Human Trafficking

Human trafficking is a pressing public health concern that transcends all races, social classes, demographics, and gender. No population is exempt from the ever-present threat of traffickers. Human traffickers are motivated by greed, driven by quota, lack respect for human rights, prey upon the vulnerable, and damage their victims' psychological and physical well-being. The extent of the economic and social impacts on society are unknown and require further research to define and guide community-based care, protocols, and formal curriculum changes.[1]

Human trafficking is a $150 billion industry globally. The International Labour Organization's (ILO) 2016 estimate reveals that 40.3 million people were victimized worldwide through modern-day slavery, 5.4 victims per every thousand people worldwide. Of these 40.3 million victims in 2016, 29 million were women and girls (72% of the total). Almost 5 million in 2016 were victims of forced sexual exploitation globally, with children making up more than 20% of that number. According to new 2016 global estimates, data collected by the ILO and the Walk Free Foundation (WFF) in partnership with the International Organization for Migration (IOM) as part of their contribution to the Sustainable Development Goals (SDG), puts the number close to 25 million persons who have been subjected to forced labor worldwide and 15.4 million in forced marriages. Loss of freedom is the common thread that binds them together. The exact number of trafficking victims is difficult to quantitate due to the concealed nature of the rapidly progressing disease and public health emergency.[2]

Distinguishing between human trafficking and human smuggling is essential. According to the Trafficking Victims Protection Act (TVPA), an anti-trafficking federal law established in 2000 under President Clinton's administration, human trafficking is defined as the exploitation of a person or persons for sex or labor using "force, fraud, or coercion."

Smuggling differs from trafficking because it involves the illegal crossing of borders and is usually consensual. Typically, the relationship between the smuggler and the person being trafficked terminates upon arrival to the destination country. Smuggling indebtedness can lead to trafficking as a means to resolve a fee owed to the smuggling entity. 

Trafficking in persons (TIP), also known as modern-day slavery, is a crime in all 50 states under federal and international laws and does not require the physical transport of a person. TIP can and often does occur in local communities and schools as well as near popular sporting venues.[3]

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 used to compel the victim to provide commercial sex acts, labor, or other services.[4]

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 minors under 18 years involved in any commercial sex act because minors cannot consent to sex with an adult. Minors are easier to exploit and manipulate, thus vulnerable to trafficking.

The TVPA's definition of 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."

The United States Department of Health and Human Services's (HHS) "Look Beneath the Surface" campaign and SOAR training in 2017 provided much-needed insight into TIPs based on the latest amendments to the TVPA. For example, force may involve rape, torture, beatings, or imprisonment and can be psychological or physical.

Physical confinement is rare; however, "invisible chains" are often used to maintain power and control, similar to intimate partner violence. Fraud may include false claims of a job, marriage, promises of a better life, or a family. Coercion also involves threats, debt, or bondage that help foster a climate of fear and intimidation and may consist of abuse of the legal process.

According to the TVPA, a commercial sex act is any sex act where anything of value is given to or received by any person, such as survival sex, drugs, transportation, food, or clothing. 

Over the past 18 years, the US Congress has passed several comprehensive bills to bring this crime to light in domestic and international communities. This legislative process finds its basis in the 13th Amendment to the US Constitution, which banned involuntary servitude and slavery in 1865. One such law adopted in 2000 is the TVPA that combats TIPs using the "3 Ps" approach: protection, prosecution, and prevention.[5][6][7]

The TVPA established several necessary protective measures for trafficking victims in the United States. Regardless of immigration status, trafficked foreign persons are eligible for federally funded benefits, such as healthcare and immigration assistance. The T nonimmigrant status (T visa) is a protective measure that prohibits deportation or removal of a trafficked victim and sometimes offers a path to permanent residency. Human trafficking victims are especially vulnerable to re-trafficking within two years of first being trafficked and upon return to an originating country due to debt bondage or psychological, emotional, and economic conditions. Reintegration into society, coupled with functioning within societal pre-determined norms, can be traumatic for an already traumatized person who traffickers have exploited. Re-victimization must be avoided by enacting protective measures. 

Under the TVPA act, federal prosecutors were armed with additional tools to bring traffickers to justice for their crimes against humanity. The TVPA explored the existing statutes and broadened their conservative approach. The new legislation mandated financial restitution to the persons they had exploited through trafficking and offered more substantial penalties for those convicted of trafficking crimes. Revisions of the TVPA and subsequent enactments further defined human trafficking as "severe forms of trafficking in persons," including both sex trafficking and labor trafficking.

The third "P," prevention, is perhaps the most important. The TVPA strengthens prevention efforts on behalf of the US government. International incentives were enacted to improve economic conditions around the world to deter TIPs. The Office to Monitor and Combat Trafficking in Persons was created within the State Department due to the TVPA. According to the US Department of State, annual TIP reporting was mandated and rated countries on their efforts to reduce TIPs.[8][9][10][11]

Furthermore, the TVPA required the creation of an Interagency Task Force to Monitor and Combat Trafficking and TVPA reauthorizations were enacted in 2003, 2005, 2008, and 2013. In 2015, the adoption of the Justice for Victims of Trafficking Act allowed for additional tools to address this human rights issue and directed the Attorney General to create a National Strategy to Combat Human Trafficking and ensure its ongoing maintenance.[12][13]

These legislative directives, ensured by the passage of the TVPA and the Trafficking Victims Protection Reauthorization Act (TVPRA), bring human trafficking to the forefront of the conversation internationally. Prevention through education is paramount in efforts to curb the growth of this $150 billion industry, which is thought by some to surpass the drug trade in the market value of criminal enterprises. Healthcare providers are on the frontline of these efforts as the first point of contact for most victims. 

The US Department of State also prosecutes human trafficking and smuggling cases. Diplomatic Security Service (DSS) agents and analysts often support foreign law enforcement agencies in an attempt to combat the global epidemic of TIP. On a domestic front, the US Department of State works with federal, state, local, and tribal leaders to investigate potential modern-day slavery cases for sex or labor exploitation.

The disease of human trafficking may find its etiology in a multitude of contributing factors that make a person susceptible to a trafficking situation.

Adverse Childhood Experiences (ACES) can increase the likelihood of risk-taking behavior that could predispose a person to a trafficking situation. A better understanding of how a high ACE score can potentiate a trafficker's hold on a victim is best explored through research. The CDC-Kaiser Permanente Adverse Childhood Experiences study was a massive study, which began in 1995 and concluded in 1997, that investigated the ramifications of child abuse and neglect on health and well-being later in life.[14] The CDC continues ongoing surveillance of study participants. Annually, through local state-based Behavioral Risk Factor Surveillance System (BRFSS) reporting, the effects of ACES on survivors, communities, and overall public health is measured. The ACE Pyramid conceptualizes the framework for the ACE study as it relates to individual health and well-being across the lifespan, from conception to death.

According to the ACE Pyramid, neurodevelopment is disrupted or stunted following an adverse childhood experience. Social, emotional, and cognitive impairments can result in high-risk behaviors that negatively impact overall health. Disease, disability, and social problems ensue, cascading to an early death. Therefore, a correlation exists between a higher ACE score and an increased risk of poor physical and mental health due to poor choices, risky behaviors, and social issues.

An ACE questionnaire asks difficult, emotion-provoking questions about 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 score calculation. ACE scores 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 higher. 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.[5]

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) surveys. 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.[15]

The transgender community may seek expensive hormone therapy and resort to "survival sex." This vulnerable position of needing money to buy hormone therapy from black-market suppliers at inflated prices with exorbitant interest rates can increase the chances of being lured into trafficking. Transgender youths may have additional vulnerabilities that heighten their risk of being trafficked, such as homelessness, addiction, depression, lack of financial or emotional support from family, being victims of intimate partner violence, and a history of sexual abuse as a child. Transgender individuals with HIV are also vulnerable to being trafficked if they struggle to meet their basic needs of food and shelter.

The National Center for Transgender Equality (NCTE) conducted a 2015 US Transgender Survey and found that 5% of all participants had engaged in sex work for income in the past year. Fifty-five percent of those who had resorted to survival sex in the past year were transgender women. Approximately 19% had participated in "survival sex" for money, food, sleeping quarters, or other goods or services. According to one study, those who had engaged in sex for money were more likely to have experienced some form of intimate partner violence or sexual assault. Debt bondage places an invisible chain that binds a victim to a "Romeo" or "guerilla" pimp. The invisible chain tightens with unmet quotas and may become a physical one.[16]

Further resources provided by the Polaris Project address the risks of being trafficked within the LGBTQ community and are available on their website.

Sexual abuse puts an individual at risk for substance abuse, mental health issues, and a lack 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 an individual are the initial perpetrators of the insult or crime. "Forgotten," "invisible," "different," "broken," and "discarded" are all words used to describe the feelings of victims of human trafficking. Traffickers prey upon this vulnerability, use it to their advantage, and strategically place 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 a profiler, trolling for victims to turn a profit.

Traffickers do not discriminate based on gender, race, social demographic, immigration status, or economic status. No exact mold fits a victim. Anyone is at risk, but specific populations have a higher vulnerability risk. The US Department of Health Office on Trafficking in Persons provided a fact sheet in 2017 to further highlight at-risk groups, such as survivors of child abuse, sexual abuse, assault, interpersonal or intimate partner violence, gang violence, or community-violence exposure.[1]

The SOAR Campaign further delineates at-risk, vulnerable individuals as those lacking a stable support structure or home life, such as a runaway, a foster child, a child in the juvenile justice system, a homeless youth, an unaccompanied minor, a person displaced due to a natural disaster, or an individual with a language or cultural barrier. Increased risk also involves those with substance abuse problems, undocumented or migrant workers, and the LGBTQ population. Minorities, those with disabilities, and those on Native American reservations can be at a higher risk of being trafficked.

The US Department of Education published a fact sheet for schools entitled "Human Trafficking of Children in the United States" that discussed the vulnerability of school-age children and human trafficking incidence. In identified child-trafficking cases, children commonly were involved in stripping acts, pornography, forced begging, commercial sex, and drug sales. Children at most significant risk were identified as working in restaurants, in hair and nail salons, as nannies or au pairs, or in agricultural settings. Signs of child trafficking include unexplained absences, poor attendance, runaway behavior, boasting about frequent travel to other cities, inappropriate dress for the current weather, being sleep-deprived or malnourished, or impairment due to drugs or alcohol.[17]

Lack of a stable support structure and social media accessibility 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 be another student. A trafficker may promise a "happening" party or a good time 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 of victims of human trafficking. The Blue Campaign by the Department of Homeland Security offers sex trafficking awareness videos to educate youth on the risks of being trafficked in familiar places such as schools, coffee shops, malls, sporting venues, and other hangouts.[dhs.gov/blue-campaign]

When exploring the epidemiology of human trafficking, one must first examine data collection, results, and the organizations that provide this service. The US Department of HHS funds the National Human Trafficking Hotline, operated by Polaris, a nongovernmental organization. The National Human Trafficking Hotline's data collection gathers invaluable information to assist training programs and victims domestically and abroad. For example, 2017 data collection indicates that California, Texas, and Florida rank the highest in reported cases and referrals.[18][19][6]

To date, the hotline has answered more than 100,000 calls; 7,000 were from potential victims of human trafficking. According to Polaris hotline statistics for the United States, more than 30,000 cases of trafficking in persons and more than 8,000 tips to law enforcement were identified since 2007. The National Human Trafficking Hotline is a 24-hour, confidential, multilingual hotline covering more than 200 languages for victims, survivors, and witnesses of human trafficking.

The hotline number is 1-888-373-7888.

Text "HELP" to 233733.

Live chat at humantraffickinghotline.org.

Email help@humantraffickinghotline.org.

Another resource for reporting cases and gaining information as it relates to the trafficking of minors is the National Center for Missing and Exploited Children (NCMEC). In 2016, The NCMEC estimated that one in six endangered runaways were likely victims of sex trafficking. Sex traffickers target children as young as nine, 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 that of the 4.8 million sexually exploited in 2016, 20% were children.[2][20][21]

To report sexually exploited or abused minors, call the National Center for Missing and Exploited Children’s (NCMEC) hotline at 1-800-THE-LOST, 1-800-843-5678.

In the case of an immediate emergency, call the local police department or emergency access number.

Child protective surfaces and local law enforcement will assist healthcare providers in local reporting requirements for minors involved in a possible abuse situation. Ages of sexual consent may vary from state to state. Thus, the need to consult local agencies. 

The International Organization for Migration (IOM) in partnership with Polaris and the UN Migration Agency has launched a Counter-Trafficking Data Collaborative (CTDC) with a global repository of data on trafficking in persons. Victim identities are protected and the information gathered assists in bridging gaps in publicly available data. Essential components of the CTDC's role to combat the war on human trafficking are data collection efforts and providing public access to the data. The first of its kind, this global repository of data combines data from the IOM records of more than 45,000 human trafficking cases and more than 31,000 cases from Polaris. This collaborative data tracking system fosters a data-rich environment and transcends borders and individual agency operational challenges. This comprehensive, international database is a positive byproduct of this partnership. See the CTDC website.

Each year, thousands of individuals fall victim to national and international trafficking. Almost no country is exempt from human trafficking infractions or being the originating, transient, or destination country. The United Nations Office on Drugs and Crime (UNODC) Global Report on Trafficking in Persons further explores the bond between trafficker and victim and the trafficking origin.

The 2016 UNODC Global Report on Trafficking in Persons shines a light on the trafficker's profile and relationship with the one who is trafficked. Traffickers and their victims tend to originate from the same geographical area, speak the same language, and share the same ethnic background. These commonalities foster a level of trust between the trafficker and the victim. The trafficker exploits this relationship for financial benefit. Traffickers rarely travel abroad to recruit, instead focusing on domestic recruitment. 

Globally, local trafficking is on the rise. A trafficker will go to a destination country to exploit the victim. Countries most vulnerable to trafficking are those with high levels of organized crime and those ravaged by conflicts. From 2012 to 2014, more than 500 different trafficking flows were detected, and countries in Western and Southern Europe identified victims of various citizenships. The 2016 UNODC Global Report on Trafficking in Persons reports 79% of classified trafficked individuals globally are women and children and documented a clear link between migration and human trafficking. The movement of migrants and refugees is the most substantial reported migration since World War II, with an estimated 244 million international migrants worldwide. 

Forced migration resulting from refugees fleeing war-torn areas makes women and children especially vulnerable to exploitation by traffickers. The movement of Syrians escaping the war is one such example. Children face exploitation as "child soldiers." Armed guards abduct individuals on migratory routes and exploit them as slaves for forced labor or sex. In September 2015, world leaders adopted the 2030 Sustainable Development Agenda and embraced the war against trafficking in persons on a global front. This plan called for all forms of violence against women and girls to cease. 

According to the 2016 UNODC Global Trafficking in Persons Report, no country is immune from trafficking in persons, and over 500 migratory flows of trafficking were detectable. Sub-Saharan African and East Asian victims are trafficked to numerous global destinations. Affluent areas, such as Western and Southern Europe, North America, and the Middle East, have victims from all parts of the world. In Southeast Asia, forced marriages are on the rise. Central America, the Caribbean, and South America frequently report cases of girls becoming victims of sexual exploitation. Trafficking in fishing villages for forced labor is a problem in parts of the world, such as Ghana and Taiwan. Organ retrieval as a form of trafficking is less frequent but exists in some parts of the world. 

The UNODC 2016 study also reports a change in the victim profile over the past decade. The number of male victims is increasing. The total number of forced labor victims increased between 2012 and 2014, with 63% being men. Another alarming fact from this report is that female participation increased. Of 6800 persons convicted of human trafficking during 2012-2014, 60% were male. Young girls are recruited and controlled by older women. More couples are actively involved in trafficking. Posing as "stable couples" allows traffickers to seem more genuine and trustworthy while actively recruiting and exploiting victims as a team. Former victims become active participants in recruitment, some to reduce their debt bondage and end their sexual exploitation. Others who willingly participate in the abuse use tactics of power and control. If trafficked persons are engaged in criminal activity, they are less likely to cooperate with police, thus allowing the trafficker even more control.

According to the UNODC, the average number of trafficker convictions was low, with five victims per convicted offender. North America had the highest number of convictions compared to the rest of the world. The United States reported 150 to 200 convictions annually, while Europe reported the highest number of trafficking victims.[22].

A recent study revealed that 87.8% of human trafficking survivors had been in contact with a healthcare provider in some capacity during their victimization. Furthermore, 68.3% had received an evaluation in the emergency department.[23] Missed opportunities to identify, inform, and empower these victims allow this physically and psychologically debilitating disease to spread.

Recently, a smaller study of emergency department nurses in an urban setting concluded that the nurses want better awareness of the specific resources available to human trafficking victims. Ongoing research into the impact of institutional policy, human trafficking protocols, and continuing education regarding the recognition and treatment of trafficked individuals is required[22].

Myths or misperceptions often lead to missed opportunities to identify victims[DOS, 2013]. Education on these potential media-induced sensationalized myths is essential for healthcare providers and first point-of-contact personnel. First, trafficking in persons is not just a crime that occurs in a faraway place or only involves migrants or foreign nationals. Individual exploitation happens in every part of the world including suburbs, big cities, and hometowns.

Victims can be coerced to take part in crimes, thus landing them in a detention center or jail. They may present to the emergency department for medical clearance. Proper screening of these individuals is vital in our attempts to identify victims, recognize the red flags of trafficking, and take appropriate action. Having the mindset that this patient is "just a criminal or "just a prostitute" is a bias that inhibits practitioners from reading verbal and nonverbal cues and recognizing the patient as a human trafficking victim. A victim may be revictimized if returned to an exploitative environment. Revictimization is a chief concern for practitioners. The United Nations Convention against Corruption defines “revictimization” as "a situation in which the same person suffers from more than one criminal incident over a period of time." Perhaps more important when assessing and interviewing a potential victim of trafficking is the potential for "secondary victimization.”  The UNODC Model Law on Justice in Matters involving Child Victims and Witnesses of Crime defines secondary victimization as "victimization that occurs not as a direct result of the criminal act but through the response of institutions and individuals to the victim."[22]

If an individual is free to come and go, then he or she may not be recognized as a person being trafficked. As discussed previously, bonds are often not physical chains or cuffs, but "invisible" or psychological ones. Fear paralyzes victims, acting as a shackle that emotionally confines them to the trafficking situation. Mental weapons used by the trafficker to exercise power and control over a victim may include threats of harm to children, siblings, or other family members; deportation or return to a traumatizing situation; calls to social services; and physical violence or reminders of past violence for misguided offenses. 

Debt bondage, withholding of pay, and maintaining possession of identifying documents may further lead to an invisible bond or tie to the pimp/trafficker. Trafficked victims may use a school bus, a public bus, a train, or a taxi. Control over the trafficked person is far beyond a physical wall, chain, or border. Much like intimate partner violence, victims usually do not self-identify, self-report, or recognize that they are being manipulated, controlled, stigmatized, or dehumanized.

Language barriers and cultural misconceptions may lead to a missed opportunity to identify a potential victim.[24] Inconsistencies in stories or history may become lost in translation, especially if a provider fails to obtain an interpreter with no relationship to the exploited. A staff member versed in the same language or who shares the same culture as the victim may be able to spot these subtle clues and ease cultural shock and miscommunication. However, the availability of staff members with the optimal background and primary language is not always feasible in a busy healthcare setting. When red flag behaviors are passed off as specific cultural behaviors, this demographic profiling could create a missed opportunity to identify the patient as a victim.

In suspected cases of human trafficking or intimate partner violence, it is imperative that no family member or accompanying party be allowed to translate. Ensure that your institution provides a certified interpreter.

Seeking health care for victims presents the opportunity for discovery. Traffickers may only seek care for their victims when they become seriously ill.[25] A multitude of factors should lead a practitioner to seek medical services for a person who is a suspected victim of human trafficking.

Emergent medical conditions, such as profuse bleeding or pain caused by a beating or forced abortion, injury on a job site, or complications during pregnancy, such as an ectopic pregnancy

Gynecological services for sexually transmitted infections caused by debris in the vagina from packing during menstruation or forced sex without condom use

Follow up with an OB/GYN for a repeat beta HCG or ultrasound for a possible ectopic pregnancy identified in an emergency setting

Addiction issues such as a severe overdose or withdrawal signs and symptoms

Dental emergencies or plastic surgery consultations

Prenatal care or lack thereof

Health-related mental problems such as depression, suicide attempt, or anxiety disorder

A patient on a psychiatric hold or court-mandated order

Severe wound infections with signs of septicemia may force introduction into the healthcare system

Traffickers seek out the quickest means of care, and lengthy emergency department waits may lead to their decision to leave with the victim before receiving medical treatment. They may also "hospital shop" for quicker wait times from door to the provider. An accompanying "family member" that is impatient, "in your face," or upset over lengthy delays in overcrowded emergency rooms or clinics may, in fact, be a trafficker. Another indicator is the "spouse" or "boyfriend" that insists that a high-risk patient, such as one with a possible ectopic pregnancy or appendicitis, leave without being seen, against medical advice, or before care is completed.

Remember, a victim comes from all walks of life and may be perceived as having a stable home in a suburban community. Victims will never look or act the same; their individual responses to their traumatic event will follow no specific protocol. Healthcare providers must be diligent in identifying these silent victims, forced into a situation of no fault of their own, and made to carry out acts that reap emotional and social ramifications for years to come.