Texas Human Trafficking Training

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The following course content

Introduction   

Often likened to modern-day slavery, human trafficking is a heinous global crime that is getting more and more attention in recent times. Healthcare practitioners should be up to date on the topic as much as possible, considering they are very frequently a point of contact for individuals being trafficked.

It is imperative to recognize the signs of trafficking, as well as resources available to those involved. Furthermore, it is crucial that the practitioner develops trust with the victims he or she encounters, providing patient-centered, trauma-informed care.

• Identification: Potential indicators of trafficking; barriers to survivor disclosure; strategies for building trust with victims; challenges and opportunities faced by practitioners; appropriate language and documentation. 
• Health Impact: Acute and chronic physical health problems experienced by trafficking victims; quality of life and independence issues; mental health concerns.
• Response and Follow-up: The practitioner’s role in intervention; mandated reporter obligations; resources on state and federal levels; the importance of survivor-centered, multidisciplinary organizational protocols

Human Trafficking 

A 2018 report confirms that between 50-88% of human trafficking survivors accessed healthcare services, yet only six percent of healthcare workers report treating a survivor during their career (27).  

While human trafficking remains an often-hidden crime, there are still many signs that everyone should be able to recognize. There are myriad resources available for victims of trafficking, including the National Human Trafficking Hotline Number (888-373-7888) and its text line, BeFree (233733). These options are available to call or text 24 hours a day, 7 days a week, 365 days a year. Other local and statewide resources are available and will be discussed throughout this course.  

Case Study: Mahad 

Just after midnight, a 23-year-old man named Mahad presents to the ED where you work. The triage notes state that he has been coming in for generalized fatigue, muscle aches, and nausea for the past three days. He is accompanied by an older man who states he is Mahad’s uncle and has translated for Mahad thus far.  

Upon exam, Mahad appears significantly malnourished with a firm, distended abdomen. He is noted to have jaundiced sclera, dark circles under his eyes, and several wounds of varying age on his bilateral lower extremities. The uncle states that Mahad works in a metal stamping plant and occasionally gets injured on the job.  

Mahad is reluctant to talk to you and does not make eye contact. He defers to his uncle to do the talking and translation, flinching whenever the uncle moves. Both Mahad and the uncle seem wary of the law enforcement officer walking on the floor. You feel this encounter is concerning for human trafficking, so excuse yourself to go talk with some of your colleagues about this situation.

What Is Human Trafficking?  

Human trafficking is a crime and a human rights abuse. It includes at least one of the three components of force, fraud, or coercion to obtain labor and/or a commercial sex act (3,4). It can also be defined as “the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, solicitation, patronage or coercion for the purposes of subjection to involuntary servitude, peonage, debt bondage, or slavery.” (2).  

This can happen to anyone at any time; a person of any race, age, gender, religion, or nationality can be a victim of trafficking (3). Healthcare practitioners should be aware that boys, men, and people over the age of 18, and those of any racial or socioeconomic group may be victims.  

Human trafficking is an enormously egregious yet profitable industry, comprising some $150-$600 billion of the global economy each year and affecting roughly 25-50 million people worldwide (11, 17). In Texas alone, this crime has already affected some 313,000 people (17). The majority of trafficking happens in the form of forced private sector labor, despite sexual exploitation being what initially comes to mind for many people (11).  

Unfortunately, the general public and even people being trafficked are not always aware of what is happening, for a myriad of reasons. This may be due in part to a lack of recognition of what exactly is involved in human trafficking.  

In the year 2000, the United States Congress passed the Trafficking Victims Protection Act of 2000, also known as TVPA (1). This legislation helps to define human trafficking and protect those involved.  

What Is Not Considered Trafficking 

Despite many media portrayals, human trafficking is not synonymous with smuggling or sex work.  

• Smuggling involves illegally crossing state or international borders (5). Human trafficking deals solely with the exploitation of people; human smuggling is a crime against a country and involves transportation, whereas human trafficking is a crime against a person (6, 7).  
• Consensual commercial sex (i.e., sex work) is not trafficking, provided that the person is over the age of 18. Anyone under the age of 18 who provides commercial sex, regardless of circumstances, is considered to be trafficked (3). This is because a minor, in the United States, is legally unable to provide consent for commercial sex (4, 6, 7). 

Types of Human Trafficking  

While many people think of human trafficking only involving sex exploitation, it can also include labor trafficking, child soldiering, and more (6).  

• Forced Labor – occurs when force, fraud, or coercion are used to exploit the services or labor of another person (6, 9, 19), and often involve physical or verbal violence, forced overtime, limited freedom of movement or communication, and lack of freedom to resign (8). Forced labor can include the following industries or elements: 
  • Domestic Servitude involves work in a private residence, where victims’ food, housing, and transportation are often controlled by their exploiter. 
  • Forced Child Labor still occurs in the United States, despite labor laws, and in this situation, children are forced or compelled to work. 
  • Agriculture  
  • Construction/Landscaping 
  • Illicit Activities 
  • Health and Beauty 
  • Traveling Sales Crews 
  • Retail/Small Businesses 
  • Restaurant/Food Service, Hospitality
• Sex Trafficking requires the components of acts, means, and purpose to establish a sex trafficking crime for those age 18 and over (anyone under the age of 18 who engages in commercial sex, regardless of circumstances, is a victim of child sex trafficking) (6).  
• Child soldiering is a type of human trafficking that involves unlawfully recruiting children – through force, fraud, or coercion- to act as combatants or other workers for government armed forces, paramilitary organizations, or rebel groups (10, 18). Children can also be used in sexual slavery, where they are forced or coerced to “marry” or be raped by commanders or combatants (6, 18). 

All types of human trafficking include actions, means, and purpose (7).  

• Actions are met when a trafficker does any of the following: 

• • Recruits by targeting a vulnerable person and/or using grooming behaviors 
  • Harbors by isolating, confining, and monitoring 
  • Transports by arranging travel for or moving the victim 
  • Provides something to the victim (like food or housing) 
  • Patronize the person by giving them financial support 
  • Obtains by forcibly taking or exchanging something for the ability to control the victim 
  • In cases of sex trafficking, the trafficker may also solicit or receive something of value in exchange for sexual acts by the victim 
  • They may solicit forced labor or other acts of servitude from a person in exchange for something of value. 

• Means include force, fraud, or coercion used by the trafficker. Examples of these include threats to others, debt manipulation, psychological harm, or threats of serious physical harm.  
• Purpose is the commercial sex act itself, or forced labor, and can occur in many places: in private homes, online, in hotels, brothels, massage parlors, and more.

The Trafficking Victims Protection Act of 2000 (TVPA) 

Although human trafficking has been around for centuries, no real legislation had existed in the United States or internationally to address it. There were also no good working definitions of human trafficking, as it often shares overlapping characteristics with sexual assault, smuggling, and the commercial sex trade. Since the inception of the United States, not until this century has there been any significant progress on making laws related to human trafficking. 

In November of 2000, the Palermo Protocol was adopted by the United Nations in order to prevent, suppress, and prosecute human trafficking on a global level (24). This was the year that United States followed suit by passing the TVPA (23). This legislation has also had reauthorization acts that updated measures and refined the language in 2003, 2005, 2008, 2013, 2017, and 2018 (25).  

The TVPA has three goals, also called the three Ps: to protect victims, prosecute offenders, and prevent future human trafficking occurrences (23, 25).  

Protection of victims includes efforts such as issuing a T-visa to victims of trafficking if they meet eligibility requirements and cooperate in the investigation and prosecution of traffickers. The T-visa grants non-immigrant status and allows victims to remain legally in the United States for up to four years.  

After three years or the closing of the related criminal case, they can apply for permanent residency (22). Furthermore, those who were previously ineligible for government assistance may be able to obtain it under the TVPA (25).  

Prosecution of perpetrators involves creating a series of new federal crimes that now define human trafficking and make it prosecutable in every state (25).  

Prevention of human trafficking includes both foreign and domestic efforts to increase awareness and establish laws related to this crime (25).  

The TVPA, established and amended as 22 USC §7102, recognizes that human trafficking includes three specific means, not all of which need be used, defining them as follows (1,2, 7):  

• Coercion: “Threats of serious harm to or physical restraint against any person,” a plan that would lead someone to believe that not performing a certain act would lead to serious harm, as well as “abuse or threatened abuse of the legal process”  
• Force: Can include physical harm or restraint, sexual assault, and beatings. During the early stages, the trafficker might monitor and confine victims to control them and break down resistance. 
• Fraud: False promises in regard to wages, working conditions, employment, a better life, marriage, or love. The victim may experience unexpected changes in the nature of a relationship or working conditions.  

Case Study: Mahad 

Upon consulting with the attending physician at your ED, you both agree Mahad is a potential victim of human trafficking. Since you are both new to the facility, you work with others on your team to locate appropriate resources to address Mahad’s situation. One of the nurses tells you that you should use the official translation service available in the ED and ask Mahad’s uncle to step outside of the room.  

 
When you come back to see Mahad, you bring the translation device with you and ask Mahad’s uncle to step out, which he does after a few quick phrases to Mahad. Another nurse escorts Mahad’s uncle to the waiting room, and you prepare to interview and assess Mahad more fully.

Who Is Trafficked?  

Anyone can be trafficked at any time, provided the right circumstances. While many people tend to think of girls and young women as the main trafficked persons, many boys and men are also trafficked (4, 6).  

For sex trafficking in the United States, victims are more likely to be Black (40%) or white (26%) versus other races; those being trafficked for labor are more likely to be Latino (63%) or Asian (17%) (22).  

Many victims of trafficking have certain vulnerabilities and situations that make them more likely to be trafficked (4, 12). These include, but are not limited to:  

• Experiencing poverty or economic hardship
• Being victims of violence
• Having physical or cognitive disabilities
• Presence of childhood abuse, neglect, or trauma
• Working as migrant laborers
• Being of a racial or ethnic minority
• Identifying as lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals
• Being children in foster care and/or juvenile justice systems
• Having run away as a youth or not having adequate housing
• Experiencing housing insecurity or being homeless as adults
• Having a history of substance abuse
• Surviving a natural disaster, political instability, or armed conflict

Who Are the Traffickers?  

Just as anyone can be trafficked, anyone can be a trafficker as well; there is no universal trafficking profile. Many times, the traffickers themselves are close to or are family of those whom they traffic in (13, 14). These can include parents, intimate partners, gang members or networks, restaurant and other business owners, government representatives, corporate executives, and many more (15).  

Some traffickers experience the same types of financial or social oppression as their victims, while others use positions of power and privilege as a means of control (15.) Many traffickers target people whose needs are not being met, like young adults who seem to lack confidence, or whose emotional, financial, or material needs aren’t being met (13).  

Regardless of who the traffickers are, they are illegally participating in the exploitation of others for personal gain.  

What Are Some Common Trafficking Methods or Techniques?  

While there is a constellation of ways by which a trafficker may entrap, coerce, or defraud their victim, there are some common characteristics (14, 16). Approximately two-thirds of traffickers are men, though women are often prosecuted at a far higher rate (18).  

Many times, traffickers offer jobs or opportunities that seem too good to be true, such as a modeling contract or promise of high salary for a factory position. They may give promises of love and a place to live or shower the victim with expensive gifts. Sometimes, particularly in the case of debt bondage, the trafficker forces the victim’s children or other family members to help pay off debts (18).  

For labor trafficking, traffickers may force their victims to: 

• Live at the business, sometimes in crowded conditions with others. 
• Sign a contract in a language they cannot read. 
• Work long shifts or unusual hours, often in isolation. 
• Engage in debt bondage, where the trafficked person owes a large debt that is never paid off and continually increases. 
• Give up control of their identification documents and finances. 
• Produce goods or services that are priced below general market rates. 

For sex trafficking, traffickers may employ the following tactics: 

• Brand the people they traffic with tattoos.  
• Prohibit the victim from coming or going as they please, especially if they live in a “massage” business. 
• Hold identification documents so that the victim cannot access them.  
• Prohibit any outside communication with others that is not monitored.  
• Control their finances. 

 In addition to the methods above, there are other potential red flags that someone might be a victim of trafficking. These include, but are not limited to, the individual (34):  

• Making little, if any money, or only being paid in tips. 
• Trying to pass themself off as older, particularly if involved in commercial sex acts.
• Exhibiting a flat effect and/or avoiding eye contact.
• Acting unusually anxious, restless, fearful, tense, submissive, or nervous; particularly when there is any mention of law enforcement.
• Appearing malnourished.
• Showing signs of physical abuse, torture, restraint, and/or confinement.
• Exhibiting prolonged, untreated illness or disease and/or unexplained injuries.
• Being unable to produce any form of identification, money, or other personal possessions.
• Not being allowed to speak for themselves when in the presence of someone else who escorted them in.
• Demonstrating a lack of knowledge of the city / geographic location they are in.
• Exhibiting a sense of loss of time.
• Having several inconsistencies in their story.
• Being brought in by police for medical clearance; they may have been part of an illegal activity.

(19) 

Why Don’t We Have Better Data?  

Getting accurate data on human trafficking is an imprecise science. Due in part to the stigma associated with trafficking, as well as victims themselves are not aware of their situation. When these factors are coupled with the many types of trafficking that exist, it is difficult to get precise figures on the matter (17).  

Victims may be coached on what to say by their traffickers, or these cases may be reported under the heading of child abuse or neglect instead of being identified also as a case of human trafficking (26). Healthcare providers may lack a trauma-informed approach, leading them to miss the signs of trafficking or for the victim to lack enough trust to confide in the provider (26). As discussed above, only in the past few decades has a definition of human trafficking even been formalized, so many laypeople and healthcare practitioners may be unaware that they have even encountered a victim of trafficking.  

Human trafficking is also often a hidden crime, hard to identify, and embedded in everything from housekeeping to nail salons to agriculture. While men make up as much as 20% of trafficking victims in the United States, they are often criminalized or deported at a much higher rate than females, making their numbers virtually impossible to track (20).  

Finally, since human trafficking takes place on a global level, it is difficult to aggregate data from each country, particularly when there is no good way to reliably report known cases.  

The Health Impact of Human Trafficking  

Human trafficking can cause or exacerbate myriad physical and mental health problems among its victims and survivors. Healthcare providers should be fully versed in all the ways these can present when victims are seen in clinical settings. In a 2017 study, nearly 88% of sex trafficking victims sought treatment in the United States healthcare system but were often left unidentified or not offered adequate resources by the clinical treatment team (21).  

Acute Injuries  

When those being trafficked seek healthcare, they may present to any of the following or more: dental offices, emergency departments, walk-in clinics, OB/GYN offices, mental health care facilities, substance use disorder treatment centers, and primary care providers. Upon presentation, certain acute injuries may be present. These include, but are not limited to (20, 22):  

• Amputation  
• Anxiety and/or depression 
• Back or neck pain 
• Burns 
• Contusions  
• Dental complaints 
• Fractures 
• Headaches
• Head and neck trauma
• Infectious diseases from worksite, including parasites, hepatitis, and tuberculosis
• Musculoskeletal pain or trauma
• Pelvic pain and/or pelvic inflammatory disease
• Respiratory problems from occupational hazards
• Sexually transmitted infections
• Skin conditions: scabies, lice, suspicious tattoos
• Substance abuse
• Suicidal ideation
• Unplanned pregnancy or abortion complications  

Almost 60% of human trafficking survivors report physical injuries, with up to 95% of those enduring physical and/or sexual violence (20). There is a degree of overlap between domestic violence signs and those found in human trafficking; healthcare providers should note wounds or injuries of varying ages, injuries around the head or genital areas, burns or contusions, and any wound that appears self-inflicted (20).  

Other acute injuries to be aware of are dehydration and/or malnutrition, visual complaints, somatization, injuries, or illness due to exposure to unsafe water or hazardous chemicals, poor dental care, and impacted tampons in vagina (19).  

Chronic Injuries  

Due to the nature of trafficking occurring primarily within the labor and sex markets, there are some chronic injuries the healthcare provider might anticipate. Some of these include (20, 22):  

• Addiction disorders 
• Back pain 
• Cancer 
• Chronic generalized or localized pain
• Headaches
• Hearing loss from working conditions
• Hepatitis
• Human Immunodeficiency Virus (HIV)
• Pelvic inflammatory disease 

Many chronic conditions may stem from repetitive work, such as those involved in factories or through repeated sexual trauma. These can also include reproductive and mental health issues as well.  

Mental Health Issues  

Since force, fraud, and/or coercion are necessary parts of human trafficking, a plethora of mental health problems can be experienced by its victims. While many survivors report having a preexisting mental health condition before being trafficked, these conditions can also be created or exacerbated by the condition of trafficking (20, 21, 22).  

Human traffickers often use methods like sleep or food deprivation to increase compliance of their victims (20). They may also employ tactics such as forced social isolation, close monitoring of behavior, control over identification documents and finances, abuse, and neglect (20).  

Mental health issues often experienced by victims and survivors include, but are not limited to:  

• Anxiety disorder 
• Autonomic arousal 
• Cognitive or developmental delays, learning disabilities in the younger population
• Depression
• Dissociation, which can lead to memory loss or impairment
• Insomnia, sleep disturbances, nightmares
• Obsessive-compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)
• Self-harm or mutilation
• Suicidal ideation
• Trauma bonding (i.e., Stockholm Syndrome)  

 Also, due to its horrific impact on body and mind, human trafficking can cause other mental health problems, such as: anger, irritability, hopelessness, isolating behavior, fear of being alone, denial, exhaustion, aggression, recurrent or intrusive memories of abuse, guilt/ shame/ self-blame, increased crying, numbness, distrust or fear of strangers, difficulty concentrating, and more (22).  

Furthermore, many victims may be retraumatized if faced with other instances of violence or having to face their trafficker(s) again, perhaps in a courtroom setting (22).  

Healthcare providers should be aware of the impact their own demeanor can have on people who are trafficked; if particularly curt or rushed with a patient, that can cause the victim even further traumatization and more reluctance to disclose their situation.

Other Health Impacts  

While human trafficking undoubtedly causes or exacerbates countless physical and mental health conditions, it has other overlapping impacts as well.

Substance Abuse  

Substance abuse is a very common comorbidity within the human trafficking realm, and for many reasons. Some victims already had a history of substance abuse, others use(d) it as a coping mechanism for their situation, and others yet were forced or coerced to use substances of abuse (22). Since traffickers understand that those who are addicted are more easily manipulated and controlled, this remains a popular tactic used (22). A victim of human trafficking who is abusing a substance may also be afraid to seek out help from law enforcement, as they might fear prosecution (20).

Reproductive and Sexual Health Concerns  

While mentioned above in both acute and chronic conditions, sexual health concerns can leave a lasting impact on a trafficked person’s life. Since those being trafficked for sex often encounter a large number of sexual partners, STIs and unwanted pregnancies occur at high rates (20, 21, 22). Some victims have absorbent items like sponges placed in their vaginal vaults during menstruation so that they may still “work;” this can lead to chronic pelvic infections and vaginal pain (20). Repeated pregnancies and abortions can also take their toll on a victim’s body, leading to chronic pain, infections, and fertility problems (20, 22). Finally, since up to 80% of sex trafficking victims in the US are female, healthcare practitioners who provide women’s services should be aware of how to identify, treat, and provide resources to victims (20).

Quality of Life, Autonomy, and Independence  

During the time a person is trafficked, much of their life is often not under their control. They frequently have their whereabouts monitored, social interactions limited, and do not have a great deal of physical or mental autonomy and independence. As discussed above, many victims of human trafficking experience physical and psychological abuse, leading to innumerable problems. Psychological issues and substance abuse often go hand-in-hand, severely limiting the victim’s quality of life (22). The repeated trauma, potential for trauma bonding, and lack of basic needs being met can severely interfere with long-term healing and establishment of independence for survivors.  

Case Study: Mahad 

Now that you know Mahad is willing to meet with you away from his uncle, you, and another nurse plan how to best approach the situation. Since neither of you has much experience with people who have potentially been trafficked, you decide on some basic care parameters for this encounter.

Trauma-Informed Care 

Providers involved in the care of any vulnerable population should be cognizant of trauma-informed care. This paradigm acknowledges that traumatic experiences can pervade all aspects of an individual’s life and behavior, including their self-perception and their relationships with others (44).  

Trauma-informed care prioritizes the emotional, psychological, and physical safety for everyone involved, including staff members. Further, this type of care emphasizes the goals of treating, educating, and empowering the patient, not for the disclosure of victimization (37).  

The Substance Abuse and Mental Health Services Administration (SAMHSA) defines individual trauma as a circumstance or event that results in mental, physical, and/or life-threatening harm (31). Furthermore, SAMHSA goes on to describe the “three Es” of trauma (32):  

• Event: A circumstance or set of events that occurred to an individual, which may include natural disasters, violence, warfare, and so on 
• Experience: How the person experiences the event defines it as traumatic to them or not; for it to be traumatic, it needs to be physically or psychologically harmful.  
• Effects: These can be acute or chronic, and adversely impact the person’s physical, social, emotional, mental, and/or spiritual well-being.  

 As victims of human trafficking are very often traumatized, it is essential that the practitioner provide care specifically geared toward this population. SAMHSA has developed some goals of such care, called the trauma-informed approach, that is ideal for interactions with survivors of human trafficking (32).

The main goals of trauma-informed care are:  

• Safety: Patients and the staff around them feel safe, physically, and psychologically 
• Trustworthiness and Transparency: The goal of building trust is developed through making decisions in a transparent manner 
• Peer Support: Others with a similar experience are involved in care, and are used by the treating organization as an integral part of the services provided 
• Collaboration: Whenever possible, shared decision-making is utilized among patient, clinician, and other staff 
• Empowerment: Strengths of both patient and provider are recognized and built upon, fostering the ability to heal from trauma in a resilient way 
• Humility and Responsiveness: Any biases and stereotypes are recognized and addressed, as is historical trauma  

What can practitioners do? SAMHSA offers “four Rs” to using the trauma-informed approach (32):  

• Realizing the prevalence and immense impact of trauma 
• Recognizing the clinical and signs and symptoms of trauma in patients and other staff members 
• Responding to the situation by utilizing the appropriate resources in the institution and within the wider community 
• Resisting re-traumatization of the people being served by not making the situation worse with language or action 

Patient-Centered Approach 

When providing high-quality care to potential victims of human trafficking, it is essential to use a trauma-informed, patient-centered approach. This means providing for the person’s safety, well-being, and dignity first and foremost.  

The following are some elements of this type of care (33):  

• Safety: Ensure that the patient is alone, having escorted other guests to a waiting area while any screenings or assessments are being conducted. The person should feel comfortable with the provider and any other staff members or professional interpreters present. If possible, give the patient the option of where to sit in the room, perhaps with the door in sight. 
• Physical needs: Since victims of human trafficking are often sleep- or food-deprived, it is reasonable to offer them food or water if appropriate. This may not be feasible for those who need a SANE evaluation, but for others, it may make it easier for them to respond. Offer bathroom breaks and check to see if the patient is as physically comfortable as possible. Soft lighting may also help, if available.  
• Use non-threatening, open body language: Try not to cross arms across the chest and sit or squat near the patient. Establish eye contact frequently, and respect personal space. Do not touch the patient unless necessary for the exam, and always inform them beforehand.  
• Engage the patient: Use calm, slow, nonjudgmental speech. Try to keep facial expressions neutral and avoid generalizing about the person’s experience. Make sure to give adequate time for listening.  
• Resist probing too many details: Since the goal is to ensure the patient’s safety and adequate care, only obtain information necessary for their care at this time. Avoid criticizing the trafficker, since this can cause the trafficked person to become distressed or defensive.  
• Use respectful, empathetic language: Say things such as: 

• “This seems difficult for you to talk about. Please, take your time and let me know if you need anything, including a break. I will try to make this as brief and comfortable as possible for you.” 
• “Please answer the following questions as ‘yes,’ ‘no,’ or ‘I don’t know.’ You do not have to answer a question if it makes you too uncomfortable.”  
• “I want you to feel safe here. Please let me know if I can do anything else to help.” 

• Be prepared to help coach the patient through a trauma reaction. Talking about such difficult experiences can re-traumatize the patient, potentially resulting in a trauma reaction. In this case, the person may experience a flashback or anxiety/panic attack. These techniques can help:  

• 4-7-8 breathing: Have the person put their tongue on the roof of their mouth, behind their teeth. They should then exhale through their mouth loudly, close their mouth, and inhale through their nose for 4 counts. Have them hold their breath for 7 seconds. Finally, have them exhale again through their mouth with the tongue still on the roof of their mouth. This 4-7-8 cycle can help immensely and can be done in the future.  
• 5-4-3-2-1 technique: Have the person think of 5 things they can see in the room, 4 things they can feel, 3 they can hear, 2 they can smell, and 1 they can touch. This can help ground the person in the present moment, instead of getting lost in traumatic memories.  

Identification and Assessment  

While a healthcare provider may suspect a patient is potentially being trafficked, certain considerations need to be made when assessing this population. A person being trafficked may be present for care at any time, in any situation. They may want to be seen for an injury related to their trafficking, or for something else, like mental health services, dental care, evaluation of pre-existing conditions, addiction treatment, or a general check-up (19).  

In a 2014 study, nearly 88% of human trafficking victims sought healthcare while in their situation, 68% of which were emergency services (19). Perhaps more concerningly, more than half of the survivors surveyed in another study stated that they were not asked any questions about trafficking or abuse during their healthcare visit (27).  

Challenges and Opportunities When Interfacing with Trafficked Persons  

While there are many reasons human trafficking goes undertreated and underreported, the practitioner must keep in mind that disclosure is not necessarily the ultimate goal when encountering these victims.  

First and foremost, the person’s safety is paramount, then their medical care, and finally, if appropriate and with available resources, disclosure of the potential crimes.  

Though not exhaustive, the following are some challenges healthcare professionals may face when they encounter potential victims of human trafficking, and ways they may be addressed: 

1. Guilt or shame: Victims may often feel guilty for what has happened to them or feel ashamed of their situation. The practitioner should do their best to provide calm, non-judgmental care. This can be conveyed through open body language, cultural awareness, eye contact as appropriate, and a non-rushed manner of talking and assessing.  

What to say:  

“I’m here for you to listen to what you have to say. It is not my job to judge you”.  

“This situation is not your fault.”  

What NOT to say:  

“How come you let yourself get into this situation?”  

“Does your mother know what you do for a living?” 

1. Lack of trust: Due to the nature of the crime, traffickers have likely conditioned their victims to distrust healthcare providers, law enforcement professionals, and others. Though more time consuming, building as much trust as possible is in the best interest of human trafficking victims.  

Ways to establish oneself as trustworthy are to first establish a private setting to interview and assess the patient. Follow through on promises, give the person time to speak, exude a calm demeanor, and reiterate to the person that they are in a safe place.  

What to say:  

“I care about your safety and your health.”  

“I will help you to the best of my ability.”  

What NOT to say:  

“What do you think I can do for you today?”  

“We’ll send you home soon and make a follow-up appointment”  

1. Language barrier: English may not be a language the victim speaks well or at all. Be wary of anyone accompanying the patient who wishes to act as sole interpreter. It is absolutely critical to use a formal interpreter provided by the practitioner’s facility.  

As much as possible, ensure that the interpreter has no relation to the potential victim or their situation, and has training in translating in situations such as these.  

What to say:  

“We will get you a professional interpreter.”  

“Please let me know if you don’t feel comfortable talking about this.”  

What NOT to do:  

Do NOT use the person who accompanied the patient as the interpreter.  

Do NOT use your phone’s translation app or other informal web-based program.  

1. Psychological disturbances: Whether from prior history, acute trauma, substance abuse, or a combination of these factors, many people who are trafficked may not be able to fully discuss their situation upon initial assessment. It may take time for the victim to be more coherent, particularly if the disturbances are drug-induced.  

What to say:  

“I’m here for you if you would like to talk.” 

“I can wait until you feel a little better.”  

What NOT to say:  

“Why did you use drugs if you knew you were going to come in here?” 

“Focus and talk to me.” 

Case Study: Mahad 

After getting Mahad in the room alone, you secure the services of your facility’s formal interpretation service. Through the interpreter, you ask Mahad if his cell phone is off. After a minute, he reluctantly turns it off. Next, you ask Mahad if he would like a male interviewer instead, or a male chaperone, since some cultures prefer to speak with the same gender for these types of encounters. Mahad declines, and you are able to begin your formal history and physical.  

Throughout the process, you discover that Mahad came to this country from Somalia on a student visa three years ago, and his visa is now expired. The man accompanying him is not his uncle, but rather one of the people he works for at the metal stamping plant. The man, who just goes by the letter J, found Mahad when his student visa was expiring, and promised him a lucrative factory job and a place to stay. After a month of working without a paycheck, Mahad asked J where his money was. J told Mahad that he owed him the cost of the room at the factory, as well as a referral bonus for getting him the job in the first place. That was now six months ago, and Mahad has yet to see any money.  

When Mahad tried to leave the factory to return home to Somalia, he found the factory perimeter locked and a guard who prevented him from leaving. J confronted Mahad and told him if he left, he would face arrest and deportation. At that time, J took Mahad back to his room and severely beat him. Mahad states that he has been working for 14 to 16 hours a day with hardly any breaks. At night, he and the other workers drink whiskey until they fall asleep, since J provides one meal a day and allows the workers to bond over drinking alcohol the company provides. Mahad states there are seven other men living with him in cramped quarters, all of them from Somalia. The other men tell Mahad that they have been there for years and have been threatened with death or deportation if they leave the factory grounds.  

Mahad states that this is his third visit to the emergency department. He had come before due to a concussion sustained from a work-related injury, as well as alcohol poisoning before that. He said no one had ever asked him much about his situation, assuming he was a lazy alcoholic.  

Upon examination, Mahad is cooperative but with a flat affect. He states things matter-of-factly, without much emotion. His skin assessment reveals bruises on all extremities, his back, and his abdomen. His sclera appears jaundiced, and he endorses right upper quadrant pain accompanied by intermittent nausea. He states he has had no appetite for the past few days and was only allowed to come to the emergency department because of his inability to work. J stated that he was to get seen, get put on medications to help, then get back to work immediately.  

Barriers to Disclosure  

As stated before, the healthcare provider’s main goal with a potential victim of human trafficking should be to maintain safety and focus on their well-being. There may be myriad, insurmountable reasons a person may not want to disclose their situation. These include, but are not limited to (22):  

• Fear of arrest: Due to the illegal nature of human trafficking and some of the illicit industries it encompasses, the victim may worry about being arrested and incarcerated.  
• Fear of retaliation: Traffickers may have threatened the victim’s family or friends if disclosure occurs.  
• Fear of deportation: If the victim is not a US citizen, they may worry that they will be sent back to their country of origin, where the situation may be even worse for them.  
• Fear of stigmatization: It may be humiliating or embarrassing for a person to disclose all that has happened, exacerbated by the extra layer of social stigma.  
• Lack of trust of the healthcare workers: Even if the trafficker has not predisposed their victim to mistrust of the healthcare system, the particular individuals the victim encounters may not develop sufficient trust for the victim to feel comfortable disclosing their situation.  

Provider Challenges to Identification and Response  

In addition to the barriers related to a victim’s self-disclosure of their trafficking, there are more challenges to identifying potential human trafficking victims. Generally, these fall into two categories: provider-related and individual-related (29). To prevent individual-related barriers, the practitioner should be aware of them and be prepared to resolve them.

Provider-Related Barriers 

While there is increasing awareness of healthcare providers to identify and treat human trafficking victims, some roadblocks still remain. Common reasons providers may not be able to properly recognize or assist victims may include:  

• Lack of understanding of human trafficking and related laws 
• Bias of how a person who has been trafficked may present 
• Feeling the case may be too complex for their level of practice 
• Uncertainty of available resources or referral options 
• Not having adequate training on trauma-informed care; may exhibit victim-blaming and/or culture stereotyping 
• Misidentifies the case, often as abuse or neglect without further context 
• Lack of access to neutral and appropriate translators 
• Feeling that it is not their role to get too involved in the case 
• Frustration with questioning patient: may feel their story is rehearsed, or that the patient is hostile or uncooperative 
• Concern over fears of violating HIPAA (Health Insurance Portability and Accountability Act)  

Individual-Related Barriers 

Since human trafficking is a complex matter with no cookie-cutter case, the victims themselves may also have difficulty identifying themselves as such. Other possible obstacles of people who have been trafficked include:  

• Language barriers and/or limited literacy that hinder communication 
• Lack of identification 
• Legal worries: not understanding their rights in this case, or feeling complicit in an illegal activity  
• Concern that the traffickers will cause harm to the patient or their loved ones 
• Fear of deportation, arrest, being sent back to an abusive place, or going into foster care 
• Presence of trauma bonding (also called Stockholm Syndrome) with the trafficker and/or other victims 
• Feelings of shame, fear, guilt, hopelessness, and helplessness 
• Lack of trust toward the provider and/or other authority figures 

How to Combat Barriers to Identification  

First and foremost, it is crucial to establish trust with the potential victim of trafficking. The healthcare provider must have the person’s well-being and safety as their primary goals. Trust can be developed by slowly talking to the patient, keeping body language open and non-judgmental, and giving plenty of time to speak. Personal space and eye contact are to be dictated by the patient’s perceived comfort, as well as their culture.  

The provider should reiterate to the person that the clinical environment is always a safe one, and that their information will be kept as confidential as possible, within the limits of the law. If possible, it may be helpful to enlist the help of others in the facility: a social worker, sexual assault nurse examiner (SANE) nurse if required, legal counsel, patient advocate, and others. If the patient fears retaliation on their family members or other loved ones, they should know they can get help in this matter and can return to the healthcare facility any time as needed.  

Providers need to be aware of their own implicit biases. Human trafficking victims are a diverse population; there is no single gender or racial or ethnic makeup that comprises this group of people. Men, especially those working in manual labor jobs and the hospitality industry, can also be trafficked, regardless of age, race, or religion. Furthermore, the provider should be aware that in cases of sexual assault or abuse, a further investigation needs to be done to determine if the situation involves trafficking. Simply treating a sexually transmitted disease and discharging the patient after being seen by a SANE nurse is not sufficient care if trafficking is suspected.  

The Importance of a Professional, Unbiased Interpreter 

In the United States, it is estimated that over 350 languages are spoken (30). It is thus likely that in any given shift, a healthcare provider will need at least some degree of translation services for their patients. When working with potential human trafficking victims, it is of the utmost importance that an unrelated, unbiased, professional translator be used. This interpreter should have familiarity with medical language and be free from judgment when translating for the patient. Some things to keep in mind when using an interpreter service for potential victims are (30):  

• If possible, talk to the interpreter alone before talking with the patient to briefly explain the situation. The interpreter should be calm and free of prejudice, ideally having had experience with this type of situation before. Both the provider and interpreter should use a trauma-informed, patent-centered approach.  
• Ensure the patient’s comfort with the particular interpreter; the patient may wish to specify a certain gender, race, or dialect to best meet their needs.  
• An in-person translator is always preferrable, though not always feasible.  

Maintaining a Safe Environment for Staff and Patients  

Without proper safety measures, an encounter with a person who is potentially being trafficked, especially if they are present with their trafficker, can become dangerous very quickly. Providers should remember that human traffickers are criminals and may be armed or violent (35).  

The healthcare practitioner must take steps to ensure that everyone remains safe, including other staff members and patients. When meeting with a potential victim of human trafficking, here are some ways to best maintain a safe environment (35, 37):  

• Privacy: Have a plan to get the patient alone to conduct the interview and assessment. This may be difficult to enforce, so it is critical to have a protocol in place to ensure private conversations with those suspected of being trafficked. There should be a plan to physically separate the patient from their escort and may require the services of security personnel. Some strategies may include: 

• • Assess the power dynamics between the patient and accompanying person(s), and if the patient seems to be comfortable talking about their situation 
  • Decide who is to do the separating  
  • Give reasons such as the patient needs to go for a diagnostic test in another area; cite clinic or hospital policy to interview the patient alone; ask the accompanying party to step out to help complete paperwork or a phone call for scheduling an appointment 
  • Always maintain safety in the environment, noting that involving law enforcement at this point might not always be in the best interest of the patient, particularly terms of future safety 

• Safety Screening: Ask questions pertaining to the person’s physical safety at the time of the interview. This might include asking:  

• • Do you feel safe talking here?  
  • Is there anything that would make you feel safer here as we talk?
  • Can you bring information or phone numbers back with you?
  • Is it safe to contact you another day? If so, which phone number is best? How should I introduce myself when I call? How can we get back in touch if we get disconnected?  

• Conclusion of Visit: If the patient is discharged, how can it be done safely? If the patient is admitted for further care, what will be done with the person escorting them? Does law enforcement need to be involved? If so, how will that be handled? There should be a protocol in place to address these and other immediate safety concerns.  

The Healthcare Provider’s Role  

If the healthcare practitioner suspects a patient is being trafficked, these are the steps that should be taken (47):  

1. Provide safety and privacy for the person.  
2. Assess and treat the medical conditions.  
3. Follow mandatory state reporting laws, as described in the Mandated Reporting section below. 
4. Follow institutional policies for law enforcement involvement if patient is in immediate, life-threatening danger. As much as possible, work with the patient to determine whether or not to involve law enforcement. 
5. Offer the patient resources for reporting and additional services, as described below.  
6. During discharge planning, address safety concerns and future plans. 
7. Ensure proper documentation of assessment and treatment, as described below.  

Survivor-Centered, Multidisciplinary Referrals 

For a situation as sensitive as human trafficking, it is crucial to provide survivor-centered, multidisciplinary referrals to all victims. The referrals should be both within the healthcare organization where the survivors are seen, as well as with community partners. Having survivor engagement enables organizations to better serve this population, as well as create better programs and opportunities within the healthcare system and the larger community.  

Since each survivor is unique, he or she will require a specific mix of resources. These can include any and all of the following: public health professionals, survivor networks, healthcare, legal aid, law enforcement, social services, and behavioral health. Depending on the person’s situation, emergency resources might be needed for housing, food, medical and mental healthcare, substance abuse treatment, legal assistance, and overall safety (48). Ongoing needs may also include transportation to service appointments, therapeutic counseling, and emotional support.  

Appropriate Documentation  

As with all other aspects of nursing, documentation is key. In cases of human trafficking, however, this proves challenging for several reasons. First and foremost, the healthcare practitioner’s role with the patient is to diagnose and treat, while providing for safety. There may be legal ramifications for any information included in the medical record, and legal counsel should be available in cases such as these (37).  

Some aspects to consider include (37): 

• Limit the amount of initial questioning if a SANE nurse evaluation will be done; the SANE nurse will collect evidence with patient consent, and keeping the rehashing of the situation to a minimum will reduce the likelihood of retraumatizing the patient even further.  
• If the case goes to trial, some information entered into the medical chart can harm the victim (e.g., if the patient was involved in illicit activity, they may be prosecuted for this). It is best for the practitioner to clarify with law enforcement and prosecutors how the information may be used and released.  
• In cases of sexual assault or injury, using direct quotations from the patient can be helpful, but might be detrimental if any of the details of the story change later on.  
• Any photographs taken during the medical assessment may be shared with a defense attorney and potentially the traffickers themselves; this can retraumatize the victim, particularly if these photographs are displayed during their trial.  
• Developing an institutional system for flagging potential victims of human trafficking is beneficial; documentation of resources provided (e.g., “Gave patient number for National HT Hotline” or “Referred patient to community agency…”) can both protect the patient and show the clinician’s suspicion of the situation.

Mandated Reporting  

The healthcare provider is in a unique position when it comes to human trafficking cases. While the primary goals are to provide patient safety and give high-quality medical care, there are also legal obligations in certain cases.  

If a minor, elderly person, or person with a mental or physical disability is suspected of being a victim of human trafficking, they are classified as being abused under Texas law, and thus fall under the mandated reporting category for healthcare professionals (41).  

In Texas, mandated reporting obligations pertain to suspected abuse, neglect, or exploitation of the following populations (38):  

• Children under the age of 18 
• Elderly persons aged 65 or older
• People with disabilities

Suspected abuse or neglect of children must be reported within 48 hours. For suspected abuse or neglect of those 65 or older or adults with disabilities, a report must be made to the Department of Family and Protective Services (DFPS) and/or law enforcement immediately. This task may not be delegated to anyone else; the provider who suspects the abuse is responsible for making the report (40, 41).  

The following information for must be included in cases involving the elderly or people with disabilities: The name, age, and address of the suspected victim; the name and address of the caretaker or person involved; the nature and extent of the abuse, neglect, or exploitation; the basis of the reporter’s knowledge; any other relevant information. Failure to report suspected cases can result in a Class A misdemeanor. Further, as long as the report was made in good faith, the reporting party is immune from civil or criminal liability in Texas (38).  

All suspicions described above should be reported to the Texas Department of Family and Protective Services (DFPS) at 1-800-252-5400, particularly if they are urgent and need to be investigated within 24 hours (40).  

As always, in a life-threatening situation outside of a hospital or correction facility, it’s best to call 9-1-1. For matters that can wait more than 48 hours, an online report may be made to DFPS here: https://www.txabusehotline.org/Login/Default.aspx .  

As of September 1, 2023, all reports of children suspected of being abused, neglected, or exploited can no longer be made anonymously to DFPS. Reporters must give their first and last name and a phone number where they may be reached. Though not anonymous, this information is kept confidential by law. If the reporter wishes to make an anonymous report, they may do so with local and state law enforcement agencies instead (40).  

A healthcare provider is not to report the abuse of adults younger than 65 and with no disability without the trafficked person’s consent. Still, the provider can submit a report to the National Human Trafficking Hotline (888-373-7888), without the trafficked person’s identifying information (46). It should be reiterated to the patient that they are welcome to return to the facility any time, that they are safe there, and that they can decide to report at any time.  

Implications of Law Enforcement  

As discussed in this course, victims of human trafficking may be understandably fearful or apprehensive of law enforcement. Depending on the concurrent crimes involved during the period of trafficking, the survivor may face legal repercussions. Luckily, law enforcement officials can provide some resources to healthcare providers, including (42):  

• Local victim service providers 
• A network of resources available through a human trafficking task force, where available 
• Assistance with applying for immigration relief  

It is best for the provider to limit disclosures to law enforcement related to the individual if the potential victim of trafficking wishes to speak to law enforcement, or if the provider suspects imminent danger to the staff and/or individual (42).  

Contacting Community, Local, and/or State Resources  

Fortunately, there are a wide variety of resources available for people who are trafficked and the clinicians who take care of them.  

The National Human Trafficking Hotline, or NHTH (888-373-7888), is available 24/7, toll-free.  

The NHTH is also available by texting BeFree, or 233733.  

This hotline helps maintain a federal database of anti-trafficking agencies and resources and is a response to protecting trafficked persons. The NHTH also has an online directory of anti-trafficking services and groups: https://humantraffickinghotline.org/en/find-local-services.  

In Texas, there is a wide array of online resources that can aid practitioners and potential victims of human trafficking or other forms of abuse:  

• Texas Association against Sexual Assault (TAASA): https://taasa.org/
• The TAASA Service Directory: http://taasa.org/wp-content/uploads/2018/10/TAASA_Service-Directory-102318.pdf
• Texas Department of Family and Protective Services (DFPS) and/or local law enforcement: Reporting Abuse, Neglect, or Exploitation: https://www.dfps.texas.gov/Contact_Us/report_abuse.asp
• Texas Health and Human Services (HHS) Provider Guidebook: Services for Victims of Human Trafficking in Texas: https://www.hhs.texas.gov/sites/default/files/documents/services/safety/human-trafficking/provider-guidebook-services-victims-human-trafficking-texas.pdf
• Office of the Texas Governor’s Child Sex Trafficking Team: https://gov.texas.gov/organization/cjd/childsextrafficking 

(3) 

Organizational Protocols 

With such a multifaceted issue as human trafficking, it is essential that every healthcare organization have clear policies, guidelines, and protocols for responding to this situation. While awareness of the issue is on the rise, many facilities are lacking adequate resources and training to combat human trafficking. 

The benefits of organizational protocols include some of the following (37): 

• Optimizing patients’ interaction with healthcare staff 
• Improving staff’s ability to recognize and appropriately treat patients at risk for trafficking  
• Maximizing staff and patient safety 
• Assuring adequate support for trafficked patients who are not ready or able to disclose their situation or accept assistance  

To develop a functional and helpful protocol within a healthcare setting, these are some of the first steps (37): 

1. Identify community multidisciplinary responders 
2. Engage non-medical community entities  
3. Utilize medical stakeholders within the community 
4. Understand local and national indicators of health and human trafficking  
5. Create and convene an interdisciplinary protocol committee 
6. Develop a multidisciplinary treatment and referral plan

(49)

Building a Trusted Local Network of Resources  

Since each community has its own unique population, various resources may be needed to appropriately address the needs of the individuals involved. It would behoove the practitioner and their institution to establish or build upon a list of resources available for human trafficking. In addition to the list above, there may be other services available in each community. Establishing a good working relationship with local social workers, lawyers, and law enforcement officers is crucial for any healthcare establishment.  

Conclusion

Human trafficking is a heinous crime that affects individuals from every walk of life. In the United States, most of those who are trafficked will seek some form of healthcare during the time they are trafficked. It is up to healthcare professionals to collaborate with relevant community resources to provide safe, adequate, compassionate care to this vulnerable population.  

It is essential that healthcare providers be aware of the people and organizations available to help their patients, and to have an institutional protocol in place to appropriately address the issue of human trafficking.  

By providing patient-centered, trauma-informed care, the healthcare professional will be able to best assist survivors of human trafficking. This means adopting a nonjudgmental approach to all patients, and to realize why disclosure is not necessarily a goal of each encounter. Local law enforcement and social services may be needed, and accurate documentation is crucial in all these cases.  

Finally, the practitioner should be aware of mandated reporting laws, as well as how to best provide adequate safety and confidentiality for their patients. It is with all these concepts in mind that the healthcare field may help more fully address the challenges inherent in human trafficking.  

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