Human Trafficking Nursing CE Course

#182 and #138. Human trafficking has been identified within the US in many industries and locations, such as hotels, restaurants, cleaning services, construction, factories, agriculture, and salons or spas (Greenbaum et al., 2017; NHTH, n.d.-c).

Adult victims of sex trafficking are commonly maintained through force, fraud, or coercion, while minors engaging in commercial sex are automatically considered victims of sex trafficking regardless of force, fraud, or coercion due to their age. Trafficking may occur in sham massage parlors, escort services, residential brothels, strip clubs, hostess clubs, truck stops, or public streets. An estimated 1 in 6 endangered runaways is likely a victim of sex trafficking. According to global estimates, 4.8 million individuals are trapped in sexual exploitation (NHTH, n.d.-g). In most cases of human trafficking in the US and worldwide, the victims are adolescent or young adult females (NPWH Board of Directors, 2017).

Federal Legislation

The Trafficking Victims Protection Act (TVPA) of 2000, which can be referenced fully by searching for 22 USC §7102, was the first comprehensive federal law regarding human trafficking or trafficking in persons (TIP) in the US (NHTH, n.d.-a; Toney-Butler & Mittel, 2022; TVPA, 2000). It has been reauthorized six times since that date (NHTH, n.d.-a). Revisions have further defined human trafficking as severe forms of TIP, including sex and labor trafficking (Toney-Butler & Mittel, 2022). As defined by this legislation, there are three essential components comprising the A-M-P model: action (what is done, referred to below as process), means (how it is done), and purpose (why it is done, referred to below as end; Figure 1). The means are not required to qualify as human trafficking if the victim is a minor (OTP, 2017; OVC, n.d., sect 1.4; Toney-Butler & Mittel, 2022; United Nations Office on Drugs and Crime [UNODC], n.d.). At least one item from each of the three components must be present to establish a case for the human trafficking of an adult (NHTH, n.d.-g). In addition to the means in Figure 1, traffickers may utilize abduction, deception, forced drug use, abuse of power, or the provision of payments or benefits. Their purpose may also include slavery, removal of organs, or other types of exploitation (UNODC, n.d.).

Figure 1

A-M-P Model of Human Trafficking

(OVC, n.d., sect 1.4)

The TVPA (2000) established a three-pronged approach to TIP (often called the 3Ps or the three pillars): protection, prosecution, and prevention. The protection approach establishes federally funded benefits for victims and survivors of trafficking, such as healthcare and T visas, to protect these individuals from deportation. These protective measures also help reintegrate survivors into society to avoid re-victimization. Prosecution refers to the addition of financial restitution payments by the TVPA in 2000 and more substantial penalties for convicted traffickers. Finally, prevention includes international incentives to deter TIP by improving global economic conditions. The TVPA created a new department (The Office to Monitor and Combat Trafficking in Persons) within the US State Department and mandated annual TIP reporting. Finally, the TVPA required the formation of an interagency task force to address human trafficking (Toney-Butler & Mittel, 2022). Then, the Obama Administration signed the Preventing Sex Trafficking and Strengthening Families Act (2014), which required states to improve their policies and programs to better identify, document, and provide services for children at risk for sex trafficking. In addition, a 2015 act was passed regarding improved and consistent training of HCPs regarding how to assess and manage victims of human trafficking (Leslie, 2018).

In 2021, the White House authored the National Action Plan (NAP) to Combat Human Trafficking, which called on the US Department of Justice to enhance education and outreach by producing and disseminating culturally sensitive and age-appropriate educational tools that augment existing prevention efforts. A working group was recommended to study the potential role of demand-reduction strategies and protection for workers on non-immigrant visas within the Senior Policy Operating Group (SPOG). The NAP called upon the Office of the US Trade Representative to ensure that products created using forced labor are not imported into the US. Protection enhancements include developing and updating human trafficking screening forms by the SPOG to be made available to all federal officials, HCPs, social workers, and other front-line workers, along with victim-centered training to respond appropriately (White House, 2021).

A public awareness campaign was recommended to increase victim identification and provide victims with information on seeking help. The NAP requires the justice system to protect trafficking victims from incarceration or criminal penalties. It also supports the provision of financial remedies for victims through the Justice for Victims of Trafficking Act. The prosecution pillar requires improved coordination among law enforcement agencies to target, dismantle, and hold complex trafficking networks accountable. The NAP also advised law enforcement to develop and encourage advanced training to investigate and prosecute these criminals and deploy a broader range of non-criminal tools and federal enforcement options such as civil forfeiture actions, sanctions, travel restrictions, and enforcement of reporting requirements. The NAP also included a fourth "crosscutting" pillar to improve the collaboration and coordination of the three initial pillars by increasing understanding of human trafficking, information sharing, and incorporating survivor input (NAP to Combat Human Trafficking, 2020). It is becoming evident that to be effective in anti-trafficking efforts, organizations must be both trauma-informed and survivor-informed (RF, personal communication, March 17, 2023).

Impacts of Human Trafficking

From 2003 onward, researchers have attempted to identify the effects of human trafficking on survivors (Powell et al., 2017). A systematic review in 2016 included 31 studies that determined that victims of human trafficking experience increased violence. Physical health symptoms reported most often by victims included headaches, abdominal pain, and back pain. Common mental health conditions include depression, anxiety, and post-traumatic stress disorder (PTSD). Victims of human trafficking often report symptoms suggesting a higher-than-average prevalence of sexually transmitted infections (STIs), although serological evidence of this trend is lacking. Many studies contain methodological weaknesses and differences in their definition and operationalization of trafficking (Ottisova et al., 2016). Studies in Asia and Africa estimate that women and girls who experience forced sexual encounters are 50% more likely to acquire HIV than those who do not. This data may be due to inadequate condom use, immature cervical epithelium, or cervical ectopy leading to microscopic breaks and inflammation in the vaginal mucosa. In addition to STIs, female victims have increased risks of pregnancy, urinary dysfunction/infection, and complications related to forced tampon use. Often referred to as "packing of the vagina," victims may be forced to insert tampons before sexual encounters while menstruating, leading to foreign debris and reports of lost tampons requiring medical assistance for removal (Greenbaum et al., 2017; Hachey & Phillippi, 2017; National Human Trafficking Resource Center [NHTRC], 2016a; Toney-Butler & Mittel, 2022; Tracy & Macias-Konstantopoulos, 2022).

Victims of labor trafficking are often abused or threatened at work, restricted from taking breaks, and denied adequate personal protective equipment (PPE); they also report being recruited for different work than they currently do (Leslie, 2018; NHTH, n.d.-d; NHTRC, 2016a). Victims of labor trafficking often present with signs of severe dehydration, malnutrition, heat exhaustion, or hypothermia. They often experience neck or back injuries, carpal tunnel syndrome, or vision problems due to a lack of proper safety equipment. They are at increased risk of infectious diseases due to overcrowded and unsanitary working, living, or travel conditions. These conditions may lead to the acquisition of tuberculosis (TB), typhoid, malaria, silicosis, Chagas disease, toxoplasmosis, toxocariasis, cysticercosis, scabies, lice, or other skin infections. Skin infections with Vibrio vulnificus, a bacterium often encountered by migrant workers in warm climates exposed to shallow coastal waters, can lead to necrotizing fasciitis and, eventually, septicemia. Human trafficking increases the risk of chronic pain, substance use disorder (SUD) and related complications, sleep disorders, chronic medical conditions, and self-harm or suicide. Chronic conditions caused or escalated due to extreme stress are common among trafficking victims, such as cardiac arrhythmias, hypertension, acute respiratory distress, constipation, and irritable bowel syndrome. As a less visible but equally damaging indicator, victims typically report a diminished quality of life and long-term fear of autonomy or independence (Greenbaum et al., 2017; Hachey & Phillippi, 2017; NHTRC, 2016a; Toney-Butler & Mittel, 2022; Tracy & Macias-Konstantopoulos, 2022).

Trafficked children often lack adequate shelter, safety, sleep, exercise, balanced nutrition, clean water/air, appropriate clothing/shoes, and hygiene/sanitary products. The trauma leads to significant and lifelong mental, emotional, and physical effects, including PTSD, severe affective disorders (e.g., anxiety, depression, bipolar disorder), attachment disorders, depersonalization, dissociation disorders, and extreme stress and adjustment disorders. Children will often display evidence of significant delays in physical and cognitive development and poor social skills. One disorder that trafficking victims often describe is memory disruption, whereby the victim's recollection of events becomes disjointed, decreased, or inaccurate, especially surrounding traumatic events. Alternatively, many victims develop a phenomenon referred to as trauma bonding or Stockholm syndrome, in which they develop loyalty to and concern for the trafficker(s), refusing to report or testify against them and returning to their previous state of bondage when able (NHTRC, 2016a, 2016b; Wood, 2020).

Risk Factors for Human Trafficking

Anyone—in any community or country—can become a victim of human trafficking. However, certain groups have more significant risks of experiencing human trafficking than other groups. People of color and members of the LGBTQ+ (lesbian, gay, bisexual, transgender, queer/questioning) community are more likely to become victims than others. This may be due to several factors, such as generational trauma, historical oppression, and discrimination. Populations at increased risk also include those residing on Native American reservations (NHTH, n.d.-d; Toney-Butler & Mittel, 2022; Tracy & Macias-Konstantopoulos, 2022). Minors are inherently at increased risk for human trafficking due to their incomplete development and immature brains (Wood, 2020). Individual factors that increase the risk of victimization include:

• individuals with a disability
• an unstable living condition/homeless
• history of experiencing violence (e.g., domestic, or sexual violence, intimate partner violence, gang member violence, or others exposed to community violence)
• a minor who has run away from home
• a minor involved in the juvenile justice or child welfare system
• undocumented or recent immigrants or those with a language/cultural barrier
• poverty or economic need
• those with a SUD or addiction
• those with a caregiver or family member with a SUD (CDC, 2022; NHTH, n.d.-d, 2019; Toney-Butler & Mittel, 2022)

Adverse childhood experiences (ACEs) increase the likelihood of risk-taking behaviors, predisposing an individual to trafficking situations. The landmark study by Felitti and colleagues (1998) originally proposed this connection, correlating high scores on an ACE questionnaire with an increased risk for victimization and poor outcomes. It has since been confirmed with subsequent research. The original work focused on psychological, physical, and sexual abuse; violence against the mother; or living with individuals with SUD, severe mental illness (including suicidality), or history of incarceration. These childhood exposures, or ACES, significantly increase the risk for adult SUD, smoking, poor self-rated health, obesity, inactivity, STIs, depression, suicidality, and many common chronic diseases (e.g., ischemic heart disease, cancer, chronic lung disease, and liver disease). Moreover, the number (quantity) of exposures increased that risk further (Felitti et al., 1998).

A 2017 study found that a prior history of sexual abuse was the most reliable predictor for individual exploitation via human trafficking. This history increases the risk of substance abuse and mental health disorders. It may also damage the assault victim's concept of social norms, belonging, and family; it could engender feelings of distrust toward authority figures. All of these reactions are potential vulnerabilities or weaknesses that perpetrators may exploit. Higher ACE scores may contribute to the increased trafficking risk among members of the LGBTQ+ community (Toney-Butler & Mittel, 2022). The 2021 Data Report by NHTH and the Polaris Project indicated that the top risk factors for experiencing sex or labor trafficking include a history of mental or physical illness and highlighted the elevated risk of those with SUD or a recent history of migration or relocation (NHTH, 2021).

Identifying the perpetrators of human trafficking, often referred to as traffickers, can be more difficult than identifying victims. Traffickers may be of any race, nationality, gender, age, or sexual orientation. They may be related to the victim, partners, or strangers (NHTH, n.d.-d). They may be US citizens or foreign nationals. Traffickers prey on lost individuals searching for a better life and make false promises to them (e.g., of a loving relationship, a good job, safety/protection, or new opportunities). They may work alone or belong to a more extensive, organized network. Traffickers may share the same national, ethnic, or cultural background as their victims, lending insight and understanding regarding their vulnerabilities and making exploitation easier (NHTH, n.d.-h). Traffickers may also be young girls trained to recruit other young girls after being in the life for a period and wanting to increase rank. Many victims are recruited through the internet and popular social media applications (RF, personal communication, August 11, 2021, March 17, 2023). The 2021 Data Report by NHTH and the Polaris Project showed that the top five recruitment tactics used by perpetrators of sex trafficking in 2021 consisted of an intimate partner/marriage proposition, familial tactics, a job offer advertisement, posing as a benefactor, or false promises/fraud. Perpetrators of labor trafficking were most likely to use a job offer advertisement, dishonest promises/fraud, smuggling-related tactics, familial tactics, or posing as a benefactor. The high profits associated with TIP are a significant motivator for the perpetrators, with a relatively low associated risk level in most circumstances (NHTH, 2021). While a stereotypical trafficker is affiliated with a gang or functioning as a pimp, many traffickers often publicly masquerade as small business owners or employers, such as:

• massage parlors or brothels
• cleaning services
• domestic assistants
• landscaping companies
• agriculture administration- managers and site supervisors
• labor brokers
• factory owners/managers
• nail salons/spas
• international matchmaking services ("mail-order bride")
• modeling agencies
• au pair agencies
• strip clubs (ICE, 2017; NHTH, n.d.-h; NHTRC, 2016b)

Most traffickers target vulnerabilities and sell a dream to recruit victims. These dreams often include red flags, such as a job opportunity that sounds too good to be true, an employer who refuses to answer detailed questions or provide an employment contract, or an employment contract provided in a language the employee cannot read. Labor traffickers may request payment from an employee victim before starting work. Sex trafficking victims may suddenly be coerced into a highly asymmetric relationship (i.e., a significant difference in age or financial/social status) with copious amounts of expensive gifts or money (NHTH, n.d.-d). In many cases, victims genuinely believe they are in a relationship with their trafficker (RF, personal communication, March 17, 2023).

             Aside from violence and forced migration, the American Academy of Pediatrics (AAP) has noted additional family factors, such as poverty and unemployment, that increase the risk of trafficking of minor children. In addition to the violence mentioned previously, community factors that increase this risk include a tolerance of sexual/labor exploitation within the community, natural disasters, community upheaval, high demand for inexpensive labor, a lack of community resources or support, and a lack of awareness among community members regarding trafficking practices. The AAP highlighted societal risk factors like gender-based violence and discrimination, cultural beliefs or stigma, a weak recognition of child rights, and political or social unrest (Greenbaum et al., 2017).

Traffickers often exploit, intersect with, or exist alongside legitimate businesses for their space, transportation services, or other resources to facilitate their trafficking system. This includes advertising companies, transportation providers (e.g., airlines, buses, rail, taxis), money transfer services, and hotels or motels. Owners and operators of these businesses have the ability and moral obligation to recognize and report when their services are being misused (NHTH, n.d.-h).

Identification of Victims/Survivors in Healthcare Environments

The majority (over 85%) of trafficking victims report accessing healthcare services during their period of trafficking. While most victims report accessing care via an emergency department, HCPs in other settings must all be aware of and watchful for the indications of possible TIP, including primary care offices, pediatric offices, gynecology/obstetrics, health departments, urgent care clinics, and school nurses (NHTRC, 2016b; Toney-Butler & Mittel, 2022). Trauma-informed care requires the multidisciplinary healthcare team to recognize "the scope of the impact of the trauma on an individual victim's lifespan and lessens any chance of inflicting more injury on this victim" (Toney-Butler & Mittel, 2022, p. 17). A victim-centered approach attempts to ensure that the victim is not re-traumatized or re-victimized and is defined as "the precise focus of attention, catering to the needs of the victim to ensure delivery of care in a compassionate, culturally sensitive, linguistically appropriate, nonjudgmental, and caring manner. A victim's wishes, safety, and well-being are considerations" (Toney-Butler & Mittel, 2022, p. 17).

The acronym SOAR (stop, observe, ask, and respond) may help HCPs in all settings to identify and respond appropriately to human trafficking in the healthcare setting. Stop asks HCPs to pause and recognize the scope of the human trafficking problem in the US. Observe refers to the awareness of verbal and non-verbal indicators of trafficking to help HCPs identify those at risk. Ask indicates that the HCP should listen carefully to the victim's responses to questions, providing victim-centered and trauma-informed care. Finally, respond refers to identifying needs, knowledge of available resources, and providing support or assistance when requested. SOAR training is available online through the US Department of Health and Human Services (train.org) for free to HCPs and confers one contact hour of continuing professional development credit (OTP, 2019). Overall, the goal of the HCP should not be to rescue the victim or convince them to disclose but rather to establish a safe and nonjudgmental space to facilitate the proper identification of victims and provide them with whatever assistance they require or request (NHTRC, 2016a). The "rescue" may not be to remove an adult victim from their situation that day but rather to provide them with resources for when they are ready to exit the life (RF, personal communication, August 11, 2021).

Victims may seek care after assaults for injuries or unrelated or preexisting conditions. However, victims rarely self-identify, even to HCPs whom they trust; this may be attributed to feelings of shame or guilt; fear of retaliation by their trafficker; fear of arrest (with a prior criminal record), deportation, or report to social services; a lack of transportation or controlled movement; or a lack of understanding of the US healthcare system (Hachey & Phillippi, 2017; NHTRC, 2016b; Toney-Butler & Mittel, 2022). There may also be a language barrier, distrust of authority figures, stigma regarding their situation, or another underlying cause (NPWH Board of Directors, 2017). Victims may feel partially responsible for their current situation or be concerned about large financial debts that may cripple themselves or their families if not paid. Victims may lack insight, not recognizing exploitation due to brainwashing by their trafficker into thinking their current situation is "normal" or of their choosing. They may not view their trafficker as an abusive perpetrator, especially if that individual is a family member or "romantic partner." Traffickers may also "test" their victims by allowing them to be questioned to assess their loyalty. Victims of labor trafficking may feel trapped due to debts owed to their employer, immigration status, or threats of violence. Trafficking victims often do not possess or control crucial legal documents (e.g., their driver's license, birth certificate, passport, or immigration paperwork/visa) and have few personal possessions (Leslie, 2018; NHTH, n.d.-d; Wood, 2020).

Trafficking victims may have a significant discrepancy between their reported and suspected age. They are typically isolated from others or may be living in dangerous, overcrowded, or unsanitary conditions. Trafficking victims often live where they work or are accompanied by guards while transported to and from work (Leslie, 2018; NHTH, n.d.-d; NHTRC, 2016a).

Trafficking victims may be unable to recite their address or explain where they live; they often claim they are "just visiting" the area. They may be accompanied by a partner, guardian, or "sponsor" who will not allow them to be alone with anyone else, including HCPs, and will often answer questions for the patient. An accompanying family member who is rude, impatient, or anxious to leave, or a victim who leaves without being seen or against medical advice, may indicate a trafficking situation. The restrictions on trafficking victims may be invisible if they are emotional and psychological, as traffickers often utilize fear, threats, and mental control. Based on the SOAR acronym mentioned above, these indicators are best identified when the HCP takes the time to stop, observe the patient (including verbal and nonverbal cues, which may be subtle), and ask open-ended, nonjudgmental questions in a private setting (The Joint Commission, 2018; HTHT, n.d.-d; NTHRC, 2016a; OTP, 2019; Toney-Butler & Mittel, 2022). Table 1 provides a summary of the indications that suggest human trafficking.

Table 1

Physical and Behavioral Indicators of Human Trafficking

Either Labor or Sex Trafficking: somatization (e.g., recurring headaches, abdominal pain, fatigue) anxiety/panic attacks, seems nervous or fearful of touch unexplained or conflicting stories, resistant to answering direct questions, or recitation of a script-like history overly vigilant or paranoid behavior irritability or affect dysregulation (depressed or flat affect) refusal to change into hospital gown or cooperate with examination avoidance of eye contact an inability or aversion to making independent decisions inappropriate attire for environmental conditions or season a significant delay between injury occurrence/onset and seeking care, refusal of additional follow-up Labor Trafficking: musculoskeletal/ergonomic injuries (e.g., fractures, strains/sprains) malnutrition dehydration lack of routine preventative care poor dental hygiene untreated skin infections or inflammation injuries or illness due to repeated exposure to harmful chemicals or unsafe water ophthalmology issues, vision concerns an inability or aversion to speaking without an interpreter Sex Trafficking: frequent emergency care visits using language from “the life” indications of substance or alcohol use disorder multiple/recurrent STIs or urinary tract infections (UTIs), including pelvic inflammatory disease (PID) an abnormally high number of sexual partners signs of physical trauma, especially vaginal or rectal trauma, cigarette burns, multiple bruises or contusions, or self-inflicted injuries impacted tampon found in the vagina suspicious tattoos/branding multiple miscarriages or aborted pregnancies (often with complications) Sex Trafficking in Minors: early initiation of sexual activity or pregnancy or abortions at a young age history of running away from home or placement in foster care excessive absences and truancy from school highly sexualized behavior or attire anger or aggression with staff

(Hachey & Phillippi, 2017; The Joint Commission, 2018; Leslie, 2018; NHTRC, 2016a, 2016b; Toney-Butler & Mittel, 2022)

HCPs should avoid stereotyping patients as criminals, prostitutes, difficult, uncooperative, or drug-seeking. Instead, they should consider that these patients could be potential victims who require a careful and nonjudgmental assessment of their needs. HCPs should also recognize that no "perfect" victim exists, as no victim fits an exact or predetermined model. Instead, any patient presenting with the above indication(s) of human trafficking should be screened.

Screening for Victims of Human Trafficking

A multidisciplinary approach using all available resources has proven most effective, especially in teams with experienced social workers. Collaboration and communication across the healthcare team, community service providers, law enforcement, and investigators increase the chances that all victims' needs are met efficiently and effectively. Institutions and organizations should carefully establish multidisciplinary protocols and policies regarding the care of trafficking victims, and HCPs should refer to them as needed. Professionals expected to identify and care for trafficking victims should be adequately trained to effectively recognize red flags, establish professional rapport, use screening tools, and provide a trauma-informed response. Protocols help educate HCPs on identifying and responding to victims, increasing the likelihood that victims will be identified and assisted. Without clear protocols, the identification and response require the HCP to rethink their response anew each time, becoming a stressful waste of time and increasing the victim's anxiety (Greenbaum et al., 2017; Joint Commission, 2018; NHTRC, 2016a; NHTTAC, 2018).

Protocols should include common indicators and red flags, strategies for privacy when interacting with patients, interview techniques, safety strategies for the patient and the healthcare team, and referral or resource information. Mandatory reporting guidelines, NHTH contact information, and follow-up data should also be included. Some protocols may also establish staff training requirements and assessments. Information on accessing interpreter services should also be included in institutional policies to ensure they are used consistently. When developing victim-centered protocols, some researchers advocate for the inclusion of survivors on the strategic planning committee. The National Survivor Network is a reliable resource for local survivor leaders to serve as knowledgeable and trusted voices and resources to ensure appropriate and comprehensive protocols. Hospital staff must be trauma-informed as well as survivor-informed. Once the staff is trained and protocols are being carried out, institutions should regularly and methodically assess their effectiveness and modify them when needed. Despite this guidance, each situation will be unique to the particular victim, and the response should be tailored to their scenario and needs. If questions arise, HCPs have 24/7 access to assistance through the NHTRC hotline for guidance and determining the next steps. They also offer tele-interpreting services for over 200 languages (Baldwin et al., 2017; Joint Commission, 2018; NHTRC, 2016a; NHTTAC, 2018; Toney-Butler & Mittel, 2022; Tracy & Macias-Konstantopoulos, 2022).

As mentioned, victim-centered care should be culturally and linguistically tailored to the patient whenever possible. If English is not the patient's primary language, they should be offered the use of a professional, competent interpreter who is not related to or accompanying the patient. Interpreters should have signed confidentiality and nondisclosure agreements. In addition to providing a more efficient interview by communicating in the patient's native language, an interpreter may provide valuable insight by identifying subtle cues and inconsistencies in the patient's story and enhancing the patient's comfort level by easing cultural shock. The patient should be interviewed by someone of the same gender if desired, and a similar choice regarding interpreters should be offered whenever possible. If possible, patients should be matched with service providers and case managers of the same ethnicity or cultural background to help overcome language barriers and heighten cultural sensitivity. Providers should reference the National Standards for Culturally and Linguistically Appropriate Services (CLAS) for additional guidance (NHTRC, 2016a; NHTTAC, 2018; Simich et al., 2014; Toney-Butler & Mittel, 2022).

A simple checklist of red-flag indicators is insufficient as a screening technique. Patients identified as high-risk based on a red-flag checklist should be given a screening interview. While validated screening tools for HCPs are in relatively short supply, they are available. The Trafficking Victims Identification Tool (TVIT) by Simich and colleagues (2014) is based on 2 years of research conducted by the Vera Institute, an independent nonprofit funded by the National Institute of Justice. This tool has been validated with labor and sex trafficking victims, men and women, and US-born and foreign-born victims. It was not validated with individuals with disabilities or LGBTQ+ individuals. It is an interview tool consisting of 16 core questions (a short version) and four additional questions regarding migration to be used with individuals born outside the US (Simich et al., 2014).

The accompanying manual gives specific suggestions to optimize the tool's effectiveness, such as fulfilling the victim's basic needs before interviewing them (e.g., food, water, clothing, medical care) and performing the interview in a private, secure, comfortable location away from and out of view of the potential trafficker in a professional yet friendly manner. The patient should be told the purpose and length of the interview at the beginning. The interviewer should reassure the patient by recounting their prior experience with similar cases; be patient, caring, and sensitive to the patient's needs; avoid placing any blame or responsibility on the victim; allow the patient sufficient time to tell their story in their own words; and remain mindful and respectful of the patient's cultural background. Expressing sorrow or empathy is encouraged, but the HCP should avoid appearing judgmental or shocked. All interviews should be confidential, and the patient should be aware of this information from the beginning of the interview. If a mandatory reporter, the HCP should explain their requirements to report, if applicable. In some jurisdictions, certain portions or details of the interview may be deferred to a service provider (e.g., attorneys or clergy members) who can legally claim privileges (Simich et al., 2014).

The TVIT refers to "work or other activities" regarding sexual services and informal work. However, victims may not conceptualize forced prostitution (rape), forced shoplifting, or forced drug smuggling as work. Therefore, the interviewer should attempt to mirror the patient's own words and terminology throughout the interview whenever possible. The long and short versions of the TVIT and the accompanying user guide can be accessed on the Vera Institute's web page at Vera.org (Simich et al., 2014). Critics of the TVIT report that the short version takes longer than an hour to administer, not including the time required to establish a rapport with the patient before administration. They also warn that this tool has not been validated in multiple settings (as it was validated only for use within victim service organizations), potentially making it inappropriate for use in public health (NHTTAC, 2018).

The NHTTAC (2018) has also developed a toolkit along with their Adult Human Trafficking Screening Tool (AHTST). This 8-question verbal screening tool is designed to be used by HCPs and members of the behavioral health, social service, and public health sectors, but it is not yet validated. They recommend screening patients who are considered at-risk based on an established red-flag checklist of signs, symptoms, and indications of potential human trafficking. The goals of the AHTST are to help recognize the signs of trafficking, respond appropriately, and make the appropriate referrals. It is an evidence-based, survivor-centered, and trauma-informed tool. This means that it is designed to:

• recognize the effects of violence on human development and coping
• ensure that services are accessible and readily available
• identify co-occurring problems comprehensively
• ensure that services are culturally and linguistically appropriate
• minimize the possibility of re-traumatizing
• emphasize education, choice, and resilience (NHTTAC, 2018)

The NHTTAC user guide stresses the importance of developing and establishing institutional policies and a referral network or plan before screening patients within their institution. The user guide suggests establishing a trusting relationship before the screening interview (with tips included in Table 1 of the NHTTAC user guide) and maintaining a neutral attitude toward the trafficker throughout the interview. Victims often react by defending the trafficker if they are criticized or condemned by the interviewer; therefore, accusatory language should be avoided. In addition to conducting the interview in a safe place and addressing the patient's physical needs first, as described above, the user guide suggests utilizing open, non-threatening body positioning (e.g., remain at eye level, sit or squat, respect personal space, and avoid crossing the arms), engaging the patient (e.g., maintain a calm tone of voice and a warm and natural facial expression, make eye contact), matching their pace and mirroring their language, offering an interviewer of the same sex, and avoiding probing for unnecessary details. Calm, empathetic, and respectful language should be used, and the interviewer should allow themselves and the patient ample time and avoid rushing through the screening interview. The following eight questions are included in the AHTST (NHTTAC, 2018, pp. 16-17):

1. Sometimes lies are used to trick people into accepting a job that does not exist, and they get trapped in a job or situation they never wanted. Have you ever experienced this, or are you in a situation where you think this could happen?
2. Sometimes people make efforts to repay a person who provided them with transportation, a place to stay, money, or something else they needed. The person they owe money to may require them to do things if they have difficulty paying because of the debt. Have you ever experienced this, or are you in a situation where you think this could happen?
3. Sometimes people do unfair, unsafe, or even dangerous work or stay in dangerous situations because if they do not, someone might hurt them or someone they love. Have you ever experienced this, or are you in a situation where you think this could happen?
4. Sometimes people are not allowed to keep or hold on to their own identification or travel documents. Have you ever experienced this, or are you in a situation where you think this could happen?
5. Sometimes people work for someone or spend time with someone who does not let them contact their family, spend time with their friends, or go where they want when they want. Have you ever experienced this, or are you in a situation where you think this could happen?
6. Sometimes people live where they work or where the person in charge tells them to live, and they're not allowed to live elsewhere. Have you ever experienced this, or are you in a situation where you think this could happen?
7. Sometimes people are told to lie about their situation, including the kind of work they do. Has anyone ever told you to lie about the kind of work you are doing or will be doing?
8. Sometimes people are hurt or threatened, or threats are made to their family or loved ones, or they are forced to do things they do not want to do in order to make money for someone else or to pay off a debt to them. Have you ever experienced this, or are you in a situation where you think this could happen?

For each question, the interviewer should note how the patient responds in the center column (yes, no, I do not know, or declined to answer) and any important notes/details in the final column. A single affirmative answer may indicate that the individual is currently at risk of or is being trafficked. The HCP should be prepared to help de-escalate if the screening interview triggers a trauma reaction in the patient. Common grounding techniques that may be helpful include 4-7-8 breathing (the patient inhales through the nose with a closed mouth for the count of 4, holds their breath for a count of 7, and then exhales through their mouth with the tip of their tongue pressed against the roof of their mouth, making a whoosh sound, for a count of 8, then repeat) or the 5-4-3-2-1 game (ask the patient to name five things that they can see, four they can feel, three they can hear, two they can smell, and one good thing about themselves). After the interview, the HCP should conclude by discussing the patient's primary concerns, interest in additional referrals, and the importance of a safety plan. Obvious shortcomings identified within the AHTST include its limited screening for adult victims only and its current lack of validation (Hachey & Phillippi, 2017; Leslie, 2018; Mumma et al., 2017; NHTTAC, 2018).

If the patient declines to participate in a screening interview, the HCP should ask permission (if it is safe) to give the patient information, including contact details for the NHTH, to review at another time. Institutions should develop and maintain printed materials with contact information for local resources. A small shoe or key card may be provided and hidden in the patient's shoe or another discrete location. If the patient does not feel that having the phone number or printed information is safe, assist the patient in memorizing the hotline number for later use if desired. The number is easiest to remember by separating it in the following manner: 888-3737-888. The patient should be reminded that the NHTH is completely confidential unless the caller threatens to harm themselves or others, is in imminent danger, or is experiencing a life-threatening emergency (Joint Commission, 2018; NHTRC, 2016b, 2016a; NHTTAC, 2018; Toney-Butler & Mittel, 2022). The HCP can also utilize recommended messaging techniques for victims of human trafficking, such as the following (Toney-Butler & Mittel, 2022, p. 13):

• We are here to help you, and our priority is your safety. Our goal is to keep you safe and protected.
• We can provide you with the medical care that you need and find you a safe place to stay.
• Everyone has the right to live without being abused or hurt, and that includes you.
• You deserve a chance to live on your own and take care of yourself, be independent, and make your own choices. We can help you with that.
• We can try to get you help to protect your family and your children.
• You have rights and deserve to be treated according to those rights.
• You can trust me. I know it's hard to know who to trust. I will do everything within my power to help you. Assistance is available for you under the law, and there are special visas to allow you to live safely in this country.
• No one should have to be afraid all the time. We can help.
• Help us, so this does not happen to anyone else.
• You can decide what is best for you.

Documentation regarding any injuries such as lacerations, contusions, scars, or other indications of trauma should be detailed, including the size, shape, color, location, and pattern of bruising. Proper documentation, including photos, may prove vital and allow the victim to prosecute their trafficker successfully later (Hachey & Phillipi, 2017; Leslie, 2018; Toney-Butler & Mittel, 2022). Since HCPs obtain a medical history for diagnosis and treatment, they can testify in court utilizing the history on behalf of the patient under the medical exemption to hearsay. This unique ability of HCPs may make the difference in delivering justice or saving a life. Proper documentation also communicates the concerns to other healthcare team members if the patient returns for future visits. Before any screening interviews, the patient's basic needs should be met, and they should be reassured of their current safety. Patient statements should be placed in quotation marks, and specific details of patient demeanor, tattoos, and clothing should be documented, as well as any names stated for safety purposes (RF, personal communication, August 11, 2021). The HCP should be prepared for the patient to respond with various trauma responses, including anxiety, mood fluctuations, aggression, shame, guilt, detachment, hopelessness, fear, or hypervigilance. Victims may appear easily startled, jumpy, reserved, or hesitant (Joint Commission, 2018; NHTRC, 2016b; National Human Trafficking Training and Technical Assistance Center [NHTTAC], 2018). If you have a forensic nursing program at your hospital or in your community, this would be a patient for them to treat cooperatively (RF, personal communication, March 17, 2023).

Trauma-Informed Care: Response, Referrals, Resources, and Reporting

In addition to the suggestions mentioned in both of the toolkits discussed above, the NHTRC (2016b) also recommends that HCPs attempting to deliver victim-centered care should remain sensitive to power dynamics throughout their interactions with the patient and intentionally avoid re-traumatization by imposing their will and preferences upon the patient or probing for unnecessary details. For example, offering a victim multiple options throughout the day for their upcoming interview appointment or the ability to meet with a provider/agent of a particular gender may provide the victim with a crucial sense of control, decrease their vulnerability, and lead to improved interactions and communications between the victim and the care team. HCPs, by the nature of their role/position, knowledge, and education, are in a position of power and influence over the survivor. This is often compounded by culture and socioeconomic status. The HCP should recognize that this position comes with privilege and a responsibility to use that power to assist and empower the survivor while avoiding misusing that power, even unintentionally. Survivors may be re-traumatized by a lack of control, an unexpected change, or feeling frightened, threatened, attacked, judged, shamed, or vulnerable. A trauma-informed approach involves understanding trauma's social, physical, and emotional impact on the victims and the professionals helping them. This understanding requires (a) realizing the prevalence of trauma, (b) recognizing its effects on everyone involved, and (c) application of this knowledge in practice (NHTRC, 2016b). The OVC (n.d.) offers free online Victim Assistance Training (VAT) on trauma-informed care for victim service providers and allied professionals through their site, ovcttac.gov.

Institutional protocols will help guide appropriate behavior following a positive screen for potential human trafficking (NHTRC, 2016b). Various resources should be offered to the patient once primary medical care has been provided. This may include referrals to local support, resources, and services and the option to report the incident(s) to law enforcement. Based on the administration of the screening tool, concerns regarding the patient's mental health should trigger an immediate referral to an appropriate mental health provider available locally (NHTTAC, 2018). The NHTRC/NHTH offers a massive referral network with an online directory on their website. They can facilitate connections with anti-trafficking organizations, legal service providers, shelters, and trained local social service agencies (NHTH, n.d.-e). Many metropolitan areas in the US also have Human Trafficking Task Forces established to connect with local resources (Joint Commission, 2018; Tracy & Macias-Konstantopoulos, 2022).

Beyond medical care, examples of expected needs experienced by human trafficking victims include clothing, food, and housing, which may be obtained through a local homeless shelter or crisis center. Victims often request assistance locating and contacting friends or family. Victims may require transportation, employment services (e.g., job training), crisis intervention, case management, and life skills training. Legal services can help address issues related to immigration, child custody, and legal defense for prostitution/drug or other related charges (NHTRC, 2016b). The local Rescue and Restore Coalition (if available) and the HT Pro Bono Center may provide legal referral sources locally (Baldwin et al., 2017). Malnourished patients should be referred to a dietician, while other patients with specific health concerns (communicable disease, pregnancy, infertility, unwanted tattoos/branding, irritable bowel syndrome, SUD) should be referred to the appropriate corresponding specialists (infectious disease, obstetrics and gynecology, dermatology, plastic surgery, gastroenterology, addictionology) as needed (Toney-Butler & Mittel, 2022). Beyond their immediate needs, victims of human trafficking should be referred to a local administrator for the Victims of Crime Act (VOCA), which offers victim compensation to reimburse them for crime-related costs and lost wages (OVC, n.d.).

As mentioned earlier, the interviewer should be forthcoming and upfront regarding any mandatory reporting requirements within their state or jurisdiction. HCPs must report any suspicion of child maltreatment and may also be required to report domestic violence, although regulations vary by state for adult victims. In some states, reporting is mandatory if serious bodily injury or a firearm is involved. If unsure, the HCP can confer with www.victimlaw.org to find the mandatory reporting laws in their state. Otherwise, the interviewer should obtain consent from adult victims before disclosing personal information to others, including referring service providers (NHTRC, 2016a; Toney-Butler & Mittel, 2022). All Texas HCPs, including nurses, must report any suspicion of abuse or neglect involving a minor within 48 hours of this suspicion. Texas HCPs are also required to report the suspected abuse or neglect of adults with a disability or those over 65. Any such concerns should be reported immediately to the local law enforcement agency and/or the Department of family and Protective Services (DFPS). Attorneys and clergy members are not privileged in Texas and, therefore, are mandated to report any suspected abuse of a minor, an adult over 65, or an adult with a disability in that state (Texas Family Code, § 261.101[c]; Texas Human Resources Code, § 48.051[c]).

HIPAA regulations also affect how and what information can be exchanged between care providers (NHTRC, 2016a; Toney-Butler & Mittel, 2022). However, HIPAA was never designed to prevent reporting a crime and allows for reporting abuse under certain circumstances (if necessary, to avoid serious harm). Reports can be filed without identifiable patient health information (i.e., include the gender and age of the patient, along with the type of trafficking that is occurring; NHTTAC, 2018).

After obtaining the patient's consent (or if such action is mandatory), the interviewer or HCP should make the agreed-upon report to the appropriate state or local agency and contact the NHTH. Suppose reporting is not mandatory, and an adult patient younger than 65 and with no disabilities does not wish to report the incident. In that case, the interviewer or HCP should provide only the desired referrals for care or services and contact the NHTH for additional guidance. If the patient is an adult younger than 65 and with no disabilities, the HCP should never report to authorities without consent unless required by law, as it could place the patient in more danger. Contacting the NHTH/NHTRC does not fulfill the state and local mandatory reporting requirements (Joint Commission, 2018; NHTRC, 2016b; RF, personal communication, March 17, 2023). Victims under 18 also have agency and opinions and should be allowed to participate in shared decision-making whenever possible (Wood, 2020).

Safety Planning

A safety plan for a human trafficking victim should assess their current risk, identify existing and potential concerns, offer strategies to reduce or avoid the threat of harm, and involve concrete responses if safety is threatened. It should be individualized and include practical steps for the patient to keep themselves safe while in the current trafficking situation, if planning to leave, and after leaving. It may consist of coping skills, discussing the abuse with friends or family, and taking legal action. The HCP helping the victim develop their safety plan should remember that the victim understands their situation best. The HCP should honor their requests without questioning their motives or judgment. As suggested above, communication should be open and nonjudgmental when assessing and interviewing potential victims. If possible, try to communicate in person, as traffickers can discover written communication or text messages. Phone calls are a reasonable second option if in-person communication is impossible, but the HCP should remain mindful that phone calls can be intercepted or overheard. A word or code can be established ahead of time to indicate if communication can proceed safely. Most importantly, the HCP should listen carefully to the victim's concerns, needs, and wishes from this point onward (NHTH, n.d.-f; NHTTAC, 2018).

Safety plans may include simple steps, such as avoiding confrontations with their trafficker in the kitchen (due to the presence of knives) or around firearms. Copies of essential documents and medicine should be kept in a safe place that can be retrieved quickly and easily. During violent encounters, the victim should be encouraged to avoid rooms with potential weapons and/or no exit (e.g., garage, basement, closet). A code word or signal (e.g., flashing the front porch light three times) can be communicated ahead of time to a close neighbor or trusted friend to signal when the victim may be in danger. If this is discussed, the victim should be clear about what the neighbor or friend should do in that circumstance (e.g., call 911, send help, pick up the children). Children should be told they are never responsible for protecting an adult, how to call for help if needed, and where to hide during violent incidents. Victims should be reminded to contact 911 if they encounter life-threatening or immediate danger. Safety apps, such as Circle of Six, Bsafe, and SafeTrek, may be downloaded to smartphones (NHTH, n.d.-f; NHTTAC, 2018).

When assessing the current level of risk or danger, the HCP should consider whether the trafficker is present at the medical facility and whether the patient is a minor. Traffickers may be female and appear of a similar age, accompanying the victim as a stated friend. The HCP should never assume that the individual accompanying a potential victim is safe, regardless of their appearance. The HCP should also ask the patient whether they believe anyone else, including their family, may be in danger and how they think the trafficker might respond if they do not return. If the victim is in immediate danger, law enforcement involvement may be the most appropriate safeguarding method. Law enforcement can assist with filing a formal report to initiate the prosecution process and provide immediate security via a protective (restraining) order (Joint Commission, 2018; NHTRC, 2016b; NHTTAC, 2018). Institutional policies may dictate when law enforcement is to be contacted, but this decision should be made in tandem with the patient whenever possible (NHTRC, 2016a). If law enforcement officers participate or assist, they should wear civilian clothing with no visible weapons (Simich et al., 2014). When calling to make a report, the HCP should ask if the department has a specific team that investigates human trafficking, as they may be better versed and prepared to handle the case (RF, personal communication, March 17, 2023). The NHTRC can help facilitate a report to specialized law enforcement units trained to address human trafficking or accept anonymous tips (NHTRC, 2016a, 2016b).

Cultural barriers between survivors and the law enforcement community may make communication difficult. Survivors should be warned that they may feel an inevitable loss of control over the case after filing a report with a law enforcement agency. The Department of Homeland Security (866-347-2423) or the Federal Bureau of Investigation's Lost Task Force (800-CALL-FBI) can be contacted to identify local officials and agents with expertise in HT during protocol development. Protocols should specify when certain officials should be contacted, depending on the case's details. Many local law enforcement agencies have an anti-trafficking task force or a trained officer with expertise in trafficking. Local agencies should be asked to clarify their policy on arresting potential victims related to their trafficking victimization (e.g., prostitution, truancy), which may force agents to arrest victims with open warrants. Community-based diversion programs divert defendants facing criminal charges to avoid incarceration. Most of these programs allow for the dismissal of charges if completed and may include counseling, substance abuse treatment, and vocational training (Baldwin et al., 2017).

Safety planning should also consider the safety of the HCPs intervening in these situations. The NHTTAC (2018) suggestions include regular risk assessments and an updated risk management plan within the institution or organization, notification of a colleague regarding the provider's whereabouts when conducting a screening, and periodic safety checks. Screenings conducted outside of a facility should have two staff members present, and the screener should be alert and aware of who may be within earshot. Confidential data and personal identification information should be handled professionally and disposed of confidentially (NHTTAC, 2018). All cell phones and other communication devices should be turned off, as traffickers may use these methods to keep tabs on the victim at all times. HCPs should never attempt to address the situation with the victim in front of the accompanying friend or family member, as they may be the trafficker or a "guard." Collecting a urine sample or escorting the patient to the radiology department for an imaging study are valuable methods of creating privacy and separation between the patient and an accompanying individual (Toney-Butler & Mittel, 2022). The NHTTAC (2018) recommends a simple explanation that "our policy allows only patients in this area during tests" (p. 32).

If a victim is considering leaving the trafficking situation and is unsure of their location, they should attempt to use street signs, newspapers, magazines, pieces of mail, street numbers on buildings/mailboxes, or passersby to obtain as much information as possible regarding their whereabouts. The victim should plan an escape route in times of danger, with a backup if their path becomes blocked, and practice this route until memorized. If there are children present, they should also be involved in planning and practicing the escape route. Medications, essential documents, and a prepared bag with a change of clothes should be easily accessible or hidden in a safe location to retrieve after leaving. Significant phone numbers should be written or memorized in case the victim's phone is taken or damaged. An immediate plan for shelter should be arranged with a trusted family member or a friend or by contacting the NHTH to locate the closest crisis center or shelter (NHTH, n.d.-f; NHTTAC, 2018).

Survivors continue to be at risk of violence after exiting a trafficking situation. They should be educated on why and how to file a protective order against the trafficker(s), which may be done civilly in some locations without involving law enforcement if they would like to. Survivors should be counseled on options such as changing their phone number and avoiding sharing their new address or phone number except with a few trusted individuals. Typically, their phone belongs to their trafficker, or they may have multiple phones. They should consider accessing the Address Confidentiality Program, keeping their doors locked, and keeping their cell phone or an emergency phone on their person. Survivors should be advised to document any contact attempts made by the trafficker, including saving voicemails or text messages. A safety plan should be communicated to any children involved, detailing their actions if the trafficker attempts to contact them alone. As explained above, a code word or signal should be agreed upon with a close neighbor or trusted friend to communicate if the survivor may be in danger and exactly how the individual should respond. If appropriate, additional resources should be offered, such as articles on rebuilding finances after leaving a financially abusive relationship (NHTH, n.d.-f).

The HCP should be aware of the resources available in their community and how to access them. The HCP can quickly activate the "what is next" process when the need arises by building relationships with community partners. The nurse should be familiar with the process of forensic/sexual assault nurse examiner (SANE) exams. If the patient is an adult, they are not required to make a police report to obtain a SANE exam. The kit is saved and stored but not turned into the crime lab without the victim's consent allowing them time to decide. This should be explained to the victim and may convince them to undergo the evidence-collection process (RF, personal communication, August 11, 2021).

 

Resources

             The NHTH/NHTRC can be contacted 24/7 by calling 1-888-373-7888. They also accept text messages at 233733 and emails at [email protected]. They offer information, resources, an online reporting form, and an option for a live chat on their website: www.humantraffickinghotline.org or www.traffickingresourcecenter.org. The Rescue America Hotline, 833-599-FREE (3733), has facilities nationwide with hands-on teams that meet the patient where they are to help get them directly to the services they need. Their website can be accessed at www.rescueamerica.ngo.

Survivor Voice Note:  As a victim of trafficking, when entering a healthcare facility, we don’t know what “trafficking” means. We don’t use that term. We call it being in the life or the game or being out on the track or the blade. So be conscious to not use terms that are outside of our linguistic knowledge. And use the same language we talk in. This includes anatomical terms referenced. Do not change the terms to be more anatomically correct, sensitive, or appropriate. Document and use words that victims use without changing their vocabulary and making them seem less than. Remember that your documentation in the medical record is crucial for justice long term. (RF, personal communication, August 11, 2021).

References

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