Human Trafficking

What is Human Trafficking?

Human trafficking is a major public health concern affecting individuals of all races, social classes, ages, and genders. Nobody is immune to the potential threat posed by human traffickers. These individuals are driven by greed and have no regard for human rights. They prey on the vulnerable and harm victims both physically and mentally. The social and economic effects on society are not completely known and more research is needed to inform community care, guidelines, and education.

It’s shocking to realize that human trafficking is a $150 billion global industry. According to estimates from the International Labour Organization in 2016, around 40.3 million people around the world are victims of modern-day slavery, equivalent to about 5.4 victims for every thousand people globally. Out of these victims, around 72% or 29 million were women and girls. Almost 5 million of all these victims were victims of forced sexual exploitation, with children forming more than 20% of that number. It’s estimated that around 25 million people have been forced into labor and 15.4 million into forced marriages. These numbers are hard to determine accurately, due to the hidden nature of this rapidly growing crisis.

It is important to recognize the distinction between human trafficking and human smuggling. Human trafficking, as defined by a federal law called the Trafficking Victims Protection Act (TVPA), refers to exploiting individuals for sex or labor through force, fraud, or coercion. In contrast, human smuggling refers to the illegal transportation of individuals across borders, and is typically done with the consent of the individual. The relationship between the smuggler and individual usually ends once they reach their destination. However, sometimes smuggling can turn into trafficking as a way to repay smuggling fees. Trafficking, also known as modern-day slavery, is a crime in all 50 states and internationally, and it does not require physically moving a person. It can happen locally in communities and schools.

Human trafficking involves three main components: action, means, and purpose, based on the National Human Trafficking Resource Center (NHTRC) and the TVPA’s model. This involves a trafficker recruiting, harboring, transporting, providing, or obtaining an individual using force, fraud, or coercion to compel the victim into commercial sex acts, labor, or other services. Force, fraud, or coercion don’t need to be present for minors under 18 years involved in any commercial sex act because minors cannot consent to sex with an adult. Minors are more easily exploited and manipulated, making them especially vulnerable to trafficking.

The TVPA defines labor trafficking as recruiting, harboring, transporting, providing, or obtaining a person for labor or services, via force, fraud or coercion, resulting in involuntary servitude, peonage (a form of debt slavery), debt bondage, or outright slavery.

Over the past 18 years, the US Congress has passed several bills to address and bring awareness to human trafficking in the US and globally. These laws draw their basis from the 13th Amendment to the US Constitution, which banned slavery in 1865. The TVPA, enacted in 2000, approaches trafficking through three main actions: protection, prosecution, and prevention. The TVPA ensures victims of trafficking in the US are eligible for federally funded benefits, regardless of immigration status. This includes healthcare and immigration assistance, and protection from deportation under the T visa.

The TVPA equipped prosecutors with more resources to hold traffickers accountable and provide financial restitution to victims. The legislation also improved measures for preventing trafficking, including efforts to improve global economic conditions, annual reporting on trafficking, and the creation of a task force to monitor and combat trafficking.

Understanding and preventing human trafficking is key to addressing this global $150 billion industry, which some believe is larger than the drug trade. Healthcare providers often serve as the first point of contact for victims and play a crucial role in recognizing and responding to this issue. The US Department of State also prosecutes cases of trafficking and smuggling, both globally and domestically.

What Causes Human Trafficking?

Human trafficking, or the illegal trade of people for exploitation or commercial gain, can result from a variety of factors that make a person more likely to fall victim to this crime.

One such factor is Adverse Childhood Experiences (ACEs), which are traumatic events in a child’s life such as abuse, neglect, or witnessing violence. These experiences can lead to risk-taking behavior, making a person more likely to end up in a trafficking situation. The Center for Disease Control and Prevention (CDC) and Kaiser Permanente conducted a large study between 1995 and 1997 exploring the impact of ACEs on a person’s health and wellbeing in later life. This study showed that people with a high ACE score, meaning they’d experienced a lot of adversity in childhood, could suffer from disrupted brain development and emotional, social, and cognitive problems. These issues could lead to behaviors that harm their overall health and increase their chances of being trafficked.

A questionnaire is used to calculate the ACE score, which ranges from zero (no exposure to ACEs) to 10. It includes questions about physical, emotional, or sexual abuse, suicide of a family member, drug addiction, and mental health issues. A recent study from Florida showed a higher risk of trafficking among children with an ACE score of six or above. Sexual abuse was identified as the most reliable predictor of trafficking.

For lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals, the risk of trafficking is also higher. Recent surveys found higher ACE scores among lesbian, gay, and bisexual people compared to their heterosexual peers. The transgender community often struggles with additional vulnerabilities, such as homelessness, addiction, depression, or a history of sexual abuse, making them more susceptible to trafficking.

The National Center for Transgender Equality conducted a survey in 2015, showing that 5% of transgender participants had turned to sex work for income in the past year. Those who engaged in sex work were more likely to be victims of violence or sexual assault. This is often due to a lack of basic necessities, such as food and shelter.

In general, being exposed to sexual abuse can increase the risk of substance abuse, mental health problems, and social isolation, which are all contributing factors to human trafficking. Traffickers take advantage of these vulnerabilities to exploit their victims. They often present themselves as a rescuer or a chance at a better life, while their true intention is to profit from the victim’s suffering.

The US Department of Health Office on Trafficking in Persons identified several groups at higher risk of being trafficked. These include survivors of child abuse, sexual abuse, violence, or exposure to violence, and those living without a stable support structure or in precarious environments, due to being runaways, homeless, undocumented migrants, or members of the LGBTQ community.

A fact sheet published by the US Department of Education highlighted the vulnerability of school-age children, citing places like restaurants, salons, and agricultural settings as common places for child trafficking. Programs like the Blue Campaign, created by the US Department of Homeland Security, aim to raise awareness about the risks of human trafficking among young people at places like schools, malls, and online platforms.

Risk Factors and Frequency for Human Trafficking

The US Department of Health & Human Services supports the National Human Trafficking Hotline, which is run by Polaris. This confidential, 24/7 hotline provides support in over 200 languages to victims, survivors, and witnesses of human trafficking. Their information helps with training programs and supporting victims both in the United States and internationally. Data from 2017 shows that Texas, Florida, and California are the states with the highest number of reported trafficking cases.

• The hotline has answered over 100,000 calls.
• About 7,000 of those calls were from potential trafficking victims.
• Since 2007, they have identified over 30,000 trafficking cases and given more than 8,000 tips to law enforcement.

The hotline’s contact information is:

• Phone number: 1-888-373-7888.
• Text “HELP” to 233733.
• Live chat at humantraffickinghotline.org.
• Email help@humantraffickinghotline.org.

The National Center for Missing and Exploited Children (NCMEC) is another important resource, particularly for cases involving minors. They report that 1 in 6 endangered runaways is likely to be a victim of sex trafficking. Kids as young as nine are at risk, with the most common ages for trafficking falling between 11 and 14.

• You can report any suspected abuse to NCMEC using their hotline: 1-800-THE-LOST, 1-800-843-5678.
• Call your local police or your emergency access number if there’s an immediate crisis.

Another significant resource in the fight against human trafficking is the Counter-Trafficking Data Collaborative (CTDC). They’ve compiled a global repository of trafficking data to assist in combatting human trafficking.

Each year, thousands are victim to trafficking, with virtually no country being free of involvement. The UNODC Global Report on Trafficking in Persons explains how traffickers and their victims often share the same ethnic background, speak the same language, and come from the same geographic area. These commonalities can unfortunately lead to a misplaced trust being exploited by traffickers.

Over the past decade, victim profiles have evolved. More men are victims of trafficking, and more women are becoming involved in trafficking operations.

The number of convictions relative to the number of victims remains dishearteningly low, according to UNODC. North America, however, reports the highest number of convictions of any world region. Between 150 to 200 traffickers are convicted in the United States each year.

The UNODC’s report provides further details on trafficking: https://www.unodc.org/documents/data-and-analysis/glotip/2016_Global_Report_on_Trafficking_in_Persons.pdf

Signs and Symptoms of Human Trafficking

Those in the healthcare field can play a crucial role in identifying victims of human trafficking. Some key places where exploitation often occurs include farms, fisheries, factories, nail salons, massage parlors, and restaurants. Victims of labor trafficking might work in traveling sales, begging groups, landscaping, construction, or as domestic help. They could face risks such as being abandoned in unfamiliar cities, leading to homelessness or resorting to “survival sex”. Moreover, language barriers can make it easier for manipulative individuals to take advantage of immigrants.

Common locations for sex trafficking include hotels, motels, street locations, homes-turned-brothels, commercial-front brothels, escort-service companies, truck stops, bars, and strip clubs. It’s even possible for sex trafficking to occur within a victim’s own family, with family members acting as the traffickers. Victims might not see themselves as victims, and refer to their trafficker as their “daddy” or “boyfriend”.

Two key vulnerabilities that labor traffickers exploit are visa status and fear of deportation. Workers in fields like agriculture, factories, and domestic service might be promised certain work conditions, only for their employers to renege on these promises and manipulate them. They might be forced to work long hours for poor pay, be confined or isolated, and be deprived of proper communication tools. Additionally, labor laws might not apply to subcontractors or independent contractors, thus increasing their vulnerability. Those exploited are usually kept isolated, vulnerable due to their immigration status, and devoid of resources and protections.

There are some common red flags to be aware of to identify potential cases of human trafficking. These include a person being reluctant to discuss their work situation, being unable to make decisions or control their finances, not knowing their address, or being accompanied by a controlling individual. Remember, your role as a provider is to recognize potential cases of human trafficking, empower the person being exploited, and provide a framework for a trauma-informed approach to healthcare.

While it’s important to look for signs of physical abuse like bruising, scarring, burns, fractures, and other injuries, it’s also crucial to recognize signs of psychological hurt. Symptoms could include depression, suicidal ideations, self-harm, anxiety, PTSD, flashbacks, nightmares, or feelings of isolation, shame, or guilt. Often, in order to cope with their horrifying experiences, victims may describe their situation as if they were an outsider looking in.

It’s important for healthcare professionals to document all of this, as it can help victims legal pursue action against their trafficker in the future. Be sure to follow your institution’s policies for record-keeping and obtain any required consent forms.

Testing for Human Trafficking

If a healthcare professional suspects that a person might be a victim of human trafficking, it’s important to establish a private, quiet, and safe space for further evaluation, similar to the way you would in cases of suspected child or elder abuse. The goal is to build trust and make the person feel empowered. This can help in creating a network of trusted people and institutions that can provide assistance.

In this age of smartphones, it is vital to ensure mobile devices are switched off and kept at a distance. Traffickers often use cell phones to maintain control over the victim. Even if the victim is alone, they could be constantly on their phone as a means for the trafficker to ‘keep tabs’ on them.

When communicating with a potentially trafficked person, maintain eye contact, speak in a quiet and gentle manner, and avoid looking down on them. It is also important to keep your conversation on an equal footing, unless doing so would clash with the person’s cultural norms. Offering an empowering and safe zone could allow the person to confide in you about their situation.

Before starting a conversation, you should ask the person if they feel safe talking at that moment, and if they are comfortable with your presence. Always remember that it’s their call to confirm that they feel safe. If the person signals that they do feel safe, you can then proceed with the conversation.

Finding a suitable room for an interview or a private conversation with the patient is crucial. In some cases, a bereavement room may be an appropriate choice.

You should also inform the person in question that you are legally required to report certain disclosures. Pay attention to their verbal and nonverbal cues, and take care to avoid any reactions that may reinforce negative stereotypes or further victimize the person.

Starting a conversation with victims of human trafficking can be challenging for healthcare providers. The Department of Health and Human Services (HHS) has created a resource called ‘Messages for Communicating with Victims of Human Trafficking’ to assist healthcare providers in these scenarios.

Remember only to promise what you can provide. Healthcare providers are not required to determine if a crime has taken place, but they can help create an empowering and caring environment that may eventually lead to identifying victims, sharing necessary resources, and helping them start their journey towards physical and emotional recovery.

There are unique challenges when the person suspected of trafficking is the family member who refuses to leave the patient alone. In such cases, healthcare providers can create an opportunity to take the patient to the restroom for a urine sample or to another room for an X-ray or CT scan and inform the family member that they cannot come along.

The safety of both the patient and staff is essential. Professionals must be aware of their surroundings and follow established protocols, involved law enforcement and security personnel when necessary. The National Human Trafficking Resource Center (NHTRC) can also assist in assessing the level of danger and contacting law enforcement when the patient consents.

If a patient discloses that they are a victim of human trafficking, ask them if they are comfortable with you calling the NHTRC hotline number. Encourage them to call and provide them with the number. They can have this number hidden in a discrete location.

The NHTRC hotline is available around the clock and offers confidential reporting as per the law. It’s a resource for help, for accessing services, and to ask for assistance. The hotline has language support for more than 200 languages. A caller does not need to disclose personal information; they can stay anonymous.

Requirements for reporting suspected human trafficking cases may vary depending upon the facility, location, and state and federal laws. The Health Insurance Portability and Accountability Act (HIPAA) may restrict the release of protected health information to NHTRC unless patient consents. However, in some circumstances, such as suspected injury or abuse, HIPAA allows the release of certain information.

Treatment Options for Human Trafficking

While human trafficking carries inherent health risks for both labor and sex trafficking victims, these issues need further exploration.

Studies conducted in South Africa and West Bengal, India, discovered women and girls who were trafficked and forced into sexual encounters were at a 50% increased risk of acquiring HIV. This can be due to their physical vulnerability as breaks in their vaginal tissue from constant abuse can lead to inflammation, making it easier for HIV to spread. Youthfulness and lack of sexual experience also contribute to this risk, as repeated exposure to older men and lack of protection increase the risk of sexually transmitted infections (STIs).

Victims of sex trafficking should be checked for signs of physical injury, HIV/AIDS, herpes, syphilis, gonorrhoea, chlamydia, trichomonas, hepatitis, and molluscum contagiosum — all potential infections from sexual abuse. In cases of recent forced sexual encounters, important considerations include emergency contraception and preventive treatment for STIs. Health practitioners must also be ready to address withdrawal issues triggered by forced substance use or addiction. Nurses should also check for foreign debris present in the vagina and conduct cervical cultures to evaluate any discharge detected.

On the other hand, labor trafficking victims are prone to severe dehydration or malnutrition because they are often forced to work for long hours under harsh conditions. Victims hailing from Southeast Asia and transported to other regions via unsanitary, crowded cargo ships may also face infectious conditions. These workers may contract infectious diseases such as silicosis, tuberculosis, HIV, and typhoid, as well as skin infections. Those in the fishing and seafood industry are at risk of exposure to a harmful bacterium named Vibrio vulnificus which can cause severe skin infections and blood poisoning if left untreated. Labor trafficking victims are also subject to work-related injuries such as back and neck problems, vision issues, carpal tunnel syndrome, and headaches due to poor ergonomics at workspaces.

What else can Human Trafficking be?

Domestic violence or intimate partner violence (IPV) is a form of abuse that occurs within a romantic relationship or partnership. It can affect anyone, regardless of age, gender, sexual orientation or identity. The forms of abuse can vary and include emotional, physical, sexual, economic, spiritual, or psychological harm. IPV is essentially about one partner trying to exert power and control over the other through abusive behaviors.

Just like human trafficking, domestic violence is a major public health problem that affects millions of people worldwide. Those who experience IPV, especially teenagers, are at risk of engaging in risky behaviors such as drug use and sexual promiscuity. These risky behaviors can make them susceptible to becoming victims of human trafficking. Traffickers exploit these vulnerabilities to gain power and control over their victims.

The Human Trafficking Power and Control Wheel is a tool derived from a similar one used for domestic violence. This wheel represents the different forms of abuse traffickers use to manipulate their victims. The principal tool traffickers use is power and control, which is at the center of the wheel, designed to keep victims under their dominion.

Traffickers also resort to various means to demoralize and dehumanize their victims, which includes coercion and threats. These include, but not limited to:

• Intimidation: This involves using or threatening to use physical violence against the victims, their loved ones, or their property.
• Emotional Abuse: Traffickers might humiliate their victims, blame them for their situations, or make them feel worthless and dependent.
• Isolation: Victims may be isolated physically or emotionally, and denied access to basic medical care.
• Denial and Blaming: Traffickers often downplay their involvement in the abuse or blame victims for their situations.
• Sexual Abuse: Victims may be forced into unwanted sexual situations or pregnancies to exert control and manipulation.
• Using Citizenship or Residency Privilege: Traffickers may misuse power related to immigration status or documentation as a means of control.
• Economic abuse: Debt bondage, where victims are kept in perpetual debt, can be a method of control.
• Coercion and Threats: Threats of physical abuse or deprivation of basic needs are strategies used by traffickers.

This summary provides an overview of the large scope and different forms that such abuses can take.

What to expect with Human Trafficking

In taking care of victims of human trafficking, it’s crucial to adopt a victim-centered approach. This means that care is primarily focused on the victim, designed according to their needs, and delivered in a compassionate, understanding, and respectful way that respects their culture and language. It’s important to respect the victim’s choices and prioritize their safety and well-being.

The goal is to ensure victims don’t experience further harm or emotional distress. Trauma, which refers to the emotional or physical harm that a person experiences following an incident and its long-term effects on their overall well-being, should be avoided.

In providing care for victims of human trafficking, it’s critical to use a trauma-informed approach. This involves healthcare providers understanding the vast impact of trauma on the victim’s life and ensuring they don’t cause any additional harm. It’s important for providers to be able to recognize signs of trauma, both in what the victim says and the signals they give off, and to offer suitable treatment options and referrals where necessary.

An effective trauma-informed approach involves the whole healthcare team and engagement in shared decision-making, drawing on the skills and expertise of multiple professionals. It’s important to respect cultural diversity, promote gender equality, and consider the needs of the LGBTQ community, by creating an empowering environment.

Empowering victims helps them start to regain control over their lives. This includes giving staff the tools to recognize signs of human trafficking and provide appropriate care and resources. Training should aim to empower providers to advocate for changes and create improved methods for handling these cases.

Developing protocols for encountering victims of human trafficking should be similar to those for domestic violence or sexual assault. It’s important to know what local resources are available, such as women’s shelters, assistance centers, and support from law enforcement. Also, these protocols need to cover how to identify potential victims, how to talk to them, and how to keep them and others safe.

Considering long-term psychological impacts is crucial when referring these patients for further treatment. Given their complex emotional and physical states, providing ongoing care can be a challenging task. Coordination with multiple care providers is essential, as is ensuring victims’ basic needs – such as clothing, food, and safe accommodation – are met.

Referrals could include consultation with a dietician for severe malnutrition, infectious disease specialists for communicable diseases or sexually transmitted infections, and surgeons or dermatologists for the removal of tattoos or treatment of burns or other injuries. For children who have experienced delays in their development, additional support will be necessary.

Community support groups, faith-based programs, and legal services can also play a huge role in assisting victims in their transition to survivors. The survivors themselves can provide valuable insights, helping to guide care and training programs for this vulnerable group. For instance, a study conducted in 2015 highlighted that victims felt intimidated and judged by healthcare providers, suggesting that care should be delivered in a more compassionate, understanding and nonjudgmental way.

Continuing research in this area is needed to better understand and respond to this hidden crime, and survivors should be involved in educating healthcare providers about their experiences and needs.