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Course Library

Human Trafficking

2.5 Contact Hours
This peer reviewed course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Athletic Trainer (AT/AL), Certified Nursing Assistant (CNA), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Nursing Assistant (LNA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN), Respiratory Therapist (RT)
This course will be updated or discontinued on or before Friday, October 13, 2023
BOC
FPTA Approval: CE21-665734. Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors.
Meets Human Trafficking requirements for Florida and Michigan
Outcomes

≥92% of participants will know how to identify and appropriately report victims of human trafficking.

Objectives

After completing this continuing education course, the participant will be able to meet the following objectives:

  1. Differentiate between the types of human trafficking.
  2. Recognize possible factors that place a person at greater risk of being trafficked.
  3. Describe possible profiles of traffickers and their means of victim recruitment.
  4. Identify a victim of human trafficking in a healthcare setting.
  5. Explain the importance of providing Trauma-Informed Care (TIC) to all suspected trafficking victims.
  6. Appropriately report victims of human trafficking.
  7. Describe the steps involved in referring victims of human trafficking to additional support services immediately and into the future.
  8. Interpret the numerous long-term health implications that are often suffered by victims of human trafficking.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Alyssa King (Nurse Planner, DNP, APRN, CPNP-PC, CLC)

Definition

Human Trafficking is modern-day slavery. It is the business of making a profit by stealing other's freedom (Polaris Project, 2021).

The United States Department of Justice Trafficking Victims Protection Act (TVPA) of 2000 defines trafficking in persons as:

  • Sex trafficking in which a commercial sex 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; or
  • The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through force, fraud, or coercion for subjection to involuntary servitude, peonage, debt bondage, or slavery
  • Trafficking does not require crossing international or state borders

Types of Human Trafficking

Victims of human trafficking can be of any age, race, gender, or nationality. It happens to Americans and immigrants. The different types of human trafficking are (Polaris Project, 2021):

  1. Sex Trafficking: Utilizing force, fraud, or coercion to make another individual sell sex. Common examples include escort services, street solicitation, pornography, or illicit massage parlors.
  2. Labor Trafficking: Utilizing force, fraud, or coercion to require another individual to work or provide services. Common examples include domestic labor, cleaning services, restaurant help, and agricultural work.

Victims of trafficking are found in both legitimate and illegitimate labor industries. These areas are typically underpaid and under-regulated industries. Forced labor in foreign countries is used to produce the products American's buy (Stoklosa, 2017).

Victims are trapped through combinations of extreme psychological manipulation and shaming, financial bondage, rape, or physical abuse. Many are bound to their traffickers by addiction to heroin or opioids (Stoklosa, 2017).

Human Trafficking vs. Consensual Commercial Sex

The difference between human trafficking and the existence of consensual commercial sex is the very word "consensual." Human trafficking occurs when a trafficker is using the means of force, fraud, or coercion for the very purpose of compelling the victim to provide the desired commercial sex acts (National Human Trafficking Hotline, n.d.). The presence of the means of force, fraud, or coercion indicates that the victim's consent was not given (National Human Trafficking Hotline, n.d.). In the event that the victim is less than the age of 18, all individuals, regardless of the use of force, fraud, or coercion, are considered victims of human trafficking (National Human Trafficking Hotline, n.d.).

Human Trafficking vs. Human Smuggling

These two things are often confused. However, they are very different. Human trafficking involves exploiting men, women, and children for forced labor or sex against the victim's will (U.S. Immigration and Customs Enforcement [ICE], 2017). Human smuggling, however, involves a provided service of typically transportation or fake documentation to an individual who knowingly and consentingly seeks to obtain illegal entry into a foreign country (ICE, 2017).

Statistics

Because of the clandestine nature of human trafficking, most data are only estimations. The Polaris Project published its 2019 Data Report in 2020. This report includes the statistics of victims and survivors identified by the U.S. National Human Trafficking Hotline. The most current statistics are as follows, in 2019 (Polaris Project, 2020):

  • 22,326 victims and survivors were identified:
    • 14,597 involved in sex trafficking only
    • 4,934 involved in labor trafficking only
    • 1,048 involved in both sex and labor trafficking
    • 1,747 not specified
  • 4,384 traffickers were identified
  • 1,912 suspicious businesses were identified

According to the International Labor Organization (ILO) and Walk Free Foundation's September 2017 report, an estimated 24.9 million individuals are trapped in modern-day slavery. Of these:

  • 16 million (64%) exploited for labor
    • 7.5 million (47%) work in construction, manufacturing, mining, or hospitality
    • 3.8 million (24%) are domestic workers
    • 1.7 million (11%) work in agriculture
  • 4.8 million (19%) sexually-exploited
  • 4.1 million (17%) exploited in state-imposed forced labor
  • 71% of trafficking victims around the world are women and girls, and 29% are men and boys
  • 15.4 million victims (75%) are aged 18 or older, 25% are children

Sex trafficking among lesbian/gay/bisexual/transgender/queer (LGBTQ) youth is unfortunately quite prevalent (Polaris Project, 2019). Without enough community and family support, youth who identify as LGBTQ are particularly at risk (Polaris Project, 2019). As of 2019, up to 40% of homeless youth are members of the LGBTQ community (Polaris Project, 2019). Of these individuals, 46% ran away because of their family rejecting them. In addition, these individuals are 7.4 times more likely to experience acts of sexual violence than compared heterosexual individuals of the same age group (Polaris Project, 2019).

Scope of the Problem

Every year, thousands of innocent individuals are subjected to forced sex or labor work in all areas of the world. As an outright violation of basic human rights, human trafficking results in the breakdown of the individual, families, and the community, the fueling of organized, victimized crime, and challenges public health (Raker, 2020). It results in a major negative impact on the quality of life, autonomy, and overall independence of its' victims (Tracy & Macias-Konstantopoulos, 2021).

The victims of human trafficking suffer severe, life-long physical and psychological consequences of being at the mercy of their captors. While under control, these individuals often experience extreme stress levels, deprivation of food, water, and sleep, sexual assault, and hazardous environments (Raker, 2020).

Due to the violence and neglect that is frequently endured, victims often seek medical care at many healthcare settings, including urgent care, primary care, the school nurse, dental clinics, and emergency room settings (Raker, 2020). In fact, 99% of sex trafficking victims have suffered from at least one physical health problem requiring an evaluation from a medical professional while in the custody of the entity trafficking them (Raker, 2020). Therefore, it is of the greatest importance that all healthcare personnel are adequately trained to identify and care for victims. It is essential that all individuals must be educated thoroughly on the risk factors, health implications, and reporting criteria to both be able to recognize and advocate for this special, vulnerable population.

Legal/Economic Implications

Prosecutions of Human Traffickers are historically low. The Federal Human Trafficking Report (2020) cited that, since 2013, the overall conviction rate in human trafficking cases ranged from 91-96%. However, the 2020 conviction rate dropped to 89% of cases (Feehs & Currier Wheeler, 2020). It is believed that the COVID-19 pandemic has negatively impacted the conviction rate due to court closures and proceeding delays (Feehs & Currier Wheeler, 2020).

The Trafficking Victims Protection Act (TVPA) (2000) creates a comprehensive federal law to address human trafficking. A three-pronged approach is used in addressing trafficking:

  1. Protections through immigration relief for foreign national victims of human trafficking.
  2. Prevention through public awareness programs.
  3. Prosecution through new federal criminal statutes.

The Federal Bureau of Investigation (FBI) has statutory authority to investigate matters of forced labor, trafficking with respect to peonage, slavery, involuntary servitude, or forced labor and forced sex trafficking (Federal Bureau of Investigation [FBI], 2021).

TVPA gives law enforcement the ability to protect international victims of human trafficking through several forms of immigration relief, including Continued Presence and the T visa (FBI, 2021). TVPA also established a law requiring defendants of human trafficking investigations to pay restitution to the victims (FBI, 2021).

Continued Presence allows law enforcement officers to request temporary legal status in the U.S. for an immigrant whose presence is necessary for the success of an investigation (FBI, 2021). The T visa allows foreign victims of human trafficking to become temporary U.S. residents (FBI, 2021). The victims may become eligible for permanent residency after three years.

Because of the profits in human trafficking, the economic and political impact of the unabated crime is huge. Immigration policies and human rights are major global political concerns.

Risk Factors

Being aware of the most common risk factors of human trafficking enhances one's ability to identify potential victims in the clinical setting. Each patient encounter must be made with a heightened awareness of these warning signs.

The top risk factors for both sex and labor trafficking include (Polaris Project, 2020):

  1. Recent migration/relocation
  2. Substance-use concern
  3. Runaway homeless youth
  4. Unstable housing
  5. Mental health concern

It is also important to note that although trafficking victims consist of people of all ages and sexes, the most common victims are women and children (Raker, 2020). Additional risk factors of note are poverty, a history of abuse, disability, lack of formal education, social exclusion (rural location, LGBTQ+ individuals), and limited support systems (Raker, 2020).

Profile of the Perpetrators

Traffickers can be a single person or an entire network/company of individuals. A human trafficker is anyone who knowingly is involved with the victimization and exploitation of an individual forced to work or participate in sexual acts against their will (Zigelman, 2020). These individuals include (Zigelman, 2020):

  • Recruiters: Promising friendship, relationship, marriage, higher education, profitable employment
  • Transporters: Hired help to take victims from one location to the next
  • Document providers: Professionals at forging government documents; might assign new names to victims
  • Corrupt officials: Law enforcement or governmental officers who are participating in trafficking
  • Employers: The true exploiters who enslave individuals, subject them to inadequate living conditions, require sexual favor, or garner/take all pay that victims under them have made

Traffickers exploit other people for the profit gained from forcing them to participate in labor or commercial sex (National Human Trafficking Hotline, n.d.). These individuals lure and trap people into these situations by hunting, manipulating, and exploiting their vulnerabilities (National Human Trafficking Hotline, n.d.). They utilize calculated methods to prey on individuals searching for a better life, who need money/jobs, have unstable home lives, or lack an adequate support system (National Human Trafficking Hotline, n.d.). Victims are promised high-paying jobs, an opportunity to move to a new country, a loving relationship, or other exciting opportunities that the victim feels they cannot get elsewhere. They then utilize physical and psychological violence to control them (National Human Trafficking Hotline, n.d.).

Based on cases that the National Human Trafficking Resource Center has identified, examples of traffickers include (National Human Trafficking Hotline, n.d.):

  • Fake massage business owners
  • Domestic services employers
  • Gangs
  • Criminal network members
  • Intimate partners/family members
  • Brokers of labor work
  • Factory owners
  • Pimps
  • Small business owners/operators

Perpetrators often share the same national or cultural background as their victims (Florida State University [FSU], n.d.). Interestingly enough, a recent study found that those who trafficked minors for sex (FSU, n.d.):

  • The average age of the trafficker was 28.5 years of age
  • Traffickers were 24.4% women
  • 45.1% of the traffickers knew their victims

Common Sex Trafficking Sites include (FSU, n.d.):

  • Hotels/motels
  • Massages businesses
  • Truck stops
  • Residential brothels

How Do Traffickers Appear and How Do They Recruit

Social media has existed as a major recruitment source as long as the internet has been around (Polaris Project, n.d.). Common sites include Facebook, Instagram, Snapchat, Kik, Meetme.com, WhatsApp, and plenty of dating sites such as Tinder and Grindr (Polaris Project, n.d.). Social media sites are portals that allow the building of an intimate relationship from afar or advertise fake job opportunities (Polaris Project, n.d.).

Traffickers have a variety of profiles and recruit their victims with a variety of recruitment tactics. Recruitment tactics that are most common and cited by Florida State University (FSU) include (FSU, n.d.):

  • The "Boyfriend" Tactic: Sweet-talks the individual, promises love, gives gifts (this perpetrator often appears innocent and loving and then, similar to that of domestic violence, becomes intermittently violent and then vehemently apologizes, creating a cycle of abuse).
  • The "Helping" Tactic: Assists the individual in the running away, gives them a place to stay, provides drugs.
  • The "Gang" Tactic: As a member of a gang or as a loved one of a member of a gang, the individual is pressured into prostitution or sexual acts.
  • The "Isolation" Tactic: Isolates the individual from their support group, controls the use of their phone or their whereabouts, controls their social media presence.
  • The "Abduction" Tactic: Victim is abducted and held against their will.
  • The "Bait and Switch" Tactic: The victim is provided a loan, and then they are forced into various acts to pay off that debt.
  • The "Preying" Tactic: The victim has intellectual disabilities and is, therefore, unaware they are being exploited.
  • The "Grooming" Tactic: The victim is a child exposed to pornography, has sex with the perpetrator, has explicit photos taken of themselves.

How Are Traffickers Able to Control Their Victims

Perpetrators of human trafficking utilize many tactics to maintain control over their victims. Examples of types of controlling tactics used by traffickers provided in the National Prevention Toolkit by FSU include (FSU, n.d):

  • Shame/blackmail: Threatening to hurt them or family; threatening to post pornographic photos of them
  • Obligation: Grooming loyalty because the trafficker "saved" them or are their only friend/family
  • Involving Victim in Crime: Forcing the victim to steal or deal drugs and then claiming to out them for their part in it
  • Pregnancy/Child: Impregnating or not allowing a victim to see their child unless they do what they are told
  • Financial Control: Trafficker in charge of all money and possessions
  • Violence/Intimidation: Physical harm/abuse

Identifying a Victim of Human Trafficking in a Healthcare Setting

As mentioned above, human trafficking victims often present to emergency departments and women's health or family planning clinics. Healthcare providers have an opportunity to identify victims of human trafficking (Tracy & Macias-Konstantopoulos, 2021).

Victims of human trafficking are hard to identify. Victims rarely self-report because of fear of the trafficker, distrust of authorities, feelings of shame and hopelessness, trauma bonds (i.e., Stockholm Syndrome), and threats (Tracy & Macias-Konstantopoulos, 2021). Victims may not seek healthcare unless they have no other options (Tracy & Macias-Konstantopoulos, 2021). Healthcare providers must recognize that their role is not disclosure or rescue; but to create a safe, non-judgmental place that will help identify trafficking indicators and assist the patient (Tracy & Macias-Konstantopoulos, 2021).

If human trafficking is suspected or confirmed, assess acute healthcare needs and perform a complete physical to identify common medical conditions in trafficked persons. Sex-trafficked and sexually abused labor-trafficked victims should be offered a forensic medical evaluation. Pregnancy testing and emergency contraception should be offered (Tracy & Macias-Konstantopoulos, 2021).

Patient Interview

The first, arguably most important, step in assessing a suspected victim of human trafficking is to create a safe environment. It is vital that the patient feel as comfortable and secure as possible. Individuals who might be victims will be more likely to share information and seek future healthcare if they feel that they are not being judged (Raker, 2020). Make the best effort to ensure the conversation is private and be willing to spend the time to build rapport and garner trust with the suspected victim.

Take time to answer the victim's questions and acknowledge and address their fears (Tracy & Macias-Konstantopoulos, 2021). It is important to be sensitive to cultural differences, gender differences, and language barriers and use an interpreter when needed (U.S. Department of Homeland Security, 2021).

It is also quite common that the individual has a person accompanying them for a visit, which shows signs of a dominating personality. Although not always possible, it is important to attempt to get the patient alone for the interview. It often helps to take the patient off for "some additional testing" where the other individual is not allowed to be present.

Other helpful strategies for interviewing the possible victim alone include (Health, Education, Advocacy, Linkage [HEAL] Trafficking, 2018):

  • Have the accompanying person wait in another place
  • Have pre-prepared reasons to give the accompanying individual for a reason for the need for separation:
    • A diagnostic test in a small area
    • It is a clinic or hospital policy that the interview is conducted alone
    • They are needed to fill out important paperwork at a different location or make a phone call for another necessary appointment
  • What to do if the accompanying person refuses to leave the patient:
    • Weigh the options if this is necessary to continue to push this issue. This decision includes:
      • Presence of aggression of the accompanying individual
      • The current health and safety of the possible victim
      • A desire to not raise any suspicion

It is best to interview the possible victim alone. Still, if the patient refuses or if the accompanying individual refuses the separation, it might be a safer plan to allow them to remain together (HEAL Trafficking, 2018). If the accompanying individual feels threatened, it may risk the opportunity to provide medical services to this patient or increase the chances that potential harm will fall to the victim after they leave (HEAL Trafficking, 2018).

Communicating with these individuals will often be challenging as many will choose not to share what they are going through or seek any assistance as they are often fearful of authority figures or possible retribution (Raker, 2020). Therefore, communication must be clear, direct, therapeutic, and non-threatening to encourage an authentic patient response (Raker, 2020).

For example, appropriate screening questions that can be asked include (Raker, 2020):

  • Can you come and go from your home as you would like to?
  • Have you ever felt pressured to do something you did not want to?
  • Do you feel you get enough food to eat?
  • Does anyone where you live make you feel unsafe?
  • Are you able to keep all of the money you earn?
  • Does someone else keep your identification?
  • What does this tattoo mean?
  • Why did you leave your country?

During this patient interaction and as these questions are asked, it is important to notice subtle signs. These signs can include the responses to the questions being asked appearing to be scripted, a hesitancy to answer the questions, and a demonstration of nervous behavior (no eye contact, increased heart and respiratory rate, uncomfortable body language) (Raker, 2020). Each separate sign, if present alone, might not indicate a trafficking situation.

Assessment Tools and Indicators for Identifying a Human Trafficking Victim

Blue Campaign's Indicators of Human Trafficking

Indicators of a victim of human trafficking vary by type of trafficking. Many of these indicators require information that a healthcare provider may not have. Making a referral to social services provides a mechanism to obtain information that would verify indicators.

The U.S. Department of Homeland Security developed the Blue Campaign to provide resources to fight human trafficking. Included in their most recent published brochure (2020) are the following questions that have been adapted for clarity to ask yourself to identify common signs of human trafficking:

Behavior or Physical State:

  • Does the victim act fearful, anxious, depressed, submissive, tense, or nervous/paranoid?
  • Does the victim defer to another person to speak for them?
  • Does the victim show signs of physical or sexual abuse, physical restraint, confinement, or torture?
  • Has the victim been harmed or deprived of food, water, sleep, medical care, or other life necessities?
  • Does the victim have few or no personal possessions?

Social Behavior of the Victim:

  • Can the victim freely contact friends or family?
  • Is the victim allowed to socialize or attend religious services?
  • Does the victim have freedom of movement?
  • Has the victim or family been threatened with harm if the victim attempts to escape?

Social Behavior of the Trafficker:

  • Does it seem that someone else is restricting the victim from contacting friends/family?
  • Does it seem that someone else is limiting the victim's use of social media or stalking/monitoring their accounts?
  • Is someone else preventing the victim from attending religious services or socializing in general?
  • Is someone else not allowing the children to go to school and forcing them to work instead?
  • Are they being held with a large group of people in a place with poor conditions?
  • Does the accompanying person seem to watch this potential victim constantly?
  • Is someone else threatening the potential victim/victim's family with harm if they do not work?
  • Is someone else posting harmful content online specifically about this individual that might be pushing them to engage in sexual acts?

Work Conditions and Immigration Status:

  • Does the possible victim experience repetitive verbal/physical abuse at the hands of their boss/supervisor?
  • Are they prevented from taking work breaks?
  • Are they made to work in unsafe conditions?
  • Are they forced to meet daily quotas?
  • Does the victim work excessively long or unusual hours?
  • Is the victim a juvenile engaged in commercial sex?
  • Was the victim recruited for one purpose and forced to engage in some other job?
  • Does the potential victim appear to be living in the same place they work?
  • Is the victim's salary being garnished to pay off a smuggling fee? (Paying off a smuggling fee alone is not considered trafficking.)
  • Is their employer creating a never-ending balance of debt?
  • Is their employer escorting the possible victim to their bank or using their account?
  • Has the victim been forced to perform sexual acts?
  • Has the victim been threatened with deportation or law enforcement action?
  • Is the victim in possession of identification and travel documents; if not, who controls the documents?

Minor Victims:

  • Is the victim a juvenile (under the age of 18) engaged in commercial sex?

National Human Trafficking Resource Center (NHTRC) Red Flags and Indicators (2016)

General Indicators of Human Trafficking:

  1. Shares a scripted or inconsistent history
  2. Is unwilling or hesitant to answer questions about the injury or illness
  3. Is accompanied by an individual who does not let the patient speak for themselves, refuses to let the patient have privacy, or who interprets for them
  4. Evidence of controlling or dominating relationships (excessive concerns about pleasing a family member, romantic partner, or employer)
  5. Demonstrates fearful or nervous behavior or avoids eye contact
  6. Is resistant to assistance or demonstrates hostile behavior
  7. Is unable to provide their address
  8. Is not aware of their location, the current date, or time
  9. Does not have their identification documents
  10. Is not in control of their own money
  11. Is not being paid or wages are withheld
Labor Trafficking IndicatorsSex Trafficking Indicators
  • Has been abused at work or threatened with harm by an employer or supervisor
  • Is not allowed to take adequate breaks, food, or water while at work
  • Is not provided with adequate personal protective equipment for hazardous work
  • Was recruited for different work than they are currently doing
  • Is required to live in housing provided by the employer
  • Has a debt to employer or recruiter that they cannot pay off
  • Patient is under the age of 18 and is involved in the commercial sex industry
  • Has tattoos or other forms of branding, such as tattoos that say, "Daddy," "Property of…," "For sale," etc.
  • Reports an unusually high number of sexual partners
  • Does not have appropriate clothing -for the weather or venue
  • Uses language common in the commercial sex industry

Healthcare providers should screen patients for potential trafficking when red flags and indicators are identified in the presentation, history, or physical examination (NHTRC, 2016).

Response to Victims

Once a victim is identified, the primary goal is to remove them from the danger (Raker, 2020). Most victims experience intense fear of their traffickers and of being deported. Therefore, it is important to reassure the victim that they are safe, so they can begin the process of getting protection and assistance to rebuild their lives (Tracy & Macias-Konstantopoulos, 2021; U.S. Department of Homeland Security, 2021).

Gaining the trust of trafficking victims is important. Sample therapeutic massages to help gain trust include (Tracy & Macias-Konstantopoulos, 2021; U.S. Department of Homeland Security, 2021):

  • "We are here to help you."
  • "Our priority is your safety."
  • "We will give you the medical care that you need."
  • "We can find you a safe place to stay."
  • "You have a right to live without being abused."
  • "You deserve the chance to become self-sufficient and independent."
  • "We can help get you what you need."
  • "We can help to protect your family."
  • "You can trust me."
  • "We want to make sure what happened to you doesn't happen to anyone else."
  • "You have rights."
  • "You are entitled to assistance."
  • "We can help you get assistance."
  • "If you are a victim of trafficking, you can receive help to rebuild your life safely in this country."

The healthcare professional can now focus on the immediate medical needs of this patient and the rest of the medical team. After these needs are met, multidisciplinary services can be solicited to begin prompt referral for additional assistance.

Steps Taken After Identification of Victims

Each situation of human trafficking is unique and requires a victim-centered response (NHTRC, 2016). First, the victim must be medically stabilized. Priority is given to any signs of trauma, neglect, dehydration, injuries, and unmanaged medical conditions (Gordon et al., 2018). A comprehensive physical work-up including diagnostics (blood work or imaging studies) that correlate with history and physical assessment (Gordon et al., 2018). After the patient is medically stabilized, the psychiatry team needs to evaluate the patient for any possible presence of potentially dangerous thoughts or behaviors directed to oneself or others (Gordon et al., 2018). Additional concerns include signs of intoxication, signs that could indicate potential withdrawal from substances, and the need for admission to an inpatient psychiatric unit for more acute psychiatric assessment and stabilization (Gordon et al., 2018).

After the patients' initial needs are met, additional referrals need to be initiated. A procedure or protocol specific to the needs and safety of human trafficking victims should be in place at each facility. It should include a multidisciplinary approach employing law enforcement, social work, nursing, and hospital administration (NHTRC, 2016; Tracy & Macias-Konstantopoulos, 2021; Raker, 2020). The plan should identify potential sources of legal assistance, transportation, vocational training, employment, childcare, and housing and should focus on the importance of being a trusted local network of survivor resources (NHTRC, 2016; Tracy & Macias-Konstantopoulos, 2021; Raker, 2020).

Social work can connect victims to community resources for food and housing, mental health specialists can facilitate any required behavioral therapy, and law enforcement can be contacted for safety concerns and to complete a further investigation (Tracy & Macias-Konstantopoulos, 2021; Raker, 2020).

It is important, too, to remind victims that they are not criminals. These victims are protected under the Trafficking Victims Protection Act (TVPA) (U.S. Congress, 2000). Victims can apply for special visas or receive other forms of immigration relief (Raker, 2020). If the victim is under 18, it is mandatory to report sexual exploitation under both state and federal law (U.S. Department of Homeland Security, 2021).

Traffickers can be involved in organized crime, local gangs, or other crime networks; therefore, staff and patient safety are top priorities. Safety measures include (Tracy & Macias-Konstantopoulos, 2021):

  • Establish a relationship with the local police force
  • Obtain a security audit
  • Develop an emergency notification system
  • Periodically have emergency drills or review plans
  • Restrict after-hours access
  • Install lighting
  • Security cameras
  • Panic buzzers
  • Deadbolts or electronic locks
  • Preprogram emergency access phone numbers

Confidentiality is critical. Trafficked individuals and their families can be at risk for trying to report or escape the situation (Tracy & Macias-Konstantopoulos, 2021).

If a patient discloses that they have been trafficked (NHTRC, 2016):

  • Provide the patient with the National Human Trafficking Resource Center (NHTRC) hotline number and encourage them to call the NHTRC hotline (1-888-373-7888) or the text number BeFree (233733). The NHTRC has a tele-interpreting service with at least 200 languages available.
  • Do not provide written information if there is a chance that the trafficker will see the documents.
  • If there is an immediate, life-threatening danger, follow your institutional policies for reporting to law enforcement.
  • Provide the patient with options for services, reporting, and resources. Ensure that safety planning is included in the discharge planning process.
  • Accurately document information regarding the patient's injuries or treatment. Written documentation of abuse presented in an unbiased manner may help prove a case against a trafficker; however, information about the victim can also be used against them in court (Tracy & Macias-Konstantopoulos, 2021).

If the patient does not want to leave the trafficking situation, patients should be educated about available resources. Do not give out physical materials unless the patient agrees that the information will not place the patient at risk for retaliation from the trafficker (Tracy & Macias-Konstantopoulos, 2021; NHTRC, 2016). Healthcare providers can discuss specific safety plans, including the development of a safe contact system.

Recovery for trafficked persons is long and complex. Victims being repatriated and returned to live with their families is inappropriate and results in returning to a situation where they suffer further harm (Tracy & Macias-Konstantopoulos, 2021; NHTRC, 2016).

Referral Options for Legal and Social Services

Legal and social services resources are provided locally. Healthcare facilities need a list of resources that can be called or shared based on the patient's needs.

As referenced above, the National Human Trafficking Resource Center (NHTRC) is an excellent resource for healthcare facilities to help identify and connect with existing local resources.

  • Call: 1-888-373-7888. (24/7). NHTRC has a Service Referrals Network of over 3,200 referral contacts to assist victims of human trafficking, is available, including (NHTRC, 2016):
    • Anti-trafficking organizations
    • Legal service providers
    • Shelters
    • Law enforcement
    • Local social service agencies

Many of the services available for victims are time-limited. Such services include domestic violence shelters and runaway and homeless youth programs, where on-site counseling services are offered. These resources generally provide for short stays that do not allow adequate time to establish trusting relationships needed for a victim to open up and begin to address their trauma (Tracy & Macias-Konstantopoulos, 2021; NHTRC, 2016).

Resources for Reporting Human Trafficking and Seeking Help for the Victim

Every situation of human trafficking is unique; it is important to use a victim-centered response. Not all victims of trafficking will be comfortable disclosing their situation, nor will all victims be ready to seek assistance from service providers, law enforcement, or even medical providers (NHTRC, 2016).

Healthcare providers may or may not be required to report human trafficking. Legal requirements differ from state to state. Refer to your local or state requirements regarding mandatory reporting (NHTRC, 2016).

For example, Michigan has specific reporting requirements for human trafficking (Michigan Department of Health & Human Services [MDHHS], 2017; MDHHS, 2021):

  • Healthcare professionals are required to report if you suspect that any child or adult is a victim or is at risk of becoming a victim by calling 855-444-3911 at any time.
  • If the individual is in imminent danger, immediately call 9-1-1.
  • Law enforcement must be contacted immediately through the state's centralized intake system, Children's Protective Services (CPSP) MDHHS, if a child is found to be engaged in any commercial sexual activity.
  • MDHHS begins investigating the complaint as soon as possible but within 24 hours. The CPS investigation must include a determination as to whether the child is in danger of substantial physical or psychological harm and requires protective intervention, including the initiation of child protective or dependency proceedings.

Michigan Law's definition of Child Labor Trafficking is (MDHHS, 2017):

A 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. Labor trafficking victims must prove that force, fraud, or coercion existed while they were in the care of their trafficker, regardless of whether the victims are children or adults.

In child sex trafficking, proof of force, fraud, or coercion is not required (MDHHS, 2017).

You must have patient consent before disclosing any personal information about adult victims of human trafficking. HIPAA regulations apply. If the patient is a minor, follow mandatory state reporting laws and institutional policies for child abuse or serving unaccompanied youth (NHTRC, 2016).

National Human Trafficking Resource Center (NHTRC) provides help for you to determine if you have encountered a victim of human trafficking, identifies local resources available in your community, and helps you coordinate with local social service organizations. All communications with the NHTRC are strictly confidential to the extent permitted by law, and personal information does not have to be disclosed to access services.

Again, you must have the patient consent to share any individual's personal information. Contacting the NHTRC does not fulfill mandatory reporting requirements (NHTRC, 2016).

Blue Campaign is the United States Department of Homeland Security's sponsored website dedicated to ending human trafficking provides information on identifying victims and training programs. Anonymous tips regarding possible victims can be reported to Federal law enforcement (Department of Homeland Security [DHS], 2021):

Trauma-Informed Care

Trauma-Informed care (TIC), also called trauma-sensitive care, is a care approach framework that integrates acknowledgment of the impact of traumatic events and the importance of instilling a sense of safety and autonomy in each patient (Tracy & Macias-Konstantopoulos, 2021; Hopper, 2017). Essentially, this patient-centered approach focuses on the basic understanding that the trauma the patient has endured very much impacts their life from now on (Tracy & Macias-Konstantopoulos, 2021; Hopper, 2017). This approach aims to avoid any possible reinjury, focus on survivor strengths and overarching resilience, empower healing and recovery, and promote the creation of survivorship skills (Tracy & Macias-Konstantopoulos, 2021; Hopper, 2017).

TIC can be applied to all patients as it simply involves the healthcare personnel's practice modification to be critically aware of the general traumatic events this specific patient has lived through (Tracy & Macias-Konstantopoulos, 2021; Gaillard-Kenney et al., 2020). To be trauma-informed means asking the patient permission before completing an examination, allowing them to remain clothed per their comfort level, assessing them in a place that is comfortable to them, informing them of the steps in what you are doing so they can know what to expect each step of the way, and even offering the patient a mirror to allow them to be a part of the physical exam if they so choose (Tracy & Macias-Konstantopoulos, 2021). The patient should also be asked what their expectations are for your time with them and how you can help them feel as comfortable as possible throughout the proceedings, which often could mean even leaving the door open slightly ajar (Tracy & Macias-Konstantopoulos, 2021). It is also helpful for these patients to identify a "safe word" or a "signal" that patients can utilize if they begin to feel unsafe or distressed during the visit (Tracy & Macias-Konstantopoulos, 2021).

Providing TIC for these patients is extremely vital. TIC helps the patient trust the healthcare personnel and best opens the lines for communication (Tracy & Macias-Konstantopoulos, 2021; Gaillard-Kenney et al., 2020; Hopper, 2017).

If a patient is admitted to an inpatient psychiatric unit following initial medical stabilization and psychiatric assessment, it is crucial that all care should continue to be culturally and gender-specifically trauma-informed as well (Gordon et al., 2018).

Health Impact

As mentioned above, the health implications of victims of human trafficking are often very severe and long-lasting.

The healthcare needs of human trafficking victims range from physical abuse to psychological trauma. Unlike other violent crimes, trafficking usually involves prolonged and repeated trauma, including (Tracy & Macias-Konstantopoulos, 2021):

  • Physical, sexual, psychological abuse
  • Deprivation
  • Torture
  • Forced use of substances
  • Manipulation
  • Economic exploitation
  • Abusive working and living conditions

The health problems of trafficking victims relate to the type of trafficking. For instance (Stoklosa, 2017):

  • A sex worker may have repeated sexually transmitted diseases.
  • A construction worker may have injuries due to unsafe working conditions.
  • A nail salon worker may have lung disease from inhaling chemicals.
  • An agricultural worker may have dehydration due to working without adequate rest and water.

In addition, victims of human trafficking also often suffer significant psychological stress. This stress manifests itself in many mental health conditions. The mental health repercussions of trafficking include (Raker, 2020; Stoklosa, 2017):

  • Complex forms of Post-Traumatic Stress Disorder (PTSD)
  • Drug addiction
  • Depression
  • Anxiety
  • Homicidal/suicidal ideation
  • Panic disorders
  • Self-inflicted injuries

Trafficked children and adolescents are at risk for physical, mental, and psychological repercussions. These victims should be screened for the following (Tracy & Macias-Konstantopoulos, 2021; Raker, 2020):

  • Delayed physical and cognitive milestones
  • Impaired social skills
  • Stunted growth
  • Long-term effects of untreated common childhood diseases
  • Vitamin deficiencies
  • Poor access to childhood immunizations

The following tables list health-related indicators and consequences of human trafficking published by the National Human Trafficking Resource Center (NHTRC) (2016). This list of physical and mental health indicators of human trafficking is not exhaustive. Trafficking survivors may experience one or more of these indicators, none of these indicators, or health indicators not on this list.

Health Indicators and Consequences of Human Trafficking
Physical Health IndicatorsMental Health IndicatorsSocial or Developmental Indicators
  1. Signs of physical abuse or unexplained injuries
  • Bruising
  • Burns
  • Cuts or wounds
  • Blunt force trauma
  • Fractures
  • Broken teeth
  • Signs of torture
  1. Neurological conditions
  • Traumatic brain injury
  • Headaches or migraines
  • Unexplained memory loss
  • Vertigo of unknown etiology
  • Insomnia
  • Difficulty concentrating
  1. Cardiovascular/respiratory conditions that appear to be caused or worsened by stress, such as:
  • Arrhythmia
  • High blood pressure
  • Acute Respiratory Distress
  1. Gastrointestinal conditions that appear to be caused or worsened by stress, such as:
  • Constipation
  • Irritable bowel syndrome
  1. Dietary health issues
  • Severe wight loss
  • Malnutrition
  • Loss of appetite
  1. Reproductive issues
  • Sexually-transmitted infections
  • Genitourinary issues
  • Repeated unwanted pregnancies
  • Forced or pressured abortions
  • Genital trauma
  • Sexual dysfunction
  • Retained foreign body
  1. Substance use disorders
  2. Other health issues
  • Effects of prolonged Exposure to extreme temperatures
  • Effects of prolonged exposure to industrial or agricultural chemicals
  • Somatic complaints
  1. Depression
  2. Suicidal ideation
  3. Self-harming behaviors
  4. Anxiety
  5. Post-traumatic stress disorder
  6. Nightmares
  7. Lack of emotional responsiveness
  8. Feelings of shame or guilt
  9. Hyper-vigilance
  10. Hostility
  11. Attachment disorders
  • Lack of or difficulty in engaging in social interactions
  • Signs of withdrawal, fear, sadness, or irritability
  1. Depersonalization or derealization
  • Feeling like an outside observer of themselves, as if watching themselves in a movie
  • Emotional or physical numbness or senses
  • Feeling alienated from or unfamiliar with their surroundings
  • Distortions in perception of time
  1. Dissociation disorders
  • Memory loss
  • A sense of being detached from themselves
  • A lack of a sense of self-identity, or switching between alternate identities
  • A perception of the people and things around them as distorted or unreal
  1. Increased engagement in high-risk behaviors, such as running away or early sexual initiation of a minor
  2. Trauma bonding with trafficker or other victims (e.g., Stockholm syndrome)
  3. Difficulty establishing or maintaining healthy relationships
  4. Delayed physical or cognitive development
  5. Impaired social skills

Psychiatric/Mental Health Follow-Up Care

Survivors of human trafficking require a multitude of follow-up services. Due to the repetitive and traumatic nature of most human trafficking cases, a complete psychiatric evaluation of victims of human trafficking is needed to provide the mental health providers with a complete picture of the victim. This evaluation should include prior traumatic experiences, presentation of co-morbidity, assessment of the patients' functioning, and availability of basic resources (Gordon et al., 2018).

Treating the psychological consequences of human trafficking requires long-term, comprehensive, multi-faceted therapy. Mental health therapy usually includes one or more theories of psychological treatment (Gordon et al., 2018). Follow-up with mental health professionals in the outpatient setting is necessary to facilitate continued education about the processing of lived trafficking experience to promote healing and effective coping (Gordon et al., 2018).

As previously mentioned, human trafficking victims can have PTSD. The current evidence-based treatments for PTSD include (Gordon et al., 2018; Altun et al., 2017):

  • Behavioral therapy
  • Cognitive therapy
  • Psychodynamic/combination therapy

Behavioral therapy essentially manipulates the environment to increase desired behaviors and decrease problem behaviors.

Cognitive therapy alters a patient's comprehension and understanding of significant life experiences that change behaviors and feelings.

Psychodynamic therapy explains behavior and personality as being motivated by inner forces and targets patients' unconscious. These inner forces include past experiences, inherited instincts, and biological drives.

Major Depressive Disorder is the most common mood disorder among victims of human trafficking (Gordon et al., 2018; Altun et al., 2017). Effective, evidence-based treatments include cognitive-behavioral therapy (CBT). CBT treatment involves a working effort to alter the patient's thinking patterns to reframe experiences (American Psychological Association [APA], 2017). Doing this assists the patient in focus on developing effective coping methods (American Psychological Association [APA], 2017).

A human trafficking survivor might receive other possible forms of therapy include relaxation training, breathing retraining, thought-stopping training, exposure therapy, eye movement desensitization, reprocessing therapy, and stress inoculation training (Gordon et al., 2018; Altun et al., 2017).

Supporting Survivors

In addition to the importance of psychological support and medical care following a trafficking experience, survivors also need financial assistance. In many cases, traffickers have taken complete control of the victim's financial identity or bank accounts, resulting in depletion of funds and annihilation of their credit score (U.S. Department of State, 2021). Financial institutions and the government can help survivors obtain secure financial access, utilize victim support services, work to repair their credit, and receive restitution payments when they are able (U.S. Department of State, 2021).

Survivor Perspectives

Human trafficking survivors are the experts of their lived experiences (Chisolm-Straker, 2020). These individuals can have valuable insight into what healthcare professionals should know and ask to help identify other victims in the future (Chisolm-Straker, 2020).

One such survivor study specifically asked survivors of human trafficking what they would recommend being included in human trafficking education provided to healthcare professionals (Chisolm-Straker, 2020). Based on each of the 51 survivor's experiences, the content that the majority felt was necessary includes acceptable physical and psychosocial exam tips and tricks, more guidance for health care professionals in how they are to report victims, and safer discharge planning instructions to get the victim out of the hospital and to a safe and secure place (Chisolm-Straker, 2020).

Understanding the experiences and perspectives of survivors, too, is helpful to inform healthcare personnel further how we can better provide for, advocate for, and support victims of human trafficking (Tsai et al., 2020). Collecting qualitative information from the survivors also assists us in improving anti-human trafficking policy and practice (Tsai et al., 2020).

One study conducted in Cambodia (2020), another key country destination for human trafficking, followed the experiences of 128 survivors from 2010 to 2020 in a post-trafficking shelter (Tsai et al., 2020). The average age of the survivors at the beginning of their involvement in the study (so following their trafficked experience) was 16 years of age, meaning they were trafficked at even younger ages (Tsai et al., 2020). Five major themes of needs while the survivors stayed within a shelter among other survivors were identified in their interviews (Tsai et al., 2020):

  1. Importance of emotional safety
  2. Experiencing harsh treatment from the staff
  3. Stigmatization
  4. Not being believed
  5. Lack of trust/confidentiality

These survivor-consulted themes help to communicate the major needs that survivors of human trafficking have following their personal trafficking experiences. While many of the survivors were quite comfortable and felt supported in their stay, others who felt they were being judged or that the staff did not believe what they had gone through felt negatively about their shelter experiences (Tsai et al., 2020). Consistently providing TIC, as described in the section above, will help to eliminate these possible situations of not feeling comfortable or safe (Tsai et al., 2020; Tracy & Macias-Konstantopoulos, 2021).

All healthcare personnel must remember the trauma involved in trafficking experiences and be sensitive to the encounters of survivors to best assist them in their treatment, healing, and reintegration into society (Tsai et al., 2020; Tracy & Macias-Konstantopoulos, 2021). Because TIC also assumes that all individuals have experienced some level of trauma in their lives, the very structure of all organizations should reflect the need for sensitivity surrounding each interaction and conversation (U.S. Department of State, 2021).

Conclusion

Healthcare professionals have a duty to assist in the identification of victims of human trafficking. As widespread as the issue of human trafficking is, we all must do our part in knowing the risk factors and the physical/psychological signs of either a victim or perpetrator of trafficking. Remember that due to the sensitive nature of these situations, it is important to remain calm, respectful, non-judgmental, and private in any patient encounter you suspect might be related to trafficking. Take the time to refresh yourself on the protocols and procedures you must enact in your own workplace/unit so that you are immediately ready to act if you face a potential victim while at work. It is important to be aware that in some situations, much like with abusive relationships, the victim might not be ready to admit the need for help and might not want to leave their trafficking situations due to many reasons cited above. Do not take these decisions made on their part to mean that you have failed. Remember that your sympathetic words, thoughtful actions, and the time you spent with that patient all carry great weight and might contribute to making a difference in their lives in the future.

Additional Human Trafficking Resources

For more information, please see these additional Human Trafficking resources:

  • Anti-Slavery International is a human rights organization and works to eliminate all forms of slavery around the world. Visit Site.
  • Coalition Against Trafficking in Women (CATW) is an international, non-government organization that works to end human trafficking and the commercial sexual exploitation of women and children. Visit Site.
  • HEAL Trafficking (Health, Education, Advocacy, Linkage) is a network of public health groups that connects interdisciplinary health professionals in the fight to end human trafficking. Visit Site.
  • Polaris Project is a nonprofit organization dedicated to the global fight to eradicate modern slavery. Text HELP or INFO to BeFree (233733). Visit Site.
  • Rescue and Restore Campaign is supported by the Office on Trafficking in Persons of the United States Department of Health and Human Services (HHS) Office of the Administration of Children and Families. This site provides tips for identifying and helping victims of human trafficking, screening questions, lists of health problems seen in victims, and brochures and posters printed for the office. Visit Site.
  • SOAR (Stop, Observe, Ask, Respond) to Health and Wellness Training is a program for health care and social service providers sponsored by the Administration for Children and Families, United States Department of Health and Human Services. Visit Site.

Case Study

A 40-year-old Hispanic male presents to the ED with severe dehydration. This patient is thin; his skin is very dry with healing wounds on his arms and hands. His clothes are very worn and crusted with accumulated sweat and dirt. The patient is accompanied by a man who identifies himself as the patient's supervisor, presents the patient's identification, and insists on accompanying the patient to his room.

The patient is identified as an agricultural worker. The supervisor is providing interpretation for the Spanish-speaking patient. The supervisor answers most questions without consulting the patient. When the supervisor questions the patient, the patient gives short, abrupt answers. The patient avoids eye contact with the healthcare providers.

There are no previous charts available for review. Today's history is brief and focuses on the patient's symptoms. No questions relating to social history and very few questions relating to past medical history are asked. The physical exam and lab work are performed. Intravenous hydration is started.

The supervisor is impatient and repeatedly tells the nurse they need to leave. After hydration is complete, the patient is discharged with instructions, in Spanish, about how to prevent and identify dehydration.

An independent interpreter should have been used, and the supervisor should have been separated from the patient. A more detailed history of this patient's background, social history, and home situation may have identified some forced labor and abuse indicators.

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References

  • Altun, S., Abas, M., Zimmerman, C., Howard, L. M., & Oram, S. (2017). Mental health and human trafficking: Responding to survivors' needs. BJPsych international, 14(1), 21–23. Visit Source.
  • American Psychological Association. (APA). (2017). What is cognitive behavioral therapy? Visit Source.
  • Chisolm-Straker M, Miller CL, Duke G, & Stoklosa H. (2020). A framework for the development of healthcare provider education programs on human trafficking, part two: survivors. Journal of Human Trafficking, 6(4), 410–24. Visit Source.
  • Department of Homeland Security. (DHS). (2021). Blue Campaign. Visit Source.
  • Federal Bureau of Investigation (FBI). (2021). Human trafficking/involuntary servitude. Visit Source.
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  • Gaillard-Kenney, S. F., Kent, B., Lewis, J., & Williams, C. (2020). Effects of Trauma-informed Care training on healthcare providers caring for victims of human trafficking. Internet Journal of Allied Health Sciences & Practice, 18(3), 1–8. Visit Source.
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  • Health, Education, Advocacy, Linkage (HEAL) Trafficking. (2018). Protocol toolkit for developing a response to victims of human trafficking in health care settings. Visit Source.
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  • National Human Trafficking Resource Center (NHTRC). (2016). What to look for in a healthcare setting. Copyright © 2010 National Human Trafficking Resource Center. All rights reserved. Visit Source.
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  • Polaris Project. (n.d.). Social media in recruitment. Visit Source.
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  • Tracy, E. & Macias-Konstantopoulos, W. (2021). Human trafficking: Identification and evaluation in the healthcare setting. UpToDate. Retrieved August 24th, 2021. Visit Source.
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  • U.S. Congress. (2000). Trafficking Victims Protection Act (TVPA). Visit Source.
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