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Hidden in Plain Sight: A Guide to Human Trafficking for Home Healthcare Clinicians

Wyatt, Theresa R., PhD, RN, CCM, CFN, CCRE, FACFEI; Sinutko, Jaime, PhD, RN

doi: 10.1097/NHH.0000000000000731
Feature: CE Connection

Human trafficking is a global problem reaping $150 billion annually, mainly from commercial sex or forced labor activities involving adult and child victims. Eighty-seven percent of human trafficking victims are known to have been seen by a healthcare provider at least once during the time held captive, but due to lack of awareness, this opportunity to identify and aid victims is often missed. Home healthcare providers have access to homes where human trafficking victims may be hidden in plain sight. It is critical that home healthcare providers know the signs of human trafficking, how to screen a potential victim, how to report any suspicious activities, and ways to remain safe while working in the community. If a human trafficking victim or perpetrator is identified or even suspected, home healthcare providers should move to a safe location and call the 24/7 National Human Trafficking Hotline (1-888-373-7888).

Theresa R. Wyatt, PhD, RN, CCM, CFN, CCRE, FACFEI, is an Assistant Professor, McAuley School of Nursing, University of Detroit Mercy, Detroit, Michigan.

Jaime Sinutko, PhD, RN, is an Associate Dean Undergraduate Nursing, McAuley School of Nursing, University of Detroit Mercy, Detroit, Michigan.

The authors declare no conflicts of interest.

Address for correspondence: Theresa R. Wyatt, PhD, RN, CCM, CFN, CCRE, FACFEI, McAuley School of Nursing, University of Detroit Mercy, 4001 West McNichols Rd., Detroit, MI 48221 (

For 9 additional continuing nursing education activities on human trafficking, go to



Human trafficking is a serious public health concern that has been recognized as a form of modern-day slavery. It is an approximately $150 billion per year industry, with over 300,000 victims in the United States (International Labour Organization, 2017), and an estimated 21 million victims globally (Polaris Project, 2018). The United Nations Office on Drugs and Crime (UNODC) (2017) defines human trafficking as the “recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or other forms of coercion” to manipulate adult individuals for the purpose of labor or sexual exploitation. However, a child under the age of 18 who is rescued from the sex industry should always be considered a trafficking victim and is not required to prove force, fraud, or other means of control (National Human Trafficking Resource Center [NHTRC], 2016).

According to NHTRC (2016), human trafficking is a thriving business due to high demand for labor and commercial sex, combined with a perceived low probability of detection. At present, it is thought traffickers are not concerned about discovery due to lack of law enforcement, community, and healthcare provider awareness. This creates an urgency to promote awareness of human trafficking. It is imperative that everyone, but especially healthcare providers, be educated and prepared to identify and provide aid to human trafficking victims. Eighty-seven percent of human trafficking victims are known to have visited a healthcare provider at least once during the time held captive (Lederer & Wetzel, 2014); however, this opportunity to identify victims is often missed. Sadly, victims of human trafficking are invisible while in plain sight of healthcare providers as well as the public.

Of the 21 million victims of human trafficking, 68% are in some form of forced labor, 55% are women and girls, and 26% are children (Polaris Project, 2018). These victims are from all geographic, socioeconomic, ethnic, racial, and educational backgrounds (Polaris Project). However, there are important characteristics that make some populations more vulnerable than others (Polaris Project; Sinay, 2017; Washburn, 2018). The factors identified as increasing risk for adults include developmental delays; identifying as lesbian, gay, bisexual, or transgender; alcohol or substance abuse; mental illness; experiencing emotional pain or distress; significant or prolonged family struggles or dysfunction; poverty; homelessness; suffering from hunger or malnourishment; and history as a victim of domestic violence (National Center on Safe Supportive Learning Environments [NCSSLE], 2018; NHTRC, 2016; Polaris Project).

Traffickers prey on an individual's vulnerability by initially offering to provide for a need, for example, buying a meal or clothing, offering a place to sleep, or paying for transportation. Larger amounts of money spent on behalf of the victim may include providing a plane ticket for a “job offer” or to begin a romantic relationship. Once the “act of kindness” is complete, the victim quickly learns of the deception and debt, triggering an indentured cycle of dependency (Polaris Project, 2018).

Children are particularly vulnerable. The following factors place children at particular risk of being victims of trafficking: homelessness or having run away from home; being from an unstable home; having alcohol or substance abuse issues; having a history of sexual abuse; and having developmental or learning disabilities. As with adults, lesbian, gay, bisexual, transgender youth are particularly vulnerable (NCSSLE, 2018). An unimaginable statistic to consider is the average life expectancy of a minor who is sex trafficked is 7 years (Child Rescue Network, 2018).

Immigrants and illegal aliens are at high risk of becoming adult victims of labor trafficking (U.S. Immigration and Customs Enforcement [ICE], 2017). Many immigrants are brought to the United States under the false pretenses of a promised education or a high-paying job waiting for them (ICE). Some victims are brought to the United States by a “sponsor” or with the promise of marriage (ICE; UNODC, 2017). Child immigrants may be brought into the country with falsified documents, identifying the victim as adult age (NHTRC, 2016). Once arriving in the states, documentation and proof of identity are taken. The victims quickly learn they are now enslaved by “debt” and are forced into commercial sex or labor captivity (NHTRC; Polaris Project, 2018).

The main goal of traffickers is tremendous financial gain. Traffickers use many types of recruitment techniques to access their victims, including deception, kidnapping, acts of violence, or substance abuse (Polaris Project, 2018). More often, a trafficker uses deception to gain the trust of the victim through an acquaintance, family member, neighbor, known community member, business owner, or an employment agency (Alpert et al., 2014; Polaris Project). The relationship begins with the trafficker creating an unreasonable or unfair situation of dependency for the victim (NHTRC, 2016). What follows is various means of coercive behavior that includes emotional, verbal, and physical abuse; financial control; threats of violence; and isolation (NHTRC). Whether trafficked within the United States or brought into the country illegally, forms of identification, money, and personal belongings are taken from the victim, thus, thwarting any attempts to escape (Alpert et al., 2014; NHTRC; Polaris Project; Stevens & Berishaj, 2016).

There is a devastating psychological component to the victim–trafficker relationship (Baldwin et al., 2015; Lederer & Wetzel, 2014). As the foundation of trust is broken, victims find the concept of trust repeatedly misused and violated. Traffickers are relentless in their use of verbal insults, threats, and other forms of verbal abuse intended to humiliate, shame, embarrass, and belittle, along with physical abuse that may include repeated rape, or being punched, kicked, or beaten to intimidate and control the victim into submission (Baldwin et al.; Lederer & Wetzel). Victims live in a constant state of fear, anxiety, and stress that destroys their self-esteem creating a psychological bondage of shame and humiliation that hinders their ability to ask for help or attempt escape (Lederer & Wetzel). Once the victim is rescued, recovery is a long process that involves both physical and psychological healing (Polaris Project, 2018). Physical healing includes health management with attention to issues related to lack of access to healthcare during captivity. Psychological healing is an individual journey that begins with learning to trust in safe relationships and feeling safe in their new environment with posttraumatic stress and depression being the most common struggles (Lederer & Wetzel).

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Types of Human Trafficking

Although there are several forms of human trafficking recognized including labor, sex, debt, and organ donation (Alpert et al., 2014), the most common forms of trafficking are child labor and sexual trafficking, and adult labor and sexual trafficking (NHTRC, 2016; Polaris Project, 2018). Labor trafficking accounts for 68% of trafficking and involves forced hard or long labor with a focus on agricultural, textile, “sweat shop” type environments, or domestic work as nannies or house servants (NHTRC). Sex trafficking environments may include strip clubs, massage studios, pornography production, and prostitution (NHTRC).

Child labor occurs in many countries around the world and involves various forms of heavy manual work with long hours and exposure to toxic chemicals (Polaris Project). Many victims enter into sexual trafficking as children and remain victims into adulthood. An individual considered to be in prostitution and who is under the age of 18 years should always be considered a human trafficking victim (Polaris Project). Although runaways are particularly vulnerable, children can be abducted or sold by family members and friends to traffickers, then bought and sold online (NHTRC, 2016; Polaris Project).

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Implications for Home Healthcare Providers

Home healthcare providers are unique in that they access homes in the community much like service providers such as plumbers, gas or electric workers, or pest control companies. The “Look Again” (Michigan State Police, 2018) campaign was created and designed to help those who work in and around homes to understand the subtle signs that may suggest an individual is a victim of human trafficking. The campaign uses social media to educate through video scenarios designed to promote viewer awareness and to “look again” at concerning situations. This training encourages those working in the community to be more aware of their surroundings and to identify situations, individuals, or barriers that appear out of place, or may not make sense. The Michigan State Police “Look Again” video can be viewed at:

Home healthcare providers need to be aware of the many risk factors related to human trafficking in order to identify a possible victim. With physical abuse resembling injuries from domestic violence, there are concerns that healthcare providers may confuse a trafficking victim with a domestic violence victim, although there are significant differences (NCSSLE, 2018). Although human trafficking and domestic violence victims may be terrorized, exposed to threats, and experience physical, psychologic, emotional, and sexual abuse, a trafficking victim may fear multiple traffickers rather than a significant other, are thought to be more isolated, and may be fearful of uniforms, especially law enforcement and medical uniforms (NCSSLE; NHTRC). It is important to understand an individual may not identify themselves as a victim of human trafficking. Victims may be convinced their behavior and choices triggered their predicament (NHTRC). In fact, victims may be completely unfamiliar with the term and concepts of human trafficking.

Although it is unlikely traffickers will allow home healthcare providers access within the home to treat a victim, it is important to consider there may be victims hidden in plain sight. This could include nannies or home servants, or you may sense there is a person being kept out of sight within the home when you visit. Home healthcare providers should recognize that trafficked individuals may be in a near constant state of neglect, lacking the ability to bath or address hygiene needs, access food and drink, lack opportunity for adequate rest and sleep, and may experience physical and emotional trauma and abuse as means of control (Alpert et al., 2014; NHTRC). Keep in mind, however, sex trafficking victims may be required to be well-groomed hair, nails, and makeup. If the opportunity arises to speak with a potential victim, early discussion should include a few screening questions to aide in identification of an extremely vulnerable victim. Table 1 includes screening questions that can be adapted to the patient's developmental level of understanding. Table 2 lists signs that suggest a person is a possible victim, and Table 3 includes physical assessment findings associated with human trafficking. Home care clinicians should familiarize themselves with the warning signs and screening questions as there might not be a second encounter.

Table 1

Table 1

Table 2

Table 2

Table 3

Table 3

Victims of human trafficking are protected under the Human Rights Victims Protection Act. The National Human Trafficking Resource Center Hotline is available 24/7 across the United States to provide support for victims as well as for individuals wanting to report possible trafficking situations. The NHTRC has information available for victims including social and legal supports services within their geographic location. See Box 1 for additional resources.

Box 1

Box 1

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Safety in the Work Environment

Working in the community creates the potential for unique safety hazards (Mathiews & Salmond, 2013). In light of these dangers, home healthcare providers need to have a safety plan in place for every home care visit (National Association of Social Workers [NASW], 2013). It is recommended that home healthcare providers have their schedule posted within the agency so their whereabouts are known. In addition, keep cell phone full charged and readily available with the global positioning system enabled and emergency contacts programmed. Home healthcare providers should develop a code text or word that can be used for emergency situations as a means to alert the team of present danger without upsetting a potentially violent person or unusual situation (NASW). Equally important is to act on intuitions and remove yourself from any unsafe situation. If a potential human trafficking victim is identified or suspected, go to a safe location and call the National Human Trafficking Hotline (1-888-373-7888) or 911 for help. A caller does not need to be 100% certain—all suspicions should be reported. You can also text HELP to 233733 (BEFREE).

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Sadly, human trafficking is a crime that has been allowed to exist and thrive because of lack of awareness on the part of society, law enforcement, and healthcare providers. With 87% of trafficked individuals known to seek healthcare at least once during their captivity, it is imperative that healthcare providers recognize the signs that suggest an individual may be a victim, and know how to safely report suspicions to the proper authorities. It is critical that home healthcare providers be aware of the signs that suggest a person may be a victim, know how to screen possible victims and report suspicious activities, and maintain safety while working in the community.

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Instructions for Taking the CE Test Online Hidden in Plain Sight: A Guide to Human Trafficking for Home Healthcare Clinicians

  • Read the article. The test for this CE activity can be taken online at Tests can no longer be mailed or faxed.
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Registration Deadline: September 4, 2020

Disclosure Statement:

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