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The truth about human trafficking

Perkins, Amanda MSN, RN

doi: 10.1097/01.NME.0000471841.37883.f5
Feature: CE Connection
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Does it surprise you that 27 million people are enslaved throughout the world today? It's known as human trafficking—the control and exploitation of individuals for money. Learn how to recognize the signs.

Amanda Perkins is an Assistant Professor of Nursing at Vermont Tech in Randolph Center, Vt.

The author and planners have disclosed no potential conflicts of interest, financial or otherwise.

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Human trafficking is an extremely lucrative business with an estimated net worth of $32 billion—making it the second most profitable criminal enterprise in the world. It's hard to combat this problem because victims are often afraid to go to authorities for assistance. One of the reasons that human trafficking is so profitable is that people are a reusable resource, meaning that they can be repeatedly employed with little money spent on clothing, food, healthcare, and shelter. Human trafficking is often thought of as a problem that exists outside of the United States; however, it does occur within U.S. borders.

In this article, you'll learn about human trafficking, including sex and labor trafficking; how to identify a potential victim; how traffickers control their victims; health complications associated with human trafficking; and how you can help.

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Two types

Human trafficking is defined under a federal law called the Trafficking Victims Protection Act (TVPA). The TVPA provides definitions for both sex trafficking and labor trafficking. With sex trafficking, an individual is utilized for commercial sex acts; with labor trafficking, an individual is utilized for labor or services. Although the two types of trafficking are differentiated, it's important to note that in some cases labor trafficking victims may also be sexually abused or assaulted.

Traffickers control their victims through the use of:

  • force—controlling an individual through physical violence and/or physical confinement
  • fraud—misleading an individual with false promises, such as job offers
  • coercion—instilling fear in an individual so that he or she will comply with orders; for example, the threat of physical abuse for noncompliance.

Legally, force, fraud, and/or coercion must be present for a case to be labeled as human trafficking. The only exception to this rule is minors (those under age 18). Minors are unable to legally consent and, as a result, force, fraud, and/or coercion don't need to be present for a case to be considered human trafficking.

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Sex trafficking

Clues that a patient may be involved in sex trafficking include:

  • being a minor involved in the sex industry (Keep in mind that minors can't consent; therefore, any participation of a minor in the sex industry is considered trafficking.)
  • record of being arrested for prostitution
  • appearance doesn't match stated age (The patient states that he or she is 21, but appears to be approximately 14.)
  • evidence of sexual trauma
  • branding tattoos, such as with an individual's name
  • being underage in a relationship with an older individual.

Examples of sex trafficking venues include:

  • streets
  • massage parlors
  • escort services
  • residential brothels
  • hotels and motels
  • truck stops
  • bars
  • pornography (online [individuals are also advertised and sold online for escort services and brothels], in videos/movies, or in print).

In many cases, sex trafficking victims will be assigned a nightly quota and must meet that quota to avoid harm. For example, victims being kept in residential brothels may be required to have sex with 25 clients per day, every day of the week. This adds up to a staggering 9,125 unwanted sexual encounters per year. The victim may not able to choose whether the client uses protection during the sexual encounter. Often, the trafficker will take all of the victim's earnings, leaving him or her dependent on the trafficker for everything.

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Labor trafficking

Clues that a patient may be involved in labor trafficking include:

  • illnesses related to heat exposure, such as heat stress or heat stroke
  • dehydration
  • musculoskeletal injuries
  • exposure to chemicals and pesticides
  • illnesses related to poor water quality and/or sanitation
  • sleep deprivation
  • untreated infections.

Examples of labor trafficking venues include:

  • domestic servitude, such as nannies or maids
  • agriculture
  • forestry
  • fishing
  • construction
  • peddling and begging rings
  • factories
  • hotels
  • restaurants
  • small businesses
  • pornography
  • exotic dancing.

Labor trafficking victims may be forced to work 12 to 20 hours per day with little to no pay. In some cases, victims may be required to go for days without sleep. They may be physically abused, sexually assaulted, isolated, and confined.

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A look at the perpetrators

Human traffickers are skilled at recognizing vulnerabilities and manipulating people. According to the Polaris Project, a nonprofit organization that works to combat and prevent human trafficking, “human traffickers recruit, transport, harbor, obtain, and exploit victims—often using force, threats, lies, or other psychological coercion.” Victims of human trafficking often make initial contact with the trafficker voluntarily because of false promises about jobs, stability, educational opportunities, and loving relationships. Although many victims are tricked into willingly meeting with human traffickers, there are instances in which victims are obtained through kidnapping and violence. Traffickers may work alone or be part of an extensive network.

According to the Polaris Project, the following types of individuals have been found guilty of human trafficking:

  • pimps
  • gang members
  • family members
  • labor brokers
  • employers of domestic servants
  • small business owners
  • large factory owners.

Human traffickers don't fit into any one mold; however, they do have one thing in common: a willingness to exploit others in the pursuit of money.

Traffickers utilize Maslow's hierarchy of needs to find, recruit, manipulate, and control their victims. As nurses, we're familiar with Maslow's hierarchy, which includes the following:

  • physiologic/basic needs—food, water, air, sleep, sex
  • safety and security—avoiding harm, physical safety, freedom from fear
  • love and belonging—companionship, satisfactory relationships, identification within a group
  • self-esteem—self-respect, respect of others, success in work
  • self-actualization—feeling of self-fulfillment, realization of highest potential.

As the name implies, humans must meet their most basic needs, such as food, water, and safety, before they can meet higher-level needs, such as self-esteem and self-actualization.

The following personal account, as cited by the Polaris Project, provides an example of human traffickers using Maslow's hierarchy of needs to control a human trafficking victim: “You will do anything to feel like his everything. And he promises you everything. And the things he convinces you to do, they don't seem that bad if afterwards he shows you how much he loves you...and as long as your profits meet expectations, you will have what you've wanted your whole life: love.”

Human traffickers may recruit individuals using the following process:

  • identify the vulnerabilities and needs of the individual
  • address and fulfill the individual's vulnerabilities and needs to gain trust
  • remove all other sources able to meet those needs to gain control
  • exploit the individual for financial gains.

The following is a quote from the leader of a prostitution ring, as cited by the Polaris Project, “Always make them need and depend on you so you have power over them. Power is control.” Traffickers typically control their victims by building up trust and then breaking them down emotionally. Much like domestic abuse situations, there's often a complex bond with the trafficker, making it challenging for the victim to leave the situation. Additionally, human traffickers may make victims fearful of authority figures by telling them that they'll be arrested and/or deported if they speak up and ask for help.

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Who's at risk?

It's important to remember that victims of human trafficking don't fall into any one category. They can be men, women, or children; U.S. citizens or foreign nationals; well educated or poorly educated; and from wealthy, middle class, or poor families. The one thing that victims have in common is vulnerability.

The following risk factors are known to increase the chances of an individual becoming a victim of human trafficking:

  • runaway youth
  • homelessness/lack of stable housing
  • domestic violence
  • sexual assault
  • child abuse/neglect
  • war or conflict
  • social discrimination
  • substance abuse
  • financial difficulties.

In some instances, individuals may become indebted to human traffickers posing as labor recruiters. For example, the trafficker brings an individual to the United States, paying his or her travel expenses and possibly adding on recruitment fees. After the individual arrives in the United States, the human trafficker takes possession of his or her documentation and forces him or her to “work off” the debt. In reality, the victim will never be able to work off the debt because the trafficker continues to add on living expenses, such as food and shelter. After a human trafficker has an individual's documentation, he or she is essentially trapped.

Individuals who've been brought to a different part of the world are at risk because they have no nearby support systems; they don't know where they are; they're often moved around frequently to avoid detection and make escape more difficult; they don't know the laws or their rights; and they may speak a different language, making it difficult to ask for help.

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Health complications

Human trafficking victims may have a myriad of associated health complications, including:

  • substance abuse—individuals who are addicted to a substance(s) are more vulnerable to human trafficking
  • exhaustion—victims are exhausted after minimal hours of sleep and countless hours of work; some may be required to go without sleep for days
  • posttraumatic stress disorder—individuals may have flashbacks of traumatic event(s), nightmares, and debilitating anxiety when thinking about the event(s)
  • trauma bonding/Stockholm syndrome—victims may develop empathy for and an emotional bond with the trafficker(s); when trauma bonding occurs, it can be more difficult for victims to leave
  • depression/suicide attempts/suicide—many victims become depressed and, in some cases, may attempt or commit suicide
  • sexually transmitted infections (STIs)/ sexual dysfunction—in many cases, STIs remain untreated for long periods of time and may cause long-term complications, such as infertility or sexual dysfunction
  • difficulty attaining and maintaining healthy relationships—victims often have difficulty in this area as a result of the broken relationships that they developed while being trafficked.
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How can you help?

It has been estimated that up to 30% of all human trafficking victims will have contact with a healthcare provider during the period of time that they're being victimized. Let's do a bit of math here: an estimated 27 million individuals are victims of human trafficking. If we take 30% of 27 million, we end up with 8.1 million. Take a minute to roll that figure around. Approximately 8.1 million victims will come into contact with a healthcare provider at some point during their human trafficking ordeal. The disappointing fact is that the majority of human trafficking victims that come into contact with healthcare professionals won't be identified and, therefore, won't receive the assistance they need.

The following quote from a human trafficking survivor, as cited by the Polaris Project, demonstrates the need for assistance by healthcare professionals, “During the time I was on the street, I went to hospitals, urgent care clinics, women's health clinics, and private doctors. No one ever asked me anything...”

As a nurse, you can help by utilizing your assessment skills and following up when something feels wrong to you. Keep your eye out for red flags indicating possible human trafficking:

  • evidence that the patient is being controlled
  • evidence that the patient is unable to come and go as he or she chooses
  • evidence that the patient is unable to leave/quit his or her job
  • signs of physical abuse, such as bruises or burns
  • fear or depression
  • the patient doesn't speak for him- or herself
  • the patient has no documentation, such as a passport or driver's license
  • paranoia, anxiety, and/or nervousness
  • numerous inconsistencies in the patient's story
  • malnourishment
  • medical issues that haven't been treated in a timely manner
  • infrequent visits to healthcare providers despite medical issues
  • no health insurance.

If you're caring for a patient and you suspect that he or she is a victim of human trafficking, ask follow-up questions. Be careful how you ask the questions and who's around when you ask. If another individual came to the healthcare setting with the patient, try your best to separate the patient. Always make sure that your environment is safe for both you and the patient. It's also important to ensure that you speak with the patient in a confidential location.

Don't ask the patient outright if he or she is a victim of human trafficking and don't ask about immigration status. Asking these two questions may scare the patient and stop him or her from talking. Additionally, it may be a good idea to ensure that female healthcare providers work with female victims of human trafficking. It may be more difficult for a female victim to open up to a male healthcare provider. When in doubt, ask the patient if she prefers to be cared for by a male or female caregiver.

The following are sample questions you can ask when talking with a suspected human trafficking victim:

  • Who came in with you today? Can you tell me a little bit about them?
  • What type of work do you do?
  • Are you being paid for the work that you do?
  • Could you quit your job if you wanted to?
  • Are you able to come and go as you please?
  • Have you or your family been threatened?
  • Have you ever felt pressure to do things that you didn't want to do?
  • What are your working conditions like?
  • What are your living conditions like?
  • Where do you sleep and eat?
  • Do you have to ask permission to carry out everyday tasks, such as eating, sleeping, or going to the bathroom?
  • Are there locks on your doors and windows so you can't get out?
  • Has your identification or documentation been taken away?
  • Are you sexually active? (Ask about consensual and nonconsensual sexual experiences.)

For more in-depth assessment tools for healthcare providers, visit www.polarisproject.org/tools-for-service-providers-and-law-enforcement.

Never be judgmental when caring for a human trafficking victim or a patient whom you suspect is a human trafficking victim. If a patient does open up to you, it's important to control emotions such as outrage or disgust. Remember that human trafficking victims who speak with healthcare providers or attempt to leave the trafficker will most likely be placing themselves in danger and, in some cases, their family as well.

Ask about and assess the patient's safety. If he or she wishes to leave the trafficker and doesn't have a safe place to stay or the ability to leave, you may need to assist by connecting the patient with the appropriate resources. It's unwise to contact the authorities without permission because doing so can place the victim at risk. However, if the victim is a minor, it may be appropriate to contact law enforcement without permission.

When providing a human trafficking victim with information, give verbal information instead of written information. The patient may be searched if he or she goes back with the trafficker and providing written information can place him or her in danger. Be aware that, in some cases, victims may not want to leave immediately and may wait to leave or ask for assistance until they feel safe. Encourage the patient to contact the National Human Trafficking Resource Center at 1-888-373-7888 or send a text to BeFree (233733). If the patient isn't a U.S. citizen, he or she may be eligible for a special visa allowing him or her to remain in the United States under the TVPA.

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Looking ahead

In order to protect current and potential victims of human trafficking, it's our professional responsibility to educate ourselves about human trafficking, including on-the-job training, screening tools, and available resources for victims. As frontline healthcare providers, nurses are in a unique position to help stop human trafficking. Remember that you may be the only outside person that the victim comes into contact with who's able and/or willing to help him or her attain safety and freedom.

You may be wondering if you've ever come into contact with a victim of human trafficking and missed an opportunity to help a person in need. I know that I've wondered the same thing. You can't change the past or missed opportunities, but going forward you can be diligent to ensure that you don't miss any opportunities for assistance.

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Red flags

cheat sheet

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  • Evidence that the patient is being controlled
  • Evidence that the patient is unable to come and go as he or she chooses
  • Evidence that the patient is unable to leave/quit his or her job
  • Signs of physical abuse, such as bruises or burns
  • Fear or depression
  • The patient doesn't speak for him- or herself
  • The patient has no documentation, such as a passport or driver's license
  • Paranoia, anxiety, and/or nervousness
  • Numerous inconsistencies in the patient's story
  • Malnourishment
  • Medical issues that haven't been treated in a timely manner
  • Infrequent visits to healthcare providers despite medical issues
  • No health insurance
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consider this

Male sex trafficking victims

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Although thought of as mostly a problem affecting women, men are also victims of sex trafficking; in some parts of the world, they're victimized more often than women. It's estimated that 98% of sex trafficking victims are female and 2% are male. The common belief that men aren't subjected to sex trafficking has led to thousands of victims being ignored. It's also important to remember that it's believed that the actual number of male victims may be higher than estimated because of underreporting.

Monitor for male victims, as well as female victims. Keep in mind that identification may be difficult due to a lack of awareness on the part of healthcare providers and, in many cases, male victims may be hesitant to speak up due to shame or humiliation. Additionally, male victims may have a more difficult time accessing resources; the majority of services for sex trafficking victims are geared toward women and don't offer programs solely for men.

Sources: Chin YS. Trafficked boys overlooked. www.jjie.org/trafficked-boys-overlooked-underrepresented.

Greve A. Human trafficking: what about the men and boys? http://humantraffickingcenter.org/posts-by-htc-associates/men-boys/.

Lillie M. Invisible men: male victims of sex trafficking. http://humantraffickingsearch.net/wp/invisible-men-male-victims-of-sex-trafficking/.

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key points

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  • There are an estimated 27 million human trafficking victims worldwide.
  • Approximately 8.1 million human trafficking victims will come into contact with healthcare providers.
  • Sex trafficking and labor trafficking affect both males and females.
  • Traffickers use force, fraud, and/or coercion to victimize others.
  • Medical professionals, social workers, and law enforcement are in a unique position to assist victims of human trafficking.
  • Don't forget to utilize the social workers in your facility—they can assist with identification, escape, and long-term treatment/care of victims.
  • You can always call the National Human Trafficking Resource Center at 1-888-373-7888.
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Questions to ask your patient if you suspect human trafficking

cheat sheet

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  • Who came in with you today? Can you tell me a little bit about them?
  • What type of work do you do?
  • Are you being paid for the work that you do?
  • Could you quit your job if you wanted to?
  • Are you able to come and go as you please?
  • Have you or your family been threatened?
  • Have you ever felt pressure to do things that you didn't want to do?
  • What are your working conditions like?
  • What are your living conditions like?
  • Where do you sleep and eat?
  • Do you have to ask permission to carry out everyday tasks, such as eating, sleeping, or going to the bathroom?
  • Are there locks on your doors and windows so you can't get out?
  • Has your identification or documentation been taken away?
  • Are you sexually active? (Ask about consensual and nonconsensual sexual experiences.)
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consider this

Female labor trafficking victims

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Much like men are “invisible” in the sex trafficking industry, women are often overlooked victims of the labor trafficking industry. Although labor trafficking is thought to mostly affect men, it has been estimated that nearly half of all labor trafficking victims are female. As healthcare providers, we can't make the assumption that all labor trafficking victims are male because in doing so we miss opportunities to assist all individuals affected by labor trafficking. Monitor for female victims, as well as male victims.

Source: Freedom Network USA. Labor trafficking is a women's rights issue. http://freedomnetworkusa.org/wp-content/uploads/2012/05/Labor_Trafficking_is_a_Women_s_Rights_Issue_September_2010b.pdf.

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on the web

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REFERENCES

Clause K, Lawlwer KB. The hidden crime: human trafficking. Pennsylvania Nurse. 2013;68(2):18–23.
    Florida Board of Medicine. Human trafficking. http://flboardofmedicine.gov/latest-news/human-trafficking/6/.
      Hodge DR. Assisting victims of human trafficking: strategies to facilitate identification, exit from trafficking, and the restoration of wellness. Social Work. 2014;59(2):111–118.
        National Human Trafficking Resource Center. Recognizing and responding to human trafficking in a healthcare context. http://traffickingresourcecenter.org/resources/recognizing-and-responding-humantrafficking-healthcare-context.
          National Human Trafficking Resource Center. What to look for during a medical exam/consultation. www.traffickingresourcecenter.org/resources/what-look-during-medical-examconsultation.
            Polaris Project. Human trafficking. www.polarisproject.org/human-trafficking/overview.
              Polaris Project. Sex trafficking in the U.S. www.polarisproject.org/human-trafficking/sex-trafficking-in-the-us.
                Shared Hope International. Why her? What you need to know about how pimps choose. http://sharedhope.org/2013/04/10/why-her-what-you-needto-know-about-how-pimps-choose/.
                  U.S. Department of Health and Human Services. Identifying and interacting with victims of human trafficking. www.acf.hhs.gov/sites/default/files/orr/tips_for_identifying_and_helping_victims_of_human_trafficking.pdf.
                    U.S. Department of State. U.S. laws on trafficking in persons. www.state.gov/j/tip/laws/.
                      Vermont Center for Crime Victim Services. Vermont human trafficking task force. www.ccvs.state.vt.us/nomoreslaves.
                        Williams LS, Hopper PD. Understanding Medical Surgical Nursing. 5th ed. Philadelphia, PA: F.A. Davis Company; 2015.
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