitals don’t have the same needs or resources as large urban ones, each assessment tool needs to be customized for the organization and its local resources, breaking it down and reconstructing it to fit the needs of the community.
Organizations need to focus on a victim-centered approach. Safety and proper support can help transform the victim into a survivor. When you identify a potential victim you may be overwhelmed with emotion, but proper training will help you to remain professional and stay focused. The first task is to keep everyone safe. If the abuser is present, take care to avoid a confrontation that could turn violent or, at the very least, result in the abuser taking the patient away.
Simply asking patients if they are trafficking victims is fruitless, especially if the abuser is present. Further, many victims do not think of themselves as victims. During the process of grooming, victims are led to believe they are making a good choice for themselves—but as time passes, they come to believe there is no way out (Egyud & Whiteman, 2016). Traffickers are usually very “protective” of their victims because they allow the abuser to live lavishly; traffickers can earn $150,000 to $200,000 per year with only 4 to 6 victims in captivity.
Training staff on signs of trafficking is imperative to the support and survival of the victims. There are a number of ways victims can be trafficked and staff should be aware of them. A trafficker may use one or more of the following to control victims:
If your agency has a possible trafficking victim and is unsure what to do, the hotline of the National Human Trafficking Resource Center (800 373 7888) can be called to help conduct an assessment. The hotline can be called anonymously if staff are nervous about identifying themselves.
In 2016 there were 7,572 cases of trafficking reported in the United States: 73% as sex trafficking, 14% as labor trafficking, and 3.5% reported as both. The NHTRC provides an assessment tool on its website to assist potential victims of trafficking.
The box below presents the guideline from the NHTRC website that can be adjusted to fit the needs and resources for your organization.
Human Trafficking Assessment Tool for Domestic Violence Programs
Discuss involving law enforcement or calling NHTRC, then notify. Be vigilant of immediate environment: who is watching, listening, calling, etc. You can ask the hotline to assist in assessing level of danger.
Sex Trafficking may include persons who are:
Labor Trafficking may include persons who (are):
If no perceived danger:
Consider asking the potential victim the following questions:
If perceived danger:
The Hotline can assist in determining the next steps. You may need to involve law enforcement for victim safety. Hotline can assist in determining appropriate, sensitive law enforcement contacts.
National Human Trafficking Resource Center Hotline:
888 373 7888
(24/7) and access to 170 languages
Ask for assistance with assessment questions, resources, and next steps.
Indicate which questions you used from the previously mentioned steps.
Hotline can help determine appropriate next assessment of potential danger
Consider asking the potential victim the following questions:
The NHTRC is a first step to assist agencies in identifying and supporting possible victims. The resource center will also help facilities determine and build protocols to respond to trafficking victims.
Another valuable resource is the U.S. Department of Health and Human Services (DHHS). The DHHS lists multiple resources, including legal rights information, on their website.Their motto is “Rescue and Restore.” The DHHS has built a task force and training services to inform the public about identifying victims and how to contact organizations that provide help. Clinicians or the general public can email email@example.com or call 844 648 8822 to speak with a specialist. Services are free and delivered as needed.
Because human trafficking is a global issue it is difficult to say exactly how and why people are trafficked. Countries trade people in different ways; for example, in Africa or India a family member (usually a young woman) may be traded through family contacts for as little as £300, while in Vietnam and Afghanistan Mafia-type organizations sell and trade human victims (Adams, 2012).
Local hospitals and communities may be able to partner with charity organizations. Depending on the area, some charities offer resources for trafficking victims. Clinicians can contact their local charities to establish a relationship and provide assistance to one another if a trafficking victim is identified in the area.
Once victims are identified, it is necessary to interview them, but it is important that you care for the person’s basic needs first (food, clothing, shelter, safety). Interviewing the victim about a trafficking experience is a very sensitive and stressful process. We must develop trusting relationships with patients in a safe environment for them to feel safe enough to talk openly.
Without cooperation from the victim, prosecution of the trafficker is nearly impossible. Up to 95% of victims experience some form of sexual or physical abuse (Olguin, 2015). Because of the abuse, they may not be able to open up to medical staff or law enforcement during the first interview. You must be careful not to re-traumatize victims by asking questions that stress them. This applies especially when dealing with children; for example, virginity demands a higher price, so children are at higher risk (Adams, 2012). With any victims under 18 years of age, Child Protective Services must be informed.
The Trafficking Victim Identification Tool (TVIT) provides a guideline and interview questions that have been proven to identify victims of human trafficking. These questions should be asked by a trained healthcare professional and in a secure environment.
The manual, Screening for Human Trafficking: Guidelines for Administering the Trafficking Victim Identification Tool (TVIT), is based on research conducted by the Vera Institute of Justice and was found to be highly reliable in predicting both sex and labor trafficking victims. The screening tool offers both long and short versions, with the short 16-question version as reliable as the long version.
The tool should be used to guide the interview process with potential victims. Effectiveness of the tool will be based on the rapport built between the victim and the clinician and the willingness of the victim to answer honestly and freely. Consent must always be obtained from the patient prior to calling the hotline or beginning the interview process. We need to be honest with the patient about the purpose of the screening and describe the victim’s rights, the interview process, and the roles of everyone involved (TVIT, 2014).
Traffickers often use the fear of immigration officials to control their victims. Many victims may be afraid to reveal immigration status to law enforcement because they do not know enough about the protections regarding trafficking. If law enforcement is present during the interview, they need to keep tactical gear, weapons, and badges hidden and convey a caring attitude (TVIT, 2014).
The interviewer can use phrases such as “We are here to help you,” or “Your safety is our priority,” and “You have the right to live without being abused” (TVIT, 2014). These words can help put the victim at ease during the interview process. The discussion and questioning about immigration must be handled carefully so as to not frighten the victim or worry them about legal consequences.
The interviewer should always ask the victim about their country of birth to determine if the migration section of the screening tool will be needed. The screening tool offers the language for the screener to use for foreign-born victims:
Now I am going to ask you some questions about your country of origin. I am not asking you this to find out about your immigration status. I am only trying to understand what your circumstances are so that we can refer you for the right help, if necessary. The questions ask about your emigration to the United States, who was involved, and how it was arranged. (TVIT, 2017)
For children, it can be stated:
We would like you to tell us about what happened to you when you traveled to the United States. (TVIT, 2014)
For best results, the screening tool should not be used until there is trust between the victim and the interviewer; also, it is best to keep the number of people to a minimum when working with these patients to avoid overwhelming them.
During the interview process it is important to take the time to get the full story. Pay attention to the words the victim uses throughout the conversation. The TVIT inquiries about “work or other activities” performed during the capture. This is to solicit information about sexual services and other types of informal work (TVIT, 2014). Victims may not think of rape, forced prostitution, forced shoplifting, or forced drug smuggling as “work” (TVIT, 2014). Screeners should use the same terminology as the victim.
Note: Currently there is no validation tool that has been established for persons with disabilities or LGBTQ victims (TVIT, 2014).
Since every trafficking case is unique, there is no single way to use the screening tool. Victims may have come from anywhere in the world. Many victims may be trafficked to certain areas for specific events. For example, the Super Bowl is the single biggest occasion for human trafficking (Olguin, 2015).
Identification, protection, and safety are the top priorities when working with potential victims. Overall findings during the interview will determine how the facility and law enforcement can proceed. There is not a defined yes or no answer to the assessment tool, but a comprehensive result as to whether the victim has been trafficked based on the victim’s answers and the training and experience of the screening professional.
The TVIT screening tool is best utilized by trained social workers or other healthcare workers who have received adequate training. Human trafficking is everyone’s issue. The more resources we can provide for victims the more we can assist in their safety and—hopefully—prosecute their captures.
The TVIT, both long and short versions, is available online from Vera Institute of Justice (Vera, 2014). The document includes a Post Interview Assessment that is to be filled out by the interviewer. You can find this tool by clicking here.
Human trafficking does occur in the United States. It is a global problem that does not discriminate against any age, gender, or race. The United States is the second largest sex trafficking market in the world (Lake, 2017). Healthcare providers are important figures in this battle as advocates for victims.
Training for all healthcare workers on signs of trafficking is imperative to change these victims into survivors with a chance for recovery. The fight doesn’t end when they are removed from their abuser. Support will need to continue as they begin the healing process. Healthcare providers at all levels can make a positive impact as they help in the recovery process and re-acclimate the survivors to a new and healthy life.
Setbacks are common as many suffer from post traumatic stress issues, anxiety, and depression. Physical or mental scars must be dealt with once they are free from their captures. Support and encouragement from healthcare professionals may be all the assistance a victim has. Even when no physical abuse is evident, mental abuse can be hidden and even more damaging. Survivors likely will have to deal with the memories and trauma for the remainder of their life.
A public health approach to target anti-trafficking efforts can help to reduce the risk of the most vulnerable populations (OTIP, 2017). Local organizations should work collaboratively to provide the best possible resources for the victims of human trafficking.
Collaboration and training of all healthcare workers is only the beginning. A great deal of work must continue to support survivors. This work is not easy. To expose trafficking victims without a plan to address their complex situations can endanger them (Rothman et al., 2017). We must do our best to turn victims into survivors, directing them to the resources designed to give them back their life and freedom.
Source: DHS, 2017.
Adams P. (2012). Identifying victims of human trafficking. Practice Nursing 23(9):463–64.
Baldwin SB, Fehrenbacher AE, Eisenman DP. (2015). Psychological coercion in human trafficking: An application of Biderman’s framework. Qualitative Health Research 25(9):1171–81.
Clause KJ, Lawler KB. (2013). The hidden crime: Human trafficking. Pennsylvania Nurse 18–23.
Department of Health and Human Services (DHHS). (2017. SOAR image. Retrieved August 2017 from https://www.acf.hhs.gov/otip/training/soar-to-health-and-wellness-training.
Department of Homeland Security (DHS). (2017). Blue Campaign trafficking images. Retrieved August 7, 2017 from https://www.dhs.gov/blue-campaign/infographic.
Department of Homeland Security (DHS). (2017a). Human Trafficking. Retrieved from https://www.dhs.gov/topic/human-trafficking.
Department of Justice (DOJ). (2016). Fact Sheet on Recent Justice Department Efforts to Combat Human Trafficking. Retrieved from https://www.justice.gov/archives/file/904856/download.
Department of Licensing and Regulatory Affairs. (LARA). (2018). What is Act 62 of 2016? Retrieved January 8, 2018 from http://www.michigan.gov/lara/0,4601,7-154-59886_76917-386912--,00.html.
Eccleston D. (2013). Identifying victims of human trafficking. Community Practitioner 40(2).
Egyud A, Whiteman K. (2016). Failure to rescue: Improving healthcare provider recognition of human trafficking. Pennsylvania Nurse 16–19.
Gorman KW, Hatkevich BA. (2016). The issue is: Role of occupational therapy in combating human trafficking. American Journal of Occupational Therapy 70, 7006360010. Retrieved July 2017 from http://dx.doi.org/10.5014/ajot.2016.016782.
Health and Human Services, State of Michigan. (2017a). Human Trafficking of Children. Overview. Retrieved January 8, 2018 from https://dhhs.michigan.gov/OLMWEB/EX/SR/Public/SRM/300.pdf#pagemode=bookmarks.
Health and Human Services, State of Michigan. (2017b). Human Trafficking of Children Protocol. Retrieved January 8, 2018 from http://www.michigan.gov/documents/dhs/HumanTraffickingProtocol_440356_7.pdf.
Hodge DR. (2014). Assisting victims of human trafficking: Strategies to facilitate identification, exit from trafficking, and the restoration of wellness. Social Work 59(2):111–18.
Human Trafficking Assessment Tool for Domestic Violence Programs. (2017). Retrieved August 2017 from https://humantraffickinghotline.org/resources/human-trafficking-assessment-tool-domestic-violence-programs.
International Labour Organization (ILO). (2017). Forced labour, modern slavery and human trafficking. Facts and Figures. Retrieved from http://www.ilo.org/global/topics/forced-labour/lang--en/index.htm.
Lake K. (2017). Human trafficking: Hidden in plain sight. Michigan Nurse 1.
Long M. (2014, September 24). Image. Basic Stages of Grooming for Sexual Exploitation. End Slavery Now. U.S. National Tip Hotline: 888 373 7888. Retrieved August 4, 2017 from http://www.endslaverynow.org/blog?type=4966.
National Human Trafficking Hotline (NHTH). (2017). Michigan. Retrieved January 8, 2018 from https://humantraffickinghotline.org/state/michigan.
National Human Trafficking Resource Center (NHTRC). (2016). Human Trafficking. Retrieved from https://humantraffickinghotline.org/audience/service-providers.
National Institute of Justice (NIJ). (2016). A Screening Tool for Identifying Trafficking Victims, September 20, 2016. Retrieved July 2017 from http://nij.gov/topics/crime/human-trafficking/Pages/screening-tool-for-identifying-human-trafficking-vicitms.aspx.
Office on Trafficking in Persons (OTIP). (2017). Facts sheet: Labor trafficking. Retrieved from https://www.acf.hhs.gov/otip/resource/fact-sheet-labor-trafficking-english.
Olguin S. (2015). What Nevada is doing. Nevada RNformation 13.
Reid JA, Baglivio MT, Piquero AR, et al. (2017). Human trafficking of minors and childhood adversity in Florida. American Journal of Public Health Research 107(2):306–11.
Resendez R, Ethridge P. (2012). Human Trafficking and Smuggling: Myths, Facts and Perils. UTPA International Days, November 15, 2012.
Roe-Sepowitz D, Hickle K, Bayless A, et al. (2013). Sex trafficking for nurses: What you need to know. Arizona State Board of Nursing Regulatory Journal 10(2):22–25.
Rothman EF, et al. (2017). Public Health Research Priorities to Address U.S. Human Tracking. AJPH 107(7). doi: 10.2105/AJPH.2017.303858. Retrieved August 9, 2017 from http://academicworks.cuny.edu/cgi/viewcontent.cgi?article=1463&context=cc_pubs.
Schwarz C, Unruh E, Cronin K, et al. (2016). Human trafficking identification and service provision in the medical and social service sectors. Health and Human Rights Journal 18(1):181–89.
Shared Hope International. (2017). Policy Research and Resources. Retrieved July 2017 from http://sharedhope.org/wp-content/uploads/2017/04/FrameworkBriefs.pdf.
Stempniak M. (2017). How hospitals can fight human trafficking. Hospitals and Health Networks 16.
Trout, K. (2010). The role of nurses in identifying and helping victims. Pennsylvania Nurse 18–20.
Vera Institute of Justice. (2014). Screening for Human Trafficking: Guidelines for Administering the Trafficking Victim Identification Tool (TVIT). Retrieved August 2017 from https://www.ncjrs.gov/pdffiles1/nij/grants/246713.pdf.
Weitzer, R. (2014). New directions in research on human trafficking. American Academy of Political and Social Science 653:6–21.
Wikipedia. (2017). Human Trafficking in the United States. Retrieved July 2017 from https://en.wikipedia.org/wiki/Human_trafficking_in_the_United_States.