Human Trafficking

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

As mentioned above, traffickers utilize force, fraud, and coercion in order to subject victims to engage in human trafficking. The following are the definitions of these specific terms as they pertain to the trafficking of victims (Department of Health & Human Services [HHS], 2017):

• Force: This includes any physical restraint, sexual assault, beatings, or otherwise physical harm. This also includes monitoring and confinement that is often used in the early stages of victimization to break down the victim’s resistance and control them.
• Fraud: This includes false promises of wages, working conditions, benefits, love, marriage, employment, or simply a better life.
• Coercion: This includes threats of physical restraint or serious harm against any person. It also can include psychological manipulation, the confiscation of personal documentation, and shame and fear-inducing threats of sharing their information with authorities.

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).

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.).

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).

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).

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.

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.

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).

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 Hotline 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
• Massage businesses
• Truck stops
• Residential brothels

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.

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

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).

Any victim of human trafficking whose first language is not English or otherwise is not able to communicate fully with staff should necessitate the use of a professional interpreter (Office for Victims of Crimes, n.d.). 

There are some important considerations when identifying and selecting a proper interpreter (Office for Victims of Crimes, n.d.):

• Interpreters must remain neutral
• Another victim, family member, or someone who has a relationship with the victim should not be the interpreter
• The interpreter must have a thorough understanding of both the language the interviewer is using and the language the victim is using
• Depending on the victim’s preferences, an interpreter of the same gender or same cultural community might be preferred
• Depending on the victim’s preferences, an interpreter provided via phone might be preferred rather than someone in physical presence
• The interpreter should be prepped prior to the conversation to fully understand the difficult and invasive questions that might need to be asked
• The interpreter must translate exactly what the interviewer states and what the victim states, without brief summaries or the use of euphemisms
• If a break is needed to allow the victim time and space or for the interpreter to regroup, this break should be honored

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 messages 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.

Each situation of human trafficking is unique and requires a victim-centered response (NHTH, 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 (NHTH, 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 (NHTH, 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 (NHTH, 2016):

• Provide the patient with the National Human Trafficking Hotline (NHTH) hotline number and encourage them to call the NHTH hotline (1-888-373-7888) or the text number BeFree (233733). The NHTH 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; NHTH, 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; NHTH, 2016).

Mandated reporting of abuse of older adults and adults with disabilities is typically defined as a legal obligation of a specific profession or individual to report suspected abuse, neglect, or exploitation of another individual meeting that state’s specific definition of an adult eligible for special protection under the law (Keck School of Medicine of USC, n.d.). Reports must be made to that specific entity in the state that is required to investigate such allegations. Each state defines who is the mandated reporter, what situations they are required to report on, when they must report, and to whom they are required to report to (Keck School of Medicine, n.d.). Some states require only certain professions while others require universal reporting, in other words everyone is a mandatory reporter (Keck School of Medicine, n.d.). The most often named mandated reporters are law enforcement and medical professionals.

Although exact reporting requirements of who is required to report and to which state agency varies for each state, many states, such as Texas, require any individual who has a reasonable cause to believe that either a child (less than age 18), a person 65 years of age or older, or an adult with disabilities is being abused, neglected, or exploited in any way are mandatory reporters who must report these crimes (Texas Department of Family and Protective Services [DFPS], n.d.) According to the Texas Department of Family and Protective Services (n.d.), any individual who fails to report suspected abuse can be held liable for a misdemeanor or a felony.

Many states also protect these mandatory reporters by keeping the name of the person making the report confidential and giving them immunity from civil or criminal liability if they are reporting in good faith (Texas Department of Family and Protective Services, n.d.).

To review laws specific to your state, please review the following link with an embedded link to read a PDF copy of a tool, Human Trafficking and Health Care Providers: Legal Requirements for Reporting and Education here.

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).

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 Hotline (NHTH) (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.

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).

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).

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).

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.

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.

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.

• 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.
• Department of Health & Human Services (HHS). (2017). Fact sheet: Human trafficking. Visit Source.
• Federal Bureau of Investigation (FBI). (2021). Human trafficking/involuntary servitude. Visit Source.
• Feehs, K., & Currier Wheeler, A. (2020) Federal human trafficking report, Human Trafficking Institute. Visit Source.
• Florida State University. (FSU). (n.d.). Sex trafficking training. Visit Source.
• 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.
• Gordon, M., Salami, T., Coverdale, J., & Nguyen, P. T. (2018). Psychiatry’s role in the management of human trafficking victims: An integrated care approach. Journal of Psychiatric Practice®, 24(2), 79–86. Visit Source.
• Health, Education, Advocacy, Linkage (HEAL) Trafficking. (2018). Protocol toolkit for developing a response to victims of human trafficking in health care settings. Visit Source.
• Hopper, E. K. (2017). Trauma-informed psychological assessment of human trafficking survivors. Women & Therapy, 40(1/2), 12–30. Visit Source.
• International Labor Organization. (ILO). (2017). Statistics on forced labour, modern slavery, and human trafficking. Visit Source.
• Jones Day. (2021). Human trafficking and health care providers: Legal requirements for reporting and education. Visit Source.
• Keck School of Medicine of USC. (n.d.). Mandated reporting of abuse of older adults and adults with disabilities. Visit Source.
• Michigan Department of Health & Human Services. (MDHHS). (2021). Human trafficking. Visit Source.
• Michigan Department of Health & Human Services. (MDHHS). (2017). Human trafficking of children protocol. Visit Source.
• National Human Trafficking Hotline. (n.d.). Sex trafficking. Visit Source.
• National Human Trafficking Hotline (NHTH). (2016). What to look for in a healthcare setting. All rights reserved. Visit Source.
• Office for Victims of Crime. (n.d.). Human trafficking task force e-guide: Interpreters. Visit Source.
• Polaris Project. (2021). Human trafficking. Visit Source.
• Polaris Project. (2020). U.S. national human trafficking hotline data report. Visit Source.
• Polaris Project. (2019). Sex trafficking and LGBTQ youth. Visit Source.
• Polaris Project. (n.d.). Social media in recruitment. Visit Source.
• Raker, K. A. (2020). Human trafficking education: A guide for nurse educators. Journal of Professional Nursing, 36(6), 692–697. Visit Source.
• Stoklosa, H. (2017). STAT. Doctors often unaware they are treating human trafficking victims. Visit Source.
• Texas Department of Family and Protective Services. (DFPS). (n.d.). Report abuse, neglect, or exploitation. Visit Source.
• Tracy, E. & Macias-Konstantopoulos, W. (2021). Human trafficking: Identification and evaluation in the healthcare setting. UpToDate. Retrieved August 24th, 2021. Visit Source.
• Tsai, L. C., Lim, V., & Nhanh, C. (2020). Perspectives of survivors of human trafficking and sexual exploitation on their relationships with shelter staff: Findings from a longitudinal study in Cambodia. British Journal of Social Work, 50(1), 176–194. Visit Source.
• U.S. Congress. (2000). Trafficking Victims Protection Act (TVPA). Visit Source.
• U.S. Department of Homeland Security. (2020). Blue Campaign human trafficking 101 fact sheet. Visit Source.
• U.S. Department of Homeland Security. (2021). Blue Campaign: A victim-centered approach. Visit Source.
• U.S. Department of Justice. (2000). Definition of trafficking. Visit Source.
• U.S. Department of State. (2021). 2021 Trafficking in persons report. Visit Source.
• U.S. Immigration and Customs Enforcement. (ICE). (2017). The Cornerstone Report: Human trafficking vs. human smuggling. Visit Source.
• Zigelman, K. (2020). Profile: Who are traffickers? Spectrum Labs. Visit Source.