Texas Human Trafficking

Etiology

Anyone can be a victim of human trafficking. The causes of this crime are multifactorial. Human traffickers are criminals motivated by money and profits and do not respect human rights or the health and safety of their victims.[1] Human trafficking is often discussed using the A-M-P model (action-means-purpose). Actions include recruiting, harboring, and transportation. Means are force, fraud, and coercion. The purpose of sex trafficking is for commercial or sex labor. 

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 cannot consent to a sex act with an adult. Minors are easier to exploit and manipulate and so are more 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 Service’s (HHS) "Look Beneath the Surface" campaign and Stop, Observe, Ask, and Respond (SOAR) training in 2017 attempted to teach healthcare providers and the general public to identify victims of trafficking. Force may involve rape, torture, beatings, or imprisonment and can be psychological or physical. Physical confinement is rare. More often, "invisible chains" are used to maintain power and control, similar to their use in 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."[1]

Force, fraud, and coercion are the defined means of exploitation for human trafficking. 

Force: The use of physical power

• Example: Beatings, physical restraint, rape

Fraud: The use of false promises

• Example: Promising payment or citizenship for work

Coercion: Threats of harm

• Example: Blackmail

Intimate partners and family members are potential traffickers and tend to use force more than fraud or coercion.[5]

Epidemiology

Human trafficking is the second-largest global criminal enterprise after drug trafficking.[6] Because there is no validated screening tool for human trafficking, it is difficult to determine the exact number of people who are currently victims.[7] Different types of human trafficking include commercial labor (such as working in a factory, farm, etc.) and commercial sex trafficking. In Texas, an estimated 234,000 people are the victims of labor trafficking at any given time, with 79,000 of these estimated to be minors. (Busch-Armendariz, et al., 2016). 

 In 2007, a non-governmental organization, Polaris, established the National Human Trafficking Hotline. The US Department of HHS funds the National Human Trafficking Hotline, which is operated by Polaris. The National Human Trafficking Hotline gathers invaluable information to assist victims domestically and abroad."

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.

• The hotline number is 1-888-373-7888, provided by Polaris’s Be Free Text line.
• Text "HELP" to 233733 (BEFREE).
• Email help@humantraffickinghotline.org.

Analysis of calls made to this hotline provides some statistics regarding reported cases of human trafficking.[4] Statistics from this hotline can be used to determine risk factors for human trafficking. 

Childhood Statistics/Cases

Another resource for reporting cases and gaining information related 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 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. 

Data from the National Human Trafficking Hotline in 2019 involved 11,500 reported cases.[4]

In 2019:

• Texas ranked second in reported cases (1080)
• The most common type of trafficking in the US was sex trafficking (8,248 out of 11,500)
• The top venues for labor trafficking were: domestic work (218) and agriculture (108)
• The top venue for sex trafficking was: Illicit massage/spa business (1,247)

Gender numbers for reported trafficking victims in the US were as follows:

• 9, 357 female/ 1,304 male/ 99 gender minorities.
• 6,684 victims were adults, and 2,582 were minors. 
• 1,098 were reported US citizens, 1,417 were reported foreign nationals, the rest were unknown.

Hotline Statistics | National Human Trafficking Hotline

These statistics highlight that a border (national or state) does not need to be crossed for an individual to be a trafficking victim. Human trafficking victims may also be a part of minority groups treated inequitably, such as LGBT, undomiciled persons, persons from a war zone, victims of abuse, those with early childhood trauma.[8] However, the presence of these factors does not mean that this patient is automatically a victim of trafficking.

Pathophysiology

Major forms of human trafficking are sex trafficking, forced labor, and domestic servitude.

Sex trafficking is "a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age." It is the most prevalent form of trafficking in the United States and includes prostitution, pornography, mail-order brides, and other non-consensual sex work. Consensual commercial sex is not considered human trafficking. Minors cannot legally consent and therefore cannot participate in consensual commercial sex. Recruitment techniques used by traffickers include contact via social networking sites, public places (malls, schools), group and foster homes.[6] Other forms of recruitment include finesse pimping and guerilla pimping. Finesse pimping is often used with young or vulnerable targets. The trafficker uses false kindness, psychological manipulation, or promises to build a relationship with the victim they then abuse. A finesse pimp may present as a "boyfriend" of the patient. Guerrilla pimping is more commonly used in adults and involves physical force and beatings to manipulate the victim. 

Labor trafficking is "the recruitment, 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." Peonage is paying off a debt through labor. In debt bondage, the victim is forced into labor to pay off a loan, debt, or other obligation. Labor trafficking is used in agriculture, domestic services, hospitality, and construction. Traffickers often target victims in or near poverty.[6] 

Child trafficking encompasses child sex trafficking, forced child labor, and the use of child soldiers. Trafficking Victims Protection Act (TVPA) in 2000 established that force, fraud, or coercion did not need to be established in cases of sex trafficking in minors.[9]

The profile of a human trafficker is broad. They can be of any gender, race, or background. They may present with the patient as a family member, coworker, or friend. In sex trafficking, the victim may report that the trafficker is their boyfriend or is taking care of them. As previously described, anyone can be a victim of human trafficking. However, vulnerable populations are often targeted by traffickers. The following are risk factors of vulnerable populations:

Adverse Childhood Experiences

Adverse Childhood Experiences (ACES) can increase the likelihood of risk-taking behavior that could predispose a person to become a trafficking victim. The CDC-Kaiser Permanente Adverse Childhood Experiences study investigated the ramifications of child abuse and neglect on health and well-being later in life. The study was done from 1995-7 with ongoing surveillance of study participants by the CDC. According to this study, 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, which may lead to an early death. The study found 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.[10]

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 calculating 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.[11]

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.[12]

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 used sex to meet basic needs in the past year were transgender women. Approximately 19% had participated in some form of 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 a sense of family. Vulnerability and feelings of distrust towards authority figures take the place of security. Often, those who are supposed to protect the victim 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, looking 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. The US Department of Health Office on Trafficking in Persons in 2017 identified at-risk groups:

1. survivors of child abuse, sexual abuse, assault, interpersonal or intimate partner violence
2. gang members subjected to violence
3. those exposed to community violence.

The SOAR Campaign identifies the lack of stable support structure or home life as a risk factor for trafficking. Lack of social support is found with runaways, foster children, children in the juvenile justice system, homeless youth, unaccompanied minors, persons displaced due to a natural disaster, and individuals who possess a language or cultural barrier. Increased risk also occurs in substance abuse patients, undocumented or migrant workers, and the LGBTQ population. In addition, minorities, people with disabilities, and those living 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. Examples of identified child trafficking cases involved stripping, pornography, forced begging, commercial sex, magazine crews, drug sales, and the cultivation of illegal products. 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 potential victims of human trafficking. Signs of child trafficking include unexplained absences, poor attendance, runaway behavior, frequent travel to other cities, inappropriate dress for the current weather, sleep deprivation, malnourishment, or impairment due to drugs or alcohol.

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 youth exploitation.  School hallways pose a risk, as a trafficker may, in fact, be another student. A promise of a party or other 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."

History and Physical

A majority of human trafficking victims will at one point come into contact with the health care system. Therefore, providers need to be aware that any of their patients could be trafficking victims. 

Exploitive Environments

When healthcare workers encounter potential victims of trafficking, detailed work history and social history will assist in identifying red flags. In addition, a better understanding of the 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, elderly 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 the type of 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 if their work visa and immigration status is 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, fences, and locks. The seasonal nature of their work and movement from place to place heightens their vulnerability as they are often in 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. 

Workers in strip clubs and bars may have fraudulent work visas and ties to organized crime, rendering them vulnerable to trafficking. Drugs and alcohol are used as manipulation tools. Labor laws may not apply to subcontractors or independent contractors, thus increasing vulnerability. Traffickers seek to keep the victim isolated by proximity or language, vulnerable due to immigration status, without resources, in debt, and unprotected by labor laws to increase their 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 usual safety equipment such as safety belts, gloves, goggles, and masks. 

Labor Trafficking Red Flags

The healthcare worker's most important role is to recognize a potential case of human trafficking. The provider may also 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.

The healthcare provider should start by asking open-ended questions in a private area. The approach should be non-judgmental to allow free disclosure by the potential victim. The provider should look for verbal and nonverbal clues of distress. Useful questions may include and not be limited to the list below:

1. Are you being paid the wages that were part of the initial agreement?
2. Can you change jobs if you want to?
3. Would anything happen to you if you did quit your job?
4. Can you come and go as you please, take bathroom breaks, eat when you want?
5. Do you live with others? What are the home conditions, and where do you sleep? Do you have a bed? Do you sleep on the floor? Is it too cold or too hot?
6. Did you pay a fee to get your job? Do you owe a debt to your employer?
7. Do you have access to your money, your identification? 
8. Has your employer ever threatened you? 
9. Did you have eye protection, a mask, a safety harness? Personal protective equipment such as gloves? Respirators?
10. Does your employer provide your housing? 
11. Are you working in the job you were hired to do? 
12. Are you concerned about your safety? Your family, or your children's safety?
13. How many hours do you work a day? How many days per week?
14. Have you moved around a lot? Do you know your address? Can you give me directions or the location of your house?
15. Do you take care of others?
16. Are there locks on the doors or bars on the windows? Can you leave freely?[13]

Barriers to Identification of Victims

Healthcare providers may fail to stop, observe, and ask questions to identify a potential victim of human trafficking. Lack of knowledge about trafficking and the absence of protocols to identify trafficking can contribute to missed cases of trafficking. Victims may be frightened of the consequences of identifying their trafficker. They may not trust the healthcare system or provider and may not recognize that they are being exploited.

A patient who presents with multiple visits for a pain complaint with no organic cause may be a victim of trafficking. Patients that present with stress-related issues on multiple visits or return frequently may be victims of trafficking. Patients with overdoses, suicidal ideation, or suicidal attempts may be victims of trafficking.  Traffickers can pose as parents, grandparents, or spouses. Providers must investigate any suspicion of an exploitive relationship. The healthcare system may be the only contact the victim has with potential help.

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:

1. Inconsistent history or a history that appears coaxed. This may be difficult to determine if a language barrier is present.
2. Resistant to answer questions about the injury or incident.
3. Avoids eye contact, is nervous, fearful of touch.
4. No idea of address or general area where they live.
5. No control over their finances and lacks decision-making capacity.
6. Accompanied by a controlling companion or family member that refuses to let the patient speak for themselves or be alone for care or insists on being the translator.
7. Exhibits bizarre, hostile behavior. Resistant to care and assistance. They may have initially consented but changes their mind after being asked to undress for an exam.
8. No identification or the companion has it in their possession.
9. Under the age of 18 and involved in a commercial sex act.
10. Tattoos or branding signs. Markings may say "daddy" "for sale," imply ownership or read like an advertisement for a product.
11. Multiple sex partners.
12. Inappropriate attire for the environmental conditions of the area.
13. Attempt to reason away bruises or ligature marks by claiming a bruising or rare blood disorder.
14. Silent, afraid to speak, cringes at the sound of a loud voice.
15. Uses trafficking "lingo" such as "the life" or other words common in the commercial sex industry.
16. Has addiction issues such as opioids.
17. Admits to a forced sexual encounter or being forced into sex acts.
18. It has a cover story to avert suspicion, but details may vary or be inconsistent.

Head-to-Toe Assessment[14]

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 be uncooperative, vague, or give an inconsistent history. These reactions are manifestations of their trauma. The difficult history can frustrate the provider. This frustration may lead to the desire to hasty decisions about diagnosis and treatment. The potential exists for "diagnostic overshadowing." and premature closure of the case. As with any trauma patient, a high index of suspicion should be present for co-existing conditions and comorbidities.

The patient assessment must be in private, without anyone accompanying the patient present. This private evaluation should be presented to the patient as standard procedure. A chaperone and certified interpreters should be used as usual. These providers can be used to establish trust and rapport with the patient.  Using a same-sex provider for the physical exam may be helpful, if possible.  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:

• Bruising; old, healing or new lacerations; hematomas; signs of acute or chronic head trauma or a headache; missing hair or bald spots.
• Trouble hearing; damage to the auditory canal or eardrum; signs of trauma to the oropharynx such as lacerations or burns, blood in the mouth, ulcerations, tooth decay, broken teeth, gingival irritation, tongue abnormalities; signs of anemia or dehydration in the oral mucosa.
• Visual defects; tattoos or brands in the hairline or on the neck; signs of strangulation.
• Signs of chest trauma, murmurs; cigarette burns; bruising in various stages of healing;
• Respiratory issues that would indicate inhalation injuries from chemical exposure, toxic fume exposure, asbestos exposure, or mold exposure.
• Signs of tuberculosis such as night sweats, coughing up blood, fever, weight loss.
• Signs of stress-related cardiovascular, respiratory or gastrointestinal problems.
• Damage to lung tissue due to prolonged exposure to chemicals or pesticides, aspiration pneumonia, or other inhalation injuries; 
• Hypothermia or hyperthermia from environmental exposure from working in damp, cool, poorly insulated factories or buildings; mold exposure signs/symptoms.
• Signs of gastrointestinal issues such as nausea, vomiting, diarrhea, constipation, or abdomen pain; rectal pain, itching, trauma, or bleeding; parasites in the feces or signs of abdominal trauma.
• Bruising to the back or scarring; tattoos that imply advertisement, ownership, or are sexually explicit in the pubic hair.
• Sexually transmitted infections; anogenital trauma; foreign bodies in the vagina, vaginal bleeding, discharge, rashes, itching, signs of injury, or forced sex
• There are signs of bruising or lower back scarring from repeated beatings; musculoskeletal issues such as signs of repetitive trauma; work-related injuries or injuries such as back problems from wearing heels for hours walking the streets or neck and jaw problems from frequent, forced oral sex.
• Fractures, old or new, any contractures. Cigarette or scald burns. Ligature marks/scars around ankles or wrists. Signs of scabies, infestations (scalp or body). Impetigo. Fungal infections.
• Signs of nutritional deficits such as vitamin D deficiencies from lack of exposure to sunlight, anemia, mineral deficiencies, brittle or fine hair.
• Signs of anorexia, bulimia, loss of appetite, malnutrition, severe electrolyte abnormalities.
• In children, growth and development abnormalities, dental cavities, or misaligned poorly formed teeth.
• Signs of opioid or other addiction.[14][15]

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. As a result, bruises, lacerations, marks, or scars may be present in areas usually hidden by clothes so as not to disfigure the product/victim and make the person being trafficked less marketable. 

It is important to note that some cultures practice such as cupping therapy may cause bruising and scars. Correlate this finding with 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 or psychological illness. The provider should consider trafficking in all cases of unexplained mental distress. Look for signs such as depression, suicidal ideations, self-mutilation injuries, anxiety, post-traumatic stress disorder (PTSD), and feelings of shame or guilt. 

A trafficking victim may describe a situation as if they were an outsider looking in. They may use this mind-body separation to create a safe, alternate reality to cope with their situation.  They may use a third-person, omniscient point of view in their storyline. Patients exhibiting this behavior may be categorized as impersonal or devoid of emotion, numb to their surroundings, or detached. This is their survival adaptation.

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 with the prosecution of the trafficker. Follow established documentation guidelines and reporting requirements based on state and local statutes or federal laws.  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."[1][16]

Evaluation

Recognition and Intervention

Once a practitioner identifies a potentially trafficked person, it is imperative to establish a private, quiet, safe place to assess the patient. Further, building rapport and providing an opportunity for the victim to feel empowered is of utmost importance. This builds trust and helps establish a network of people and institutions to assist the victim.

It is preferable to perform the assessment and physical examination with the patient’s cell phone turned off or out of reach. Cell phones can be a way the traffickers control the victim. For example, 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 chair at eye level, unless contrary to the patient's cultural norms. Ensure an environment where the victim can establish a sense of power and control. This zone of safety may allow them to reveal their situation to the provider.

Ask the patient if it is safe to talk and if they are comfortable with their providers. Ask if they would prefer a different provider. 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 can guide your care. A pre-determined location such as a bereavement room may be used.

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 healthcare providers. Therefore, 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

Sample messages for communicating with a victim of human trafficking, according to the Department of HHS.

1. We are here to help you, and our priority is your safety. We can keep you safe and protected.
2. We can provide you with the medical care you need and find you a place to stay. 
3. Everyone has the right to live without being abused or hurt, and that includes you. 
4. You deserve a chance to live independently, take care of yourself, be independent, and make your own choices. We can help you with that. 
5. We can get you help to protect your family and your children. 
6. You have rights and deserve to be treated according to those rights.
7. You can trust me. I will do everything within my power to help you. Assistance is available for you under the law, and there are special visas to allow you to live safely in this country.
8. No one should have to be afraid all the time. We can help.
9. Please help us so this does not happen to anyone else. 
10. You can decide what is best for you, but let me provide you with a number to call for help 24-hours a day. You do not even have to tell them your name if you do not want to. They are there to help you anytime, day or night. The National Human Trafficking Resource Center hotline number is 1.888.3737.888. 

Do not make false promises. Only offer what you can 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. 

Creating an Opportunity for Intervention

The trafficker may be an accompanying family member or friend that declines to leave the patient alone. Similar to intimate partner violence, it can be useful to create an opportunity for privacy by taking the patient to the bathroom or radiology, informing the family member that they cannot go with the patient. In addition, it may be useful to notify the 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 or girlfriends, 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 harm the victim if they suspect that the victim reported abuse.

While there are no validated screening tools for the evaluation of human trafficking, some are being evaluated.[17] For adult patients, establishing a good rapport and using motivational interviewing to determine the victim's readiness to leave are valid first steps in their care.[18] Trafficking victims are more likely to discuss their situation with a health care provider than they are with the police.[17] A provider may find that they have identified a victim of human trafficking who is not ready to leave their situation. With motivational interviewing, it is also important to assess the patient's stage of change. The stages of change are pre-contemplation, contemplation, preparation, action, maintenance, and termination.[19] It is important to offer the patient services and remind them of continuous availability if their desire to exit changes.[16]

Motivational interviewing

O: Use open-ended questions to allow patients to give more information such as their feelings instead of just "yes" or "no."

A: Provide the patient with affirmations such as statements of understanding and emphasize that being a victim is not their fault.

R: Reflections on what the patient has said to allow them to continue personal exploration.

S: Summarize what the patient has said.[18]

When determining if an adult patient is a victim of human trafficking, it is important to identify components of the A-M-P model. However, for victims of sex trafficking who are minors, means of exploitation do not need to be determined and should immediately be reported per organizational policy.

Safety

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 contacting law enforcement if the patient consents. For example, 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. Use a trained social worker, if available. Involve security or law enforcement, if needed. Follow preset policies and procedures regarding abuse and neglect at your institution and according to local and state statutes. 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. 

Reporting

If a patient reveals they are victims 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 card that can be hidden in their shoe or other discrete location. 

The National Human Trafficking and Resource Center hotline 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. The NHTRC provides training information and technical support on its website. The NHTRC can guide a provider in an assessment of a potential victim. 

• Report Online or Access Resources & Referrals: www.traffickingresourcecenter.org
• Call: 1-888-373-7888 (24/7) Email: nhtrc@polarisproject.org

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. This must be considered. The decision to alert law enforcement should be based on predetermined protocols, local and state laws coupled with patient wishes. For example, some states mandate reporting if serious bodily injury or a firearm is involved. 

The patient's right to privacy must be considered when reporting possible trafficking. 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. Examples of mandated disclosure of protected healthcare information include child abuse or neglect, elder abuse or neglect, and in cases, reports to the medical examiner. Reporting is permissible under HIPAA regulations if the disclosure involves a crime, is an emergency, if the disclosure is necessary to prevent harm to the patient if the patient consents to the disclosure and any situation where local, state, or federal law requires reporting. In general, follow institutional guidelines and policies in place for HIPAA reporting requirements.[1]

Treatment / Management

Trauma-informed care is central to the treatment of human trafficking victims.[20] Trauma-informed care aims to realize the impact of trauma on patients, recognize the signs and symptoms of trauma, avoid retraumatizing the patient, and improve the systemic response to this trauma. In the best case, the provider recognizes the signs of trafficking, provides the patient with appropriate resources, reports events as required by law, and ensures the victim's safety.[21] Victims of trafficking may have complex social and health-related needs. Established protocols and organizational policies can help interprofessional teams address these needs.[22] In a study of interprofessional clinics that work exclusively with human trafficking victims, it was recognized that mental health services are often needed.[23]

Management of human trafficking in Texas is centered on the prevention, recognition, and reporting of human trafficking.

• The 24-hour hotline to report suspicious activity is 1-888-3737-888 or text the words "help" or "info" to 233733.
• Call law enforcement through the non-emergency number and request to speak with someone who works with cases of human trafficking.
• Call the Texas Department of Public Safety to request a victim advocate.
• If a minor is involved, call child protective services at 1-800-252-5400.
• The Human Trafficking and Transnational/Organized Crime Section can be contacted at 512-463-1646 or by email at humantrafficking@oag.texas.gov.

Mandatory reporting in Texas

In Texas, reporting suspected abuse or neglect cases for children, the elderly, and adults with disabilities is mandatory. While this is not specific to human trafficking, mandatory reporting could be necessary for many victims of human trafficking. For many adults who have been trafficked, reporting is not mandatory. In these cases, motivational interviewing can be used to assess readiness to exit trafficking and gain consent for reporting. This is similar to mandatory reporting laws in other states. Other mandatory reporting laws in Texas include threats of violence and gunshot wounds.

Trafficking Health Implications

Labor and sex trafficking carry inherent health risks that need exploration. Research studies in South Africa and West Bengal, India determined that women and girls who experienced forced sexual encounters through being trafficked were 50% more likely to acquire HIV. In younger patients, 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. Vulnerability and inexperience may lead to HIV and other sexually transmitted infections due to inadequate condom use and exposure to many people throughout the trafficking lifespan. 

Sex Trafficking Health Implications

All patients who may have been trafficked should be screened for injury and sexually transmitted infections (STI). If a recent forced sexual encounter has occurred, emergency contraception and STI prophylaxis should be provided. The patient can also be offered birth control treatment. Concealable birth control such as intrauterine and implantable devices are particularly appealing in this situation. These are highly effective, long-term solutions that can be hidden from the trafficker.

When a recent sexual assault has occurred, 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. Psychological pain from daily forced sexual encounters and trauma may need psychological resources. Specific to sexual trafficking, complications of forced tampon use may be seen. Packing of the vagina by traffickers to facilitate sexual encounters (unnoticeable to customers) while victims are menstruating may be of concern. Foreign objects may be present in the vagina on pelvic examination. The patient with a lost tampon may be a victim of trafficking.

Labor Trafficking Health Implications

Labor trafficking victims may experience dehydration or malnutrition due to being forced to work long hours in construction, on farms, at factories, or in "sweatshops." In addition, 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 may cause a variety of infectious diseases.

Communicable or infectious diseases such as tuberculosis, HIV, and typhoid may occur. 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."[1]

Referral Considerations

Long-term psychological impacts necessitate referrals for treatment of psychological trauma. 

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.[24]

Transitioning from Victim to Survivor - Potential Referrals

• Dietician consults in cases of severe malnutrition.
• Infectious disease consults for communicable diseases and sexually transmitted infections.
• Referral to obstetrics/gynecology for infertility concerns related to forced abortions, repeated trauma, or frequent miscarriages or medical problems such as prenatal concerns, addiction issues, torch infections originating from lack of preventative care, or poor access to care may need investigation. In addition, hormone replacement therapy concerns must be met for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) victims.
• Surgical or dermatology referrals for removal of unwanted tattoos or brands or to treat burns and other injuries.
• Consultations with gastroenterologists for stress-related issues.
• Children often suffer developmental delays and need assistance with transitioning into a healthy life. 
• Social stigma implications of forced homosexuality can play a role in future psychological care. Crisis intervention teams and case managers will have a role in successful integration practices.
• Perpetrators often use substance abuse to control victims, or victims use it as a form of escape from the abusive environment. As a result, addiction and sobriety treatment may be needed. Community-based organizations, support groups, and faith-based programs may ease this transition period and lessen the impact of psychological stressors.
• Legal services referrals are made for child custody issues, immigration assistance, protective/restraining orders, assistance with any offenses, and the successful prosecution of the trafficking entity. 

Survivor's Role

Cultural 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 for 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. Issues identified in this study include victims feeling intimidated, judged, and stereotyped. The study suggested that providers and front-line personnel pay attention to these patients' body language and nonverbal cues. The initial interaction, if negative, can prevent a victim from feeling safe enough to disclose their abuse. The victims in this study emphasized an approach that was not an interrogation but straightforward, direct questions asked in a compassionate, nonjudgmental way that reinforced a feeling of safety and confidentiality. 

Further research is needed in the use of trafficking survivors to aid current victims, but survivors can assist in the education of healthcare providers."[1]

Differential Diagnosis

Because human trafficking is not a medical disease, the traditional use of differential diagnosis does not apply. Instead, human trafficking should be in the differential as a cause of certain diseases or conditions. Human tracking is one type of abuse. It should be considered along with child abuse, intimate partner abuse, elder abuse, and vulnerable-populations abuse.

Trafficking often co-exists with physical and mental abuse. Human trafficking can be a cause of psychiatric disease and may also co-exist with pre-existing psychiatric disease. Trafficking should be considered as a cause of trauma and sexual assault. It also may cause certain medical conditions such as STI, dehydration, rhabdomyolysis, and heat illnesses.

Prognosis

Human trafficking is a traumatic experience, and trauma can lead to worsened quality of life.[25] Women are found to be at higher risk of PTSD following trauma. Both men and women report lower quality of life when experiencing PTSD.[26] Utilizing trauma-informed care may promote better health, compliance, and outcomes.[27] There are few studies regarding the specific outcomes of trafficked persons. Further research is needed in this area.

Complications

Victims of human trafficking are at higher risk for traumatic injuries, mental illness, substance use disorders, unwanted and high-risk pregnancies, and suicidality.[23] Common comorbid conditions, including mental illness and substance use disorders, it was found that cognitive therapies were preferred in human trafficking victims. However, further research is necessary to validate these recommendations.[28]

Common health issues seen in human trafficking victims include:

• Sexually transmitted infections
• Pelvic pain and genital trauma
• Infertility
• Chronic back pain
• Chronic cardiac and respiratory issues from unsafe work environments
• Eye issues from working in dimly lit settings
• Tuberculosis
• Traumatic injuries from beatings
• Substance abuse disorders
• Mental health issues from psychological trauma
• Feelings of shame and helplessness[29]

Concerns of victims after human trafficking include the following:[30]

• Issues with money
• Shame
• Physical health
• Mental health