Human Trafficking

Prepare healthcare providers to identify and appropriately report victims of human trafficking.

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

• Recognize factors that place a person at greater risk of being a victim of human trafficking
• Apply indicators for identifying a human trafficking victim to a specific scenario
• Identify a victim of human trafficking in a healthcare setting
• Describes procedures for sharing information related to human trafficking with a patient
• Appropriately report victims of human trafficking

“There are more slaves today than at any time in human history.¹”

Human Trafficking is modern day slavery. U.S. law defines trafficking in persons as²:

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 the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.

Human trafficking can be a transnational process where victims are recruited abroad and transported across borders into another country where they are exploited for labor and/or sex. However, human trafficking can also be a domestic phenomenon, where little or no transportation is required.

The United Nations Convention against Transnational Organized Crime defined human trafficking as³:

The recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude, or the removal of organs.

Under Michigan law, Child Sex Trafficking is defined as⁴:
Any child who has been recruited, enticed, harbored, transported, provided, or obtained for commercial sexual activity, a sexually-explicit performance or the production of pornography, is a victim of sex trafficking. Although traffickers often use force, threats, violence, false promises, manipulation, lies and other physical or psychological methods to control their victims, a child need only be sexually exploited to be considered a victim of sex trafficking in Michigan. For children 16 years of age and older who are developmentally capable of consenting to sex, the presumption is rebuttable, meaning that it can be overcome if the prosecution can prove beyond a reasonable doubt that the child was not forced or coerced into committing the offense. Further, the presumption may be lost if the child refuses or fails to substantially comply with court-ordered services. In all cases involving children under the age of 16, the presumption is absolute, and the child’s sexual conduct may not be criminalized.

Trafficking victims can be any age, race, gender, or nationality. It happens to Americans and immigrants. The different types of human trafficking are⁵:

1. Sex Trafficking
2. Forced Labor
3. Domestic Servitude

Victims are found in legitimate and illegitimate labor industries; particularly underpaid and under-regulated industries. These industries include sweatshops, massage parlors, agriculture, restaurants, hotels, and domestic service. Forced labor, in foreign countries, is used to produce the products American’s buy.

Victims are trapped through combinations of extreme psychological manipulation and shaming, financial bondage, rape, and/or physical abuse. Many are bound to their traffickers by addiction to heroin or opioids.⁶

Because of the clandestine nature of human trafficking, most data are estimated.

According to the International Labor Organization (ILO) and Walk Free Foundation, September 2017 report, an estimated 24.9 million victims are trapped in modern-day slavery. Of these²:

• 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

According to the ILO report from 2014, the following is a breakdown of profits of human trafficking²:

• $99 billion in sexual exploitation
• $34 billion in construction, manufacturing, mining, and utilities
• $9 billion in agriculture, including forestry and fishing
• $8 billion is saved annually by private households that employ domestic workers under conditions of forced labor

Prosecutions of Human Traffickers is very low. The State Department Trafficking in Persons report for 2017, shows only 14,894 prosecutions and 9,071 convictions for trafficking globally in 2016.²

The 2000 Trafficking Victims Protection Act (TVPA) creates a comprehensive federal law to address human trafficking. A three-pronged approach is used in addressing trafficking⁷:

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.

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.⁷ TVPA also established a law requiring defendants of human trafficking investigations to pay restitution to the victims.

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. The T visa allows foreign victims of human trafficking to become temporary U.S. residents. The victims may become eligible for permanent residency after three years.⁷

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. The costs of the crime of trafficking in persons includes⁸:

• value of resources devoted to its prevention
• treatment and support of victims
• apprehension and prosecution of offenders
• loss of human resources
• reductions in tax revenue

Conditions that put people at risk of being preyed on by human traffickers include^3,8:

• Economic crisis
  • poverty
  • lack of education
• Social exclusion
  • rural location
  • migration
  • lesbian, gay, bisexual, transgender
  • indigenous people
• Gender discrimination
• A weak legal or social protection system
  • young age (12 to 16-year-old girls are at greatest risk)
  • disability
  • inadequate family support and protection
  • history of abuse

Situations that contribute to weakening social protection measures include^3,8:

• Policies and practices that marginalize entire groups of people
• Natural disasters
• Conflict and political turmoil

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

“Most providers lack the training and ability to recognize victims of the sex-slave industry…victims frequently present to EDs, but are rarely detected as such.¹¹”

Human trafficking victims often present to emergency departments and women’s health or family planning clinics. One retrospective survey of 173 US survivors of human trafficking, 68% were seen by a healthcare provider and 56% seeing emergency or urgent care providers while they were being trafficked. Healthcare providers have an opportunity to identify victims of human trafficking.³

Victims of human trafficking are hard to identify in a healthcare setting. 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. Victims may not seek healthcare unless they have no other options.³ It is critical for healthcare providers to recognize that their role is not disclosure or rescue; but, to create a safe, non- judgmental place that will help you identify trafficking indicators and assist the patient.

The National Human Trafficking Resource Center (NHTRC) provides training and technical assistance on a wide range of human trafficking topics through the hotline and website. The NHTRC can also guide providers through an assessment of a potential victim.

If human trafficking is suspected or confirmed, assess acute healthcare needs and additionally perform a complete physical to identify medical conditions common 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.³

Unfortunately, the healthcare professionals’ financial and time incentives are to treat the complaint and street the patient.

Calm, open-ended questioning helps build rapport.¹¹
Avoid questions starting with “Have you ever…” because the answer will be “no,” and you will have lost an opportunity. You may ask the patient where she lives and who takes care of her, how she met her “boyfriend,” or whether she must contribute money to her family. You may suggest, “Tell me about your tattoo.”

Take time to answer questions the victim might have, and acknowledge and address their fears; Being sensitive to cultural differences, gender differences, and language barriers and using an interpreter when needed.¹²

More direct questions related to trafficking situations may be made later in the interview.

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.¹³

Gaining the trust of trafficking victims is important. Sample messages to help gain trust include¹³:

• We are here to help you.
• Our priority is your safety.
• Under the Trafficking Victims Protection Act of 2000, victims of trafficking can apply for special visas or could receive other forms of immigration relief.
• 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 needs of human trafficking victims range from physical abuse to psychological trauma. Unlike other violent crime, trafficking usually involves prolonged and repeated trauma including⁸:

• 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 instance⁶:

• 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.

The mental health repercussions of trafficking include⁶:

• complex forms of post-traumatic stress disorder
• struggle with addiction
• depression

Trafficked children and adolescents are at risk for physical, mental, and psychological repercussions. These victims should be screened for the following³:

• delayed physical and cognitive milestones
• impaired social skills
• stunted growth
• long-term effects of untreated common childhood diseases

The following is a list of health-related indicators and consequences of human trafficking published by the National Human Trafficking Resource Center and available at traffickingresourcecenter.org¹⁰

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.

There is no consensus on the optimal screening questions for identifying victims of human trafficking. The clinician should start with indirect questions that touch upon aspects of the patient's life, job, and a general sense of safety.³ As with domestic violence cases, try to separate the patient from visitors and family before beginning any sensitive discussions.¹⁴  

Interpreters should be screened to be sure they do not know the victim or the traffickers and do not otherwise have a conflict of interest.¹⁴ 

The following are sample questions health care providers can ask in screening an individual to determine if he/she is a potential victim of human trafficking. This list is published by United States Department of Health and Human Services, Administration for Children and Families. Screening tool for victims of human trafficking and available at acf.hhs.gov. ¹⁴ 

• Can you leave your job or situation if you want? 
• Can you come and go as you please? 
• Have you been threatened if you try to leave? 
• Have you been physically harmed in any way? 
• What are your working or living conditions like? 
• Where do you sleep and eat?   
• Do you sleep in a bed, on a cot or on the floor? 
• Have you ever been deprived of food, water, sleep or medical care? 
• Do you have to ask permission to eat, sleep or go to the bathroom? 
• Are there locks on your doors and windows, so you cannot get out? 
• Has anyone threatened your family? 
• Has your identification or documentation been taken from you? 
• • Is anyone forcing you to do anything that you do not want to do? 
   

A procedure or plan 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.¹¹ The plan should identify potential sources of legal assistance, transportation, vocational training, employment, child care, and housing.³ 

Traffickers can be involved in organized crime, local gangs, or other crime networks; therefore, staff and patient safety is a top priority. Safety measure include³:

• 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.³ 

If a patient discloses that they have been trafficked¹⁰:

• Provide the patient with the National Human Trafficking Resource Center (NHTRC) hotline number and encourage him/her to call 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 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. Documentation of abuse may be helpful in proving a case against a trafficker; however, information about the victim can also be used against them in court.

If the patient does not 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. Healthcare providers can discuss specific safety plans including the development of a safe contact system.³ 

Recovery for trafficked persons is long and complex. Victims being repatriated and returned to live with their families is inappropriate and results in victims being returned to a situation where they suffer further harm.⁸ Persons who leave a trafficking situation, have a potential for revictimization due to ongoing fear, shame, and vulnerability.³

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. 

National Human Trafficking Resource Center (NHTRC) is an excellent resource for healthcare facilities to help identify and connect with existing local resources at www.traffickingresourcecenter.org 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, including¹⁰:

• anti-trafficking organizations
• legal service providers, shelters
• law enforcement
• local social service agencies 

Many of the services available for victims are time limited. For example, domestic violence shelters and runaway and homeless youth programs, where most counseling services are offered on-site. 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.¹⁵

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.¹⁰

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.¹⁰

Michigan has specific reporting requirements for human trafficking. 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.⁴

The Michigan law’s definition of Child Labor Trafficking is⁴:

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 provide proof that force, fraud or coercion existed while they were in the care of their trafficker, regardless if the victims are children or adults.

In child sex trafficking, proof of force, fraud or coercion is not required.⁴

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.¹⁰

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. 1-888-3737-888 or www.traffickingresourcecenter.org. Again, you must have the patient consent to share any individual’s personal information.

Contacting the NHTRC does not fulfill mandatory reporting requirements.¹⁰

Blue Campaign is the United States Department of Homeland Security sponsored website dedicated to ending human trafficking provides information on identifying victims and training programs. Anonymous tips regarding possible victims can be reported through the HSI tip form.³https://www.dhs.gov/blue-campaign

Immigration and Customs Enforcement (ICE) Homeland Security Investigations (HSI) can be contacted at Tip-line 1-866-347-2423 or at www.ice.gov/tips.

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.¹⁷

Treating the psychological consequences of human trafficking requires long-term, comprehensive therapy. Mental health therapy usually includes one or more theories of psychological treatment. 

Behavioral therapy manipulated the environment to increase desired behaviors and decreasing problem behaviors. 

Cognitive therapy focuses on altering patient’s comprehension, and understanding of significant life experiences 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. Effective, evidence-based treatments include cognitive-behavioral therapy and interpersonal psychotherapy. Interpersonal psychotherapy helps patients improve their mood by improving their interpersonal relationships.¹⁷

Human trafficking victims can suffer from PTSD. The current evidence-based treatments for PTSD include¹⁷:

• Behavioral therapy
• Combination behavioral and cognitive therapy.

Exposure Therapy reduces anxiety and fear with confrontation of thoughts and actual situations related to the trauma.

Eye Movement Desensitization and Reprocessing combines general clinical practice with imaginal exposure and cognitive restructuring. This therapy uses rapid eye movement, imaginal exposure, and cognitive restructuring phrases. 

Stress Inoculation Training combines psycho-education with anxiety management techniques. Techniques include relaxation training, breathing retraining, and thought stopping.

Patients with substance-related disorders should be assessed to differentiate between use, misuse, abuse, and dependence.¹⁷

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 and 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. IV 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 of the indicators of forced labor and abuse.
 

1. The Blue Campaign, DHS Anti Human Tracking efforts. Retrieved 11/2/17 from dhs.gov
2. Human Rights First. Human Trafficking by the Numbers. Retrieved 10/15/19 from humanrightsfirst.org
3. E. Tracy, W. Konstantopoulos. 2016.Human Trafficking: Identification, evaluation and management in the healthcare setting. 10/18/16.
4. Michigan Department of Health and Human Services. Human Trafficking of Children protocol. Retrieved 10/20/17 from michigan.gov
5. Blue Campaign Hospitaltiy Toolkit. Retrieved 10/20/17 from dhs.gov
6. H. Stoklosa, 2017, STAT, Doctors often unaware they are treating human trafficking victims, March 16, 2017.
7. FBI. Human Trafficking/Involuntary Servitude. Retrived 10/14/17 from fbi.gov
8. United Nations, Office on Drugs and Crime. UN.Gift, United Nations Global Initiative to Fight Human Trafficking. An Introduction to Human Trafficking, Impact and Action. UN. New York, 2008
9. Department of homeland security, Blue Campaign Human Trafficking 101 dhs.gov
10. National Human Trafficking Resource Center. What to Look for in a Healthcare Setting, updated February 2016. Copyright © 2010 National Human Trafficking Resource Center. All rights reserved. traffickingresourcecenter.org
11. J. Munoz. How to Recognize, Treat Victims of Sex Trafficking. ACEP Now. 3/7/14.
12. US Department of Homeland Security, Blue Campaign, A Victim-Centered approach. Retrieved 10/21/17 from dhs.gov.
13. HHS. Resources: Messages for Communicating with Victims of Human Trafficking. Retrieved 10/21/17 from acf.hhs.gov
14. United States Department of Health and Human Services, Administration for Children and Families. Screening tool for victims of human trafficking. Retrieved 10/26/17 from traffickingresourcecenter.org.
15. H. Clawson, A. Salomon, and L. Grace. US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Treating the Hiddent Wounds: Trauma Treatment and Mental Health Recovery for Victims of Human Trafficking. retrieved 10/26/17 from acf.hhs.gov
16. Feature: Human Trafficking ICE Retrieved 9/17/17 from ice.gov.
17. E. Williamson, N. Dutch, and H. Clawson. US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Evidence-Based Mental Health Treatment for Victims of Human Trafficking. Nd.