Human Trafficking Prevention and Awareness

Editor’s note: This text-based course is an edited transcript of the webinar, Human Trafficking Prevention and Awareness, presented by Angela Hernandez-Harris, MA, LCPC. 

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

• Define human trafficking
• Recognize key indicators of human trafficking
• Identify myths and misconceptions about human trafficking

What Is Human Trafficking?

When You Think of Trafficking, What Comes to Your Mind?

Have you ever contemplated the harrowing realities of sex trafficking, the insidious nature of forced labor, the grim existence of domestic servitude, and the astounding profitability of these criminal enterprises? If these are indeed the notions that crossed your mind, you would be absolutely correct.

Human Trafficking Defined

The US Department of Justice (USDOJ) in 2023 defines human trafficking, also referred to as trafficking in persons, as a criminal activity involving the compelling or coercing of individuals to provide labor or services, or to engage in commercial sex acts. This coercion can manifest in subtle or overt forms, whether physical or psychological in nature. Alarmingly, millions of people are subjected to trafficking each year.

This course serves to elucidate the concept of human trafficking, exploring its various manifestations and shedding light on the indicators healthcare professionals should be vigilant for. Furthermore, it equips learners with the necessary tools for identifying and reporting suspected victims of human trafficking.

It is crucial to emphasize that the exploitation of a minor for commercial sexual purposes constitutes human trafficking, irrespective of whether force, fraud, or coercion were involved. Human trafficking is an omnipresent issue, even within the United States, with victims hailing from diverse backgrounds - US citizens or individuals of any nationality, age, socioeconomic status, or gender. In essence, it amounts to contemporary slavery, the exploitation of individuals through force, fraud, or coercion, encompassing any person under the age of 18 engaged in commercial sex activities. Thus, sex trafficking, forced labor, and domestic servitude all fall under the umbrella of human trafficking.

Statistics

Human trafficking is a pervasive global issue with far-reaching implications, impacting millions of individuals across the world. According to data from the International Labor Organization, a staggering 24.9 million people are estimated to have fallen victim to human trafficking on a global scale.

Disturbingly, children constitute a significant portion of these victims, as highlighted by the United Nations Office on Drugs and Crime, which reports that almost 20% of all trafficking victims are minors. Furthermore, the incidence of identified victims has exhibited an alarming upward trajectory in recent years. For instance, in 2018, the Office for National Drug Control Policy identified approximately 49,000 victims across the globe. Over an eleven-year period spanning from 2008 to 2019, the number of human trafficking victims recognized worldwide more than quadrupled, surging from around 30,000 to nearly 120,000.

Different Types of Trafficking

Human trafficking encompasses various forms. Let's define them, and provide examples of sex trafficking, forced labor, and domestic servitude.

Sex Trafficking

Sex trafficking victims find themselves manipulated or coerced into engaging in sexual acts for financial gain. Sex traffickers employ a range of tactics, including violence, threats, manipulation, and the false promise of affection, to ensnare their victims. The grim reality is that these victims can be found in a multitude of locations, including truck stops, hotel rooms, rest areas, street corners, clubs, and private residences - just a few of the places where they are compelled to sell sex.

Sex trafficking constitutes a subset of human trafficking and stands as a contemporary form of slavery, casting a dark shadow on public health. In 2016, the International Labor Organization estimated that a staggering 4.8 million individuals experienced sex trafficking and commercial sexual exploitation worldwide. Among these victims, 3.8 million were adults, and 1 million were children. Alarmingly, women and girls accounted for a staggering 99% of these victims. Understanding the true nature of this problem is essential, as it underpins our ability to formulate enduring solutions to combat trafficking.

The aforementioned estimate plays a pivotal role in assessing the global prevalence of trafficking, thereby enabling us to employ targeted measures encompassing prevention, protection, and prosecution. In the United States alone, it is estimated that between 18,000 and 20,000 individuals fall victim to trafficking annually. However, the U.S. State Department's estimate suggests that the actual number of women and girls affected falls within a wide range of 15,000 to 50,000. it is crucial to note that these figures solely reflect reported cases, thus failing to capture the full extent of human trafficking.

Forced Labor

Forced labor victims can be found across various settings, including factories, farms, and construction sites, where they are often coerced into manufacturing or cultivating products that we rely on daily. These victims endure this grueling reality through the application of force, fraud, or coercion, all while receiving minimal or no compensation. Forced labor is defined as any form of work or service extracted from an individual under the threat of penalties, without their voluntary consent.

Forced labor, in essence, encompasses work performed involuntarily, carried out under the looming threat of penalties. It encompasses situations where individuals are coerced into work through a spectrum of means, ranging from overt violence and intimidation to subtler tactics such as the manipulation of debt, confiscation of identity papers, or threats of denunciation. The International Labor Organization's 2016 findings underscore the staggering scale of labor trafficking, with an estimated 20.1 million victims globally. This category encompasses anyone who has been compelled to work or provide services under the constant specter of penalties or harm. In many instances, this takes the form of forced labor in factories, on farms, or in domestic roles, as previously described. Of these victims, 9.2 million were men, 10.9 million were women, and 3.3 million were children.

Several avenues exist for aiding victims of forced labor, including:

• Strengthening legislation: Bolstering legal frameworks to combat forced labor effectively.
• Promoting fair labor recruitment: Ensuring ethical labor practices are upheld in recruitment.
• Supporting the empowerment of at-risk individuals: Equipping vulnerable populations with the tools to resist exploitation.
• Addressing root causes: Tackling the underlying factors that make individuals susceptible to forced labor.
• Enforcing labor and relevant legislation effectively: Ensuring that existing laws are enforced rigorously.
• Enhancing education and outreach efforts: Spreading awareness and knowledge, as we are doing today, particularly targeting at-risk groups.

Domestic Servitude

Now, turning our attention to domestic servitude: Victims of this form of exploitation are often hidden in plain sight, compelled to toil within homes across the United States. They effectively become prisoners working in roles such as nannies, maids, or domestic help. Traffickers frequently confiscate their victims' identification documents and travel papers to restrict their freedom. Domestic servitude represents a subset of forced labor, where the trafficker compels the victim to perform work within a private residence. Such circumstances create distinct vulnerabilities.

Domestic workers typically find themselves in isolation, often working alone within a household. Their employers exercise significant control over essentials like access to food, transportation, and housing. Indicators of domestic servitude may include:

• Living and working within a private family home.
• Eating separately from the rest of the family.
• Lack of proper sleeping accommodations.
• Absence of time off.
• Minimal or nonexistent compensation.
• Incidents of physical abuse or threats.

Crucially, domestic servitude knows no boundaries, transcending age, race, ethnicity, gender, or socioeconomic status, as evidenced by the shared statistics.

Case Study: Sex Trafficking, Forced Labor, or Domestic Servitude (Or All Three)?

Luiza, originally from Uzbekistan, left her young son with family and traveled to Kyrgyzstan in search of work. Without a Kyrgyz ID or university degree, the 22-year-old single mother struggled to find employment in Osh, Kyrgyzstan until she heard about a waitressing opportunity in Bishkek. Eager for the prospect of a job, Luiza made the fateful decision to pursue this lead. But it was a trap. In Bishkek, she was sold into slavery and trafficked to Dubai against her will. For 18 agonizing months, Luiza was subjected to unspeakable abuse. Eventually arrested, she was thrown in jail before being able to return home.

Today, Luiza Karimova works with Podruga, an organization in Osh, Kyrgyzstan supported by UN Women that assists women subjected to sex trafficking, forced labor, domestic servitude, and other forms of violence. This is her story. As you hear Luiza bravely recount her harrowing experience, consider: was this sex trafficking, forced labor, domestic servitude, or all three?

I was a 22-year-old single mother, desperate for work when I left my son with family and traveled to Osh to find work. When I arrived in Bishkek, things were not as they seemed. We were held in an apartment while our passports were taken away. They claimed we'd be re-photographed for new waitressing documents. It felt strange, but we believed them.

We boarded the plane passport-less, told the pilot would return them. But the documents he brought were fakes. We were taken to a crowded apartment in Dubai, met by women who said coldly, "Fresh arrivals - we'll work much less now." We were to be sex slaves, doing whatever clients demanded.

The next day, I was sent to a nightclub with a $10,000 monthly quota. For 18 agonizing months, this was my life - imprisoned, exploited, abused. One night, I walked out and let the approaching police catch me. Deported with my fake ID, I spent a year in jail in Osh. Though ashamed, I returned to sex work when released.

Podruga's outreach found me in a sauna. Wary, I began trusting them and joined their work. My husband knows my past fully yet says, "Go forward, not back. We are a family now."

I visit saunas, distributing condoms, offering health information, legal aid, and support. Girls share dreams of Turkey and Dubai. I urge them - do not go. I detail my trafficking, emphasizing how we earned nothing, only buying cigarettes from tips. The pimps took it all, often burning us.

My mission is keeping the girls safe, getting checkups if needed. Preventing trafficking requires informing about its realities from a young age, providing legal help and mental health support for returnees. Luiza's powerful story highlights the need for awareness, victim assistance, and policy change.

Key Indicators: How to Identify a Victim

When considering Luiza's story, take note of the crucial indicators for identifying a victim. According to research conducted by the US Department of Justice in 2023, there is no one-size-fits-all profile for a trafficking victim. Human trafficking victims can emerge from any demographic, irrespective of their race, color, national origin, disability, religion, age, gender, sexual orientation, gender identity, socioeconomic status, education level, or citizenship status. As is often the situation in many cases of exploitation and abuse, human traffickers frequently target individuals within marginalized communities and exploit other vulnerable adults.

Vulnerable Individuals

Consider the demographics your organization serves. Where is your operational scope? Who constitutes the most vulnerable groups? What policies has your company established regarding advocacy and reporting?

Here is a list of some particularly vulnerable groups:

• Migrant Laborers
• Individuals with Disabilities
• Persons Struggling with Substance Use Disorders
• Individuals without Lawful Immigration Status in the United States
• Black People and Other Communities of Color
• American Indians, Alaska Natives, Native Hawaiians, Pacific Islanders, and Indigenous Peoples of North America
• Children within the Child Welfare System, or those who have crossed paths with the Juvenile Justice System, Runaway and Homeless Youth, and Unaccompanied Minors
• LGBTQ+ Population, Encompassing Lesbian, Gay, Bisexual, Transgender, and Intersex Individuals

Your organization's approach to serving these diverse groups should align with your policies on advocacy and reporting. According to the Department of Health Services, each year in the United States, thousands of human trafficking cases are reported, but many more remain hidden from view.

Human trafficking is a covert crime. Victims often live in fear of coming forward, and we may fail to recognize the signs, even when it unfolds before our eyes. It is imperative that we shed light on this hidden atrocity. Two decades ago, at the inception of the anti-trafficking movement, law enforcement and advocates primarily focused on enslaved irregular immigrants. Gradually, it became apparent that the same types of trafficking suffered by foreign nationals also afflicted citizens, albeit under different names like child prostitution or labor violations. Law enforcement then shifted its attention to domestic human trafficking and responded accordingly. Nevertheless, anti-trafficking advocates still encounter challenges in educating policymakers, police, prosecutors, judges, social welfare agencies, and communities to identify human trafficking in all its guises.

Exploitation takes numerous forms, constantly evolving. It could be a child begging on a street corner, a woman trapped in domestic servitude, a young girl coerced into pornography, a foster child engaged in survival sex on the streets, a restaurant busboy, a nail salon worker, a door-to-door salesman, a legal visa holder advertised as an online escort, or an irregular migrant unwittingly coerced into trafficking. The central element of human trafficking is the exploitation itself, transcending considerations of origin or movement. Our commitment to focusing primarily on exploitation is the cornerstone of our efforts to identify and aid more trafficking victims in becoming survivors, a mission we share with the United States and the Organization for Security and Cooperation.

Exploitation and How to Protect Yourself

Let's look into the topic of exploitation and discuss how to safeguard oneself, as well as how to educate children, nieces, nephews, and others in our lives. By understanding what exploitation entails and how it initiates, we can equip ourselves with the tools to say no and protect both ourselves and those around us.

Exploitation, in a general sense, involves treating a person unfairly in order to gain an advantage from their labor or actions. This can encompass various tactics, including the use of threats, manipulation, or physical force to compel someone to engage in activities they do not wish to participate in, all for the benefit of another individual. Exploitation takes on many forms, such as an employer coercing an employee into working for minimal or no compensation, or it can manifest as a romantic partner using threats of harm unless their partner engages in sexual acts in exchange for money, drugs, or shelter.

False Job Promises

You may encounter false job promises in various forms, and it is essential to remain cautious. If an offer sounds too good to be true, it probably is. Be especially alert when considering job offers in industries that are traditionally challenging to enter, such as modeling, acting, or positions in remote locations, far-off states, or foreign cities. Dangerous individuals may attempt to draw victims into isolation, separating them from their friends and family.

Indicators of a false job promise include discrepancies between the offered payment and the job description, such as an unusually high hourly salary for a typically low-paying position. Be cautious if the employer does not request any information about your prior work experience or if they ask for a photo of you as part of the application process. Additionally, be wary of employers who ask many personal questions that are irrelevant to the potential job. Other red flags include employers requesting a substantial fee to cover uniform or other expenses, asking you to keep the job a secret or lie about your age, and making false promises of love.

Individuals seeking to exploit others often use emotional, mental, and financial manipulation to establish trust and dependence. Indicators of potentially exploitative relationships may include a partner who insists on knowing your whereabouts at all times, requires permission for you to leave the home or socialize with others, limits your communication with friends and family, threatens harm to you or your loved ones if you do not comply with their demands, or withholds your identification cards, personal documents, or money.

Furthermore, be cautious if your partner makes you feel unsafe, provides financial support that obligates you to ask for money when needed, forces you to work in a job where you do not receive your own paycheck, or coerces you into engaging in sex acts for money or other items of value, such as drugs.

Myths and Misconceptions

Let's address some common myths about human trafficking and explore why misconceptions persist, along with the realities of this pervasive issue.

Myth: Human trafficking does not happen in the US. It is only a problem in other countries.

Reality: Human trafficking occurs in every country, including the United States, with cases reported nationwide in cities, suburbs, and rural areas, possibly even within your own community. While the visibility and reporting of human trafficking may vary from state to state, it is a significant issue in the US. In some cases, human trafficking may not be as readily apparent or prosecuted at the federal level, but it can still be prosecuted at the state level or go undetected.

For example, in Idaho, although there were zero new criminal human trafficking cases filed in federal courts in 2021, this does not indicate that human trafficking is absent in the state. There were eight human trafficking cases reported in Idaho in 2018, and the National Human Trafficking Hotline received 109 trafficking-related calls in 2021. These statistics reveal the complexity of the issue and the need for awareness and resources.

Idaho faces unique vulnerabilities to human trafficking due to its rural nature, proximity to major highways and borders, a significant agricultural sector, and a lack of awareness and resources. However, various organizations and initiatives are actively working to prevent and combat human trafficking in Idaho.

As you consider your role in combating trafficking in your city or state, it is essential to research and connect with local agencies and organizations dedicated to this cause. These entities play a crucial role in raising awareness, providing support to victims, and advocating for stronger legislation and enforcement. Collaborative efforts can make a significant impact in addressing and ultimately eradicating human trafficking in your community. Below are some of the barriers and risk factors that can make a state vulnerable to human trafficking. 

• Barriers and Risk Factors for Human Trafficking:
  • Rural Nature: Rural areas can be more challenging to monitor and may lack resources and awareness to combat trafficking effectively.
  • Proximity to Highways and Borders: States located near major highways and international borders may be susceptible to human trafficking due to increased movement of people and goods.
  • Agricultural Sector: States with a significant agricultural industry may attract labor trafficking, with workers vulnerable to exploitation.
  • Lack of Awareness and Resources: A lack of awareness about human trafficking and limited resources for victim support can hinder prevention and intervention efforts.

Myth: Human trafficking victims are only foreign-born and poor.

Reality: Human trafficking victims can come from any age, race, gender, or nationality and may belong to any socioeconomic group. Socioeconomic status is determined by factors like education, income, and occupation.

Myth: Human trafficking is exclusively sex trafficking.

Reality: While sex trafficking is a form of human trafficking, it is not the only type. Forced labor is another significant form of human trafficking. Victims can be found in various industries, both legitimate and illegitimate, including sweatshops, massage parlors, agriculture, restaurants, hotels, and domestic service. The common factor is the exploitation of individuals for profit.

Myth: Victims must be forced or coerced into commercial sex acts to be considered trafficking victims.

Reality: Under US federal law, any minor under the age of 18 who is induced to perform commercial sex acts is considered a victim of human trafficking, regardless of whether they were forced or coerced. The focus is on their age and the inducement to engage in commercial sex acts, recognizing their vulnerability and the need for protection.

Understanding these barriers, risk factors, and dispelling common myths is essential in effectively combating human trafficking and ensuring that victims receive the support and protection they need. It also helps promote a more comprehensive understanding of the different forms and facets of this issue. Regardless of whether or not they were forced or coerced, this is really important for our children to understand, people we know that are minors. 

Myth: Human trafficking and human smuggling are the same.

Reality: Human trafficking and human smuggling are distinct concepts. Human trafficking revolves around exploitation and does not necessarily involve crossing borders. It encompasses various forms of exploitation, such as forced labor or commercial sexual exploitation, and can occur within a single country.

Human smuggling, on the other hand, involves the illegal movement of a person across a country's border with their consent, typically in violation of immigration laws. This often occurs when individuals seek a better life in another country and willingly pay a smuggler, often referred to as a "coyote," to facilitate their journey.

However, an essential point to understand is that human smuggling can evolve into human trafficking if the smuggler resorts to force, fraud, or coercion to hold people against their will for the purposes of labor or sexual exploitation. In such cases, what initially began as a consensual act (smuggling) transitions into a criminal act of exploitation (trafficking). This highlights the importance of recognizing the distinction between the two while acknowledging the potential for overlap in certain situations.

Under federal law, any minor induced into engaging in commercial sex is deemed a victim of human trafficking. Human smuggling, on the other hand, is defined by the Department of Homeland Security as the deliberate evasion of immigration laws through the importation of individuals into the United States. This involves the transportation of people across national borders and the unlawful harboring of those who are already within the United States, a key point being the intentional evasion of immigration laws.

In contrast, while transportation does feature prominently in many human trafficking cases, the fundamental characteristic of human trafficking does not hinge on movement. Rather, it centers on commercial exploitation, bearing a resemblance to slavery. Irregular migrants, owing to their undocumented status, are especially susceptible to human trafficking, both during their journey and upon arrival in their destination country.

Certain smuggling networks share common ground with trafficking networks, occasionally serving as conduits for irregular migrants delivered into the hands of traffickers. In instances where migrants voluntarily seek entry into a country outside established channels, they may find themselves burdened with substantial debts imposed by smugglers. Tragically, these debts can become chains, coercing individuals into debt bondage—a distinct form of human trafficking.

Myth: Human trafficking victims will attempt to seek help when they are in public

Reality: However, the reality is that human trafficking is often a concealed crime, shrouded in secrecy. Victims are frequently too terrified to come forward and seek assistance. They may endure coercion or force, subjected to threats and violence that instill paralyzing fear. The specter of retribution from their traffickers, including potential harm to their families, looms large, further inhibiting any inclination to seek help. Additionally, victims may lack possession or control over their identification documents, as exemplified in the story of Luiza, adding yet another layer of constraint to their ability to reach out for aid.

Identify Warning Signs in Health Care

Let's identify warning signs and indicators of human trafficking in the healthcare field, and what healthcare providers can do if they suspect they have encountered a trafficking victim. This is crucial for raising awareness and facilitating appropriate responses.

Warning Signs and Indicators:

• Injuries and Physical Signs: Unexplained injuries, signs of physical abuse, or evidence of neglect can be indicators.
• Controlled Communication: A patient who seems to be closely monitored or controlled by another person, especially if they refuse to speak without that person present.
• Inconsistencies in Story: Inconsistencies between the patient's explanation of their situation and their physical condition or appearance.
• Signs of Fear or Anxiety: Patients who display extreme fear, anxiety, or depression, particularly when discussing their living conditions or the people they are with.
• Restricted Movement: A patient who cannot move freely, such as having limited access to their identification or personal belongings.
• Lack of Documentation: Patients without identification, passport, or personal documents, which may be held by their traffickers.

Assessing for Human Trafficking:

• Ask Indirect Questions: Use open-ended questions to create an environment where the patient feels safe disclosing potential exploitation.
• Be Non-Judgmental: Ensure the patient knows you are there to help, not judge, and that their well-being is your priority.
• Document Everything: Accurate documentation of physical findings, statements made by the patient, and any red flags is essential for potential legal actions.

What to Do if You Suspect a Victim:

• Do Not Confront Traffickers: Avoid confronting the suspected traffickers, as it may endanger both the victim and healthcare staff.
• Notify the Appropriate Authorities: Follow your facility's policies for reporting, which may involve contacting local law enforcement or reporting to a designated agency or hotline.
• Offer Support: Provide information on support services and resources available to trafficking victims.
• Maintain Confidentiality: Respect the patient's privacy and confidentiality while adhering to mandatory reporting requirements.

Resources for Reporting:

• National Human Trafficking Hotline: Call 1-888-373-7888 or text "HELP" or "INFO" to 233733.
• Local Law Enforcement: Contact your local police department or law enforcement agency to report suspected cases.
• Your Healthcare Facility: Inform your facility's designated personnel or follow internal reporting protocols.

Identifying and responding to potential human trafficking cases in the healthcare field is essential for assisting victims and preventing further exploitation. Healthcare providers play a critical role in identifying these red flags and connecting victims to the help they need.

National Human Resource Center Provides Resources on:

Common red flags and indicators for human trafficking are provided by the National Human Resource Center. These signs are vital for healthcare providers to be aware of when assessing patients who may be victims of trafficking:

• Identifying red flags and indicators for human trafficking
• How to access for human trafficking
• What to do if you are a health care provider and believe you have identified a victim of human trafficking
• Resources for reporting suspected victims of human trafficking

Red Flags and Indicators for Human Trafficking:

Please bear in mind that this list is not exhaustive, and each indicator on its own may not definitively indicate a trafficking situation. Furthermore, not all victims of human trafficking will display these signs. However, recognizing several of these indicators in a patient's situation may signal the need for referrals and further assistance. It is essential to approach these situations with sensitivity and care.

• Injuries and Physical Signs: Unexplained injuries, evidence of physical abuse, or signs of neglect.
• Controlled Communication: The patient appears to be closely monitored or controlled by someone else, and they may not speak without that person present.
• Inconsistencies in Story: Discrepancies between the patient's explanation of their situation and their physical condition or appearance.
• Signs of Fear or Anxiety: The patient displays extreme fear, anxiety, depression, or nervousness, particularly when discussing their living conditions or the people they are with.
• Restricted Movement: The patient has limited freedom of movement, such as not being allowed to leave the examination room or having limited access to their identification or personal belongings.
• Lack of Documentation: The patient lacks identification, passport, or personal documents, which may be withheld by their traffickers.
• Multiple Sex Partners: If the patient presents with signs of sexually transmitted infections (STIs) and is unable to provide a reasonable explanation for multiple sex partners.
• Tattoos or Branding: Tattoos or branding marks, often used by traffickers as a form of control or identification.
• Controlled Finances: The patient has limited control over their finances, and their earnings may be controlled or taken by someone else.
• Inability to Speak Freely: The patient seems unable to speak freely or make independent decisions.

These indicators are critical for healthcare providers to be aware of when evaluating patients, as they can help identify potential trafficking situations. However, it is essential to handle these situations with care, respecting the patient's privacy and dignity, and following appropriate reporting and referral protocols. Additional red flags and indicators for human trafficking may encompass a range of behaviors and circumstances that healthcare providers should be attentive to. Here are some more indicators to consider:

• Scripted or Inconsistent History: The victim's narrative appears scripted, rehearsed, or inconsistent, especially when explaining their injury or illness.
• Unwilling or Hesitant to Answer Questions: The victim is unwilling or hesitant to respond to questions about their injury or illness, potentially due to fear or coercion.
• Accompanied by a Dominating Individual: The victim is accompanied by someone who does not allow them to speak independently, refuses to grant the patient privacy, or insists on interpreting for them.
• Evidence of Controlling Relationships: There are signs of a controlling or dominating relationship, such as the victim expressing excessive concerns about pleasing a family member, romantic partner, or employer.
• Fearful or Nervous Behavior: The victim exhibits fearful or nervous behavior, potentially avoiding eye contact or appearing agitated.
• Resistance to Assistance or Hostile Behavior: The victim is resistant to receiving assistance, demonstrates hostile behavior, or appears confrontational.
• Lack of Awareness: The victim is unable to provide their address, is unaware of their current location, date, or time.
• Absence of Identification Documents: The victim is not in possession of their identification documents, which may be withheld by traffickers.
• Financial Control: The victim does not have control over their own money, and their wages may be withheld or controlled by someone else.

These indicators collectively form a comprehensive set of cues that healthcare providers should be prepared to recognize when assessing patients. However, it is important to remember that not all victims will exhibit all these signs, and context matters. Handling such situations with sensitivity and following proper reporting procedures is crucial to ensuring the well-being of potential trafficking victims.

Labor Trafficking Indicators

Certain indicators of labor trafficking may include instances of workplace abuse or threats of harm by an employer or supervisor. Victims may be denied sufficient breaks, access to food, or the opportunity to drink water during their work hours. In addition, they might lack the necessary personal protective equipment for hazardous tasks. Some individuals may have been initially recruited for one type of work but are now engaged in a different role, as exemplified by Luiza's case. Originally, she anticipated working as a waitress, which did not materialize. Furthermore, victims may be compelled to reside in employer-provided housing or find themselves burdened by insurmountable debts owed to employers or recruiters, creating a state of financial entrapment.

Sex Trafficking Indicators

• Age Under 18: One significant indicator of potential sex trafficking is the patient's age, particularly if they are under 18 and involved in the commercial sex industry, irrespective of coercion.
• Tattoos or Branding: Look for tattoos or other forms of branding, such as those bearing phrases like "Daddy," "Property of...," "For sale," or similar markings.
• Unusual Number of Sexual Partners: Another red flag is when the patient reports an exceptionally high number of sexual partners, which may point to their involvement in commercial sexual exploitation.
• Inappropriate Attire: Pay attention to whether the patient's clothing is inappropriate for the weather or the setting, as this can be a sign of their involvement in sex trafficking.
• Use of Industry Terminology: Be mindful of the patient's language, as they may use terminology common in the commercial sex industry, including slang or specific jargon.

These indicators are critical for healthcare providers to recognize when assessing patients who may be victims of sex trafficking. Identifying these signs can help initiate appropriate interventions, connect victims with support services, and ensure their safety and well-being. It is essential to handle these situations with care, particularly when dealing with underage victims.

Health Indicators of Human Trafficking

Here's another list of indicators of human trafficking (NHRC, 2023). This is broken down by physical health, mental health and social developmenta

Physical Health:

• Physical Signs of Abuse: Look for signs of physical abuse or unexplained injuries, such as bruising or evidence of torture.
• Neurological Conditions: Be aware of neurological conditions, including traumatic brain injuries (TBI) and difficulties with concentration.
• Cardiovascular Strain: Observe cardiovascular conditions that appear to worsen due to stress, such as arrhythmia or high blood pressure.
• Gastrointestinal Distress: Note gastrointestinal issues that worsen under stress, like irritable bowel syndrome (IBS) or constipation.
• Dietary Health Problems: Pay attention to dietary health issues, including malnourishment and unexplained weight loss.
• Reproductive Concerns: Investigate reproductive issues such as sexually transmitted infections (STIs) and genital trauma.
• Substance Abuse: Be vigilant for signs of substance abuse.

Additionally, there may be other health-related signs not included in this list that could be relevant. When encountering patients with potential indicators of trafficking-related trauma, it is crucial to consider these signs in the broader context of the patient's condition and experiences. Here are some additional examples of indicators within the physical health category. Look for worsening GI issues like IBS or constipation, malnutrition, sudden weight loss, reproductive problems including STIs or genital trauma, and substance abuse.

• Gastrointestinal Issues: Patients may exhibit gastrointestinal problems, such as irritable bowel syndrome (IBS) or chronic constipation, often exacerbated by the stress of their situation.
• Dietary Health: Look for signs of malnourishment or unexplained weight loss, which can result from inadequate nutrition.
• Reproductive Health: Investigate potential reproductive health concerns, including sexually transmitted infections (STIs) and genital trauma, especially among those involved in sex trafficking.
• Substance Abuse: Be vigilant for signs of substance abuse or dependency, which can be a coping mechanism for trafficking victims

Mental Health:

• Depression: Watch for signs of depression.
• Suicidal Ideation: Be alert to indications of suicidal thoughts or intentions.
• Self-Harm: Observe signs of self-harm.
• Anxiety: Be attentive to symptoms of anxiety.
• PTSD Flashbacks: Look for flashbacks associated with post-traumatic stress disorder (PTSD).
• Shame/Guilt: Be aware of feelings of shame or guilt.
• Hyper-Vigilance: Observe hyper-vigilance, which may indicate a constant state of alertness.
• Hostility: Note any expressions of hostility.
• Dissociation: Watch for signs of dissociation, where the individual feels disconnected from reality.
• Depersonalization: Observe signs of depersonalization, where the person feels detached from themselves.
• Attachment Disorders: Investigate signs of attachment disorders that may affect relationships.

Mental health cues include depression, suicidal thoughts, self-harm, anxiety, PTSD, flashbacks, shame, guilt, hypervigilance, hostility, dissociation, depersonalization, and attachment issues like difficulty socializing or forming relationships. With depersonalization, they may feel detached from themselves, as if watching a movie, along with emotional/physical numbness and a sense of unfamiliarity with surroundings. Dissociation could involve memory loss, detachment from self, lack of identity, alternate identities, and distorted perceptions.

Social/Developmental:

• High-Risk Behaviors: Identify high-risk behaviors, such as running away or early sexual initiation, particularly among minors.
• Trauma Bonding: Be aware of the phenomenon of trauma bonding, where the victim forms a strong emotional connection with their trafficker or other victims.
• Relationship Challenges: Recognize difficulties in establishing and maintaining healthy relationships.
• Developmental Delays: Investigate signs of delayed cognitive or physical development.
• Impaired Social Skills: Observe impaired social skills that may result from trafficking experiences.

Minors may exhibit running away, early sexual activity, trauma bonding, delayed development, and poor social skills. Staying alert to these red flags, asking questions sensitively, and offering support can encourage potential survivors to open up, receive assistance, and eventually heal.

These indicators can be invaluable for healthcare providers when assessing patients and potentially identifying human trafficking victims. it is essential to remember that this list is not exhaustive, and survivors of trafficking may display a range of these indicators or none at all. By remaining attentive to these indicators and approaching patients with sensitivity, healthcare providers can play a crucial role in identifying and supporting potential trafficking survivors. 

Victim Identification & Response

The resource center also addresses essential questions, such as how to conduct an assessment or examination when encountering a potential human trafficking victim, especially when you observe certain indicators.

It is crucial to bear in mind that victims of trafficking rarely disclose their situation in clinical settings. Hence, healthcare practitioners must approach patients with care, employ trauma-informed practices, and establish a conducive environment for discussing human trafficking. Before initiating any conversation with a patient, it is important to evaluate potential safety risks that may arise from asking sensitive questions. Recognize that the primary objective of your interaction is not to elicit disclosure or effect a rescue, but rather to create a safe, non-judgmental space that facilitates the identification of trafficking indicators and supports the patient.

Recommendations for Assessments

In terms of assessment recommendations, these steps are essential in creating a safe and supportive environment for potential trafficking victims.

• Allow the patient to choose whether they would prefer a male or female practitioner for their comfort.
• When interpretation is needed, always employ professional interpreters who have no personal connection to the patient or the situation.
• If the patient is accompanied by others, find a suitable time and location for a private conversation. it is essential, as we cannot be certain whether they may be coerced by those accompanying them.
• Invest time in establishing rapport with potential victims. If you lack the availability, consider delegating this task to another staff member who can build trust with the patient.
• Ensure that the patient fully comprehends confidentiality policies and practices, including mandatory reporting laws, which vary by state. Familiarize yourself with your state's regulations, as it is crucial.
• Refer to established institutional protocols for handling victims of abuse or sexual abuse.
• Whenever possible, utilize multidisciplinary resources such as social workers.
• If you haven't already developed a protocol for responding to human trafficking victims, consider reaching out to the National Human Trafficking Resource Center hotline. They can provide assistance with conducting assessments and determining the appropriate next steps. Their website also features an assessment tool.

What Should I Do If I Believe I Have Identified A Victim of Human Trafficking?

Every instance of human trafficking is distinct, and it is crucial to adopt a victim-centered approach, as previously discussed. It is essential to understand that not all trafficking victims will feel comfortable divulging their circumstances, nor will they all be prepared to seek help from service providers, law enforcement, or even medical professionals.

Medical providers hold a unique position where they can offer potential trafficking victims information and choices while providing support throughout the process of connecting with advocates or service providers, should the victims decide they are ready to report their situation.

IF a Patient Discloses That They Have Been Trafficked

If a patient discloses that they have been trafficked, you can provide them with the NHTRC hotline number and encourage them to call if they need assistance or someone to talk to. If the patient is concerned about having something with the number written on it due to safety reasons, you can suggest they memorize the number: 1-888-373-7888. This hotline is available 24/7. Alternatively, they can text HELP or INFO to BeFree at 233733.

In situations where there is an immediate, life-threatening danger, follow your institutional policies for reporting to law enforcement. Whenever possible, collaborate with the patient to make the decision to contact law enforcement. Offer the patient options for services, reporting, and resources, and ensure that safety planning is incorporated into the discharge planning process. If the patient is a minor, adhere to mandatory state reporting laws and institutional policies for child abuse or serving unaccompanied youth. While documenting instances of abuse can be valuable in building a case against a trafficker, it is essential to be aware that information about the victim could potentially be used against them in a court proceeding.

Case Study: Exam Room Encounter of Human Trafficking

Let's look into a case study featured in the Harvard Public Health magazine from the winter of 2016. Kimberly Chang shares her experience in a community healthcare center, addressing some of the barriers she encountered and her journey in advocacy. Let's hear her story.

In 2003, Kimberly Chang had just completed her medical residency when a 14-year-old girl entered her examination room at Asian Health Services in Oakland, California. The young girl smelled of marijuana, had bloodshot eyes, and displayed numerous bruises on her body.

The girl requested to be checked for sexually transmitted infections (STIs), and Chang diagnosed several STIs in the teen. With a sinking realization, she also discovered that her patient was being forced into sexual exploitation, battling addiction, and subjected to regular physical abuse. Over the next few years, Chang would encounter this harrowing scenario repeatedly among her primarily impoverished immigrant patients.

"Back then, I referred to them as child prostitutes. That was so unfair of me," Chang admits, cringing at the implicit blame in that term. "We did not have the right language, and I lacked the awareness." However, she persisted in viewing her role primarily as addressing their medical issues, until a pivotal moment when a severely ill teenage girl arrived at the clinic.

This girl had a high fever, a racing heart, and a rash covering her body. She had lost 30 pounds in just three months but adamantly refused to go to the hospital due to the fear of being arrested for her previous involvement in prostitution. Chang spent the entire evening negotiating with her. The girl was only willing to leave with her purchaser, a man who purchased unprotected sex from her three times a week for two hours. Chang attempted to convince the man to take the girl to the emergency room, but they never made it there. It took another day before Chang and her colleagues managed to locate the girl through her MySpace page and community contacts.

This time, Chang took personal responsibility for arranging someone to drive the girl to the hospital, where she spent two months recovering. "Guess what happened when she got out," Chang asked incredulously. "She was still sent to jail." Chang is driven by the conviction that human trafficking should be treated as a public health issue rather than solely a law enforcement matter. "How can we strengthen the healthcare system so that it can stand on equal footing with the criminal justice system?" she pondered. This question led her to Harvard Chan School of Public Health through the Commonwealth Fund Mongan Fellowship in Minority Health Policy. At Harvard Chan School of Public Health, Chang connected with individuals who, like her, were dedicated to serving populations often marginalized in mainstream medical practice. Her overarching goal was to elevate human trafficking into a prominent health concern. She expressed, "Harvard Chan has provided me with a platform to effect practical changes and reach more patients, not only within my healthcare center but across every healthcare center willing to tackle this issue."

Chang further explained that many of her teen patients came in heavily influenced by drugs and bearing signs of physical abuse. She learned to communicate with them directly yet compassionately to discern who was being coerced into sex and to provide care without judgment. Additionally, she took it upon herself to educate them about their rights. In cases involving adult patients working as domestic help, she clarified, "It is not acceptable for your employer to confiscate your passport and prevent you from leaving the country." As a newly minted public health professional, Chang also directs her attention upstream, focusing on addressing root causes. She believes that the initial step in combatting trafficking at its source is to view it as a public health concern. She sees this as a form of community surveillance.

She added, "We engaged in conversations with Cambodian elders about this issue, and they began to pay attention, realizing that their daughters were not merely going out for leisure but returning home with bruises." Although Chang's patients were primarily trafficked by individuals outside their families, such as pimps or boyfriends, it is not uncommon for people to exploit their own family members due to economic hardships. "Addressing the underlying poverty that drives these families to desperate measures is crucial," Chang emphasized. Equally important is persuading them to reevaluate what they may have accepted as commonplace. Whether in the examination room, schools, or community gatherings, she stressed, "We must alter the prevailing social norms and redefine what communities consider acceptable." Within the intricate world of trafficking, a victim today could potentially become a recruiter tomorrow.

Chang asserts that by helping young individuals evade involvement in the trade or exit it early, we can significantly mitigate the problem downstream. "By reducing the number of victims," she argued, "we can also reduce the number of traffickers." Taking a broader perspective, Chang encourages leaders in public health to actively participate in initiatives against human trafficking, as she observes that currently, most such initiatives are administered by the criminal justice sector, with a dearth of healthcare and public health involvement.

To summarize, some key takeaways from Chang's message include the red flags and indicators she identified, such as weight loss, rashes, rapid heart rate, bruises, substance use, and resistance to treatment. She emphasized the importance of adopting a victim-centered approach and highlighted the significance of working with victims to reduce the number of traffickers.

Reflecting on her most disturbing cases, Chang has witnessed that the right treatment and policy can indeed transform lives. The initial 14-year-old girl, who entered her clinic in a state of intoxication and covered in bruises, received treatment for her STDs from Chang. She was encouraged to leave the sex trade, and Chang provided her with a letter of support to enroll in a health-assisted training program. Now in her twenties and in a stable relationship, this young woman has found a new perspective on life. Her primary challenge today, according to Chang, is tackling college algebra. However, it is important to acknowledge that not all stories from the clinic end happily. Chang lost contact with the 15-year-old patient who was incarcerated for prostitution. She later heard that the girl became pregnant and was still engaged in sex work.

Nonetheless, such setbacks do not deter Chang. She underscores the importance of her next message by stating, "I want to emphasize the significance of this message." She goes on to say, "I am often asked how I avoid becoming demoralized. Well, my patients do not have that luxury." She elaborates, "I do not become demoralized because I possess the ability to effect change. If I do not harness that power, then who will?"

This profound message warrants a moment of reflection. How do you feel about it? Please take a moment to check in with your own emotions. I know that when I heard this impactful message, it resonated deeply with me and evoked memories of some of my most challenging cases. Some of these cases resulted in profoundly positive transformations, while others left me pondering the unknown paths certain individuals might have taken. Chang's resounding message reminds me that I, too, possess the power to effect change, and if I do not utilize that power, who will?

Summary

Human trafficking is a criminal act that involves coercing individuals into providing labor or services, or engaging in commercial sex acts. it is essential to overcome misconceptions about human trafficking, particularly the tendency to associate it solely with sex trafficking. Differentiating between human smuggling and human trafficking is crucial, and remember that any minor under the age of 18 induced into commercial sex acts is considered a victim of human trafficking, regardless of whether they were forced or coerced. Human trafficking encompasses various forms, including sex trafficking, forced labor, and domestic servitude, often found across legitimate and illegitimate labor sectors.

Healthcare professionals occupy a unique position to identify potential human trafficking victims by recognizing key indicators related to physical health, mental health, and social development. If a patient discloses being a victim of human trafficking, adopting a victim-centered approach is vital. Utilize your role as a healthcare provider to raise awareness and educate your community about these indicators and red flags.

Remember that reporting standards for human trafficking vary from state to state, so it is essential to be aware of the specific regulations in your state. Lastly, a survivor of human trafficking offers a powerful message: extend compassion and empathy to those who may have experienced trafficking, as small acts of kindness can make a significant impact.

References

National Trafficking Resource Center. Identifying victims of human trafficking: what to look for in a healthcare setting. Retrieved June 19, 2023 from https://humantraffickinghotline.org/sites/default/files/What to Look for during a Medical Exam - FINAL - 2-16- 16.docx.pdf

US Department of Homeland Security. Blue Campaign. What is human trafficking. Retrieved on June 15, 2023 from https://www.dhs.gov/bluecampaign/what-human-trafficking

US Department of Homeland Security. Blue Campaign. Tools that teach: what is human trafficking. Retrieved on June 19, 2023 from https://www.dhs.gov/blue-campaign/what-human-trafficking

US Department of Justice. What is human trafficking. Retrieved on June 19, 2023 from https://www.justice.gov/humantrafficking/what-is-human-trafficking