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Diagnosing Human Trafficking When a Patient is a Victim


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Originally appeared in Patient Safety Monitor Journal.

Physicians, nurses, and healthcare staff are in a unique position to help the human trafficking victims who walk through their doors. But for that to work, providers first need to know how to identify them.

There’s an estimated 1 million human trafficking victims living in America—a population roughly the size of Delaware. And statistics from the National Human Trafficking Hotline and the Polaris BeFree Textline show that reported cases of human trafficking increased 35% in 2016.

But the statistic most relevant to healthcare providers is this one: 87% of trafficking victims visit a provider at least once during their captivity and aren’t recognized as victims. These patients tend to live short, harsh lives, and less than 1% of them are rescued each year.

To change those numbers, the National Association of Pediatric Nurse Practitioners (NAPNAP) is launching a new national initiative on human trafficking and healthcare. The initiative will include tools for human trafficking awareness and prevention in healthcare, as well as the formation of the Alliance for Care Coordination of Children in Human Trafficking.

NAPNAP will be reaching out to stakeholders in the coming months to work with the Alliance on ensuring continuity of best practices in identification, treatment, and referral protocols. They’re seeking to unite professionals from healthcare, mental health, social service, law enforcement, and legal industries to coordinate public education, best practices, and resources. One of NAPNAP’s resources, online continuing education modules for all pediatric healthcare providers, will go live in August on PedsCESM.

Jessica Peck, DNP, RN, MSN, CPNP-PC, CNE, CNL, an associate professor of nursing at Texas A&M University College of Nursing in Corpus Christi and a former NAPNAP board member, says the problem of human trafficking is widespread.

“Trafficking occurs in every community, in every clinical setting,” she says. “All healthcare providers should be aware of signs of potential human trafficking.”

Human trafficking in the U.S.
Human trafficking is the fastest growing criminal enterprise in the U.S. and is extremely lucrative. A
trafficker can earn up to $300,000 per victim, and the American trafficking industry is worth an estimated $32 billion each year. By comparison, the annual revenue of Starbucks is only $19 billion.

The main barrier to identifying victims, says Peck, is the lack of awareness. However, efforts are underway to change that.

“Currently, there are many entities working to create standardized [human trafficking] screening tools for emergency departments,” she says. “It should be just as standard as screening for advanced directives and domestic violence.”

Since the average life expectancy of a trafficking victim is only seven years, rescuing them quickly is critical. And while some victims are rescued, says Peck, it’s not nearly enough.

“This is a difficult statistic to track for many reasons, including underreporting and high rates of recidivism,” she says. “In 2016, however, it was reported the number of rescues had increased to 78,000 victims from just under 45,000 victims the year before. Sadly, that number is estimated to be less than 0.2% of all trafficked victims.”

According to the Human Rights Commission, the three most common types of human trafficking are sex trafficking, forced labor, and debt bondage. Trafficking also encompasses organ harvesting, baby trafficking, and child soldiers.

Sex trafficking and prostitution makes up about 73% of the U.S. trafficking industry and tends to receive the most attention. But providers should also be aware that victims can be forced into a wide range of situations. Forced labor rates increased 47% in 2016, according to the Polaris report, but it is still widely unreported because of a lack of awareness. Victims are put to work in countless industries, including domestic service, housekeeping and janitorial services, agriculture, manufacturing, cosmetology, and hotel services.

Healthcare stigmas
There are many misconceptions around trafficking victims, says Peck, even in healthcare. A major one revolves around how victims are recruited. While some victims are abducted or kidnapped, traffickers use a wide range of tactics to recruit: debt bondage, coercion, fraud, and false promises. Some examples include posing as a benefactor, offering a job, or proposing marriage or an intimate relationship. In some cases, victims are sold to traffickers by their family members.

“Traffickers will take advantage of anyone, anywhere, in any circumstances, even people from ‘nice’ neighborhoods and ‘nice’ families,” she says. “Identification of risk factors is essential for prevention efforts.”

There are several factors that can put a person at risk for recruitment, and knowing what they are is essential for prevention efforts. Runaways, people with developmental delays, and LGBTQ teens are especially vulnerable. Other risk factors include:

  • Commuting to school alone
  • Hunger/malnourishment
  • Poverty
  • Family dysfunction or conflict
  • Emotional distress
  • Mental illness
  • Substance abuse

Providers have a common stigma related to drug use and prostitution. Signs or symptoms that providers dismiss as attributable to a patient being “troubled” or “promiscuous” deserve to be viewed from a different perspective, says Peck.

“Physical injuries are treated the same way [as abuse cases] and may present in similar fashion,” she says. “But signs to alert providers to possible trafficking scenarios have distinctive characteristics, including but not limited to tattoo ‘brandings’ to identify ownership by a pimp or having no legal identification documents; [the victim] not being aware of location, date, or time; a history of multiple sexually transmitted infections and abortions; poor dental hygiene; and severe or recurring head and neck trauma from forced oral sex.”

And when it comes to prostitution, any sex worker under the age of 18 is automatically to be considered a trafficking victim.

“There is no such thing as a minor prostitute,” Peck says. “All minors involved in prostitution are [trafficking] victims. [Nor should] adults involved in prostitution be assumed to have made an informed choice, but should be considered to be held hostage by their captor, whether that be physically, financially, or emotionally.”

Working with victims
Once a healthcare provider discovers a patient is a victim, says Peck, there are five steps the provider should immediately take:

  1. Tend to life-threatening or emergent health issues.
  2. Separate the victim from his or her suspected trafficker and cell phone, then question the victim privately. Limit the amount of staff interaction.
  3. Ask non-judgmental questions as recommended by the Polaris Project (see Resources below), including: “Can you come and go as you please?” “Do you have control over your money and identification?” “Did someone tell you what to say today?” “Have you or your family been threatened?"
  4. If concern exists, call the National Human Trafficking Resource Center (NHTRC) at 888-373-7888, who will alert the appropriate law enforcement agencies if indicated.
  5. Know what local resources are available for patients and recognize the need for multidisciplinary care.

That said, trafficking victims may be unwilling or afraid to talk about their position with a provider. If a patient denies being a victim, Peck says, providers should accept that choice and recognize the patient’s fears.

“Healthcare providers shouldn’t try to ‘rescue’ the patient, inquire about their immigration status, make promises that cannot be kept, force/deceive/coerce a patient into rescue,” she says. “Healthcare providers also shouldn’t be discouraged if a patient does not disclose their victimization and should not let it deter them from reporting in the future.”

When a patient is unwilling to discuss their situation, providers can discreetly provide information for help if the patient has a change of heart in the future. Options include a false “barcode” on a lipstick or the number for the NHTRC on a bar of soap. They should also communicate messages of hope: “You are not alone,” “You are entitled to services and help,” and, “You have rights.”

Most importantly, says Peck, providers should listen to their instincts and call the NHTRC hotline to report the incident if they have any suspicion at all.

“Awareness [about trafficking] is slowly increasing,” she says. “More and more organizations are rising up to address this issue. There is still a painful shortage of aftercare resources (housing, healthcare, counseling, etc. after rescue). Too many healthcare providers believe [human trafficking] is not happening in their clinical environment, and there are still many misconceptions and stigma which prevent victim identification. There are discrepancies in state laws protecting victims.”

Human trafficking resources and organizations