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Human trafficking: Crime in our own backyard

McNulty, Melissa S. PhD, ARNP

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doi: 10.1097/01.NURSE.0000434316.98441.1e
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IMAGINE FOR A MOMENT being in a small, cold, dark, and dirty room. You haven't seen your family in months and you're not sure if you ever will again. When the drugs that you've given begin to wear off, you feel hunger pangs because you haven't eaten anything in more hours than you can count. You hear a door opening and are filled with paralyzing fear and dread. You are never quite sure who or what will greet you on the other side of that door. You may have to endure a brutal beating, you may be forced to take drugs, or you may be raped.

Unfortunately, this is not something that some need to imagine because it's what they're forced to live every day of their lives. This is the life of a human trafficking victim.

People across the United States are victims of the growing crimes of sex or labor trafficking. As nurses, we have a unique opportunity to identify and help victims of this crime. This article discusses the scope of the problem and explains how nurses in all settings can get involved.

What is human trafficking?

In a word, human trafficking is slavery. More people are enslaved today than at any time in history.1

Human trafficking takes several forms. Sex trafficking occurs when individuals are coerced, recruited, sold, or abducted and forced into having sex or are sexually exploited. Victims may be required to engage in prostitution, stripping, or escort services.1 Those forced into prostitution may be required to solicit sex on the street or in truck stops, or may be held in hotels and houses. To instill fear and prevent victims from running away or asking for help, the victims are often beaten, tortured, drugged, and threatened. Abolition International, an organization devoted to fighting sex slavery, estimates that sex trafficking is a $35 billion industry worldwide.2

Labor trafficking occurs when individuals, often from other countries, are forced into labor for little or no pay. Labor slaves may be domestic workers such as maids or nannies, farm workers, factory workers, or other laborers.1 Because most victims speak little English and are far from family and friends, they feel helpless to escape their situation. Labor and sex trafficking can overlap; for example, when undocumented foreign laborers are sexually exploited.

Fear, intimidation, fraud, and coercion are used to keep victims compliant. Money that victims earn for their services is often required to be paid back for rent and food, which keeps them financially dependent and unable to leave.

Gangs are more frequently becoming involved in human trafficking because this crime is profitable and less risky than drug or weapons trafficking. Once detected, drugs and illegal weapons can be confiscated. However, even when confronted by someone in law enforcement, a human trafficking victim may remain silent for fear of the consequences to the victim or the victim's family.

Who are the victims?

Human trafficking was once considered a crime limited to developing countries. More and more frequently, however, victims of human trafficking are being found right in our own backyard. (See Victims by definition.) Worldwide, human trafficking is second only to drug trafficking among leading crimes; nearly half of the money generated by this crime comes from the United States.2,3

Although human trafficking can involve enslaving people for their labor, most cases (82%) involve sex trafficking.4 Victims of human trafficking can be males or females of any age. However, among adults, females are more likely to be victimized. In addition, of those trafficked for sex in the United States, over 40% are children being used for prostitution or sexual exploitation.4 In July 2013, the Federal Bureau of Investigation (FBI) conducted a nationwide sting operation that resulted in the arrest of 150 pimps and the rescue of 105 child sexual trafficking victims ranging in age from 9 to 17.5

Some victims of human trafficking are brought to the United States from other countries, either through abduction or fraudulent promises of employment. However, 83% of the victims of sex trafficking identified by the U.S. Department of Justice were United States citizens. Runaway children in the United States are extremely vulnerable, with one out of three being targeted by sex traffickers within 2 days of running away.2 Some girls are lured to a location with the promise of a modeling job and are then held against their will.

Human trafficking isn't limited to big cities. Victims have been identified in suburban and rural areas in all 50 states.1

How to identify a potential victim

Those in control view their victims as property, so they're unlikely to bring victims in for routine healthcare. They seek medical attention for their victims only if a medical problem develops. Common reasons victims are brought to the hospital include sexually transmitted infections, pregnancy, abortion attempts, or severe untreated illnesses.

Victims may not have any documentation or identification because that information is controlled by the trafficker or because they were brought into the country without documentation. Those who've come from foreign countries may speak little or no English and show signs of culture shock, such as anxiety, anger, and frustration at being unable to communicate.

The U.S. Department of Health and Human Services has identified physical and emotional signs of trafficking that nurses and other healthcare professionals should watch for.6

Physical signs and symptoms of trafficking include the following.

  • The victim may be dehydrated or malnourished from deprivation and the abuser's control over food and water intake.
  • In children, a poor diet may result in growth retardation and dental problems.
  • Poor personal hygiene may indicate a lack of access to baths and showers.
  • Signs and symptoms of sexual abuse or rape may include ecchymoses, bleeding, or tears of the genital and/or anal area, or ecchymoses of the knees or thighs.
  • Signs of other physical abuse may be present from beatings and torture. The lower back is a common injury site because this area can be hidden by clothing. Look for ecchymoses at various stages of healing, radiologic evidence of healed or fresh fractures, or scarring from cuts or burns. Take a careful history and note whether the story of how injuries occurred matches the nature of the injury.
  • Untreated conditions such as infected wounds indicate a lack of medical care. Critical or chronic illnesses such as cancer, diabetes, or heart disease may also be untreated.
  • Assess for diseases related to living in crowded, unsanitary conditions, such as tuberculosis or gastrointestinal infections.
  • Also assess for signs and symptoms of alcohol or drug abuse. This may be related to forced substance abuse by traffickers or the use of substances to numb the emotional effects of abuse.
  • Physical evidence of extreme ongoing stress may include hypertension, tachycardia, and gastrointestinal disturbances such as peptic ulcers.
  • Victims may be tattooed on the side or back of the neck or arm so the trafficker can identify individuals that “belong” to them. The tattoo may be a symbol, number, or even a bar code.

Also assess for psychological signs and symptoms. Keep in mind that while some victims are locked away from society, others regularly interact with ordinary people but remain quiet about their situation because of their intense fear.1

  • Victims often experience depression related to ongoing abuse and feeling trapped.
  • Victims may exhibit extreme fear and distrust of others. Feelings of helplessness, hopelessness, shame, and humiliation may be evident.
  • Assess for psychological signs of extreme stress, including panic attacks. The victim may appear highly stressed and tense when the individual accompanying him or her is in the room. Signs and symptoms of posttraumatic stress disorder include being fearful or easily startled, nightmares, difficulty sleeping, irritability, and anger.

Screening for victims of human trafficking

Just as nurses regularly screen for potential victims of domestic violence, we should also screen for victims of trafficking. The U.S. Department of Health and Human Services has developed a list of screening questions that should be asked of potential victims.6 (See Screening for victims of human trafficking.) As with domestic violence victims, those who are suffering from trafficking may be accompanied to healthcare visits by an individual in control of them. You're not likely get an honest answer to screening questions if the perpetrator is present. However, these questions can be asked when the patient is taken for diagnostic procedures or studies, such as X-rays, or when he or she provides a sample for urinalysis.

A medical interpreter is needed to screen and assess patients with a language barrier. In some hospitals, remote medical interpreters are available by telephone.

Take action against trafficking

If you suspect that a patient is being trafficked and is in danger, follow your facility's protocol to report trafficking victims. If your facility has no specific protocol or if victim identification occurs outside the healthcare setting, you should call 911 and report your suspicions. To report human trafficking to the FBI, you can call 1-888-373-7888 or report it online at You can also find the contact information for your local FBI office at

If the situation isn't an emergency, you can contact the National Human Trafficking Resource Center at 1-888-373-7888. If you believe that a child is being victimized, notify Child Protective Services according to facility policy and procedure and state law.

Many resources are available for those who've escaped from trafficking, including assistance with housing, food, medical care, and job training. In addition, aftercare programs are available in some locations to provide shelter and schooling for those who are victims of trafficking. Examples include The Courage House Facility in Sacramento, California, Wellspring Living in Atlanta, Georgia, and Gracehaven in Columbus, Ohio. These places give victims a safe, healing, and caring place to go to recover from the abuse they've experienced.

Programs such as these are greatly needed. If such an aftercare program isn't available in your state, consider advocating for one. For resources, see Raising awareness.

Nurses can make a difference

To put a stop to human trafficking, individuals from many different backgrounds need to work together. The first step is identifying victims and removing them from their frightening and inhumane circumstances. This vicious crime doesn't discriminate by age, race, or gender, so nurses in all specialties should be knowledgeable about the issue.

As healthcare providers, we may be the only people victims come into contact with other than their abusers. Taking the time to ask critical questions and report suspected abuse may identify a human trafficking victim and save a life.

Victims by definition1

Under the federal Trafficking Victims Protection Act of 2000, victims of human trafficking are defined as follows:

  • Minors under age 18 who've been coerced into commercial sex acts.
  • Those age 18 or older who are forced, deceived, or coerced into commercial sex acts.
  • Anyone forced to perform labor or services involuntarily through force, fraud, or coercion.

Screening for victims of human trafficking6

Responses to the following questions can help you identify a trafficking victim. For brochures and screening question wallet cards, visit the U.S. Department of Health and Human Services' Restore and Rescue Program at http://

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

Raising awareness

The following resources are available for more information about human trafficking:


1. Polaris Project. Human trafficking.
2. Abolition International.
3. United Nations Office on Drugs and Crime. UNODC on human trafficking and migrant smuggling.
4. U.S. Department of Justice. Bureau of Justice Programs. Anti-human trafficking task force initiative.
5. Corbin C. FBI rescues more than 100 children, arrests 150 pimps in sex trafficking raid. News report, July 29, 2013.
6. U.S. Department of Health and Human Services. Office of Refugee Resettlement. Anti-trafficking in persons.
© 2013 by Wolters Kluwer Health | Lippincott Williams & Wilkins.