Human trafficking is a pressing public health concern which transcends all races, social classes, demographics, and gender. No population is exempt from the ever-present threat of traffickers. Human traffickers are motivated by greed, driven by quota, devoid of respect for human rights, preying upon the vulnerable, and damaging the psychological and physical well-being of their victims. The extent of the economic and social impacts on society are unknown and require further research to define and guide community-based care, protocols, and formal curriculum changes. 
Financial and Global Statistics
Human trafficking is a $150 billion industry globally. In fact, the International Labour Organization's (ILO) 2016 estimate reveals that 40.3 million people were victimized worldwide through modern-day slavery, 5.4 victims per every thousand people in the world. Of these 40.3 million victims in 2016, 29 million were women and girls (72% of total amount). Almost 5 million in 2016 were victims of forced sexual exploitation globally, with children making up more than 20% of that number. According to new 2016 global estimates, data collected by the ILO and the Walk Free Foundation (WFF) in partnership with the International Organization for Migration (IOM) as part of their contribution to the Sustainable Development Goals (SDG), puts the number close to 25 million persons who have been subjected to forced labor worldwide, and 15.4 million in forced marriages. The common thread that binds them together is the loss of freedom. Exact numbers of trafficking victims are difficult to quantitate due to the concealed nature of the rapidly progressing disease and public health emergency. 
Trafficking Versus Smuggling
Distinguishing between human trafficking and human smuggling is essential. According to the Trafficking Victims Protection Act (TVPA), an anti-trafficking federal law established in 2000 under President Clinton's administration, "human trafficking" is defined as the exploitation of a person or persons for sex or labor using "force, fraud, or coercion."
Smuggling differs from trafficking because it involves the illegal crossing of borders and is usually consensual. Typically, the relationship between the smuggler and the person being trafficked terminates upon arrival to the destination country. Smuggling indebtedness can lead to trafficking as a means to resolve a fee owed to the smuggling entity.
Trafficking in persons (TIP) also known as "modern-day slavery" is a crime in all 50 states under federal and international laws and does not require the physical transport of a person. It can and often does occur in local communities and schools and near popular sporting venues.
Essential Elements: A-M-P Model
Human trafficking involves three essential elements: action, means, and purpose. According to the National Human Trafficking Resource Center (NHTRC) and the TVPA, the Action-Means-Purpose, or A-M-P Model helps determine whether force, fraud, or coercion was present, indicating the encounter was not consensual. A trafficker recruits, harbors, transports, provides, or obtains an individual. Force, fraud, or coercion is the means used to compel the victim to provide commercial sex acts, labor, or other services. 
Federal law defines "sex trafficking" as "the recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purposes of a commercial sex act, in which the commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age." Force, fraud, or coercion do not need to be present for a minor under the age of 18 involved in any commercial sex act because minors can not consent to a sex act with an adult. Minors are easier to exploit and manipulate, thus vulnerable to trafficking.
The TVPA's definition of "labor trafficking" is "harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage or slavery.”
The United States Department of Health and Human Services's (HHS) "Look Beneath the Surface" campaign and SOAR training in 2017 provided much-needed insight into TIPs based on the latest amendments to the TVPA. For example, force may involve rape, torture, beatings, or imprisonment and can be psychological or physical.
Physical confinement is rare; however, often "invisible chains" are used to maintain power and control, similar to intimate partner violence. Fraud may include false claims of a job, marriage, promises of a better life, or a family. Coercion also involves threats, debt, or bondage that help foster a climate of fear and intimidation and may consist of abuse of the legal process.
According to the TVPA, a “commercial sex act” is any sex act where anything of value is given to or received by any person, such as survival sex, drugs, transportation, food, or clothing.
Legislative Victories: The 3P's Approach
Over the past 18 years, the US Congress has passed several comprehensive bills to bring this crime to light in domestic and international communities. This legislative process finds its basis in the 13th Amendment to the US Constitution which banned involuntary servitude and slavery in 1865. One such law, adopted in 2000, was the TVPA, which combats TIPs using the "3 Ps" approach: protection, prosecution, and prevention. 
The TVPA established several necessary protective measures for trafficking victims located in the United States. Regardless of immigration status, foreign persons who are trafficked are eligible for federally funded benefits such as healthcare and immigration assistance. The T visa is one such protective measure which prohibits deportation or removal of a victim of trafficking and sometimes offers an opportunity for a path to permanent residency. Human trafficking victims are especially vulnerable to re-trafficking within two years of first being trafficked and upon return to an originating country due to debt bondage or psychological, emotional, and economic conditions. Reintegration into society, coupled with functioning within societal pre-determined norms, can be traumatic for an already traumatized person who has been exploited by traffickers. Re-victimization must be avoided by enacting protective measures.
Under the TVPA act, federal prosecutors were armed with additional tools to bring traffickers to justice for their crimes against humanity. The TVPA explored the existing statutes and broadened their conservative approach. The new legislation mandated financial restitution to the persons they had exploited through trafficking and offered stronger penalties for those convicted of trafficking crimes. Revisions of the TVPA and subsequent enactments further defined human trafficking as “severe forms of trafficking in persons” including both sex trafficking and labor trafficking.
The third "P," prevention, is perhaps the most important of all. The TVPA strengthens prevention efforts on behalf of the US government. International incentives were enacted to improve economic conditions around the world to deter TIPs. The Office to Monitor and Combat Trafficking in Persons was created within the State Department as a result of the TVPA. Annual TIP reporting was mandated and rated countries on their efforts to reduce TIPs according to the US Department of State. 
Furthermore, the TVPA required the creation of an Interagency Task Force to Monitor and Combat Trafficking and TVPA reauthorizations were enacted in 2003, 2005, 2008, and 2013. In 2015, adoption of the Justice for Victims of Trafficking Act allowed for additional tools to address this human rights issue and directed the Attorney General to create a National Strategy to Combat Human Trafficking and ensure its ongoing maintenance. 
These legislative directives, ensured by the passage of the TVPA and the Trafficking Victims Protection Reauthorization Act (TVPRA), bring human trafficking to the forefront of conversation on an international level. Prevention through education is paramount going forward in efforts to curb the growth of this $150 billion industry, which is thought by some to surpass the drug trade in market value of criminal enterprises. Healthcare providers are on the frontline of these efforts as the first point of contact for most victims.
The US Department of State also assists in prosecuting human trafficking and smuggling cases. Diplomatic Security Service (DSS) agents and analysts often support foreign law enforcement agencies in an attempt to combat the global epidemic of TIP. On a domestic front, the US Department of State has a working relationship with federal, state, local, and tribal leaders to investigate potential cases of "modern-day slavery" for sex or labor exploitation.
The disease of human trafficking may find its etiology in a multitude of contributing factors that make a person susceptible to a trafficking situation.
Adverse Childhood Experiences
Adverse Childhood Experiences (ACES) can increase the likelihood of risk-taking behavior that could predispose a person to a trafficking situation. A better understanding of how a high ACE score can potentiate a trafficker's hold on a victim is best explored through research. The CDC-Kaiser Permanente Adverse Childhood Experiences study was a massive study, which began in 1995 and concluded in 1997, that investigated the ramifications of child abuse and neglect on health and well-being later in life . The CDC continues ongoing surveillance of study participants. Annually, local state-based Behavioral Risk Factor Surveillance System (BRFSS) data collection measuring the effects ACES on survivors, communities, and overall public health is reported. The ACE Pyramid conceptualizes the framework for the ACE study as it relates to individual health and well-being across the lifespan, from conception to death.
According to the ACE Pyramid, neurodevelopment is disrupted or stunted following an adverse childhood experience. Social, emotional, and cognitive impairments result, which progress to high-risk behaviors that negatively impact overall health. Disease, disability, and social problems ensue, cascading to an early death. Therefore, there is a correlation between a higher ACE score and an increased risk of poor physical and mental health due to poor choices, risky behaviors, and social issues.
An ACE questionnaire asks difficult, emotion-provoking questions related to growing up during the first 18 years of life. Questions are related to physical, emotional, and sexual abuse and the frequency of such insults. The suicide of a family member, drug addiction, and mental health issues play roles in the calculation of the score. ACE scores can range from zero to 10, with zero representing no exposure.
According to a Florida study, conducted between 2009 and 2015, trafficking abuse reports were highest among children with an ACE score of six or greater. Children with a sexual abuse history in connection with a higher ACE score had an increased chance of exploitation by traffickers. According to a 2017 study, sexual abuse was the most reliable predictor of a person's exploitation by traffickers .
Lesbian, Gay, Bisexual, Transgender Questioning
A critical distinction among the lesbian, gay, bisexual, transgender, and questioning (LGBTQ) population was revealed by the 2012 North Carolina, 2011 Washington, and 2011 and 2012 Wisconsin Behavioral Risk Factor Surveillance System (BRFSS) survey. Lesbian, gay and bisexual (LGB) individuals had higher ACE scores than their heterosexual counterparts. In this 2016 study, Austin, Herrick, and Proescholdbell concluded that the higher prevalence of ACES among LGB individuals might account for some of the increased risks for poor adult health outcomes, poor choices, and heightened risk of being trafficked. [.
The transgender community may seek out expensive hormone therapy and resort to "survival sex." This vulnerable position of needing money to buy this product from black market suppliers at an inflated price with exorbitant interest rates can increase the chances of being lured into trafficking. Transgender youths may have additional vulnerabilities that heighten their risk of being trafficked such as homelessness, addiction, depression, lack of financial or emotional support from family, being victims of intimate partner violence, and history of sexual abuse as a child. It was reported in 2013 that transgender individuals with HIV also are vulnerable to being trafficked as they struggle to have their basic needs of food and shelter met.
The National Center for Transgender Equality (NCTE) conducted a 2015 US Transgender Survey and found that 5% of all participants engaged in sex work for income in the past year. Fifty-five percent of those who had resorted to "survival sex" in the past year were transgender women. Approximately 19% had participated in some form of "survival sex" for money, food, sleeping quarters, or other goods or services. According to one study those who had engaged in sex for money were more likely to have experienced some form of intimate partner violence or sexual assault. Debt bondage places an "invisible chain" that binds a victim to a "Romeo" or "guerilla" pimp. The invisible chain tightens with unmet quotas and may become a physical one.
Further resources provided by the Polaris Project address the risks of being trafficked within the LGBTQ community and are available on their website.
Trafficking Risk Factors and Vulnerability
Sexual abuse puts an individual at risk for substance abuse, mental health issues, and a lack of the concept of social norms, belonging, or sense of family. Vulnerability and feelings of distrust towards authority figures take the place of security. Often it is those who are supposed to protect them who are the initial perpetrators of the insult or crime. "Forgotten," "invisible," "different," "broken," and "discarded" are all words used to describe the feelings of individuals who are trafficked. A trafficker preys upon this vulnerability, uses it to their advantage, and strategically places themselves nearby. Often seen as a rescuer who offers a chance at a better life, security, or a remote possibility that better days are ahead, a trafficker is actually a profiler, trolling for victims to turn a profit.
Traffickers do not discriminate based on gender, race, social demographic, immigration status, or economic status. No exact mold fits a victim. Anyone is at risk, but certain populations have a higher vulnerability risk. The US Department of Health Office on Trafficking in Persons provided a fact sheet in 2017 to further highlight at-risk groups such as survivors of child abuse, sexual abuse, assault, interpersonal or intimate partner violence, gang members subjected to violence, or exposure to community violence.
The SOAR Campaign further delineates at-risk, vulnerable individuals as those lacking a stable support structure or home life such as a runaway, foster child, or child in the juvenile justice system, a homeless youth, unaccompanied minor, persons displaced due to a natural disaster, and individuals that possess a language or cultural barrier. Increased risk also involves those with substance abuse problems, undocumented or migrant workers, and the LGBTQ population. Minorities, those with disabilities, and those on Native American reservations can be at a higher risk of being trafficked.
The US Department of Education published a fact sheet for schools entitled "Human Trafficking of Children in the United States" which discusses the vulnerability of school-age children as it relates to human trafficking (ed.gov/2013). Examples of identified child trafficking cases involved stripping, pornography, forced begging, commercial sex, magazine crews, drug sales, and the cultivation of the product. Children at greatest risk were identified as working in restaurants, hair and nail salons, as nannies or Au pairs, or in agricultural settings. The fact sheet goes on to describe at-risk children and those potentially immersed in the human trafficking world. Signs of child trafficking include unexplained absences, poor attendance, runaway behavior, boasting about frequent travel to other cities, and inappropriate dress for the current weather, being sleep-deprived or malnourished, or showing signs of impairment due to drugs or alcohol [NHTRC, 2015].
Lack of a stable support structure and the accessibility of social media outlets may put a child at risk of being targeted for sexual exploitation. Social media websites, classified advertisement sites, chat rooms, and after-school programs are potential venues for exploits youth. School hallways pose a risk, as a trafficker may, in fact, be another student. A promise of a "happening" party or a good time may be used to entrap an unsuspecting, troubled, or bored youth.
Educational campaigns, such as the "Blue Campaign" created by the US Department of Homeland Security, offer much-needed insight into the identification and treatment ramifications of victims of human trafficking. The Blue Campaign by the Department of Homeland Security offers sex trafficking awareness videos to educate our youth on the risks that traffickers pose in familiar places such as schools, coffee shops, malls, sporting venues and other hangouts [DHS.gov].
The National Human Trafficking Hotline: Reported Cases
When exploring the epidemiology of human trafficking, one must first examine data collection, results, and the organizations that provide this service. The US Department of HHS funds the National Human Trafficking Hotline, operated by Polaris, a nongovernmental organization. The National Human Trafficking Hotline's data collection gathers invaluable information to assist training programs and victims domestically and abroad. For example, 2017 data collection indicates that California, Texas, and Florida rank the highest in reported cases and referrals.
To date, the hotline has answered more than 100,000 calls, 7,000 were from potential victims of human trafficking. In According to Polaris hotline statistics for the United States, more than 30,000 cases of trafficking in persons and more than 8,000 tips to law enforcement were identified since 2007. The National Human Trafficking Hotline is a 24-hour, confidential, multilingual hotline covering more than 200 languages for victims, survivors, and witnesses of human trafficking.
Another resource for reporting cases and gaining information as it relates to the trafficking of minors is the National Center for Missing and Exploited Children (NCMEC). In 2016, The NCMEC estimated that one in six endangered runaways were likely victims of sex trafficking. Children as young as nine are thought to be targeted by sex traffickers, with the average age between 11 and 14. Labor trafficking ages vary. The Global Estimates of Modern Slavery by the ILO, WFF, and IOM reported in September 2017, that in 2016 of the 4.8 million sexually exploited, 20% were children. .
Global Repository of Data
The International Organization for Migration (IOM) in partnership with Polaris and the UN Migration Agency are launching a Counter-Trafficking Data Collaborative (CTDC) that will allow for a global repository of data on trafficking in persons. Ensuring victim identities are protected and information gathered will assist in bridging gaps in data that is publicly available. Data collection and access to this data are essential components in the CTDC's role in combatting the war on human trafficking. The first of its kind, this global repository of data will combine data from the IOM records on over 45,000 cases of human trafficking and the cases from Polaris, which are higher than 31,000. This collaborative data tracking system will foster a data-rich environment that will transcend borders and individual agency operational challenges. A comprehensive, international database will be a positive byproduct of this partnership. IOM's 2017 report increased awareness of the CTDC as an essential resource for the global reduction of human trafficking cases.
Global Report on Trafficking in Persons
Each year, thousands of individuals fall victim to national and international trafficking. Almost no country is exempt from human trafficking infractions in one capacity or another; originating country, transient country, or destination country. The United Nations Office on Drugs and Crime (UNODC) Global Report on Trafficking in Persons further explores the bond between trafficker and victim and the origin of the trafficking situation.
The 2016 Global Report on Trafficking in Persons shines some light on the profile of the trafficker in relationship to that of the person who is trafficked. Traffickers and their victims tend to originate from the same geographical area, speak the same language as the victim, and share the same ethnic background. These commonalities foster a level of trust between the trafficker and the victim. The trafficker exploits this relationship for financial benefit. Traffickers rarely travel abroad to recruit, instead focusing on domestic recruitment.
Globally, local trafficking is on the rise. A trafficker will go to a destination country to exploit the victim. Countries most vulnerable to trafficking are those with high levels of organized crime and those ravaged by conflicts. From 2012 to 2014, more than 500 different trafficking flows were detected, and countries in Western and Southern Europe identified victims of 137 various citizenships. The 2016 UNODC Global Report on Trafficking in Persons reports 79% of classified trafficked individuals globally are women and children. It also found a clear link between migration and human trafficking. Further reporting that the movement of migrants and refugees is the most substantial reported migration since World War II, with an estimated 244 million international migrants worldwide.
Forced migration as a result of refugees fleeing war-torn areas makes the women, children, and boys especially vulnerable to exploitation by traffickers. The movement of Syrians escaping the war is one such example. Children face exploitation as "child soldiers." Armed guards abduct individuals on migratory routes and exploit them as slaves for forced labor or sexual exploitation. In September of 2015, world leaders adopted the 2030 Sustainable Development Agenda and embraced the war against trafficking in persons on a global front. This agenda called for all forms of violence against women and girls to cease.
According to the Global Trafficking in Persons Report of 2016, no country is immune from trafficking in persons, and over 500 migratory flows of trafficking were detectable. Sub-Saharan African and East Asian victims are trafficked to numerous global destinations. Affluent areas such as Western and Southern Europe, North America, and the Middle East have victims from all parts of the world. In Southeast Asia, forced marriages are on the rise. Central America, the Caribbean, and South America frequently report cases of girls becoming victims of sexual exploitation. Trafficking in fishing villages for forced labor is a problem in parts of the world such as Ghana and Taiwan. Organ retrieval as a form of trafficking is less frequent but exists in some parts of the world.
The UNODC 2016 study also reports a change in the victim profile over the past decade. The number of male victims is increasing. Overall, numbers of forced labor victims increased, with 63% being men between 2012 and 2014. Another alarming fact from this report is that female participation was on the rise. Of 6800 persons convicted of human trafficking during 2012-2014, 60% were male. Young girls were recruited and controlled by older women. More couples are actively involved in trafficking. Posing as "stable couples" allows traffickers to seem more genuine and trustworthy while they actively recruit and exploit victims as a team. Former victims became active participants in recruitment, some to reduce their debt bondage and end their sexual exploitation. Others, willingly participate in the abuse, using tactics of power and control. If persons being trafficked are engaged in criminal activity, they are less likely to cooperate with police, thus allowing the trafficker even more control.
The UNODC went on to discuss the conviction rates of traffickers. The average number of convictions was low, with five victims per convicted offender. North America had the highest number of convictions compared to the rest of the world. The United States reported 150 to 200 convictions per year, while Europe reported the highest number of trafficking victims. .
Missed Opportunities and Myths
A recent study revealed that 87.8% of human trafficking survivors had been in contact with a healthcare provider in some capacity during their victimization. Furthermore, it concluded that 68.3% had received an evaluation in the emergency department.  Missed opportunities to identify, inform, and empower these victims allow for the spread of this physically and psychologically debilitating disease.
Recently, a smaller study of emergency department nurses in an urban setting concluded that emergency department nurses want better awareness regarding the specific resources available to victims of human trafficking. Ongoing research into the impact of institutional policy, the existence of human trafficking protocols, and continuing education regarding the recognition and treatment of trafficked individuals is required .
Myths or misperceptions often lead to missed opportunities to identify victims [DOS, 2013]. It is essential for healthcare providers and first point-of-contact personnel to be educated on these potential media-induced sensationalized myths. First, trafficking in persons is not just a crime that occurs in a faraway place or one that only involves migrants or foreign nationals. Individual exploitation happens in every part of the world - in the suburbs, big cities, and hometowns.
Victims can be coerced to take part in crimes, thus landing them in a detention center or jail. They may present to the emergency department for medical clearance. Screening of these individuals is vital in our attempts to identify victims and recognize the red flags of trafficking and take appropriate action. Thinking this person is "just a criminal or "just a prostitute" is a bias that inhibits practitioners from reading verbal and nonverbal cues and recognizing a victim. A victim may fall into a revictimization situation if returned to an exploitative environment. This is a chief concern for practitioners as the United Nations Convention against Corruption defines “revictimization” as "a situation in which the same person suffers from more than one criminal incident over a period of time." Perhaps more importantly when assessing and interviewing a potential victim of trafficking is the potential for "secondary victimization,” defined by the UNODC Model Law on Justice in Matters involving Child Victims and Witnesses of Crime as "victimization that occurs not as a direct result of the criminal act but through the response of institutions and individuals to the victim" .
If an individual is free to come and go, then they may not be recognized as a person being trafficked. As discussed previously, bonds are often not physical chains or cuffs, but "invisible" or psychological ones. Fear paralyzes the victim, acting as a shackle that emotionally confines them to the trafficking situation. Mental weapons used by the trafficker to exercise power and control over a victim may include threats of harm to children, siblings, or other family members; deportation or return to a traumatizing situation; calls to social services; and physical violence or reminders of past violence for misguided offenses.
Debt bondage, withholding of pay, and maintaining possession of all forms of identifying documents may further lead to an invisible bond or tie to the pimp/trafficker. Trafficked victims may use a school bus, a public bus, a train, or a taxi. Control over the person being trafficked lasts far beyond a physical wall, chain, or border. Much like intimate partner violence, victims usually do not self-identify, self-report, or recognize the fact that they are being manipulated, controlled, stigmatized, or dehumanized.
Language barriers and cultural misconceptions may lead to a missed opportunity to identify a potential victim . Inconsistencies in stories or history may become lost in translation, especially if a provider fails to obtain an interpreter that has no relationship to the person being exploited. A staff member versed in the same language or who shares the same culture as the victim may be able to spot these subtle clues and ease cultural shock and miscommunication, but it is not always feasible to provide in a busy healthcare setting. Behaviors passed off as cultural may be a form of demographic profiling that creates an environment to miss red flags.
It is imperative that if a suspected case of human trafficking or intimate partner violence arises that no family member or accompanying party be allowed to translate. Ensure a certified interpreter is nearby that is obtained from your institution.
Reasons Victims/Traffickers Access Medical Care
Traffickers may only seek out healthcare for their victims when they become seriously ill since it presents a risk of discovery. . A multitude of factors should lead a practitioner to seek out medical services for a person who is a suspected victim of human trafficking.
Traffickers seek out the quickest means of care, and lengthy emergency department waits may lead to their decision to leave with the victim before receiving medical treatment. They may also "hospital shop" for quicker wait times from door to the provider. An accompanying "family member" that is impatient, "in your face," and upset over lengthy delays in overcrowded emergency rooms or clinics may, in fact, be a trafficker. Another indicator is the "spouse" or "boyfriend" that insists on a high-risk patient, such as one with a possible ectopic pregnancy or appendicitis, leaving without being seen, against medical advice, or eloping before care is completed.
Remember, a victim comes from all walks of life and may be perceived as having a stable home in a suburban community. No victim will look the same or act the same; their individual, unique responses to their traumatic event will follow no specific protocol. As healthcare providers, we must be diligent in our efforts to identify these silent victims, forced into a situation of no fault of their own, made to carry out acts that reap emotional and social ramifications for years to come.
When healthcare workers encounter potential victims of trafficking, a detailed work history and social history will assist in identifying red flags. A better understanding of most common areas where persons are targeted for exploitation will help practitioners assess a potential victim.
Victims of labor trafficking tend to be near farms, fisheries, factories, or businesses such as nail salons, massage parlors, restaurants, and areas with high immigrant populations. Traveling sales crews, begging rings, landscapers, construction workers, domestic workers, nannies, elder adult caregivers, and those in retail have a heightened risk of being labor trafficked. Immigrants may lack the power of communication due to language barriers which enable handlers from a similar background to approach them.
Sex trafficking can be hotel or motel based, street-based, or in residences functioning as brothels. Commercial-front brothels, escort services, truck stops, bars, and strip clubs can be places where sex trafficking occurs. Sex trafficking can happen at home with parents, intimate partners, or other family members as the perpetrators. Victims may not see themselves as victims, and may refer to the trafficker as their “daddy” or "boyfriend." 
Labor Trafficking Considerations
Common presenting complaints of victims of human trafficking are much like those of intimate partner violence but may vary depending on if a victim of labor versus sex trafficking. Labor traffickers prey on specific vulnerabilities to entice individuals to accept substandard working conditions. Workers in the agriculture industry, factories, and domestic servitude sectors are vulnerable to human trafficking due to their work visa and immigration status being controlled by one employer. This power over the individual and fear of deportation allows the trafficker to manipulate the worker, leading to victimization.
Agricultural and industrial workers who are forced to work long hours with substandard wages may be isolated, confined by the use of dogs, armed guards, barbed wire or other fences, and locks. The seasonal nature of their work and movement from place to place heightens their vulnerability due to regularly being subjected to unfamiliar surroundings.
Domestic workers are also isolated, forced to live on the premises, and may lack access to cell phones and other communication devices. Language barriers add to vulnerability, coupled with this inability to communicate. Traveling sales crews, begging rings, and peddlers are vulnerable due to homelessness and working in unfamiliar settings. If left behind in an unknown city, they may resort to "survival sex."
Workers in strip clubs and bars may have fraudulent work visas and ties to organized crime, rendering them vulnerable to trafficking. Drug and alcohol are used as a manipulation tool. Labor laws may not apply to subcontractors or independent contractors, thus increasing vulnerability risk. A common theme originates between persons who are exploited and traffickers: Keep the victim isolated by proximity or language, vulnerable due to immigration status, without resources and owing debts, and without the protection of labor laws and increase the ability to control and manipulate.
Trafficking in persons for labor exploitation may put a patient at risk for malnutrition, communicable diseases such as hepatitis and tuberculosis, pesticide and chemical burns, or exposure and work-related injuries due to lack of safety equipment such as safety belts, gloves, goggles, and masks.
Labor Trafficking Red Flags
Stop, Observe, Ask, and Respond (SOAR) will guide practitioners in determining whether red flags indicate a potential case of human trafficking. Healthcare providers must determine if a crime occurred or if all three elements of trafficking in persons exist: force, fraud, and coercion. The provider's role is to recognize a potential case of human trafficking, empower the person being exploited, educate the victim on resources and established support structures, and provide a framework for a trauma-informed, victim-centered approach to healthcare.
Observing for verbal and nonverbal clues as well as asking open-ended questions in a private, non-judgmental way will allow caregivers to determine a potential case of human trafficking. Questions to ask regarding labor trafficking suspicions may include and not be limited to the list below.
Barriers to Identification of Victims
Healthcare providers, for a variety of reasons, may fail to stop, observe, and ask questions to identify a potential victim of human trafficking. The absence of protocols, myths, stereotypes, biases, fear of no available resources, lack of education regarding human trafficking red flags, time constraints, lack of privacy, or an inability to separate the person from the potential trafficker all may play a part in the inability to identify victims. The victim declining to give a history and self-identify is a factor .
A patient who presents with multiple visits for a pain complaint that has no organic cause, a frequent flyer as labeled by some, may be a victim of trafficking but stereotyped and overlooked. Those problematic patients that present with stress-related issues on multiple visits or those who return over and over with psychological holds for overdoses or suicidal ideations may be victims of trafficking. Each time, there is the risk that they will be released back into the trafficking situation and victimization. Providers must recognize the potential for "diagnostic overshadowing" and be attuned to their own emotions and potential for bias. Traffickers can pose as parents, grandparents, or spouses. As providers, practitioners must stop, observe, ask and respond.
As front-line participants in the battle to combat human trafficking, healthcare workers must be aware of these potentials barriers to victim identification. Often, rushing from patient to patient or exam room to exam room, being caught between documentation and hands-on assessment and care, and treating patients in hallways, lobbies, or corridors adds to the potential for a missed opportunity.
Sex Trafficking Red Flags
According to the National Human Trafficking Resource Center (NHTRC) and hotline, general indicators or red flags of trafficking in persons may include but not be limited to the following with some modifications:
Conducting a head-to-toe, full assessment in this patient population is of vital importance. An examination may prove difficult due to the emotional and psychological state of the victim. These patients may appear as uncooperative or vague and give an inconsistent history. These reactions are manifestations of their trauma. Provider frustration or stereotyping may arise, leading to the desire to exit the room quickly, with a quick determination of probable diagnosis and treatment. As discussed above, the potential exists for "diagnostic overshadowing." As with any trauma patient, a high index of suspicion should be present for co-existing conditions and comorbidities.
Conduct the assessment in private, not allowing anyone accompanying the patient to be present. A chaperone may be present and a certified interpreter, if required, to facilitate a feeling of trust and establish rapport. Provide a same-sex provider for the physical exam/assessment if at all possible with the staffing mix currently available. During the exam, the patient may seem emotionally absent, hyperventilate, and not verbalize feelings of discomfort. Be alert to nonverbal signs. Reassure frequently and promote a relaxed, non-rushed atmosphere. Avoid interrogating the victim, ask only direct, pertinent, open-ended, yet neutral questions. Maintain eye contact with the victim, barring cultural considerations, and avoid writing while the victim is speaking. Ensure the victim is completely undressed and in a gown so a complete trauma assessment can be initiated. Specifically, examine for the following:
Signs of Physical or Psychological Torture
Signs of physical torture may present on a dermatological evaluation such as abrasions over bony prominences, scratches or linear abrasions from a wire, or "road rash" to extremities from being thrown from or drug by a vehicle. Ropes and cords can leave elongated, broad-type abrasions. Ropes may leave areas of bruising mixed with abrasions. Belts or cords may have loop marks, parallel lines of petechial with central sparing. Tramline bruising, two parallel lines of bruising, can result from being beaten with a heavy stick or baton. Cigarette burns tend to be circular with a 1 cm diameter and can fade in a few hours or a few days. Burns, in general, tend to take the shape of the object that inflicted the burn.
Trafficking victims may be beaten or subjected to torture for a variety of reasons. By the guerilla pimp as a result of not meeting a quota or set of established rules, by a customer who is displeased or is just acting out a part of the sex act, or for no apparent reason other than to maintain control on the part of the trafficker. Bruises, lacerations, marks, or scars may be present on the lower back where they are hidden more easily and do not disfigure the product/victim and inadvertently make the person being trafficked less marketable.
It is important to note that some cultures practice cupping therapy and may have bruising and scars from this practice. Correlate this finding with a detailed history as well as the presence of other red flags.
Psychological and Mental Status Examination
Mental health indicators of trafficking in persons may be missed or explained away as a panic attack. Again, one must stop and take an in-depth look, considering the flags. Look for signs such as depression, suicidal ideations, self-mutilation injuries, anxiety, post-traumatic stress disorder (PTSD), and feelings of shame or guilt. Shame may keep a victim bound to a trafficking situation, often used as a control tool by a trafficker. Does the patient report nightmares, flashbacks, irrational fears, irritability, social isolation, suicidal ideations, or depression?
A trafficking victim may describe a situation as if they were an outsider looking in, a mind-body separation , creating a safe, alternate reality to cope with the atrocities they are facing and feelings of shame and guilt. They take a third-person, omniscient point of view in their storyline since this is the most trusted viewpoint. Sometimes patients exhibiting this behavior are categorized as impersonal or devoid of emotion, numb to their surroundings, or detached. This is their survival mechanism.
Addiction issues may be present and result in withdrawal. The addiction may be fueled by the trafficker for control or by the victim to cope with the physical or emotional pain surrounding the trafficking situation.
Documentation of Assessment Findings
Documentation of physical findings is important and may assist the victim in prosecuting their trafficker at a later date if health records get subpoenaed. Follow established documentation guidelines and reporting requirements based on state and local statute or federal law as addressed previously. Photo documentation may prove vital. Follow any protocols/policies specific to your institution regarding the taking of photos and their storage and obtain all required consent forms.
Recognition and Intervention
Once a practitioner identifies a potential trafficked person, it is imperative to establish a private, quiet, safe place to assess the patient further, much like in cases of child or elder abuse. Building rapport and providing an opportunity for the victim to feel empowered is of utmost importance and builds trust. Do not start a dialogue until you can establish a safe, private, and secure place.
In this era of mobile devices where a smartphone is always within easy grasp, ensure cell phones are off and not nearby. Cell phones can be another way the traffickers control the victim. The victim may have arrived alone but is always on her cell phone. The cell phone may be the trafficker's way of " keeping tabs" or listening to everything going on in the room.
Maintain eye contact during conversation, speak slowly and quietly, and avoid looking down at the potential victim. Instead sit in a nearby chair where on-level eye contact, unless contrary to the patient's cultural norms, is possible. Ensure an environment where the victim can establish a sense of power and control. This empowering zone of safety may allow them to open up and admit they are victims, but more importantly, it may provide a venue for resources, opportunity, and the realization they are not alone and that help is available if they choose to accept it.
Ask the patient if it is safe to talk now and if it is alright if you are the one in the room or whether they would prefer someone else. Never assume it is safe for the victim; they must confirm that it is safe. Safety is critical for the victim, staff, and nearby patients. Trafficking protocols will guide your care and determine a preset location that is readily available for an interview or a few minutes alone with the patient. A bereavement room set up for family notification in the event of trauma or sudden death may be one such place.
Inform the potential victim of trafficking that you are mandated by law to report certain disclosures. Monitor their verbal and nonverbal cues. Be alert to your facial expressions, body language, and any nonverbal cues you are exhibiting. Avoid stereotyping and revictimizing the potential victim as they disclose information.
Communicating with Potential Victims
Communicating with victims of human trafficking can be intimidating for health-care providers. The Department of HHS created a resource called Messages for Communicating with Victims of Human Trafficking as part of their Rescue and Restore Campaign in 2016. These messages assist healthcare providers in building a rapport with the victim and promoting a trusting environment.
Sample Messages to Ease Communication
Do not make false promises. Only offer what you can access provide.
Providers are not required to determine if a crime or a prosecutable offense has taken place. However, they can foster an empowering, caring environment to identify a victim for a potential rescue and provide invaluable resources to assist in restoring their lives and help them to begin healing emotionally and physically.
Creating an Opportunity for Intervention
The trafficker may be the accompanying family member that declines to leave the patient alone. Similar to intimate partner violence, the provider creates an opportunity to take the patient to the bathroom for a urine sample or to radiology for an x-ray or CAT scan, informing the family member that they cannot go with the patient. Another way to get the victim alone is to notify the alleged family or significant other that hospital policy requires you to interview and examine everyone alone.
Before you separate the potential victim from the family member or controlling individual, make sure you or a dedicated, trained staff member has the time to conduct an interview/assessment at that moment.
Traffickers can be parents, "boyfriends," husbands, women, men, friends, and those you would otherwise see as protectors. If privacy cannot be obtained to interview the suspected victim alone, do not confront the situation. The trafficker may cause the victim serious bodily injury after removing them from the facility if alerted to the fact that the healthcare provider is suspicious of the situation.
Assessment of the level of danger or threat to the patient and staff is imperative. Pay attention to your immediate area and follow preset protocols by your institution in notifying law enforcement and security personnel.
The NHTRC can assist you in threat level assessment, danger risk, and the contacting of law enforcement if the patient consents. Is the trafficker still nearby? How will the trafficker act if the victim does not return? Are there minors or other family members that are in danger? Is the patient a minor?
an interprofessional approach is best, if available, with a trained social worker nearby as predetermined in your trafficking protocol. Follow preset policies and procedures regarding abuse and neglect at your institution and according to local and state statute. The NHTRC hotline offers invaluable assistance with resources, assessment, and best courses of action.
Much like intimate partner violence, ensure the patient has a safe place to go upon discharge.
If a patient reveals they are a victim of human trafficking, ask the patient if it is alright to call the NHTRC hotline number. Encourage the patient to call and provide them with the phone number. It may be dangerous for them to keep the number on hand, so ask them if they can memorize it or give them a "shoe" or "key" card that can be hidden in their shoe or other discrete location.
The National Human Trafficking and Resource Center hotline number is available around the clock and is confidential to the extent of the law. The NHTRC is a tip hotline, a place to find out about services and to ask for help. The hotline can translate and communicate with individuals in more than 200 languages. A caller does not need to disclose any personal information to the hotline; it can be anonymous.
The NHTRC is available to help healthcare providers in the event of a potential trafficking case when no protocols are available. Healthcare providers can gain information in social referrals such as anti-trafficking organizations, shelters, local social services agencies, legal services, and law enforcement numbers. Tip reporting is available. The hotline provides training information and technical support on their website. The NHTRC can guide a provider in an assessment of a potential victim.
Mandatory Reporting/HIPAA Considerations
Guidelines for the reporting of suspected cases of human trafficking for adults and children will vary depending on facility, location, state and federal laws. Adults may not want to report the incident; thus, a consideration made in the decision to alert law enforcement based on predetermined protocols and local or state laws coupled with patient wishes. Some states mandate reporting if serious bodily injury or a firearm is involved.
It is essential to consider Health Insurance Portability and Accountability Act (HIPAA) concerns. The practitioner must obtain permission from an adult victim of human trafficking to release any protected health information (PHI) or personally identifiable health information to the NHTRC. The NHTRC may be contacted and provided general information for a consult as long as no protected, identifiable health information is released. If the victim is under the age of 18 and involved in a commercial sex act, follow mandatory state reporting laws for child abuse and institutional child abuse policies.
HIPAA will permit the release of protected health information under certain circumstances such as suspected injury or abuse. For example, if the law mandates a disclosure as in the case of child abuse or neglect, elder abuse or neglect, and in cases reportable to the medical examiner. Reporting is permissible under HIPAA regulations if the disclosure involves a crime in an emergency, any disclosures necessary to prevent harm if the patient consents to the disclosure, and any situation where local, state, or federal law requires reporting. However, follow institutional guidelines and policies in place for HIPAA reporting requirements.
Trafficking Health Implications
Labor and sex trafficking carry inherent health risks and need exploration. Research studies in South Africa and West Bengal, India regarding the effects of sex trafficking and HIV risk determined that women and girls who experienced forced sexual encounters through being trafficked were 50% more likely to acquire HIV. One reason suggested that immature cervical epitheliums or cervical ectopy might lead to breaks in the vaginal mucosal and subsequent inflammation which increases the chance for HIV to spread during repeated sexual assaults in younger victims, but more research is required .
Vulnerability and inexperience may lead to HIV and other sexually transmitted infections due to inadequate condom use and repeated exposure to older adult males throughout the trafficking lifespan.
Sex Trafficking Health Implications
When treating these potential victims, screening for injury and sexually transmitted infections (STI) such as HIV/AIDS, herpes, syphilis, gonorrhea, chlamydia, trichomonas, hepatitis, and molluscum contagiosum needs consideration. If a recent forced sexual encounter, emergency contraception, and STI prophylaxis are considerations, following preset institutional guidelines.
Sexual assault kits may need to be obtained. Follow sexual assault collection of evidence protocols in your local area and per institutional policy. Project Help, Rape Crisis, and women's shelters may be a resource. Pain from daily forced sexual encounters and trauma may be an issue. Problems with urinary tract issues may warrant a urinalysis or culture. A urine sample that is not a clean catch, often referred to as "dirty urine," may be obtained to test for a sexually transmitted infection such as chlamydia. A pregnancy test may be useful. Toxicology studies may be needed, and alcohol levels and withdrawal issues addressed.
Complications surrounding forced tampon use or "packing of the vagina" by traffickers to facilitate sexual encounters (unnoticeable to customers) while victims are menstruating may be of concern. Foreign debris may be present in the vagina on pelvic examination, and cervical cultures are a possibility if any discharge is present. That "lost tampon" patient may be a victim of trafficking and require a more in-depth assessment, asking open-ended, neutral questions to spot red flags.
Labor Trafficking Health Implications
Labor trafficking victims may experience severe dehydration or malnutrition due to being forced to work long hours in construction, on farms, at factories, or in "sweatshops." Heat exhaustion or hypothermia may present in these trafficking victims.
According to the 2016 Global Report on Trafficking in Persons, Southeast Asia is emerging as a destination for short, medium, and long-distance trafficking. Increasing in frequency, these individuals are made to endure long ocean voyages as they are smuggled into the United States and other countries on cargo ships. These overcrowded, unsanitary conditions have infectious disease ramifications.
Communicable or infectious diseases such as silicosis, tuberculosis, HIV, and typhoid may be an issue. Scabies, lice, and bacterial and fungal skin infections may be a concern. Malaria, Chagas disease, cysticercosis, toxoplasmosis, toxocariasis, and trichomoniasis also may be risks. Asbestos concerns exist for miners who are victims of labor trafficking
Migrant workers who are being trafficked in the fishing and seafood industry may suffer from exposure to Vibrio vulnificus and subsequent necrotizing fasciitis with septicemia if left untreated. Vibrio vulnificus, found in warm climates with shallow, coastal waters, can infect a person through lacerations or breaks in their skin
Labor trafficking victims may suffer from injuries related to poor ergonomics, such as back and neck injuries, vision problems, carpal tunnel syndrome, and headaches.
Intimate Partner Violence
Domestic violence or intimate partner violence (IPV) takes many forms and involves the maltreatment of another within a romantic union or partnership. Men, women, teenagers, heterosexuals, gay, lesbian, bisexual, and transgender may be affected. Domestic violence may include emotional, physical, sexual, economic, spiritual, or psychological insults. IPV involves one partner in the relationship subjecting the other to some form of abuse to exert power and control over them.
Domestic violence, much like human trafficking, is a significant public health issue that plagues millions of people. Individuals subjected to IPV, especially as teenagers, are vulnerable to practicing risky behaviors such as drug use and sexual promiscuity. These vulnerabilities place them in high-risk situations to be victims of human trafficking. Traffickers feed off this opportunity to exert power and control over a victim. Power and control manifestation takes many forms of abuse on the part of the trafficker.
The Human Trafficking Power and Control Wheel
The Human Trafficking Power and Control Wheel finds its basis in the power and control wheel for domestic violence. The wheel for human trafficking depicts the different types of abuse inflicted on trafficking victims at the hands of traffickers. Power and control, the wheel center, represent the primary weapon a trafficker uses to the manipulate a victim and keep them bound to the trafficker.
Other tools in the arsenal to demoralize and dehumanize a victim involve coercion and threats.
A victim-centered approach is paramount in the delivery of care to a victim of human trafficking. 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, non-judgmental, and caring manner. A victim's wishes, safety, and well-being are considerations.
The heart of a victim-centered approach ensures a victim does not suffer re-victimization or re-traumatization. Trauma, as it relates to an individual from an initial insult, is a series of events or stressors that the individual experiences as either emotionally or physically life-threatening and has lasting ramifications on social, physical, mental, and spiritual well-being.
Human trafficking care must involve a trauma-informed approach where the healthcare provider recognizes 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. Provider understanding of the signs of trauma, verbal and nonverbal cues, and their response by following predetermined protocols for identification, treatment, and appropriate referrals are essential elements of trauma-informed care.
Trauma-informed care involves the entire healthcare team and the incorporation of shared decision-making practices using an interdisciplinary, collaborative approach. Safety, transparency, and collaboration with peers and agencies are vital. It is essential that the approach accounts for culture and gender equality, LGBTQ considerations and support, and most importantly, an empowering environment.
Empowerment allows the victim to seek out resources and take the first steps towards self-identifying. Empowerment of staff is important for them to recognize the red flags of human trafficking and feel comfortable in their training and knowledge to offer appropriate resources and follow up care to trafficking victims.
The goal is for providers to enable others to champion change and advocate for protocol development, ensuring the incorporation of the Power and Control Wheel for Human Trafficking into the identification of the victim and subsequent polytrauma complex care that will be needed to empower the survivor to become a productive, functioning member of the community.
Human Trafficking Protocols
Providers must know the local resources available ahead of time and establish a human trafficking protocol much like the one for intimate partner violence or alleged sexual assaults.
Local resources such as Project Help, rape crisis centers, women's shelters, homeless shelters, addiction centers, and churches can provide needed materials and support services for these victims and clarify any rules, such as pet policies.
Know the resources available for potential victims of human trafficking through local law enforcement or task forces?
Human trafficking protocols need to include specific vital elements such as indicators, red flags, ways to separate the potential victim from the trafficker, interview procedures, ways to maintain and ensure safety for the victim, staff, and potentially other victims and referral information.
Mandatory reporting requirements that address local, state and federal laws need to be incorporated in a protocol. Referral information must be accurate and easily understood by the victim and translated appropriately based on language needs.
Provide NHTRC Hotline information. Incorporate follow-up data into a protocol. Another part of a protocol might include a critique of staff performance and ways to improve. Mandatory staff education will play a vital role in protocol implementation.
Recognize that everyone plays a role in stopping human trafficking and identifying those at risk: social workers, case managers, customer service representatives, nurses, physicians, physician assistants, nurse practitioners, nursing assistants, medical assistants, nursing students, medical students, educators, dental assistants, law enforcement, security guards, support staff, and the community.
Long-term psychological impacts must be taken into consideration when referrals for treatment of these complex trauma patients get enacted into the treatment plan. Multifarious conditions exist emotionally and physically, rendering approaches to future care a challenge for healthcare providers .
According to the findings of a study of male and female survivors of trafficking in England conducted between 2013 to 2014, healthcare, including physical, mental, and sexual healthcare, must be a fundamental component of post-trafficking care. Follow-up care coordinated with multiple disciplines is essential. Basic needs of clothing, food, safe shelter, and transportation must be discussed. Ensure language barriers are addressed and provide resources on free classes to learn the local language. Discuss medical issues and refer to appropriate subspecialists.
Transitioning from Victim to Survivor - Potential Referrals
Cultural shock impacts and language barriers play a role in the recovery period and successful transition into society as a survivor and not a victim. Survivors of human trafficking can offer much-needed insight into the thoughts, feelings, and interactions with members of the healthcare team and guide care and training programs going forward with this vulnerable patient population .
In 2015, a study conducted in New York City’s Rikers Island jail suggested that survivor-based input was essential in addressing healthcare concerns and improving care in this patient dynamic. Themes originated from these victims regarding healthcare providers such as victims feeling intimidated, judged, and stereotyped. They suggested providers and front-line personnel pay attention to their body language and nonverbal cues they are displaying as they walk into the treatment room, up to the front desk, or after disclosure. This interaction, if negative, can impact a victim feeling safe enough to open up and not be judged. These victims emphasized an approach that was not one of interrogation but asking straightforward, normalized, direct questions in a compassionate, nonjudgmental way that reinforced a feeling of safety and confidentiality. 
Further research is needed in this area for conclusive results as this crime comes "out of the shadows," and researchers look beneath the surface, but survivors should play a role in the education of healthcare providers
The Language of Trafficking
Languages are essential to the understanding of different cultures, environments, enterprises, and socioeconomic groups. Human trafficking and smuggling have a dialect, unique to traffickers and victims. Exploration of "trafficking vocabulary" will help practitioners relate to and understand patients who have been trafficked.
It is imperative in a victim-centered approach, much like a patient-centered approach, to communicate effectively with a potential victim or patient. The following are legal definitions and terms or "lingo" used by traffickers and victims or as they relate to human trafficking. This list continues to grow as we achieve a better understanding of human trafficking victims. Other terms may become recognizable as jargon unique to a trafficking situation.
Trafficking Victims Protection Act Definitions
Human trafficking care must involve a trauma-informed approach where the healthcare provider recognizes 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. Provider understanding of the signs of trauma, verbal and nonverbal cues, and their response by following predetermined protocols for identification, treatment, and appropriate referrals are essential elements of trauma-informed care.
Trauma-informed care involves the entire healthcare team and the incorporation of shared decision-making practices using an interprofessional, collaborative approach. Safety, transparency, and collaboration with peers and agencies are vital. 
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