Continuing Education Activity

Human trafficking, a human rights violation, is a pressing public health concern that transcends all races, social classes, demographics, and gender. No population is exempt from the ever-present threat of traffickers. Healthcare providers come into contact with individuals being trafficked, usually in the emergency department. Trauma-informed care acknowledges patients’ life experiences to deliver effective care, improve patient engagement, minimize the risk of continued trauma, and reduce missed opportunities. Identifying signs of trauma, recognizing verbal and nonverbal cues, assessing a victim’s response, and referring to appropriate team members are key components of effective trauma-informed care. Missed opportunities to identify, inform, and empower these victims perpetuate this physically and psychologically debilitating disease.

Objectives:

• Understand the financial, legislative, and global implications of human trafficking.
• Identify the red flags of human trafficking.
• Improve communication and better assess responses during interviews of patients who are potential human trafficking victims.
• Describe interprofessional team strategies for improving care and early detection of human trafficking victims.

Introduction

Human trafficking is a pressing public health concern that transcends all races, social classes, demographics, and gender. No population is exempt from the ever-present threat of traffickers. Human traffickers are motivated by greed, driven by quota, lack respect for human rights, prey upon the vulnerable, and damage their victims' psychological and physical well-being. The extent of the economic and social impacts on society are unknown and require further research to define and guide community-based care, protocols, and formal curriculum changes.[1]

Financial and Global Statistics

Human trafficking is a $150 billion industry globally. The International Labour Organization's (ILO) 2016 estimate reveals that 40.3 million people were victimized worldwide through modern-day slavery, 5.4 victims per every thousand people worldwide. Of these 40.3 million victims in 2016, 29 million were women and girls (72% of the total). Almost 5 million in 2016 were victims of forced sexual exploitation globally, with children making up more than 20% of that number. According to new 2016 global estimates, data collected by the ILO and the Walk Free Foundation (WFF) in partnership with the International Organization for Migration (IOM) as part of their contribution to the Sustainable Development Goals (SDG), puts the number close to 25 million persons who have been subjected to forced labor worldwide and 15.4 million in forced marriages. Loss of freedom is the common thread that binds them together. The exact number of trafficking victims is difficult to quantitate due to the concealed nature of the rapidly progressing disease and public health emergency.[2]

Trafficking Versus Smuggling

Distinguishing between human trafficking and human smuggling is essential. According to the Trafficking Victims Protection Act (TVPA), an anti-trafficking federal law established in 2000 under President Clinton's administration, human trafficking is defined as the exploitation of a person or persons for sex or labor using "force, fraud, or coercion."

Smuggling differs from trafficking because it involves the illegal crossing of borders and is usually consensual. Typically, the relationship between the smuggler and the person being trafficked terminates upon arrival to the destination country. Smuggling indebtedness can lead to trafficking as a means to resolve a fee owed to the smuggling entity. 

Trafficking in persons (TIP), also known as modern-day slavery, is a crime in all 50 states under federal and international laws and does not require the physical transport of a person. TIP can and often does occur in local communities and schools as well as near popular sporting venues.[3]

Essential Elements: A-M-P Model

Human trafficking involves three essential elements: action, means, and purpose. According to the National Human Trafficking Resource Center (NHTRC) and the TVPA, the Action-Means-Purpose, or A-M-P Model, helps determine whether force, fraud, or coercion was present, indicating the encounter was not consensual. A trafficker recruits, harbors, transports, provides, or obtains an individual. Force, fraud, or coercion is used to compel the victim to provide commercial sex acts, labor, or other services.[4]

Federal law defines sex trafficking as "the recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purposes of a commercial sex act, in which the commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age." Force, fraud, or coercion do not 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 easier to exploit and manipulate, thus vulnerable to trafficking.

The TVPA's definition of labor trafficking is "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."

The United States Department of Health and Human Services's (HHS) "Look Beneath the Surface" campaign and SOAR training in 2017 provided much-needed insight into TIPs based on the latest amendments to the TVPA. For example, force may involve rape, torture, beatings, or imprisonment and can be psychological or physical.

Physical confinement is rare; however, "invisible chains" are often used to maintain power and control, similar to intimate partner violence. Fraud may include false claims of a job, marriage, promises of a better life, or a family. Coercion also involves threats, debt, or bondage that help foster a climate of fear and intimidation and may consist of abuse of the legal process.

According to the TVPA, a commercial sex act is any sex act where anything of value is given to or received by any person, such as survival sex, drugs, transportation, food, or clothing. 

Legislative Victories: The 3P's Approach

Over the past 18 years, the US Congress has passed several comprehensive bills to bring this crime to light in domestic and international communities. This legislative process finds its basis in the 13th Amendment to the US Constitution, which banned involuntary servitude and slavery in 1865. One such law adopted in 2000 is the TVPA that combats TIPs using the "3 Ps" approach: protection, prosecution, and prevention.[5][6][7]

Protection

The TVPA established several necessary protective measures for trafficking victims in the United States. Regardless of immigration status, trafficked foreign persons are eligible for federally funded benefits, such as healthcare and immigration assistance. The T nonimmigrant status (T visa) is a protective measure that prohibits deportation or removal of a trafficked victim and sometimes offers a path to permanent residency. Human trafficking victims are especially vulnerable to re-trafficking within two years of first being trafficked and upon return to an originating country due to debt bondage or psychological, emotional, and economic conditions. Reintegration into society, coupled with functioning within societal pre-determined norms, can be traumatic for an already traumatized person who traffickers have exploited. Re-victimization must be avoided by enacting protective measures. 

Prosecution

Under the TVPA Act, federal prosecutors were armed with additional tools to bring traffickers to justice for their crimes against humanity. The TVPA explored the existing statutes and broadened its conservative approach. The new legislation mandated financial restitution to the persons they had exploited through trafficking and offered more substantial penalties for those convicted of trafficking crimes. Revisions of the TVPA and subsequent enactments further defined human trafficking as "severe forms of trafficking in persons," including both sex trafficking and labor trafficking.

Prevention

The third "P," prevention, is perhaps the most important. The TVPA strengthens prevention efforts on behalf of the US government. International incentives were enacted to improve economic conditions around the world to deter TIPs. The Office to Monitor and Combat Trafficking in Persons was created within the State Department due to the TVPA. According to the US Department of State, annual TIP reporting was mandated and rated countries on their efforts to reduce TIPs.[8][9][10][11]

Furthermore, the TVPA required the creation of an Interagency Task Force to Monitor and Combat Trafficking, and TVPA reauthorizations were enacted in 2003, 2005, 2008, and 2013. In 2015, the adoption of the Justice for Victims of Trafficking Act allowed for additional tools to address this human rights issue and directed the Attorney General to create a National Strategy to Combat Human Trafficking and ensure its ongoing maintenance.[12][13]

These legislative directives, ensured by the passage of the TVPA and the Trafficking Victims Protection Reauthorization Act (TVPRA), bring human trafficking to the forefront of the conversation internationally. Prevention through education is paramount in efforts to curb the growth of this $150 billion industry, which is thought by some to surpass the drug trade in the market value of criminal enterprises. Healthcare providers are on the frontline of these efforts as the first point of contact for most victims. 

The US Department of State also prosecutes human trafficking and smuggling cases. Diplomatic Security Service (DSS) agents and analysts often support foreign law enforcement agencies in an attempt to combat the global epidemic of TIP. On a domestic front, the US Department of State works with federal, state, local, and tribal leaders to investigate potential modern-day slavery cases for sex or labor exploitation.

Etiology

The disease of human trafficking may find its etiology in a multitude of contributing factors that make a person susceptible to a trafficking situation.

Adverse Childhood Experiences

Adverse Childhood Experiences (ACES) can increase the likelihood of risk-taking behavior that could predispose a person to a trafficking situation. A better understanding of how a high ACE score can potentiate a trafficker's hold on a victim is best explored through research. The CDC-Kaiser Permanente Adverse Childhood Experiences study was a massive study, which began in 1995 and concluded in 1997, that investigated the ramifications of child abuse and neglect on health and well-being later in life.[14] The CDC continues ongoing surveillance of study participants. Annually, through local state-based Behavioral Risk Factor Surveillance System (BRFSS) reporting, the effects of ACES on survivors, communities, and overall public health are measured. The ACE Pyramid conceptualizes the framework for the ACE study as it relates to individual health and well-being across the lifespan, from conception to death.

According to the ACE Pyramid, neurodevelopment is disrupted or stunted following an adverse childhood experience. Social, emotional, and cognitive impairments can result in high-risk behaviors that negatively impact overall health. Disease, disability, and social problems ensue, cascading to an early death. Therefore, a correlation exists between a higher ACE score and an increased risk of poor physical and mental health due to poor choices, risky behaviors, and social issues.

An ACE questionnaire asks difficult, emotion-provoking questions about growing up during the first 18 years of life. Questions are related to physical, emotional, and sexual abuse and the frequency of such insults. The suicide of a family member, drug addiction, and mental health issues play roles in score calculation. ACE scores range from zero to 10, with zero representing no exposure. 

According to a Florida study conducted between 2009 and 2015, trafficking abuse reports were highest among children with an ACE score of six or higher. Children with a sexual abuse history in connection with a higher ACE score had an increased chance of exploitation by traffickers. According to a 2017 study, sexual abuse was the most reliable predictor of a person's exploitation by traffickers.[5]

Lesbian, Gay, Bisexual, Transgender, and Questioning (LGBTQ) Population

A critical distinction among the lesbian, gay, bisexual, transgender, and questioning (LGBTQ) population was revealed by the 2012 North Carolina, 2011 Washington, and 2011 and 2012 Wisconsin Behavioral Risk Factor Surveillance System (BRFSS) surveys. Lesbian, gay, and bisexual (LGB) individuals had higher ACE scores than their heterosexual counterparts. In this 2016 study, Austin, Herrick, and Proescholdbell concluded that the higher prevalence of ACES among LGB individuals might account for some of the increased risks for poor adult health outcomes, poor choices, and heightened risk of being trafficked.[15]

The transgender community may seek expensive hormone therapy and resort to "survival sex." This vulnerable position of needing money to buy hormone therapy from black-market suppliers at inflated prices with exorbitant interest rates can increase the chances of being lured into trafficking. Transgender youths may have additional vulnerabilities that heighten their risk of being trafficked, such as homelessness, addiction, depression, lack of financial or emotional support from family, being victims of intimate partner violence, and a history of sexual abuse as a child. Transgender individuals with HIV are also vulnerable to being trafficked if they struggle to meet their basic needs of food and shelter.

The National Center for Transgender Equality (NCTE) conducted a 2015 US Transgender Survey and found that 5% of all participants had engaged in sex work for income in the past year. Fifty-five percent of those who had resorted to survival sex in the past year were transgender women. Approximately 19% had participated in "survival sex" for money, food, sleeping quarters, or other goods or services. According to one study, those who had engaged in sex for money were more likely to have experienced some form of intimate partner violence or sexual assault. Debt bondage places an invisible chain that binds a victim to a "Romeo" or "guerilla" pimp. The invisible chain tightens with unmet quotas and may become a physical one.[16]

Further resources provided by the Polaris Project address the risks of being trafficked within the LGBTQ community and are available on their website.

Trafficking Risk Factors and Vulnerability

Sexual abuse puts an individual at risk for substance abuse, mental health issues, and a lack of social norms, belonging, or a sense of family. Vulnerability and feelings of distrust towards authority figures take the place of security. Often those who are supposed to protect an individual are the initial perpetrators of the insult or crime. "Forgotten," "invisible," "different," "broken," and "discarded" are all words used to describe the feelings of victims of human trafficking. Traffickers prey upon this vulnerability, use it to their advantage, and strategically place themselves nearby. Often seen as a rescuer who offers a chance at a better life, security, or a remote possibility that better days are ahead, a trafficker is a profiler, trolling for victims to turn a profit.

Traffickers do not discriminate based on gender, race, social demographic, immigration status, or economic status. No exact mold fits a victim. Anyone is at risk, but specific populations have a higher vulnerability risk. The US Department of Health Office on Trafficking in Persons provided a fact sheet in 2017 to further highlight at-risk groups, such as survivors of child abuse, sexual abuse, assault, interpersonal or intimate partner violence, gang violence, or community-violence exposure.[1]

The SOAR Campaign further delineates at-risk, vulnerable individuals as those lacking a stable support structure or home life, such as a runaway, a foster child, a child in the juvenile justice system, a homeless youth, an unaccompanied minor, a person displaced due to a natural disaster, or an individual with a language or cultural barrier. Increased risk also involves those with substance abuse problems, undocumented or migrant workers, and the LGBTQ population. Minorities, those with disabilities, and those on Native American reservations can be at a higher risk of being trafficked.

The US Department of Education published a fact sheet for schools entitled "Human Trafficking of Children in the United States" that discussed the vulnerability of school-age children and human trafficking incidence. In identified child-trafficking cases, children commonly were involved in stripping acts, pornography, forced begging, commercial sex, and drug sales. Children at most significant risk were identified as working in restaurants, in hair and nail salons, as nannies or au pairs, or in agricultural settings. Signs of child trafficking include unexplained absences, poor attendance, runaway behavior, boasting about frequent travel to other cities, inappropriate dress for the current weather, being sleep-deprived or malnourished, or impairment due to drugs or alcohol.[17]

Lack of a stable support structure and social media accessibility may put a child at risk of being targeted for sexual exploitation. Social media websites, classified advertisement sites, chat rooms, and after-school programs are potential venues for youth exploitation. School hallways pose a risk, as a trafficker may be another student. A trafficker may promise a "happening" party or a good time to entrap an unsuspecting, troubled, or bored youth. 

Educational campaigns, such as the Blue Campaign created by the US Department of Homeland Security, offer much-needed insight into the identification and treatment of victims of human trafficking. The Blue Campaign by the Department of Homeland Security offers sex trafficking awareness videos to educate youth on the risks of being trafficked in familiar places such as schools, coffee shops, malls, sporting venues, and other hangouts.

Epidemiology

The National Human Trafficking Hotline: Reported Cases

When exploring the epidemiology of human trafficking, one must first examine data collection, results, and the organizations that provide this service. The US Department of HHS funds the National Human Trafficking Hotline, operated by Polaris, a nongovernmental organization. The National Human Trafficking Hotline's data collection gathers invaluable information to assist training programs and victims domestically and abroad. For example, 2017 data collection indicates that California, Texas, and Florida rank the highest in reported cases and referrals.[18][19][6]

To date, the hotline has answered more than 100,000 calls; 7,000 were from potential victims of human trafficking. According to Polaris hotline statistics for the United States, more than 30,000 cases of trafficking in persons and more than 8,000 tips to law enforcement were identified since 2007. The National Human Trafficking Hotline is a 24-hour, confidential, multilingual hotline covering more than 200 languages for victims, survivors, and witnesses of human trafficking.

• The hotline number is 1-888-373-7888.
• Text "HELP" to 233733.
• Live chat at humantraffickinghotline.org.
• Email help@humantraffickinghotline.org.

Childhood Statistics/Cases

Another resource for reporting cases and gaining information as it relates to the trafficking of minors is the National Center for Missing and Exploited Children (NCMEC). In 2016, The NCMEC estimated that one in six endangered runaways were likely victims of sex trafficking. Sex traffickers target children as young as nine, with the average age between 11 and 14. Labor trafficking ages vary. The Global Estimates of Modern Slavery by the ILO, WFF, and IOM reported that of the 4.8 million sexually exploited in 2016, 20% were children.[2][20][21]

• To report sexually exploited or abused minors, call the National Center for Missing and Exploited Children’s (NCMEC) hotline at 1-800-THE-LOST, 1-800-843-5678.
• In the case of an immediate emergency, call the local police department or emergency access number.
• Child protective surfaces and local law enforcement will assist healthcare providers in local reporting requirements for minors involved in a possible abuse situation. Ages of sexual consent may vary from state to state. Thus, the need to consult local agencies. 

Global Repository of Data

The International Organization for Migration (IOM), in partnership with Polaris and the UN Migration Agency, has launched a Counter-Trafficking Data Collaborative (CTDC) with a global repository of data on trafficking in persons. Victim identities are protected, and the information gathered assists in bridging gaps in publicly available data. Essential components of the CTDC's role to combat the war on human trafficking are data collection efforts and providing public access to the data. The first of its kind, this global repository of data combines data from the IOM records of more than 45,000 human trafficking cases and more than 31,000 cases from Polaris. This collaborative data tracking system fosters a data-rich environment and transcends borders and individual agency operational challenges. This comprehensive, international database is a positive byproduct of this partnership. See the CTDC website.

Global Report on Trafficking in Persons

Each year, thousands of individuals fall victim to national and international trafficking. Almost no country is exempt from human trafficking infractions or being the originating, transient, or destination country. The United Nations Office on Drugs and Crime (UNODC) Global Report on Trafficking in Persons further explores the bond between trafficker and victim and the trafficking origin.

The 2016 UNODC Global Report on Trafficking in Persons shines a light on the trafficker's profile and relationship with the one who is trafficked. Traffickers and their victims tend to originate from the same geographical area, speak the same language, and share the same ethnic background. These commonalities foster a level of trust between the trafficker and the victim. The trafficker exploits this relationship for financial benefit. Traffickers rarely travel abroad to recruit, instead focusing on domestic recruitment. 

Globally, local trafficking is on the rise. A trafficker will go to a destination country to exploit the victim. Countries most vulnerable to trafficking are those with high levels of organized crime and those ravaged by conflicts. From 2012 to 2014, more than 500 different trafficking flows were detected, and countries in Western and Southern Europe identified victims of various citizenships. The 2016 UNODC Global Report on Trafficking in Persons reports 79% of classified trafficked individuals globally are women and children and documented a clear link between migration and human trafficking. The movement of migrants and refugees is the most substantial reported migration since World War II, with an estimated 244 million international migrants worldwide. 

Forced migration resulting from refugees fleeing war-torn areas makes women and children especially vulnerable to exploitation by traffickers. The movement of Syrians escaping the war is one such example. Children face exploitation as "child soldiers." Armed guards abduct individuals on migratory routes and exploit them as slaves for forced labor or sex. In September 2015, world leaders adopted the 2030 Sustainable Development Agenda and embraced the war against trafficking in persons on a global front. This plan called for all forms of violence against women and girls to cease. 

According to the 2016 UNODC Global Trafficking in Persons Report, no country is immune from trafficking in persons, and over 500 migratory flows of trafficking were detectable. Sub-Saharan African and East Asian victims are trafficked to numerous global destinations. Affluent areas, such as Western and Southern Europe, North America, and the Middle East, have victims from all parts of the world. In Southeast Asia, forced marriages are on the rise. Central America, the Caribbean, and South America frequently report cases of girls becoming victims of sexual exploitation. Trafficking in fishing villages for forced labor is a problem in parts of the world, such as Ghana and Taiwan. Organ retrieval as a form of trafficking is less frequent but exists in some parts of the world. 

The UNODC 2016 study also reports a change in the victim profile over the past decade. The number of male victims is increasing. The total number of forced labor victims increased between 2012 and 2014, with 63% being men. Another alarming fact from this report is that female participation increased. Of 6800 persons convicted of human trafficking during 2012-2014, 60% were male. Young girls are recruited and controlled by older women. More couples are actively involved in trafficking. Posing as "stable couples" allows traffickers to seem more genuine and trustworthy while actively recruiting and exploiting victims as a team. Former victims become active participants in recruitment, some to reduce their debt bondage and end their sexual exploitation. Others who willingly participate in the abuse use tactics of power and control. If trafficked persons are engaged in criminal activity, they are less likely to cooperate with police, thus allowing the trafficker even more control.

According to the UNODC, the average number of trafficker convictions was low, with five victims per convicted offender. North America had the highest number of convictions compared to the rest of the world. The United States reported 150 to 200 convictions annually, while Europe reported the highest number of trafficking victims.[22].

Pathophysiology

Missed Opportunities and Myths

A recent study revealed that 87.8% of human trafficking survivors had been in contact with a healthcare provider in some capacity during their victimization. Furthermore, 68.3% had received an evaluation in the emergency department. (The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities, Lederer, 2014) Missed opportunities to identify, inform, and empower these victims allow this physically and psychologically debilitating disease to spread.

Recently, a smaller study of emergency department nurses in an urban setting concluded that the nurses want better awareness of the specific resources available to human trafficking victims. Ongoing research into the impact of institutional policy, human trafficking protocols, and continuing education regarding the recognition and treatment of trafficked individuals is required[22].

Myths or misperceptions often lead to missed opportunities to identify victims[DOS, 2013]. Education on these potential media-induced sensationalized myths is essential for healthcare providers and first point-of-contact personnel. First, trafficking in persons is not just a crime that occurs in a faraway place or only involves migrants or foreign nationals. Individual exploitation happens in every part of the world, including suburbs, big cities, and hometowns.

Victims can be coerced to take part in crimes, thus landing them in a detention center or jail. They may present to the emergency department for medical clearance. Proper screening of these individuals is vital in our attempts to identify victims, recognize the red flags of trafficking, and take appropriate action. Having the mindset that this patient is "just a criminal or "just a prostitute" is a bias that inhibits practitioners from reading verbal and nonverbal cues and recognizing the patient as a human trafficking victim. A victim may be revictimized if returned to an exploitative environment. Revictimization is a chief concern for practitioners. The United Nations Convention against Corruption defines “revictimization” as "a situation in which the same person suffers from more than one criminal incident over a period of time." Perhaps more important when assessing and interviewing a potential victim of trafficking is the potential for "secondary victimization.”  The UNODC Model Law on Justice in Matters involving Child Victims and Witnesses of Crime defines secondary victimization as "victimization that occurs not as a direct result of the criminal act but through the response of institutions and individuals to the victim."[22]

If an individual is free to come and go, then he or she may not be recognized as a person being trafficked. As discussed previously, bonds are often not physical chains or cuffs but "invisible" or psychological ones. Fear paralyzes victims, acting as a shackle that emotionally confines them to the trafficking situation. Mental weapons used by the trafficker to exercise power and control over a victim may include threats of harm to children, siblings, or other family members; deportation or return to a traumatizing situation; calls to social services; and physical violence or reminders of past violence for misguided offenses. 

Debt bondage, withholding of pay, and maintaining possession of identifying documents may further lead to an invisible bond or tie to the pimp/trafficker. Trafficked victims may use a school bus, a public bus, a train, or a taxi. Control over the trafficked person is far beyond a physical wall, chain, or border. Much like intimate partner violence, victims usually do not self-identify, self-report, or recognize that they are being manipulated, controlled, stigmatized, or dehumanized.

Cultural Considerations

Language barriers and cultural misconceptions may lead to a missed opportunity to identify a potential victim.[23] Inconsistencies in stories or history may become lost in translation, especially if a provider fails to obtain an interpreter with no relationship to the exploited. A staff member versed in the same language or who shares the same culture as the victim may be able to spot these subtle clues and ease the cultural shock and miscommunication. However, the availability of staff members with the optimal background and primary language is not always feasible in a busy healthcare setting. When red flag behaviors are passed off as specific cultural behaviors, this demographic profiling could create a missed opportunity to identify the patient as a victim.

In suspected cases of human trafficking or intimate partner violence, it is imperative that no family member or accompanying party be allowed to translate. Ensure that your institution provides a certified interpreter.

Reasons Victims/Traffickers Access Medical Care

Seeking health care for victims presents the opportunity for discovery. Traffickers may only seek care for their victims when they become seriously ill.[24] A multitude of factors should lead a practitioner to seek medical services for a person who is a suspected victim of human trafficking.

• Emergent medical conditions, such as profuse bleeding or pain caused by a beating or forced abortion, injury on a job site, or complications during pregnancy, such as an ectopic pregnancy
• Gynecological services for sexually transmitted infections caused by debris in the vagina from packing during menstruation or forced sex without condom use
• Follow up with an OB/GYN for a repeat beta HCG or ultrasound for a possible ectopic pregnancy identified in an emergency setting
• Addiction issues such as a severe overdose or withdrawal signs and symptoms
• Dental emergencies or plastic surgery consultations
• Prenatal care or lack thereof
• Health-related mental problems such as depression, suicide attempts, or anxiety disorder
• A patient on a psychiatric hold or court-mandated order
• Severe wound infections with signs of septicemia may force introduction into the healthcare system

Traffickers seek out the quickest means of care, and lengthy emergency department waits may lead to their decision to leave with the victim before receiving medical treatment. They may also "hospital shop" for quicker wait times from door to the provider. An accompanying "family member" that is impatient, "in your face," or upset over lengthy delays in overcrowded emergency rooms or clinics may, in fact, be a trafficker. Another indicator is the "spouse" or "boyfriend" that insists that a high-risk patient, such as one with a possible ectopic pregnancy or appendicitis, leave without being seen, against medical advice, or before care is completed.

Remember, a victim comes from all walks of life and may be perceived as having a stable home in a suburban community. Victims will never look or act the same; their individual responses to their traumatic event will follow no specific protocol. Healthcare providers must be diligent in identifying these silent victims, forced into a situation of no fault of their own and made to carry out acts that reap emotional and social ramifications for years to come.

History and Physical

Exploitive Environments

When healthcare workers encounter potential victims of trafficking, a detailed work and social history will assist in identifying red flags. A better understanding of the most common areas where persons are targeted for exploitation will help practitioners assess a potential victim.

Victims of labor trafficking tend to be near farms, fisheries, factories, or businesses such as nail salons, massage parlors, restaurants, and areas with high immigrant populations. Labor trafficking victims are in traveling sales crews, peddling or begging rings, landscapers, construction workers, domestic workers, nannies, elder adult caregivers, and agriculture work. Victims who travel selling, peddling, or begging are vulnerable due to homelessness and working in unfamiliar settings. If left behind in an unknown city, they may resort to "survival sex." Immigrants may lack the power to communicate their situation due to language barriers; this enables handlers from similar backgrounds to approach them and speak for them. 

Some common sex trafficking sites are hotels or motels, street-based locations, residences functioning as brothels, commercial-front brothels, escort-service companies, truck stops, bars, and strip clubs. Sex trafficking can happen at home, with parents, intimate partners, or other family members being the perpetrators. Victims may not see themselves as victims and may refer to the trafficker as their "daddy" or "boyfriend." [25][22][20]

Labor Trafficking Considerations

Common presenting complaints of victims of human trafficking are much like those of intimate partner violence but may vary depending if the patient is a victim of labor or sex trafficking. Labor traffickers prey on specific vulnerabilities to entice individuals to accept substandard working conditions. Workers in the agriculture industry, factories, and domestic servitude sectors are vulnerable to human trafficking due to their work visas and immigration status being controlled by one employer. This power over the individual and fear of deportation allow the trafficker to manipulate the worker, leading to victimization. 

Agricultural and industrial workers who are forced to work long hours with substandard wages may be isolated and confined by using dogs, armed guards, barbed wire or other fences, or locks. The seasonal nature of their work and movement from place to place heightens their vulnerability due to regularly being subjected to unfamiliar surroundings. 

Domestic workers are also isolated, forced to live on the premises, and may lack access to cell phones and other communication devices. Language barriers add to vulnerability and the inability to communicate their situation and needs. Workers in strip clubs and bars may have fraudulent work visas and ties to organized crime, rendering them vulnerable to trafficking. Drugs and alcohol are used as manipulation tools.

Labor laws may not apply to subcontractors or independent contractors, thus increasing vulnerability risk. A common theme among persons who are exploited and traffickers exists. The victim is kept isolated by proximity or language, vulnerable due to immigration status, without resources, indebted, without the protection of labor laws, controlled, and manipulated. 

Trafficking in persons for labor exploitation may put a patient at risk for malnutrition, communicable diseases such as hepatitis and tuberculosis, pesticide and chemical burns, or exposure and work-related injuries due to lack of safety equipment such as safety belts, gloves, goggles, and masks. 

Labor Trafficking Red Flags

Stop, Observe, Ask, and Respond (SOAR) will guide practitioners in determining whether red flags indicate a potential case of human trafficking. Healthcare providers must decide if a crime occurred or if all three elements of trafficking in persons exist: force, fraud, and coercion. The provider's role is to recognize a potential case of human trafficking, empower the person being exploited, educate the victim on resources and established support structures, and provide a framework for a trauma-informed, victim-centered approach to healthcare.

Providers should observe for verbal and nonverbal clues and ask open-ended questions in a private, non-judgmental way to determine if the patient is a potential victim of human trafficking. Questions to ask regarding labor trafficking suspicions may include, but not be limited to, the list below.

1. Are you being paid the wages that were part of the initial agreement?
2. Can you change jobs if you want to?
3. Would anything happen to you if you quit your job?
4. Can you come and go as you, please, take bathroom breaks, and eat when you want?
5. Do you live with others? What are your home conditions, and where do you sleep? Do you have a bed? Do you sleep on the floor? Is it too cold or too hot where you live?
6. Did you pay a fee to get your job? Do you owe a debt to your employer?
7. Do you have access to your money and your identification? 
8. Has your employer ever threatened you? 
9. Did you have eye protection, a mask, or a safety harness? Personal protective equipment such as gloves? Respirators?
10. Does your employer provide your housing? 
11. Are you working in the job you were hired to do? 
12. Are you concerned about your safety? Your family or your children's safety?
13. How many hours do you work a day? How many days per week?
14. Have you moved around a lot? Do you know your address? Can you give me directions or the location of your house?
15. Do you take care of others?
16. Are there locks on the doors or bars on the windows? Can you leave freely?[26]

Barriers to Identification of Victims

Healthcare providers, for a variety of reasons, may fail to stop, observe, and ask questions to identify a potential victim of human trafficking. The absence of protocols, myths, stereotypes, biases, fear of no available resources, lack of education regarding human trafficking red flags, time constraints, lack of privacy, or an inability to separate the person from the potential trafficker all may play a part in the failure to identify victims. The victim declining to give a history and self-identify are hindrances in identifying human trafficking.[23]

Diagnostic Overshadowing

A patient who presents with multiple visits and complains of pain that has no organic cause, a "frequent flyer," as labeled by some, may be an overlooked victim of trafficking. Patients who present with stress-related issues on multiple visits or who return over and over with psychological holds for overdoses or suicidal ideations may be victims of trafficking. They risk being released back into the trafficking situation and victimization each time. Providers must recognize the potential for "diagnostic overshadowing" and be attuned to their own emotions and potential for bias.[27]  Traffickers can pose as parents, grandparents, or spouses. As providers, practitioners must stop, observe, ask, and respond.[4]

As front-line participants in the battle to combat human trafficking, healthcare workers must be aware of these potential barriers to victim identification. Often, providers rush from patient to patient or exam room to exam room, are caught between documentation and hands-on assessment and care, and treat patients in hallways, lobbies, or corridors. These practice realities add to the potential for a missed opportunity. 

Sex Trafficking Red Flags 

According to the National Human Trafficking Resource Center (NHTRC) and hotline, general indicators or red flags of trafficking in persons may include but not be limited to the following with some modifications:

1. Inconsistent history or a history that appears coaxed. It may be difficult to determine if a language barrier is present.
2. Resistant to answer questions about the injury or incident.
3. Avoids eye contact, is nervous, fearful of touch.
4. No idea of the address or general area where they live.
5. No control over their finances and lacks decision-making capacity.
6. Accompanied by a controlling companion or family member that refuses to let the patient speak for themselves or be alone for care or insists on being the translator.
7. Exhibits bizarre, hostile behavior. Resistant to care and assistance. May have initially consented but changed their mind after being asked to undress for an exam.
8. No identification or the companion has it in their possession.
9. Under age 18 and involved in a commercial sex act.
10. Tattoos or branding signs. Markings may say "daddy" or "for sale," imply ownership or read as an advertisement for a product.
11. Multiple sex partners.
12. Inappropriate attire for the environmental conditions of the area.
13. Attempt to reason away bruises or ligature marks by claiming a bruising or rare blood disorder.
14. Silent, afraid to speak, cringes at the sound of a loud voice.
15. Uses trafficking "lingo" such as "the life" or other words common in the commercial sex industry.
16. Has addiction issues such as opioids.
17. Admits to a forced sexual encounter or being forced into sex acts.[22][28][29]
18. Has a cover story to avert suspicion, but details may vary or be inconsistent with a query. Law enforcement may refer to this as a "legend."

Head-to-Toe Assessment

A head-to-toe, full assessment in this patient population is vital. An examination may prove difficult due to the emotional and psychological state of the victim. These patients may appear as uncooperative or vague and give an inconsistent history. These reactions are manifestations of their trauma. Provider frustration or stereotyping may arise, leading to the desire to exit the room quickly, with a quick determination of probable diagnosis and treatment. As discussed above, the potential exists for "diagnostic overshadowing." As with any trauma patient, a high index of suspicion should be present for co-existing conditions and comorbidities.

Conduct the assessment in private, not allowing anyone accompanying the patient to be present. A chaperone may be present and a certified interpreter, if required, to facilitate a feeling of trust, establish rapport, and build a trusted network of people and organizations willing to help. If possible, provide a same-sex provider for the physical exam/assessment with the available staffing mix. During the exam, the patient may seem emotionally absent, hyperventilate, and not verbalize feelings of discomfort. Be alert to nonverbal signs. Reassure frequently and promote a relaxed, non-rushed atmosphere. Avoid interrogating the victim; ask only direct, pertinent, open-ended, yet neutral questions. Maintain eye contact with the victim, barring cultural considerations, and avoid writing while the victim speaks. Ensure the victim is entirely undressed and in a gown so a complete trauma assessment can be initiated. Specifically, examine for the following:

• Bruising; old, healing, or new lacerations; hematomas; signs of acute or chronic head trauma or a headache; missing hair or bald spots.
• Trouble hearing; damage to the auditory canal or eardrum; signs of trauma to the oropharynx such as lacerations or burns, blood in the mouth, ulcerations, tooth decay, broken teeth, gingival irritation, tongue abnormalities; signs of anemia or dehydration in the oral mucosa.
• Visual defects, sudden or gradual onset; tattoos or brands in the hairline or on the neck; signs of strangulation such as bruising.
• Signs of chest trauma, murmurs; cigarette burns; tattoos that imply ownership; bruising in various stages of healing; signs of stress-related cardiovascular issues such as arrhythmias or high blood pressure.
• Respiratory issues that would indicate inhalation injuries from chemical exposure, toxic fume exposure, asbestos exposure, or mold exposure.
• Signs of tuberculosis such as night sweats, coughing up blood, fever, and weight loss.
• Signs of stress-related respiratory or gastrointestinal problems.
• Damage to lung tissue due to prolonged exposure to chemicals or pesticides, aspiration pneumonia, or other inhalation injuries; meth lab exposure can produce burning to the eyes, nose, and mouth, chest pain, cough, lack of coordination, nausea, and dizziness.
• Hypothermia or hyperthermia from environmental exposure from working in damp, cool, poorly insulated factories or buildings; mold exposure signs/symptoms.
• Signs of gastrointestinal issues such as nausea, vomiting, diarrhea, constipation, or abdomen pain; rectal pain, itching, trauma, or bleeding; parasites in the feces or signs of abdominal trauma.
• Bruising to the back or scarring; tattoos that imply advertisement, ownership, or are sexually explicit in the pubic hair.
• Obstetrical and gynecological complaints such as sexually transmitted infections (STI) or recurrent STIs. An STI, especially if recurrent, in a minor may be the first and only sign of sexual abuse; repeated unwanted or unplanned pregnancies or forced abortions; anogenital trauma; evidence of retained foreign bodies such as in the vagina from packing during menstruation, vaginal bleeding, discharge, rashes, itching, signs of injury or forced sex.[30][30][31]
• The number of sexual partners; condom use; genitourinary symptoms present such as burning, frequency, odor, dark urine, or history of frequent urinary tract infections.
• Signs of bruising or lower back scarring from repeated beatings; musculoskeletal issues such as signs of repetitive trauma; work-related injuries or injuries such as back problems from wearing heels for hours walking the streets or neck and jaw problems from frequent, forced oral sex.
• Fractures, old or new, any contractures. Cigarette or scald burns. Ligature marks/scars around ankles or wrists. Signs of scabies, infestations (scalp or body). Impetigo. Fungal infections.
• Signs of nutritional deficits such as Vitamin D deficiencies from lack of exposure to sunlight, anemia, or mineral deficiencies; brittle or fine hair.
• Signs of anorexia, bulimia, loss of appetite, malnutrition, and severe electrolyte abnormalities.
• Growth and development abnormalities in children, dental cavities, or misaligned poorly formed teeth. 
• Neurological issues such as seizures, pseudo-seizures, numbness or tingling, migraines, inability to concentrate, vertigo, unexplained memory loss, and seizures.
• Insomnia, nightmares, waking up frequently.
• Signs of opioid or other addiction.

Signs of Physical or Psychological Torture

Signs of physical torture may present on a dermatological evaluation, such as abrasions over bony prominences, scratches or linear abrasions from a wire, or "road rash" to extremities from being thrown from or drug by a vehicle. Ropes and cords can leave elongated, broad-type abrasions. Ropes may leave areas of bruising mixed with abrasions. Belts or cords may leave loop marks and parallel lines of petechial with central sparing. Tramline bruising, two parallel lines of bruising, can result from being beaten with a heavy stick or baton. Cigarette burns tend to be circular with a 1-cm diameter and can fade in a few hours or days. Burns, in general, tend to take the shape of the object that inflicted the burn.

Trafficking victims may be beaten or subjected to torture for various reasons. The guerilla pimp may torture the victim due to not meeting a quota or breaking established rules, a displeased customer, or for no apparent reason other than to maintain control. Bruises, lacerations, marks, or scars may be present on the lower back where they are hidden more easily and do not disfigure the product/victim and inadvertently make the person being trafficked less marketable. 

Cupping therapy may leave bruises or scars that may be mistaken for abuse. Correlate this finding with a detailed history as well as the presence of other red flags. 

Psychological and Mental Status Examination

Mental health indicators of trafficking in persons may be missed or explained away as a panic attack. Again, one must stop and take an in-depth look, considering the red flags. Look for signs such as depression, suicidal ideations, self-mutilation injuries, anxiety, post-traumatic stress disorder (PTSD), and feelings of shame or guilt. Shame, a control tool used by a trafficker, may keep a victim bound to a trafficking situation. Does the patient report nightmares, flashbacks, irrational fears, irritability, social isolation, suicidal ideations, or depression?

A trafficking victim may describe a situation as if they were an outsider looking in. This mind-body separation creates a safe, alternate reality to help them cope with the atrocities they are facing and feelings of shame and guilt. They use a third-person omniscient point of view in their storyline. Sometimes patients exhibiting this behavior are categorized as impersonal or devoid of emotion, numb to their surroundings, or detached. This point of view is their survival mechanism.

Addiction issues may be present and result in withdrawal. The addiction may be fueled by the trafficker for control or by the victim to cope with the physical or emotional pain surrounding the trafficking situation. 

Documentation of Assessment Findings

Documentation of physical findings is important and may assist the victim in prosecuting their trafficker later if health records are subpoenaed. Follow established documentation guidelines and reporting requirements based on state and local statutes or federal law as addressed previously. Photo documentation may prove vital. Follow any protocols/policies specific to your institution regarding taking photos and their storage, and obtain all required consent forms.[3][32][33]

Evaluation

Recognition and Intervention

Once a practitioner identifies a potentially trafficked person, it is imperative to establish a private, quiet, safe place to assess the patient further, much like in cases of child or elder abuse. Building rapport and providing an opportunity for the victim to feel empowered is of utmost importance. Building rapport with the patient can build trust and begin to establish a trusted network of people and institutions to assist the victim. Do not start a dialogue until you can select a safe, private, and secure place.

In this era of mobile devices, where a smartphone is always within easy grasp, ensure cell phones are off and not nearby. Cell phones can be another way the traffickers control the victim. The victim may have arrived alone but is always on the cell phone. The cell phone may be the trafficker's way of "keeping tabs" or listening to everything going on in the room. 

Maintain eye contact during conversation, speak slowly and quietly, and avoid looking down at the potential victim. Instead, sit in a nearby chair where on-level eye contact, unless contrary to the patient's cultural norms, is possible. Ensure an environment where the victim can establish a sense of power and control. This empowering safe zone may allow the patient to open up and admit to being a victim. More importantly, ensuring the patient feels safe and empowered may provide the opportunity to identify the patient as a victim of human trafficking, share available resources, and convince the patient to trust and accept help.

Before starting the conversation, ask the patient if it is safe to talk now and if they feel comfortable with you in the room or if they prefer someone else. Never assume it is safe for the victim; they must confirm that it is safe. Safety is critical for the victim, staff, and nearby patients. Trafficking protocols will guide your care and determine a preset location readily available for an interview or a few minutes alone with the patient. A bereavement room for family notification in the event of trauma or sudden death may be one such place.

Inform the potential victim of trafficking that you are mandated by law to report certain disclosures. Monitor their verbal and nonverbal cues. Be alert to your facial expressions, body language, and any nonverbal signals you are exhibiting. Avoid stereotyping and revictimizing the potential victim as they disclose information. 

Communicating with Potential Victims

Communicating with victims of human trafficking can be intimidating for healthcare providers. The Department of HHS created a resource called Messages for Communicating with Victims of Human Trafficking as part of their Rescue and Restore Campaign in 2016. These messages assist healthcare providers in building a rapport with the victim and promoting a trusting environment.[34][35]

Sample Messages to Ease Communication

Sample messages for communicating with a victim of human trafficking, according to the Department of HHS.[36][37]

1. We are here to help you, and our priority is your safety. We can keep you safe and protected.
2. We can provide you with the medical care you need as well as find you a place to stay. 
3. Everyone has the right to live without being abused or hurt, and that includes you. 
4. You deserve a chance to live on your own and take care of yourself, be independent, and make your own choices. We can help you with that. 
5. We can get you help to protect your family and your children. 
6. You have rights and deserve to be treated according to those rights.
7. You can trust me. I will do everything in my power to help you. Assistance is available for you under the law, and special visas allow you to live safely in this country.
8. No one should have to be afraid all the time. We can help.
9. Help us so this does not happen to anyone else. 
10. You can decide what is best for you, but let me provide you with a number to call for help 24 hours a day. You do not even have to tell them your name if you do not want to. They are there to help you anytime, day or night. The National Human Trafficking Resource Center hotline number is 1.888.373.7888. 

Do not make false promises. Only offer what you can provide. 

Providers are not required to determine if a crime or a prosecutable offense has occurred. However, they can foster an empowering, caring environment to identify a victim for a potential rescue, provide invaluable resources to restore their lives, and help them to begin healing emotionally and physically. 

Creating an Opportunity for Intervention

The trafficker may be the accompanying family member that declines to leave the patient alone. Similar to intimate partner violence, the provider creates an opportunity to take the patient to the bathroom for a urine sample or to radiology for an x-ray or CT scan, informing the family member that they cannot go with the patient. Another way to get the victim alone is to notify the alleged family or significant other that hospital policy requires you to interview and examine everyone alone. 

Before you separate the potential victim from the family member or controlling individual, make sure you or a dedicated, trained staff member has the time to conduct an interview/assessment at that moment. 

Traffickers can be parents, "boyfriends," husbands, women, men, friends, and those you would otherwise see as protectors. Do not talk with the patient about suspected trafficking if the patient cannot be interviewed in private. The trafficker may cause the victim serious bodily injury after removing them from the facility if alerted that the healthcare provider is suspicious of the situation.

Safety

Assessment of the level of danger or threat to the patient and staff is imperative. Pay attention to your immediate area and follow preset protocols by your institution in notifying law enforcement and security personnel. 

The NHTRC can assist you in threat level assessment, danger risk, and contacting law enforcement if the patient consents. Is the trafficker still nearby? How will the trafficker act if the victim does not return? Are there minors or other family members that are in danger? Is the patient a minor? 

An interprofessional approach is best, if available, with a trained social worker nearby as predetermined in your trafficking protocol. Follow preset policies and procedures regarding abuse and neglect at your institution and according to local and state statutes. The NHTRC hotline offers invaluable assistance with resources, assessment, and the best courses of action. 

Just like when intimate partner violence occurs, ensure the patient has a safe place to go upon discharge. 

Reporting

If a patient reveals they are a victim of human trafficking, ask the patient if it is all right to call the NHTRC hotline number. Encourage the patient to call and provide them with the phone number. It may be dangerous for them to keep the number on hand, so ask them if they can memorize it or give them a "shoe" or "key" card that can be hidden in their shoe or other discrete location. 

The National Human Trafficking and Resource Center hotline number is available around the clock, and reporting information is confidential to the extent of the law. The NHTRC is a tip hotline, a place to find out about services and to ask for help. The hotline can translate and communicate with individuals in more than 200 languages. A caller does not need to disclose personal information to the hotline; the caller can remain anonymous.

The NHTRC is available to help healthcare providers in the event of a potential trafficking case when no protocols are available. Healthcare providers can gain information on social referrals such as anti-trafficking organizations, shelters, local social services agencies, legal services, and law enforcement numbers. Tip reporting is available. The hotline website provides training information and technical support. The NHTRC can guide a provider in the assessment of a potential victim. 

• Report Online or Access Resources & Referrals: www.traffickingresourcecenter.org
• Call: 1-888-373-7888 (24/7). Email: nhtrc@polarisproject.org. Live chat: www.traffickingresourcecenter.org

Mandatory Reporting/HIPAA Considerations

Guidelines for reporting suspected human trafficking cases will vary depending on the facility, location, and state and federal laws. Adults may not want to report the incident; thus, the decision to alert law enforcement is based on predetermined protocols and local or state laws coupled with patient wishes. Some states mandate reporting if serious bodily injury or a firearm is involved. 

Health Insurance Portability and Accountability Act (HIPAA) concerns are essential considerations. The practitioner must obtain permission from an adult victim of human trafficking to release any protected health information (PHI) or personally identifiable health information to the NHTRC. The NHTRC may be contacted and provided general information for a consult as long as no protected, identifiable health information is released. If the victim is under 18 and involved in a commercial sex act, follow mandatory state reporting laws for child abuse and institutional child abuse policies. 

HIPAA will permit the release of protected health information under certain circumstances, such as suspected injury or abuse. For example, if the law mandates a disclosure as in the case of child abuse or neglect, elder abuse or neglect, and in cases reportable to the medical examiner. Reporting is permissible under HIPAA regulations if the disclosure involves a crime and is an emergency, is necessary to prevent harm with patient consent, and in any situation where local, state, or federal law requires reporting. However, follow institutional guidelines and policies in place for HIPAA reporting requirements.

Treatment / Management

Trafficking Health Implications

Labor and sex trafficking carry inherent health risks and need exploration. Research studies in South Africa and West Bengal, India, regarding the effects of sex trafficking and HIV risk, determined that women and girls who experienced forced sexual encounters through being trafficked were 50% more likely to acquire HIV. One reason suggested that immature cervical epitheliums or cervical ectopy might lead to breaks in the vaginal mucosal and subsequent inflammation that increases the chance for HIV to spread during repeated sexual assaults in younger victims, but more research is required.[38][22][38]

Vulnerability and inexperience may lead to HIV and other sexually transmitted infections due to inadequate condom use and repeated exposure to older adult males throughout the trafficking lifespan. 

Sex Trafficking Health Implications

When treating these potential victims, screening for injury and STIs, such as HIV/AIDS, herpes, syphilis, gonorrhea, chlamydia, trichomonas, hepatitis, and molluscum contagiosum, needs consideration. If a recent forced sexual encounter, emergency contraception, and STI prophylaxis are considerations, following preset institutional guidelines. 

Sexual assault kits may need to be obtained. Follow sexual assault collection of evidence protocols in your local area and per institutional policy. Project Help, Rape Crisis, and women's shelters may be a resource. Pain from daily forced sexual encounters and trauma may be an issue. Problems with urinary tract issues may warrant a urinalysis or culture. A urine sample that is not a clean catch, often referred to as "dirty urine," may be obtained to test for a sexually transmitted infection such as chlamydia. A pregnancy test may be useful. Toxicology studies may be needed, and alcohol levels and withdrawal issues addressed. 

Complications surrounding forced tampon use or "packing of the vagina" by traffickers to facilitate sexual encounters (unnoticeable to customers) while victims are menstruating may be of concern. Foreign debris may be present in the vagina on pelvic examination, and cervical cultures are a possibility if any discharge is present. That "lost tampon" patient may be a victim of trafficking and require a more in-depth assessment, asking open-ended, neutral questions to spot red flags.

Labor Trafficking Health Implications

Labor trafficking victims may experience severe dehydration or malnutrition due to being forced to work long hours in construction, on farms, at factories, or in "sweatshops." Heat exhaustion or hypothermia may present in these trafficking victims.  

According to the 2016 Global Report on Trafficking in Persons, Southeast Asia is emerging as a destination for short, medium, and long-distance trafficking. Increasing in frequency, these individuals are made to endure long ocean voyages as they are smuggled into the United States and other countries on cargo ships. These overcrowded, unsanitary conditions have infectious disease ramifications.[39][40]

Communicable or infectious diseases such as silicosis, tuberculosis, HIV, and typhoid may be an issue. Scabies, lice, and bacterial and fungal skin infections may be a concern. Malaria, Chagas disease, cysticercosis, toxoplasmosis, toxocariasis, and trichomoniasis also may be risks. Asbestos concerns exist for miners who are victims of labor trafficking.[41]

Migrant workers who are being trafficked in the fishing and seafood industry may suffer from exposure to Vibrio vulnificus and subsequent necrotizing fasciitis with septicemia if left untreated. Vibrio vulnificus, found in warm climates with shallow, coastal waters, can infect a person through lacerations or breaks in their skin.

Labor trafficking victims may suffer from injuries related to poor ergonomics, such as back and neck injuries, vision problems, carpal tunnel syndrome, and headaches. 

Differential Diagnosis

Intimate Partner Violence

Domestic violence or intimate partner violence (IPV) takes many forms and involves the maltreatment of another within a romantic union or partnership. Men, women, teenagers, heterosexuals, gays, lesbians, bisexuals, and transgender individuals may be affected. Domestic violence may include emotional, physical, sexual, economic, spiritual, or psychological insults. IPV involves one partner in the relationship subjecting the other to some form of abuse to exert power and control over them. 

Much like human trafficking, domestic violence is a significant public health issue that plagues millions of people. Individuals subjected to IPV, especially teenagers, are vulnerable to practicing risky behaviors such as drug use and sexual promiscuity. These vulnerabilities place them in high-risk situations of being victims of human trafficking. Traffickers feed off this opportunity to exert power and control over a victim. Power and control manifestation takes many forms of abuse on the part of the trafficker.

The Human Trafficking Power and Control Wheel

The Human Trafficking Power and Control Wheel finds its basis in the power and control wheel for domestic violence. The wheel for human trafficking depicts the different types of abuse inflicted on trafficking victims at the hands of traffickers. Power and control, the wheel center, represent the primary weapon a trafficker uses to manipulate a victim and keep them bound to the trafficker.[42][43][44]

Other tools in the arsenal to demoralize and dehumanize a victim involve coercion and threats. 

1. Intimidation: Intimidation is another tactic used by the trafficker and involves physical violence inflicted upon children, pets, or other victims. It may include threats with a weapon or actual weapon use, destruction of property, and misleading information regarding police.
2. Emotional Abuse: Emotional and psychological abuse can be particularly devastating to a victim. The trafficker humiliates the victim in front of others, calls them names, blames the victim for the situation, and convinces them that they would be all alone if the trafficker did not love and care for them. The exploiter repeatedly tells the person under their control how worthless they are and that they are too weak to survive outside the existence the trafficker has created for them. They may threaten to expose or shame the victim by releasing sex tapes, nude photos, drug addiction, or participation in violence or sex acts against other victims. 
3. Isolation: A trafficker may isolate a victim by confinement, frequently moving so the victim cannot become familiar with their surroundings or keep them cut off from others by a language barrier. A victim may be isolated from family and friends or be accompanied by the trafficker while in a public place. The trafficker may not allow the victim access to routine, preventative medical care. Thus, medical problems may be exacerbated, and overall health compromised.
4. Minimizing, Denying, and Blaming: A trafficker often blames the victim and denies there is anything wrong with the situation, minimizes their involvement in the abuse or exploitation, and lets the victim think the victim is the reason for their current circumstance: the victim is the one that ran away, reached out to them on social media, went to that party or hotel room.
5. Sexual Abuse: Sexual assault may be useful to the trafficker as a means of power and control. The victim is treated as a sex object, only as good as the money they bring in. They may be forced to submit to sex with multiple partners daily or risk the wrath of the trafficker. Forced abortions, threats to end a pregnancy, or violence during pregnancy are control tactics. Unwanted pregnancies, either through forced sexual assault or consensual sex, are a way to control a victim.
6. Using Citizenship or Residency Privilege: The trafficker may use privilege or superiority as a means of control. The trafficker may hide or threaten to destroy immigration papers such as work visas, passports, or other forms of identification. A victim might be used as a servant or a pawn to entice others into trafficking. The trafficker or pimp may threaten the family and threaten to report to immigration.
7. Economic abuse: Debt bondage is used to manipulate and control. The victim may be charged enormous interest rates that they can never repay. They are restricted from leaving their situation because they have no access to money, are allowed only a small allowance, or have any earnings confiscated.
8. Coercion and Threats: Threats of actual physical abuse are another manipulation tool used to exert power and control over the victim. It may involve shoving, punching, hitting, kicking, and strangulation injuries. Torture can take the form of cigarette burns or branding, as well as withholding basic needs such as food, water, and clothing. Threats to harm a child bind the victim to the trafficker for fear of no food or shelter or the actual threat of physical harm to the child. They may threaten to contact the Department of Children and Families or law enforcement. Traffickers may use drugs as a form of control over the victim. Introducing drugs to the victim or threatening to withhold drugs from a victim already struggling with addiction allows the trafficker to be in control. These addiction issues may have led the person trafficked to the initial point of contact with the trafficker or be a result of trying to cope with the trafficking situation.

Prognosis

Victim-Centered Approach

A victim-centered approach is paramount in delivering care to a victim of human trafficking. In victim-centered care, the provider precisely focuses attention on the victim, catering to the patient's needs to ensure the delivery of care in a compassionate, culturally sensitive, linguistically appropriate, nonjudgmental, and caring manner. A victim's wishes, safety, and well-being are important considerations. 

The heart of a victim-centered approach ensures a victim does not suffer re-victimization or re-traumatization. Trauma, as it relates to an individual from an initial insult, is a series of events or stressors that the individual experiences as either emotionally or physically life-threatening and has lasting ramifications on social, physical, mental, and spiritual well-being.

Trauma-Informed Approach

Human trafficking care must involve a trauma-informed approach where the healthcare provider recognizes the scope of the impact of the trauma on an individual victim’s lifespan and lessens any chance of inflicting more injury on this victim. Provider understanding of the signs of trauma, verbal and nonverbal cues, and their response by following predetermined protocols for identification, treatment, and appropriate referrals are essential elements of trauma-informed care.

Trauma-informed care involves the entire healthcare team and the incorporation of shared decision-making practices using an interdisciplinary, collaborative approach. Safety, transparency, and collaboration with peers and agencies are vital. The approach must account for culture and gender equality, LGBTQ considerations and support, and, most importantly, center around an empowering environment.[45]

Empowerment

Empowerment allows the victim to seek resources and take the first steps toward self-identifying. Educating staff to recognize the red flags of human trafficking, feel adequately trained, have the knowledge to offer appropriate resources, and provide follow-up care to trafficking victims is essential. 

The goal is for providers to enable others to champion change and advocate for protocol development. The Power and Control Wheel for Human Trafficking may be used in protocol development and is a tool to help identify the different types of abuse that can occur in labor and sex trafficking situations and the subsequent polytrauma complex care that is needed. The entire interprofessional team must work together to empower the survivor to become a productive, functioning member of the community. 

Human Trafficking Protocols

Providers must know the local resources available ahead of time and establish a human trafficking protocol much like the one for intimate partner violence or alleged sexual assaults.

Local resources such as Project Help, rape crisis centers, women's shelters, homeless shelters, addiction centers, and churches can provide needed materials and support services for these victims and clarify any rules, such as pet policies.

Know the resources available for potential victims of human trafficking through local law enforcement or task forces?

Human trafficking protocols need to include specific vital elements such as indicators and red flags; ways to separate the potential victim from the trafficker; interview procedures; ways to maintain and ensure safety for the victim, staff, and potentially other victims; and referral information.

Mandatory reporting requirements that address local, state, and federal laws need to be incorporated into protocols. Referral information must be accurate and easily understood by the victim and translated appropriately based on language needs. 

Provide NHTRC Hotline information. Incorporate follow-up data into a protocol. Another part of a protocol might include a critique of staff performance and ways to improve. Mandatory staff education will play a vital role in protocol implementation. 

Recognize that everyone on the interprofessional team plays a role in stopping human trafficking and identifying those at risk: social workers, case managers, customer service representatives, nurses, physicians, physician assistants, nurse practitioners, nursing assistants, medical assistants, nursing students, medical students, educators, dental assistants, law enforcement, security guards, support staff, and the community.

Referral Considerations

Long-term psychological impacts must be taken into consideration when referrals for treatment of these complex-trauma patients are incorporated into the treatment plan. Multifarious conditions exist emotionally and physically, rendering approaches to future care a challenge for healthcare providers.[46]

According to a study of male and female survivors of trafficking in England conducted between 2013 to 2014, healthcare, including physical, mental, and sexual healthcare, was a fundamental component of successful post-trafficking care. Follow-up care coordinated with multiple disciplines is essential. Basic needs of clothing, food, safe shelter, and transportation must be discussed. Ensure language barriers are addressed and provide resources on free classes to learn the local language. Discuss medical issues and refer to appropriate subspecialists.

Transitioning from Victim to Survivor - Potential Referrals

• Dietician consults in cases of severe malnutrition.
• Infectious disease consults for communicable diseases and sexually transmitted infections.
• Referral to obstetrics/gynecology for infertility concerns related to forced abortions, repeated trauma, frequent miscarriages, or medical problems such as prenatal concerns, addiction issues, and torch infections originating from lack of preventative care or poor access to care may need investigation. Hormone replacement therapy concerns must be met for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) victims.
• Surgical or dermatology referrals for removal of unwanted tattoos or brands or to treat burns and other injuries.
• Consultations with gastroenterologists for stress-related issues.
• Children often suffer developmental delays and need assistance with transitioning into a healthy life. 
• Social stigma implications of forced homosexuality can play a role in future psychological care. Crisis intervention teams and case managers will have a role in successful integration practices.[47][48][49]
• Perpetrators often use substance abuse to control victims, or victims use it as a form of escape from the abusive environment. Addiction and sobriety considerations will need implementing into daily routines. Community-based organizations, support groups, and faith-based programs may ease this transition period and lessen the impact of psychological stressors.
• Legal services referrals made for child custody issues, immigration assistance, protective/restraining orders, assistance with any offenses, and with the successful prosecution of the trafficking entity. 

Survivor's Role

Cultural shock impacts and language barriers play a role in the recovery period and successful transition into society as a survivor and not a victim. Survivors of human trafficking can offer much-needed insight into the thoughts, feelings, and interactions with members of the healthcare team and guide care and training programs going forward with this vulnerable patient population.

In 2015, a study conducted in New York City’s Rikers Island jail suggested that survivor-based input was essential in addressing healthcare concerns and improving care in this patient dynamic. Survivors shared that when cared for or interviewed by healthcare providers, they felt intimidated, judged, and stereotyped. They suggested providers and front-line personnel pay attention to their body language and the nonverbal cues they are displaying as they walk into the treatment room, up to the front desk, or after disclosure. This patient-provider interaction, if negative, can negatively impact the comfort of the victim to feel safe enough to open up and not be judged. These victims stated that instead of an interview, they preferred an approach in which the provider asks straightforward, normalized, direct questions in a compassionate, nonjudgmental way that reinforces a feeling of safety and confidentiality.[2][43][19]

Further research is needed in this area for conclusive results as this crime comes "out of the shadows," and researchers look beneath the surface, but survivors should play a role in the education of healthcare providers.

Pearls and Other Issues

The Language of Trafficking

Languages are essential to understanding different cultures, environments, enterprises, and socioeconomic groups. Human trafficking and smuggling participants have a dialect unique to traffickers and victims. Exploration of "trafficking vocabulary" will help practitioners relate to and understand patients who have been trafficked. 

In a victim-centered approach, much like a patient-centered approach, it is imperative to communicate effectively with a potential victim or patient. The following are legal definitions and terms or "lingo" used by traffickers and victims or as they relate to human trafficking. This list continues to grow as we better understand human trafficking. Other terms may become recognizable as jargon unique to a trafficking situation. 

Trafficking "Lingo"

• Daddy: The word a victim is required to call their pimp/trafficker.
• Gorilla Pimp: A trafficker or pimp that resorts to violence to control a victim 
• Romeo/Finesse Pimp: The trafficker that uses a false romance; a false promise of money, clothing, or other gifts; or false hope of marriage to lure victims. Often referred to as "boyfriend."
• Branding: A carving, tattoo, or mark on a victim that implies ownership by a pimp/gang/trafficker. The tattoo may say, "Daddy," "Property of...," or "For sale." 
• Quota: The amount of money expected from their trafficker/pimp each night. If quotas go unmet, the victim may be beaten, tortured, or made to work exorbitant hours until the expected amount has been delivered.
• Circuit: A series of places where prostitutes/victims get moved. Keeping them in unfamiliar surroundings increases their vulnerability and facilitates the trafficker's control over the individual.
• Date: The time and location where the sex act is to take place. The buyer or "John" meet them at this pre-determined site.
• The Life: Sex-trafficking victims refer to their situation as being in "the life."
• Bottom: A victim is chosen by the pimp or trafficker to "handle" the other victims. They may train the new victim, post ads/control social media posts, inflict punishment if rules get broken, and book the "date." This individual victim may feel tremendous shame and guilt because of her actions and treatment of other victims. The pimp may further control the "bottom" by threatening violence, increasing quotas, or reporting her to the authorities. The "bottom" may be required to entice others into servitude by posing as a student, a concerned friend, or a mother figure.  

Trafficking Victims Protection Act Definitions

• Coercion: Threats of serious harm to or physical restraint against any person; any scheme, plan, or pattern intended to cause a person to believe that failure to perform an act would result in serious harm to or physical restraint against any person; or the abuse or threatened abuse of the legal process [22 U.S.C. 7102 (3)(a)(b)(c)].
• Commercial Sex Act: Any sex act on account of which anything of value is given to or received by any person [22 U.S.C. 7102 (4)] 
• Debt Bondage: The status or condition of a debtor arising from a pledge by the debtor of his or her personal services or those of a person under his or her control as a security for a debt if the value of those services as reasonably assessed is not applied toward the liquidation of the debt or the length and nature of those services, are not respectively limited and defined [22 U.S.C. 7102 (5)].
• Involuntary Servitude: Any scheme, plan, or pattern intended to cause a person to believe that, if the person did not enter into or continue in such condition, that person or another person would suffer serious harm or physical restraint [22 U.S.C. 7102 6 (a)].
• Labor trafficking: The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, or coercion for the purposes of subjection to involuntary servitude, peonage, debt bondage, or slavery (22 USC § 7102).
• Sex trafficking:  The recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purposes of a commercial sex act, in which the commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age (22 USC § 7102).

Enhancing Healthcare Team Outcomes

Human trafficking care must involve a trauma-informed approach where the healthcare provider recognizes the scope of the impact of the trauma on an individual victim’s lifespan and lessens any chance of inflicting more injury on this victim. Provider understanding of the signs of trauma, verbal and nonverbal cues, and their response by following predetermined protocols for identification, treatment, and appropriate referrals are essential elements of trauma-informed care.

Victims may suffer a diminished quality of life and fear of autonomy and independence. The long-term mental and physical health consequences of being a victim of trafficking are immeasurable. Health professionals must work as a team to identify victims and assist in their transition to a normal and productive everyday life.

Trauma-informed care involves the entire healthcare team incorporating shared decision-making practices using an interprofessional, collaborative approach. Safety, transparency, and collaboration with peers and agencies are vital.[45]