Human trafficking can occur within a country or between countries. Often referred to as modern day slavery, human trafficking is a worldwide problem with a very significant organized crime connection exceeded only by drug trafficking in its scope. Despite this, it is a problem of which the uninvolved are predominantly unaware. What limited awareness of the problem there is among the uninvolved lies at the edge of conscious thought and often has an unreal, story-like character based on a magazine article, a book or a movie. It is seen as “illicit sex”, “out there”, “not to do with me”, or even “in the past.” The reality is that human trafficking occurs in many forms and is all around us with virtually all countries serving as source, transit and/or destination.
In November of 2000, the United Nations recognized the epidemic proportions and global nature of human trafficking when the General Assembly adopted by resolution the Convention Against Transnational Organized Crime and the Protocols Thereto. This Convention, also referred to as the Palermo Convention, recognized that crime can cross national borders and therefore requires a global criminal justice response. Thus, the agreement established a legal framework designed to promote cooperation in the prevention and combat of transnational organized crime. The three protocols attached to the convention are the Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children; the Protocol against the Smuggling of Migrants by Land, Sea and Air; and the Protocol against the Illicit Manufacturing of and Trafficking in Firearms, their Parts and Components and Ammunition. Each of the protocols addresses considerations and guidelines unique to its specific area of concern.
The Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children contains a legally-binding, agreed-upon definition of trafficking in human persons which reads as follows:
“the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs.”
This definition has three essential elements which serve to distinguish human trafficking from other similar crimes and thereby facilitate investigation and prosecution across national boundaries. These defining elements are the Action, the Means and the Purpose. The Act of trafficking is the recruitment. transportation, transfer, harboring or receipt of a person. Specific to sex trafficking are the acts of patronizing, soliciting and advertising.
The Means refers to the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person. There is no trafficking without the use of force, fraud or coercion.
The Purpose is always ongoing exploitation of the trafficked person. As indicated in the definition from the Trafficking of Persons protocol, exploitation can take many forms. It may involve commercial sex, forced or bonded labor; domestic servitude; forced marriage; organ removal; the use of children for begging, and the use of children for warfare. This last refers not just to combat but to any role in a military operation such as cook, guard, messenger or spy.
When nations ratify (make legally binding) this protocol, they are acknowledging that human trafficking is a violation of human rights and a crime. They are further committing to adopting domestic anti-trafficking legislation and to protecting and assisting the victims of trafficking in persons with full respect for their human rights. The Palermo convention which went into force in 2003, has now been signed by 187 countries worldwide, and ratified by 177. As of 2018, 119 countries have signed the Optional Protocol to the Convention concerned with Trafficking in Persons, and 91 have ratified it.
The International Labour Organization (ILO) is an agency of the United Nations that works with governments, employers and workers of 187-member states to promote decent working conditions for all. The ILO maintains statistical databases related to labor issues. According to ILO estimates, in 2016 there were 5.4 trafficking victims for every 1,000 people in the world and one in four of these was a child. This means there were 40.3 million victims at any one time in 2016. Of these, 24.9 million were in forced labor including 4.8 million in sexual exploitation and 15.4 million in forced marriage. Ninety nine percent of those in the sex industry were women and children. Actual numbers of trafficked persons are almost certainly higher because of underreporting. The hidden nature of human trafficking with its associated lack of public awareness and misconceptions about what it is are factors responsible for underreporting. Also contributing is the reluctance of victims to self-identify out of fear or shame.
In the United States, human trafficking became a federal crime with mandated restitution to its victims with the passage of the Trafficking Victims Protection Act (TVPA) in 2000. This act aligns with the United Nations Convention and trafficking protocol with its 3P Paradigm approach to the fight against human trafficking: Prosecution (of traffickers), Protection (of victims) and Prevention (of the crime). The TVPA defines a victim of human trafficking as anyone induced to perform labor or commercial sex act as a result of force, fraud or coercion. It further differentiates ‘‘severe forms of trafficking in persons’’ defining these as
Consistent with the 3P Paradigm, along with identifying, prosecuting and jailing traffickers, TVPA and all its reauthorizations have a focus on the protection of victims and prevention of human trafficking. With the original act, the Office to Monitor and Combat Traffic in Persons (TIP Office) under the US Department of State was established. This Office must publish a Trafficking in Persons Report each year which assesses countries including the US, based on their governments’ efforts to meet the “minimum standards for the elimination of trafficking”. Actions taken related to Prosecution, Protection and Prevention are described and recommendations made for further progress. The TVPA 2000 also established the T visa which permits human trafficking victims and their families to become temporary U.S. residents eligible to become permanent residents after three years.
Examples of initiatives designed to protect victims and prevent human trafficking which have been implemented under TVPA reauthorizations include establishment of a federal, civil right of action for trafficking victims to sue their traffickers (TVPRA, 2003), provisions to fight sex tourism (TVPRA, 2005), requirement that information on worker’s rights be provided by the government to everyone applying for a work or education-based visa, requirement that all unaccompanied alien children be screened as potential victims of human trafficking (TVPRA, 2008) and creation/strengthening of programs to ensure that U.S. citizens do not purchase products made by victims of human trafficking, and to prevent child marriage (TVPRA, 2013).
Despite these efforts, the problem of human trafficking is growing (14) and the magnitude of the problem has led to a call for human trafficking to be viewed and managed as a public health problem not solely a criminal justice problem. While trafficking victims can suffer from the broad range of health problems that affect people in general, there is also a myriad of physical and mental health problems specifically related to the trafficking experience. Communicable diseases related to over-crowded living conditions and poor sanitation as well as problems related to isolation, sleep deprivation and malnutrition are common. Prolonged repetitive stress associated with being trafficked results in high rates of anxiety, hypervigilance, posttraumatic stress disorder, depression, self-harming behaviors and suicidal ideation while injuries such as broken bones, contusions, dental problems disruptions, and cigarette burns result from violence. Among sex trafficking victims, the incidence of HIV, other sexual transmitted infections, and abortion is high and genital trauma, retained foreign objects along with other genitourinary problems occur. Substance abuse bounds across all trafficking victims as either an escape for the victim or a method of control by the trafficker. Trafficking victims may not have a regular source of health care so routine screenings, immunizations, and management of chronic illness such as hypertension and diabetes may be lacking. These problems not only affect the victims of trafficking but indirectly they impact the community and its population as a whole. Thus, a public health approach which would be proactive is appropriate. A public health approach would focus on understanding the root causes of human trafficking and be multifaceted in taking action aimed at prevention, intervention and mitigation of the effects of trafficking.
Anybody can be a victim of human trafficking. There is no gender, age or nationality requirement. Victims are men and transgenders as well as women; newborns and children as well as adults. Victims come from every socioeconomic background and from rural, urban and suburban communities of every type in the United States.
Groups at high risk for becoming victims include those trying to escape from poverty, violence political instability or natural disasters; children and young adults lacking safe, stable family relationships, smuggled immigrants and those whose psychological make up makes them vulnerable and easily duped by false promises. Specific correlates of human trafficking include substance use, recent migration or recently relocated, involvement with the child welfare system, runaway or homeless, mental health problem.
There is no official estimate of the number of human trafficking victims in the United States. However, the National Human Trafficking Hotline, which maintains one of the largest data bases on human trafficking in the United States, reports that in 2017, 26, 557 calls (phone calls, emails or on-line reports), were received and there were reports of 8524 cases with evidence of potential Human Trafficking. The highest number of cases were in California, Texas and Florida with 1305, 792 and 604 respectively. Of the total cases, 6081 were identified as sex trafficking with and 1249 cases involved Labor trafficking. Sex trafficking victims work in illicit massage parlors and spas, hotel and motels, residential brothels, strip clubs, through escort services and on-line ads with location unknown. Labor trafficking victims are found in homes, on farms and in both small and large businesses. They may be involved in residential domestic work as maids and nannies, in agriculture or horticulture, construction, manufacturing, food services such as catering and restaurants, and contract cleaning.
Victims are recruited and retained by traffickers in a variety of ways which can be categorized as force, fraud or coercion. Force includes both physical and emotional abuse. Force such as confinement, beating and sexual violence or threat of such may be used against the victim. A threat of force against a family member, loved one or friend of the victim also may be used to make the victim compliant. In other cases, fraudulent job offers, promises of a good salary and housing, promise of “legal papers” or even the promise of love may be the mode of recruitment. Coercion may involve debt bondage, isolation, frequent movement to unknown locations, and confiscation of identification and travel documents. Debt bondage occurs when a victim receives little or no pay until fees charged by the trafficker are paid off. Extremely high fees may be for recruitment, travel documents, basic necessities of living such as room, food, use of tools, as well as fines for insufficient productivity or poor behavior.Traffickers frequently present as benefactors. They often are family members or friends. A study of Covenant House youth found that only 9% of trafficked individual were recruited by strangers while more than one third were trafficked by immediate family, followed in decreasing order by boyfriends, family friends and employers.
Nursing’s concerns and responses to the problem of Human Trafficking derive from its professional values and the nature of its work. Five values identified by the American Association of Colleges of Nursing as essential to the professional nurse are altruism, autonomy, human dignity, integrity and social justice. Of most import to the issue of nursing’s response to human trafficking are the values of
Altruism - concern for the welfare and well-being of others.
Human Dignity - respect for the inherent worth and uniqueness of individuals and populations.
Social Justice - acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation.
The nature of nursing’s work as defined by the International Council of Nurses (ICN, 2014) is:
Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups, and communities, sick or well, and in all settings. Nursing includes the promotion of health; prevention of illness; and the care of ill, disabled, and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.
The American Nurses Association definition is:
Nursing is the protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, communities, and populations (ANA, 2010b).
It is evident from these statements with their references to human worth, fair treatment, concern for others’ welfare, safe environment, health promotion, illness care, and advocacy that nurses rightfully take action to prevent Human Trafficking and treat its victims. It is further evident that these efforts must take place at three levels: individual patient; health care organization and community. Additional support Further support for this position comes from the ANA Code of Ethics which states in part: “The nurse promotes, advocates for, and strives to protect the health, safety and rights of the patient. The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health.”
The first step in caring for a patient is assessment. To be meaningful, assessment must be unbiased and informed. In order to assess a patient for the possibility of being a victim of human trafficking one must be free of misconceptions about how a human trafficking victim looks, acts, speaks and lives. Common misconceptions about trafficking and its victims along with the actual facts are presented for review in Box 1.
At the same time that the nurse must be unbiased, he or she must know what factors need to be assessed because they are key indicators of a potential trafficking victim. As Robertson Davies says in Tempest-Tost “The eye sees only what the mind is prepared to comprehend.”
The National Human Trafficking Resource Center has identified a group of assessment findings often characteristic of trafficking victims and divided them into three categories: potential indicators of trafficking in general, potential indicators of labor trafficking and potential indicators of sex trafficking. The list is not comprehensive and none of the items on it are definitive for trafficking. The items are what they are labeled – “potential” indicators. These indicators serve to raise the level of suspicion and indicate the need for further assessment.
While some of these potential indicators of trafficking can be observed, others require that the person share the information. Thus, asking questions that yield information about the person’s experience in a non-threatening manner is essential. Examples of such screening questions prepared by the US Department of Health and Human Services Campaign to Rescue and Restore Victims of Human Trafficking are:
For safety, questions related to trafficking, however indirect, should only be asked when the patient is alone in a private setting with cell phone turned off. To separate the patient from any accompanying person(s) a plausible explanation must be given. This may be a simple as “This is hospital policy.” When possible, give the patient a choice of speaking with either a male or female caregiver. If a language barrier exists use the services of a professional interpreter to communicate, ideally one who understands the patient’s culture.
Patient centered care of a trafficking victim requires that care provided be trauma-informed. Trafficking typically involves repetitive, prolonged trauma and the experience can dramatically influence the victim’s response to assessment questions and to elements of the physical examination such as being asked to remove clothing. Trauma informed care is designed to avoid re-traumatization of the patient; to validate strengths and resilience and empower the person to regain control over life; to promote healing and recovery, and to promote development of healthy coping mechanisms. It reinforces that the person has rights, is not to blame for the situation, is entitled to help and that help is available. Building trust is essential to trauma-informed care. The approach to the patient needs to be non-judgmental, accepting, patient, empathetic and respectful.
The goal of the health care encounter is to meet immediate medical needs, keep the patient safe and provide needed resources; it is not disclosure and rescue. Victims don’t acknowledge their situations readily. Many are afraid to come forward. They fear retaliation of the trafficker, deportation for illegal immigration, arrest and prosecution for prostitution or other crimes committed while being trafficked, or report to social services. Guilt, shame, and lack of understanding of US healthcare system are other factors which inhibit disclosure. Some victims normalize their situation and see themselves as “helping out” rather than being used. In other cases, victims, even if abused, develop an emotional attachment to the trafficker and do not want to leave. This is called the Stockholm Syndrome or Trauma Bonding.
In any event, the patient must be “ready” for disclosure and moving on. Patients will vary in their receptiveness to information about available resources and where to obtain help when it is needed. At a minimum, they should be told help is available through the NHTRC hotline and given the number which is 1-888-373-7888. Because of safety concerns and the likelihood of traffickers destroying written information concerning options for help, the information should be given verbally or in an easily concealed form. The patient may be coached to memorize the hotline number as 888 37 37 888 or as three eights, thirty-seven, thirty-seven, three eights. Alternatively, the number may be written as the reference number for lab report or provided on a key or shoe card.
The nurse needs to ensure that the patient understands the agency’s confidentiality policies as well as any mandatory reporting requirements that may apply. If reporting is not mandatory, the patient’s permission should be obtained before information is shared.
Documentation of care follows the same guidelines as for any other patient encounter. It should be complete, accurate and objective. Information disclosed by the patient should be recorded in an unbiased manner, using direct, unaltered patient quotes whenever possible. Written notes of physical findings may be supplemented with photographs provided the patient chooses to give permission. If photographs are taken, the patient’s face, a page with the date, and a measure such as a ruler or a coin by which to judge the size of any wound or injury should be included. The name of the photographer and a statement that the photographs ae unaltered and accurate should be placed in the record. The words “suspected human trafficking” should also be included in the patient record when appropriate.
For the person who discloses and is ready to move on, coordination of care with other providers such as Social Services and Legal Services is essential. Immediate basic needs for food, clothing, and safe transitional shelter must be met. Subsequently assistance is needed for safety planning, transportation, medical care including mental health services, employment and in some cases, interpretation services. Help also may be needed with contacting family and with legal issues related to immigration, child custody, prosecution of the trafficker or charges of prostitution or other crime.
As a health care provider caring for victims or survivors of human trafficking, it is essential for the nurse to be knowledgeable about the resources available for guidance in dealing with patients and for the patients themselves. Box 2 presents an overview of services offered by prominent governmental, non-governmental and faith-based anti-trafficking organizations.
Box 2 Anti-trafficking Initiatives: Creating Awareness and Offering Help to Victims
Polaris is a non-profit, non-governmental group dedicated to combating modern day slavery. It seeks to Respond to victims of human trafficking effectively and immediately; Equip key stakeholders and communities to address and prevent human trafficking; and Disrupt the business of human trafficking through targeted campaigns. Efforts to this end include operating the National Human Trafficking Hotline and Be Free Textline, providing advisory services on how to combat human trafficking, facilitating multinational sharing of data, strategies and resources related to human trafficking and collecting and analyzing data to better understand the scope and dimensions of the problem.
National Human Trafficking Resource Center (NHTRC)/National Human Trafficking Hotline (NHTH)
This is a toll-free hotline that takes calls in more than 200 languages from anywhere in the United States 24 hours a day, seven days per week, every day of the year. The Hotline aims to connect victims of Human Trafficking with resources that will provide them with essential safety and support services. These resources are drawn from the NHTRC referral network of over 3,200 contacts which include anti- trafficking organizations, legal service providers, shelters, law enforcement, and local social service agencies. The Hotline is also a place for tips on trafficking to be reported and for the anti-trafficking community to obtain training, technical assistance and other tools to effectively combat human trafficking. Clinicians can be guided through an assessment of a potential victim. The Hotline also helps with reporting by facilitating report to law enforcement contacts who are trained on trafficking and designated to respond to NHTRC hotline. The NHTH is funded but not run by the Federal government and neither a law enforcement or immigration authority.
NHTH Contact information:
Human Trafficking Knowledge Portal
The Human Trafficking Knowledge Portal was created by the United Nations (UNODC) to share information about the implementation of the UN Convention against Transnational Organized Crime and specifically the Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children. The portal provides access to a Case Law Database, a Database of Legislation and a Bibliographic Database.
The Case Law Database which is organized by country, provides summaries of prosecuted cases of human trafficking. The summaries contain details about the trafficker, the victim(s), and the circumstances of the crime as well as the outcome of the case. By making this information the portal seeks to increase awareness of the crime and its consequences. The Database of Legislation provides access to laws which related to the Palermo Convention. Like the Case Law Database, it is organized by country. The Bibliographic Database contains is a searchable annotated bibliography of major articles and publications on the topic of human trafficking. https://www.unodc.org/cld/en/v3/htms/index.html
The Blue Campaign
The Blue Campaign is a program of the U.S. Department of Homeland Security (DHS) designed to combat human trafficking. The program aims to raise awareness of human trafficking and to educate the public to recognize and report it. It also offers training on detection and investigation of human trafficking as well as protection of victims to First Responders, Law Enforcement personnel and federal employees. An online document library and video series is available through the Blue Campaign webpage. Organizations can request free pamphlets, posters, wallet information cards and shoe cards with information on reaching help at https://www.dhs.gov/blue-campaign/request-materials.
Trafficking Victims Assistance Program (TVAP)
TVAP is a program run by The U.S. Conference of Catholic Bishops through a cooperative agreement with the Department of Health and Human Services’ Office on Trafficking in Persons. Through a national network of direct providers, the program offers immediate and supportive services including food and clothing, housing assistance, safety planning, health referrals, transportation, legal aid, employment training and guidance, language and educational programs, life skills and family support and immigration legal services. Men, women, and minors who are foreign born and have been subjected to commercial sexual exploitation and/or forced labor may be eligible. Derivative family members may be eligible as well. Eligibility criteria as defined in the Trafficking Victim Protection Act of 2000 is determined through an initial assessment by a local service provider in consultation with USCCB.
For information on referring a potential client or if you have questions about the TVAP, email [email protected], or call us at 1-855-708-3089.
HEAL (Health, Education, Advocacy, and Linkage) Trafficking is a not-for- profit organization composed of interdisciplinary professionals committed to using a public health approach in the effort to combat human trafficking. Major areas of focus are advocacy to better public policies, improvement of clinical care for victims, education and training for health care providers, use of media and technology to serve survivors, development of evidence-based procedures for identification, care and referral of victims, and research. HEAL Trafficking offers health care facilities the HEAL Trafficking and Hope for Justice’s Protocol Toolkit for Developing a Response to Victims of Human Trafficking in Health Care Settings to guide them in creating safe procedures and spaces for meeting the needs of trafficked patients. HEAL also offers speakers to and on its website, provides educational videos, access to information on non-profit organizations, government divisions, and academic centers concerned with trafficking and a list of media articles, reports and professional literature. https://healtrafficking.org
At the health care organization level, the most basic action is to stay informed as an individual nurse and share your knowledge with colleagues to support a culture of action in support of victims and survivors of human trafficking. Within the organization bring the topic of human trafficking forward as an area for discussion informally among colleagues and formally at unit meetings and institutional forums. Advocate for training on detection and intervention not just for nursing but for all levels of health care personnel who may come in contact with victims. Act to ensure there are safe, private areas available to meet with potential victims; support development and placement of informative pamphlets or leaflets designed for victims in public areas. Design methods for victims to safely report the need for help such as using a “Patients Only” bathroom with signs saying to put a blue marker on the specimen bottle if in danger and in need of help. Speak to the importance of a comprehensive organization-specific protocol for the identification of, and response to, human trafficking. Components of a comprehensive protocol would include a list of local trafficking indicators; name, title and contact information of a designated interviewer; guidelines for separating a potential victim and the trafficker; procedure for mandatory reporting, directions and names of contacts at social service and law enforcement for reporting, guidelines for when to intervene and actions if a patient refuses intervention, and guidelines for ensuring safety and security of the victim. A well-defined protocol is a prerequisite to the effective use of a Human Trafficking screening tool such as that
Action at the community level is essential for as the June 2018 Trafficking in Persons Report states, the local community is the first line of defense against Human Trafficking. Community level action begins with promoting awareness of human trafficking. As a healthcare professional and a member of the community you can advocate for guest speakers and placement of informational posters and brochures on human trafficking at community venues. You can take advantage of opportunities to educate parents and other adults on the importance of speaking with children about the problem of human trafficking sharing the UNICEF ten Key Messages for Your Kids (Box 3). You can support a booth focused on human trafficking at community based Health Fairs and galvanize a community action on January 11 which was designated by Congress in 2007 as Human Trafficking Awareness Day.