Overview

Today, some label human trafficking as a form of "modern day slavery," and frequently, human trafficking has been linked to sex work and prostitution, although there are other forms of trafficking, such as forced labor and domestic work. Human trafficking can involve women, men, and children. Its victims experience a host of psychologic problems, including post-traumatic stress, helplessness, and depression, due to the physical, sexual, and psychologic abuse they have experienced. This course encompasses a basic overview of human trafficking. The course will attempt to provide practitioners with a glimpse of the realities of human trafficking victims' lives and the physical, psychologic, social, and sexual abuse they experience. Specific interventions and responses are covered, including mental health, social services, educational, prevention, and legal efforts. The course provides an array of resources for victims and practitioners, including organizations/agencies, books, and films/documentaries focusing on the issue of human trafficking.

Education Category: Ethics - Human Rights
Release Date: 09/01/2019
Expiration Date: 08/31/2022

Audience

This course is designed for all health and mental health professionals in Florida who may identify and intervene in cases of human trafficking and exploitation.

Accreditations & Approvals

In support of improving patient care, NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. NetCE maintains responsibility for this course. Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is accredited by the International Association for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors. #MHC-0021.This course is considered self-study by the New York State Board of Mental Health Counseling. NetCE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. This course is considered self-study, as defined by the New York State Board for Social Work. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed marriage and family therapists. #MFT-0015.This course is considered self-study by the New York State Board of Marriage and Family Therapy.

Designations of Credit

This activity was planned by and for the healthcare team, and learners will receive 2 Interprofessional Continuing Education (IPCE) credit(s) for learning and change. NetCE designates this enduring material for a maximum of 2 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NetCE designates this continuing education activity for 2 ANCC contact hour(s). NetCE designates this continuing education activity for 2.4 hours for Alabama nurses. NetCE designates this continuing education activity for 2 NBCC clock hour(s). Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 2 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. Social workers participating in this intermediate to advanced course will receive 2 Clinical continuing education clock hours. NetCE designates this activity for 2 ACPE credit(s). ACPE Universal Activity Number: JA4008164-0000-19-041-H01-P. Successful completion of this CME activity, which includes participation in the activity with individual assessments of the participant and feedback to the participant, enables the participant to earn 2 MOC points in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABP MOC credit. NetCE is authorized by IACET to offer 0.2 CEU(s) for this program. AACN Synergy CERP Category B.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353, (valid through November 21, 2021); Arkansas, Provider #50-2405; California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Kentucky, Provider #7-0054 through 12/31/2019; South Carolina, Provider #50-2405; West Virginia RN and APRN, Provider #50-2405.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190; Texas State Board of Social Worker Examiners, Approval #3011; Texas State Board of Examiners of Professional Counselors, Approval #1121; Texas State Board of Examiners of Marriage and Family Therapists, Approval #425.

Special Approvals

This course meets the Florida requirement for Human Trafficking education. This activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Competency.

Course Objective

The purpose of this course is to provide physicians, nurses, and other healthcare professionals an in-depth, practical review of human trafficking, including the definition and scope of the problem, the means of identification and assessment of individuals who may be victims, guidance on reporting of cases, and interventions and resources available to victims.

Learning Objectives

Upon completion of this course, you should be able to:

  1. Define various forms of human trafficking and its effects on victims.
  2. Describe best practices for assessing, reporting, and intervening in cases of human trafficking.

Faculty

Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correctional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families.

Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon University, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online curriculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities.

Faculty Disclosure

Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

John M. Leonard, MD

Jane C. Norman, RN, MSN, CNE, PhD

Abimbola Farinde, PharmD, PhD

James Trent, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Table of Contents

Technical Requirements

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#97110: Recognizing and Reporting Human Trafficking in Florida

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  • Participation Instructions

INTRODUCTION

Although human trafficking has always existed, it has begun to receive increased attention as a result of awareness and outreach efforts. All social problems compete for attention, and various groups will make compelling claims about social problems using persuasive rhetoric and dramatic statistics [1]. More than just a human rights issue, it has garnered attention from feminists, religious conservatives, labor activists, immigration specialists, and the mental health professions [2]. Furthermore, attention will be drawn from the media, politicians, organizations, and public, all of whom will respond to the gravity of the condition. It is through this process of claims-making and counter claims-making that "conditions" that may not necessarily have initially attracted attention can develop into a recognized social problem [1]. How the problem is described or constructed will influence public opinion, which will then ultimately facilitate action from governmental agencies, social service organizations, and international agencies [3,4,5].

This course will provide a basic overview of human trafficking (e.g., the scope, definitions and frameworks, contributing factors, different forms). The course will attempt to provide practitioners a glimpse of the lives of human trafficking victims, including physical, psychologic, social, and sexual abuse that human trafficking victims experience and the types of control tactics perpetrators use. Specific interventions and responses will be covered, including mental health, social services, educational, prevention, and legal efforts. Finally, for practitioners who do work with human trafficking victims, the emotional toil that it takes upon practitioners as well as the importance of self-care will be discussed. The course will end by offering an array of resources. Practitioners will be encouraged to view films and documentaries about human trafficking, as this is one way to "enter the lives" of human trafficking victims and better understand the dynamics of the complex world of human trafficking.

SCOPE OF HUMAN TRAFFICKING

As the issue of human trafficking is so complex, it is difficult to determine the scope of the problem. Many scholars and researchers believe that published estimates are just educated guesses. On a global level, the International Labour Organization has estimated that there are 40.3 million human trafficking victims [6]. The estimates for the United States are not totally clear, but there were approximately 78,000 human trafficking victims reported to the U.S. State Department in 2016; only an estimated 0.2% are rescued [7]. According to Polaris, which founded and runs the National Human Trafficking Hotline, there have been a total of 40,200 cases of human trafficking reported since 2007 [7].

Weitzer's content analysis of websites and publications about human trafficking found that human trafficking is portrayed as an epidemic, growing at alarming rates, with some government reports estimating 40,000 to 50,000 individuals trafficked in the United States each year [8]. Weitzer argues that many of the reports have overestimated the scope of the problem and points out that the estimates fluctuate drastically year to year [9]. Sex trafficking tends to be portrayed more frequently due to its sensationalism. In a study of 50 human trafficking campaigns in Spain between 2004 and 2017, 40 (80%) depicted sex trafficking and exploitation involving women [10]. The U.S. Department of Justice reported 1,045 convictions for human trafficking-related crimes in 2017, including forced labor and sex trafficking of adults and minors. This was an increase of more than 78% over the number reported in 2015 [6]. In 2016, the International Labour Organization stated that there were 4.8 million victims of sex trafficking, and 15.4 million in forced marriages. The majority (62%) of those trafficked are in Asia and Pacific regions [11]. In 2017, it is estimated that there are 24.9 million people around the world who are in forced labor [11].

Florida ranks third in the United States in terms of destinations for trafficked persons [12]. In 2018, the National Human Trafficking Hotline received 1,885 contacts (e.g., phone calls, texts, e-mails) and 767 human trafficking cases reported in Florida. The most common type was sex trafficking (68%), followed by labor trafficking (16.5%) and combined sex/labor trafficking (7.5%) [12]. The majority of victims were female (69%) and adult (55.8%).

DEFINITIONS OF HUMAN TRAFFICKING

The United Nations defines human trafficking as [13]:

The recruitment, transportation, transfer, harbouring or receipt of persons, by means of threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability, or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation or the prostitution or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude, or the removal of organs.

In essence, this definition involves three elements: the transport of the person, the force or coercion of the victim, and the abuse and exploitation [14]. The United Nations Office on Drugs and Crime divides the definition of human trafficking into three sections: the act, means, and purpose [15]. The act, or what is done, generally refers to activities such as recruitment, transportation, transfer, harboring, or receipt of persons. The means of trafficking consists of threats or use of force, coercion, abduction, fraud, deception, abuse of power or vulnerability, or giving payments or benefits to a person in control of the victim. Finally, these acts are carried out for the purpose of exploitation, which includes prostitution, sexual exploitation, forced labor, slavery or forced servitude, and the removal of organs [15]. It is important to remember that human trafficking is not human smuggling. Human smuggling involves an individual being brought into a country through illegal means and is voluntary. The individual has provided some remuneration to another individual or party to accomplish this goal [16].

The Trafficking Victims Protection Act (TVPA) defines human trafficking to include both sex trafficking and labor trafficking [17]. Sex trafficking is 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. 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 purposes of subjection to involuntary servitude, peonage, debt bondage, or slavery. A victim need not be physically transported from one location to another for the crime to fall within this definition.

In many cases, women and children are considered the typical victims of human trafficking. Hart posits that women are more vulnerable to trafficking due to the lack of social safety nets in many developing countries [18]. Coupled with women's subordinate social statuses in many cultures, this leads to the "feminization of poverty." Although the social conditions may make women and children more vulnerable to human trafficking, the reality is that men are also victims of human trafficking.

Overall, the definition of human trafficking is ambiguous because of the many intersections with other issues (e.g., sexual abuse, domestic violence, forced marriage, forced labor) [19]. It occurs both domestically and internationally, but is primarily a hidden problem. This makes research efforts, the prosecution of perpetrators, and policy and community efforts to protect victims even more challenging [19].

FORMS OF TRAFFICKING

SEX TRAFFICKING

The TVPA of 2000 is a U.S. federal statute passed by Congress to address the issue of human trafficking and offers protection for human trafficking victims [17]. This statute defines sex trafficking as, "the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act" [17]. A commercial sex act is, "any sex act on account of which anything of value is given to or received by any person" [17]. In other words, it usually involves the illegal transport of humans into another country to be exploited in a sexual manner for financial gains [20]. However, it does not always involve the transport of victims from one region to another; such cases are referred to as "internal trafficking" [21]. Victims of sex trafficking could be forced into prostitution, stripping, pornography, escort services, and other sexual services [22]. Victims may be adult women or men or children, although there is a higher prevalence of women and girls. The term "domestic minor sex trafficking" has become a popular term used to connote the buying, selling, and/or trading of children younger than 18 years of age for sexual services within the country, not internationally [22,23]. An element of force, fraud, or coercion is not necessary, as the victims are children and inherently vulnerable [23]. In the United States, the children most vulnerable to domestic minor sex trafficking are those who are homeless, abused, runaways, and/or in child protective services [22].

Although highly controversial, it is said that sex trafficking victims differ from prostitutes in that sex trafficking victims are forced to involuntarily perform sexual services and are often not paid for their "work." Sex trafficking involves the use of force and coercion and can encompass other forms of criminal sexual activities, including forced erotic dancing, "mail-order brides," and pornography [21]. On the other hand, individuals involved in prostitution make a decision to provide sex services for a fee. The decision to enter prostitution does not eliminate the possibility of being a victim of trafficking if one is held against his/her will through physical and/or psychologic abuse [24]. It is also important to remember that this does not necessarily mean prostitution is a choice these individuals would have made if other options were available or that they have a choice in selecting their sexual partners and/or sexual activities [25].

BONDED LABOR/FORCED LABOR

The United Nations has defined debt bondage as [26]:

The status or condition arising from a pledge by a debtor of his personal services or of those of a person under his control as security for a debt, if the value of those services as reasonably assessed is not applied towards the liquidation of the debt or the length and nature of those services are not respectively limited and defined.

Essentially, because the individual does not have money as collateral for the debt owed, the individual pledges his/her labor or, in some cases, the labor of a child or another individual for an unspecified amount of time [27]. These individuals may be transported or trafficked into another country for the purpose of forced labor.

In many cases of bonded labor, the initial loan may be welcomed by the individual. However, the victims do not realize that with the low wages, unspoken high interest rates and other continually accruing fees, and the perpetrator's manipulation of the "accounts," laborers can never repay the loans. Some estimate that half of all persons in forced labor are bonded laborers. The majority of bonded labor cases occur in India, Bangladesh, and Pakistan [28]. Some families find themselves in a cycle of poverty as the debt cannot be paid off and is passed down from generation to generation [27]. Bonded labor can involve laborers in brick kilns, mines, stone quarries, looming factories, agricultural farms, and other manufacturing factories [27]. In the United States, individuals may be trafficked to work long hours in garment factories, restaurants, and other manufacturing sectors. Frequently, the employer/captor will take away victims' identifications, monitor their movements, socially isolate them, and/or threaten deportation if they do not comply [29]. Migrant workers are at high risk of forced labor [24].

In the United States, forced labor is predominantly found in five sectors [29]:

  • Prostitution and sex industry (46%)

  • Domestic servitude (27%)

  • Agriculture (10%)

  • Sweatshops and factories (5%)

  • Restaurant and hotel work (4%)

It is speculated that most of the forced labor occurs in California, Florida, New York, and Texas, all major routes for international travel [29].

Domestic servitude refers to a category of domestic workers (usually female) who work as servants, housekeepers, maids, and/or caregivers, often in private homes. In some cases, young women are lured with the promise of a good education and work, and when they arrive in the United States, they are exploited economically, physically, and/or sexually. Their passports or identification papers are taken away, and they are told they have to pay off the debt incurred for their travel, processing fees, and any other bogus expenses. Because they do not speak English, they find they have no other recourse but to endure exploitive working conditions [30]. Unfortunately, as in many sectors of forced labor, there are no regulations to monitor the conditions under which domestic servants operate [29].

CHILD LABOR

Child labor can be viewed as a specific form of bonded labor or forced labor. However, not all child laborers have been trafficked. Child labor is defined by International Labour Organization (ILO) as economic labor performed by a child younger than 15 years of age or hazardous labor done by a child 18 years of age or younger. Child labor is deeply rooted in poverty and the infrastructure and political stability of the country as well as market forces [31]. The ILO estimates that there are 152 million child laborers in the world [32]. Between 2000 and 2016 there was a nearly 38% decrease in the number of children in child labor. The reduction was greater for girls (43%) than for boys (34%). The largest numbers of child laborers are found in Asia and the Pacific region; however, there is evidence that the number of child laborers in Africa is increasing [32].

The definition of child labor is controversial because the definitions for "work" and "childhood" are ambiguous and often culturally defined [33]. On a conceptual level, work may be beneficial for the socialization and educational processes of children [33,34]. So, it is important to differentiate between child work and child labor. Child work has been defined as activities that are supervised by an adult and that promote the development and growth of the child, while child labor does not benefit the child [31]. Many definitions of child labor create a dichotomy whereby child work is considered not harmful while child labor has negative emotional, intellectual, and social consequences [35]. Work that is exploitive for children has been defined as working long hours at a young age, work that is poorly compensated, and work that produces physical, social, and psychologic stress that will hamper development, access to education, and self-esteem [36]. The ILO adds that child labor is work that interferes, deprives, and interrupts schooling and places children in the position of trying to balance school and long work hours [34].

It is important to remember that child labor occurs in the United States. Runaway and homeless youths are at greatest risk, often lured by promises of work and housing [37]. The Polaris Project found that the top three forms of child labor trafficking in the United States were begging, peddling, and traveling sales crews [37].

CHILD CONSCRIPTION

In some cases of trafficking, children are kidnapped and trafficked to serve as soldiers. Other times, children are coerced by a narrative indicating they will be serving a higher purpose and avenge the deaths of family and friends; this is known as comradeship [38]. Some children are actively recruited and may be promised a small salary to "voluntarily" join. In a study of 132 cases of child conscription in Columbia, 18% of the children were motivated by perceived economic rewards [39]. Many children lack educational opportunities or hope for a better future, perceiving soldiering as the only option [38]. Conscripted girls often cite educational opportunities as a motive [38]. In Nepal, former female soldiers also indicated they were driven to volunteer in the armed groups by a fear that if they stayed with their families they would be married away as children or raped [38].

It is estimated that at any one time 250,000 to 300,000 children younger than 18 years of age are currently serving as child soldiers [40,41]. Traffickers prefer to recruit children to serve as soldiers because they are inexpensive and more easily molded and shaped to comply and obey without question [42]. They are also more likely to kill fearlessly and recklessly. Child soldiers are treated as adults, without any regard to how the physical and psychologic rigors of war will affect them psychologically and developmentally. In Uganda, where children are kidnapped or recruited as child soldiers relatively often, the Lord's Resistance Army has been known to initiate new child soldiers in brutal ritualized killings of others so as to terrorize them into submission and annihilate any moral conscience they may have about killing [42]. In Afghanistan, children have been recruited by the Taliban and have served as suicide bombers [28].

It can be difficult to comprehend the atrocities that these children witness and experience. Bayer, Klasen, and Adam conducted a study involving 169 former Ugandan and Congolese child soldiers who were an average of 15.3 years of age [43]. Almost all (92.9%) reported having witnessed a shooting, 89% witnessed someone wounded, and 84% witnessed someone seriously beaten. A total of 54.4% reported having killed someone, and 27.8% reported that they were forced to engage in sexual activity [43]. In another study, the researchers found that the experience of conscription among children produced significant emotional and psychologic traumas and a host of cognitive and behavioral problems [24]. In this study of 19 child soldiers, 18 had volunteered to join the army and one had been abducted. Although most of the children volunteered into the army, their participation became involuntary. Some tried to run away or disobey, which resulted in beatings and imprisonment. If captured, they were told to commit suicide [24]. The reintegration of child soldiers is not easy. Many are stigmatized when they return to their home villages, as their families and friends fear that these former child soldiers may be violent [41,44].

FACTORS THAT CONTRIBUTE TO HUMAN TRAFFICKING

GLOBALIZATION

Human trafficking has been called one of the "darkest sides of globalization" [45]. Globalization is the term used to describe the interconnectedness of countries and nations, which facilitates easy communication, exchange of ideas, and flow of goods, capital, and services [45]. Crimes such as human trafficking are affected by globalization just as legitimate businesses are [46]. Furthermore, the ideals of Western capitalism may reinforce human trafficking as a business or industry, with its emphasis on the free market and the flow of goods and services across international borders [46].

Globalization has also created the need for cheaper labor [28,47]. A study involving 160 countries examined the effects of globalization and human trafficking trends [48]. Researchers found a positive relationship between globalization and trafficking for forced labor, prostitution, and debt bondage.

POVERTY

Poverty and incessant economic stressors caused by civil wars, natural disasters, and collapses of government systems all contribute to human trafficking [18,23,49]. Families entrenched in deep poverty may feel they have no other recourse but to sell a child or may be more easily lured with promises of money and a better future [49,50,51]. In one study, the odds of being trafficked were nine times greater for those who felt extremely hopeless about upward mobility compared with those with lower levels of hopelessness [49].

SOCIAL AND FAMILIAL DISORGANIZATION

Community factors (such as high social disorganization characterized by violence, unemployment, and high crime) contribute to higher risk of trafficking [23]. In addition, families marked by instability (e.g., domestic violence, child abuse, continual unemployment) are also at higher risk of having a member trafficked [23].

CORRUPTION

Human trafficking cannot occur without the existence of corruption within existing infrastructures. Public officials, police officers, and local leaders in many developing countries have been known to take bribes to provide protection to parties involved in various aspects of human trafficking [45,48,52].

DIGITAL TECHNOLOGY

The rampant use of digital technology, such as the Internet, greatly facilitates sex trafficking. The relative anonymity of online contact can empower traffickers to recruit or sell victims. Graphic images of women and children engaged in sexual acts can be easily disseminated over the Internet [53]. Traffickers may employ the Internet for advertising, marketing to those interested in making pornography [53]. In addition, social media sites such as Facebook, Craigslist, and Instagram have been used as a means of facilitating trafficking (e.g., by connecting and grooming potential victims) [54,55,56]. Newsgroups offer opportunities for those interested in locating women and children for sexual exploitation.

In a qualitative study, smartphones were found to be integral in the business of trafficking [54]. Researchers indicated the phones were used "to maintain contact with each other, in order to facilitate the business 'transactions' and stay in touch with transnational 'partners' and other traffickers who remained in the country of origin" [54,55].

RACIALIZED SEXUAL STEREOTYPES

Race and ethnicity have been inextricably linked to sexual violence and victimization. Myths regarding sexuality in certain cultures or racial fetishization may affect trafficking patterns. For example, there is an over-representation of Asian women on American Internet pornography sites in part due to popular myths sexualizing, eroticizing, and exoticizing Asian women. This has translated into trafficking, as traffickers respond to the demand for young Asian women and girls in part fueled by these stereotypes of exotic, docile, submissive, and eager-to-please Asian women [30]. These stereotypes devalue and dehumanize people, which is the underlying core of human trafficking. This contributes to the acceptability of the exploitation of individuals, particularly members of marginalized groups [57].

These racial stereotypes go beyond simply framing the victims in a particular manner [58]. They raise implicit questions regarding how the powers of state are depicted. In other words, the patriarchal attitudes of certain countries lead to "bad" or "backward" cultural practices or ways of being that then cause trafficking—setting up is a dichotomy of the "West" and "others" [58].

CULTURE

Although many are careful in linking cultural factors to the etiology of human trafficking for fear of imposing judgment on a particular culture, many maintain that cultural ideologies that tolerate sexual trafficking, bonded labor, and child labor may be a stronger factor than poverty in predicting trafficking rates [30,36]. For example, some cultures emphasize collectivism and prioritizing the needs of the family and group first before the needs of the individual. Some children may feel they have to sacrifice themselves for their family when traffickers promise money [30]. Traffickers also know that they can threaten to hurt victims' families to keep them from escaping [30].

Furthermore, in many cultures, boys are more highly valued than girls, and as a result, girls are considered more dispensable [30]. Sons are considered the family's social security, staying with the family while daughters marry into other families. Therefore, girls may be more likely to be sold into slavery than boys.

Child labor is also inextricably tied to cultural factors. In India, for example, child labor is common because it is believed that children in the lower levels of caste system (i.e., the "untouchables") should be socialized early to understand their positions in society [36]. It has been observed that when traditional cultural and societal norms about women's roles were relaxed in some European countries and more women entered the labor force, child labor decreased [36]. Ultimately, it is difficult to unravel the effects of poverty and culture because the pressures of poverty can lead families to use tradition as a justification to sacrifice young men, women, and children [36].

Ultimately, the conversation about human trafficking is complex, and to attempt to isolate the causes is beyond challenging. Multiple factors have been suggested as possibly predicting human trafficking, including macroeconomic factors (e.g., gross domestic product per capita), unemployment rates, female inequality, cultural oppression, and lack of protection of women's rights [59,60]. In one study, ease of land access to the destination country appeared to be a powerful predictor in terms of the number of individuals trafficked [59].

THE TRAFFICKING EXPERIENCE

Five stages of the trafficking experience have been identified [61,62,63]:

  • Pre-departure stage: The period before the victim becomes involved in the trafficking situation. This may include recruitment and preparing for travel.

  • Travel and transit stage: The time after recruitment during which the victim "agrees" or is coerced into the trafficked situation. This phase also includes the journey whereby the trafficker(s) brings the victim(s) to their work destination. It is important to remember that this stage can be very dangerous and can involve numerous transit points.

  • Destination stage: This is the period during which the victim arrives at the intended destination. This stage is marked by exploitation, abuse, victimization, and coercion. One way to control the victims is to continually inflate their debt so they have to constantly work to pay it off. Another is to confine and isolate victims.

  • Detention, deportation, and criminal evidence stage: If a victim is arrested by the police or immigration authorities, victims are held in legal proceedings and they often fear deportation, and/or retaliation from the trafficker(s).

  • Integration and re-integration stage: During this stage, government and nongovernment agencies provide services to victims that involve a long process of attempting to reintegrate the victim back into his/her community.

TRAFFICKERS: AN OVERVIEW

Much attention has been focusing on victims of trafficking; however, it is important to also understand the perpetrators.

Methods of Recruitment

It has been suggested human traffickers employ five general strategies to recruit and traffic victims [64,65,66,67]:

  • Kidnapping: Traffickers may kidnap their victims. They may lure them with food or treats or take them by force. Victims with few if any social ties are highly vulnerable, as no one will miss them or report their disappearance.

  • Targeting poor families: Traffickers may convince families to sell their children (often daughters). Because many families in developing countries live in abject poverty, traffickers will stress to victims' families how the money will help them to survive. Other traffickers may tell families that selling their daughter will provide her with more promising opportunities.

  • Developing a false romantic relationship with victim: A tactic often used with young girls, perpetrators pose as boyfriends by romancing victims, buying gifts, and proclaiming their love. Victims have a difficult time believing that their boyfriends would hurt or deceive them, making them easy targets for trafficking.

  • Fake storefronts: Some employment, modeling, or marriage agencies are fronts for illegal trafficking operations. A potential victim might be lured with the promise of employment, a lucrative modeling contract, or an arranged marriage in the United States. After victims have been lured in, traffickers come to assess their "product." Perpetrators may be family members or friends.

  • Legal storefronts: Some legal businesses in the tourism, entertainment, and leisure industries integrate trafficking activities into their business structure.

  • Recruiting local prostitutes: Traffickers might purchase prostitutes working in local night clubs from brothel owners or simply lure prostitutes by promising them a more affluent future. Women working as prostitutes may later recruit younger victims.

The Financial Profits

Unfortunately, human trafficking can be a lucrative business. According to the ILO, profits from forced labor, trafficking, and modern slavery are estimated to be $150 billion annually [68]. The majority of this total is attributable to commercial sexual exploitation ($99 billion) followed by construction/manufacturing/mining ($34 billion), agriculture ($9 billion), and domestic work ($8 billion) [68].

The receiving country and location of trafficking will affect the profits. For example, if a girl is kidnapped from a village in Nepal and taken to India, she can be sold in India for $1,000 [64]. If she is then trafficked to the United States, she could be sold for $20,000.

Interestingly, the "cost" of a slave has not risen over time. According to Bales, the cost of obtaining a slave to work in the agriculture sector in 2007 was about $100; in 1850, this same slave would cost the equivalent of $40,000 in 2007 currency [69]. In one study, it was approximated that in the United States, a trafficker can make an average of about $300,000 per victim lifetime, which would total $32 billion annually [70]. Income in larger cities (e.g., Atlanta, San Diego, Washington, DC) may be even greater.

CONSEQUENCES OF HUMAN TRAFFICKING: IMPACT ON VICTIMS

The social realities of victims of human trafficking are difficult to comprehend, and some may wonder why victims remained silent and complied with their traffickers. The Silence Compliance Model was created to explore the factors that promote victims' seeming willingness to comply to their traffickers' demands [71]. This model has three categories: coercion, collusion, and contrition. Victims are coerced, brutalized, and threatened, and basic necessities of life are withheld from them. Methods of psychologic coercion include isolation, induced exhaustion, threats, degradation, and monopolizing perception [72]. This serves to silence victims and create a sense of helplessness. By isolating and controlling victims' movements and limiting their exposure to the outside world, traffickers have complete monopoly of their attention and perception of reality [72]. Victims are then forced to collude with the traffickers as a result of their relative isolation, fear, false sense of belonging, and complete dependence on the trafficker. Finally, victims feel contrite, ashamed, stigmatized, and remorseful of the things they have been made to do [71].

PSYCHOLOGIC AND MENTAL HEALTH CONSEQUENCES

Victims of trafficking experience a host of psychologic, mental health, and emotional distress. Depression, suicidal ideation, substance use, and anxiety are typically cited mental health problems [23]. Post-traumatic stress disorder (PTSD) is also common given the trauma many victims experience, including physical and/or sexual violence and abuse; victims forced into prostitution experience continual, daily sexual assault [73]. In a study of 192 European women who were trafficked but who managed to escape, the overwhelming majority (95%) disclosed that they experienced physical and sexual violence during the time of their trafficked experience [74]. More than 90% reported sexual abuse, and 76% reported physical abuse.

Trafficked victims experience fear from the start of their capture through the transit phase and after they arrive at their destination. During the transit stage, many victims experience dangerous border crossings, risky types of transports, injury, beatings, and sexual assault [61]. Upon arrival to their destination, many trafficking victims have been socially isolated, held in confinement, and deprived of food [75]. All sense of security is stripped from them—their personal possessions, identity papers, passports, visas, and other documents [61,75]. The continual fear for their personal safety and their families' safety and the perpetual threats of deportation ultimately breed a sense of loss of control and learned helplessness. It is not surprising that depression, anxiety, and PTSD are common symptoms experienced by trafficked victims.

In a study of 164 survivors of human trafficking who returned to Nepal, the authors examined the extent to which they experienced PTSD, depression, and anxiety [76]. All of the survivors experienced some level of these disorders, but the survivors who were trafficked for sex experienced higher levels of depression and PTSD compared to those who were not trafficked for sex. In a study with Moldovan survivors of human trafficking, researchers found that six months after their return, 54% had diagnosable mental health issue. Specifically, 35.8% met the diagnostic criteria for PTSD, 12.5% met the criteria for major depression, and 5.8% were diagnosed with an anxiety disorder [77].

There is also some evidence that trafficked victims may experience complex PTSD, a type of PTSD that involves an acute change of the victims' sense of self, their relationship with others, and their relationship with God or higher being [78]. These persons direct anger inwardly (toward themselves) in addition to toward their perpetrators, which results in a loss of faith in themselves and the world [63,75,78]. Perhaps due to self-directed anger and shame, some will engage in risky sexual behaviors, self-harm, and substance abuse. Some victims also have difficulty managing and expressing how they are feeling, while others experience dissociation [75].

Substance abuse is also common among victims. In interviews, trafficked women discussed how traffickers forced them to use substances like drugs and/or alcohol so they could work longer hours, take on more clients, and/or perform sexual acts that they could not normally [61]. Other victims used substances as a means to cope with their situations. Trafficked individuals who are gender and/or sexual minorities report shame, confusion, and sexual identity issues if forced into heterosexual relationships [63].

Children forced into labor experience grueling hours and are frequently beaten by their captors. According to Clawson and Goldblatt, underage victims of domestic sex trafficking fluctuate through a range of emotions from despair, shame, guilt, hopelessness, anxiety, and fear [79]. Depending upon the level of trauma, some engage in self-destructive behaviors like self-mutilation or suicide attempts. For some, their ambivalence toward the perpetrators may be confusing. On the one hand, they want to escape the abuse, yet simultaneously, they may have a sort of traumatic bond with the perpetrators [79].

Children forced into conscription will also experience a host of psychologic symptoms. In a study comparing former Nepalese child soldiers and children who were never conscripted, former child soldiers experienced higher levels of depression, anxiety, PTSD, psychologic difficulties, and functional impairments [80]. In another study of former children soldiers from the Congo and Uganda, one-third met the criteria for PTSD [43]. The researchers found there was a relationship between greater levels of PTSD symptoms and higher levels of feelings of revenge and lower levels of openness to reconciliation [43]. In-depth narrative interviews of former child soldiers from northern Uganda found that the children spoke of the violence and atrocities they witnessed without any emotion, as if they had removed themselves from their experiences [81]. This speaks to how the victims have to numb themselves psychologically in order to cope. The researchers also found that the children who lost their mothers were more traumatized by this experience than the violence they witnessed as soldiers.

Some have argued that the diagnostic criteria of PTSD may not be easily applied to those from different cultures. As a result, it is important to assess for other psychiatric disorders, such as depression. Japan, for example, never used the PTSD diagnosis prior to 1995, despite the fact that they have a large and intricate mental health system [82]. Ultimately, PTSD cannot be universally applied to every culture and for every humanitarian crisis; therefore, if a human trafficking victim does not necessarily fall within the Diagnostic and Statistical Manual of Mental Disorders criteria for PTSD, one cannot necessarily conclude that they have not experienced trauma or are not traumatized [82].

SOCIAL CONSEQUENCES

When rescued and attempting to reintegrate into their communities, victims of human trafficking often experience stigma, ostracism, and marginalization [80,83]. For example, in Nepal, community members perceived returning child soldiers who had performed acts such as carrying dead bodies or coed sleeping as in violation of Hindu cultural norms [80]. One documentary following former child soldiers living in a refugee camp in northern Uganda found that preconceived notions and myths about children soldiers often led to ridicule and ostracism after they were liberated from the army and returned home.

However, girls who were recruited as soldiers, who were forced to have sex, or who return with children appear to be the most marginalized group [84]. In a qualitative study of former girl soldiers in Sierra Leone, researchers found that, compared to returning boy soldiers, girls were perceived to have violated gender norms and values about sexuality. Although psychologically and developmentally they were still children, the community perceived and treated them as "damaged" or "unclean" women. Their communities were not able to integrate them back in despite the victimization they experienced. These girls lacked voice and experienced shame, marginalization, poverty, and powerlessness upon their return [84]. In a study of former child soldiers in Uganda, the children reported having difficulty finding jobs or getting married when they returned home. Girls who had been raped were stigmatized and made to feel unwelcome in their communities. Others stated that their community perceived them as murderers [44].

HEALTH CONSEQUENCES

In studies of trafficked women, headaches, fatigue, dizziness, back pain, pelvic pain, stomach pain, sexually transmitted infections (STIs), unwanted pregnancies, and gynecologic infections were common, generally the result of continual physical, psychologic, and sexual abuse [23,74]. Victims of labor trafficking also experience health issues related to the type of work, workplace conditions, malnutrition, and violence [85]. It is important to remember that some of these somatic complaints, such as headaches, fatigue, and gastrointestinal problems, may be underlying symptoms of anxiety, depression, and stress [74]. Some cultural groups might not use the terms "depression," "sad," or "anxious," but may use metaphors and somatic symptoms to describe their pain, all of which are embedded within cultural ideologies. The most common culture-based idioms of distress are somatic symptoms. Some groups tend not to psychologize emotional problems; instead, they experience psychologic conflicts as bodily sensations (e.g., headaches, bodily aches, gastrointestinal problems, and dizziness).

Using an in-depth, direct interview survey designed to explore each stage of the trafficking experience, a multi-country European study identified a range of aversive health, sexual, and reproductive consequences common among women and adolescent victims of human trafficking [61]:

  • Pre-departure stage: All victims reported having had limited knowledge of the health implications of having sex with strangers, and only 1 in 25 felt well-informed regarding the risks of acquiring HIV or other STIs.

  • Travel and transit stage: Half of those interviewed reported having been confined, beaten, and/or raped during the journey.

  • Destination stage: A large majority reported having been "intentionally hurt" (as evidenced by contusions, lacerations, loss of consciousness, and signs of head trauma); subjected to solitary confinement and deprived of human contact and adequate food and nutrition; subject to a variety of physical ailments, including headache, fever, undiagnosed pelvic pain, urinary tract infection, STIs, rash/scabies, and oral/dental health issues. All had experienced repeated sexual abuse or coercion, and 1 in 4 reported at least one unintended pregnancy (often involving negative outcomes of abortions performed in unsafe and unhealthy conditions).

In the context of forced prostitution among trafficked victims, safeguards against infection (e.g., regular condom use), early diagnosis, and adequate antimicrobial treatment are inconsistently employed or absent entirely [61]. Consequently, in addition to unwanted pregnancy, the risk for pelvic inflammatory disease and subsequent infertility is relatively high. Moreover, the relationship between forced prostitution and HIV infection is stronger when sexual violence is involved. Women who are forced into prostitution are 11 times more likely to become HIV-infected than women who entered prostitution voluntarily [86]. Sexual violence may increase the transmission risk as a result of open abrasions and injuries to the vagina. Furthermore, sexual violence can negatively impact self-esteem, which could then deter victims from advocating more strongly for condom use [86].

Among child victims of human trafficking, healthy growth and development is especially problematic. Malnourishment and poor hygiene often lead to delayed bone growth, poorly formed teeth, and early dental caries [87]. The intense nature of child labor also has severe negative physical and health consequences. Children working in unsafe conditions without protection, such as in mines or mills, can lead to respiratory problems such as asthma and bronchitis [88]. A study of adult and child laborers on tobacco farms in Kazakhstan found that the workers were unaware that exposure to tobacco and pesticides could affect their health. Protective garments were also rare, with many children not even having gloves [89].

Under normal circumstances, young children are still developing physically; however, such adverse conditions can halt their development. The lungs of adolescent boys typically experience the most rapid growth around 13 to 17 years of age; working in conditions characterized by excessive toxic dust or unclean air makes them more vulnerable to developing silicosis and fibrosis [88]. In the United States, young children participating in agricultural work are at risk of the major traumas associated with farm work, such as injuries caused by tractors or falling from heights, in addition to those injuries associated with repetitive stress and exposure to toxins. Children have thinner layers of epidermis, which make them more vulnerable to the toxicity of pesticides, and this can ultimately increase their risks for certain cancers [88]. Children working in gold mines do intensive digging, lifting, and transporting and mix mercury with the crushed ore, often with their bare hands. Mercury toxicity can lead to neurologic symptoms such as loss of vision, tremors, and memory loss [89].

IDENTIFICATION AND ASSESSMENT

Healthcare providers are often the most likely to encounter a victim of human trafficking under circumstances that provide an opportunity to intervene. Yet, many providers lack the training and confidence to identify and assist victims. In a survey of 110 emergency department physicians, nurses, and physician assistants, the majority (76%) reported having a knowledge of human trafficking, but only 13% felt equipped to identify a trafficking victim and only 22% were confident in their ability to provide satisfactory care for such patients [90]. Less than 3% had ever received any training on this topic. In a separate survey of healthcare and social service providers, only 37% had ever received training on identification of trafficking victims [91].

Because human trafficking and exploitation are, by nature, covert processes, the identification and rescue of the victim can be difficult. Traffickers move victims from one area to another to reduce the risk of identification, and one of the main problems with the assessment of such individuals is that practitioners may only have a one-time encounter with the victim [92].

POTENTIAL RED FLAGS

Bruises, scars, and other signs of physical abuse may be missed on examination, as victims are often beaten in areas hidden by clothing (e.g., the lower back) so as not to affect the victim's outer appearance. Physical trauma symptoms may be present, commonly on the torso, breast, and/or genital areas [70]. Burns, broken bones, pelvic pain, and/or STIs (particularly in children) may also be red flags [93]. However, more common physical injuries are also typical with other circumstances, making physical exam of limited value. The entire clinical picture should be considered.

It may also be helpful to assess for tattoos and/or other modifications (e.g., branding, piercings). Some perpetrators use tattoos to identify victims or to signify "ownership" [56].

With regard to episodic clinical encounters, recommendations for providing safe assessments in a culturally sensitive manner are lacking. The Department of Health and Human Services Administration for Children and Families maintains a useful website that addresses practical issues of human trafficking for allied professional groups, known as the Rescue and Restore Campaign [87]. Included are diagnostic and interviewing tips to help healthcare providers recognize, intervene, and refer trafficking victims. Emergency and primary care providers should be cognizant of clues that a patient may be the victim of trafficking and prepared to engage in greater depth of inquiry with special attention to the following indicators [87,93,94,95]:

  • Does someone, other than family, who behaves in a controlling manner, accompany the patient? Traffickers attempt to guard and control most every aspect of the victim's life, while maintaining isolation from family, friends, and other common forms of human interaction.

  • Are there inconsistencies in answers to basic questions (e.g., name, age, address)?

  • Does the patient speak English? If not, has he or she recently been brought to this country, and from where? Many victims of human trafficking have recently been trafficked from other countries. As discussed, common sending countries/regions include Eastern Europe, Asia, Latin America, Africa, India, and Russia.

  • If the patient is accompanied by someone other than a family member, who does the talking, and why? Attempt to interview and examine the patient separately and alone, using an interpreter if necessary. Probe in a sensitive manner for detailed information on the situation and relationship.

  • Does the patient show signs of psychosocial stress (e.g., appears withdrawn, submissive, fearful, anxious, depressed)? Can the individual account for this?

  • Are there visible signs of physical abuse (e.g., bruises, lacerations, scars)? How does the individual explain these?

  • Does the patient lack a passport or other immigration and identification documentation (e.g., driver's license, social security number, visa)? If so, what explanation is given? To control victims' movements, traffickers often take away passports and any legal identification documents.

  • What is the patient's home and work situation? Basic questions about what they eat, where they live and sleep, who else lives with them, and what work they do can be revealing. For example, "Can you leave your work or job situation if you wish?" or "When you are not working, can you come and go as you please?"

  • Is the explanation given for the clinical visit consistent with the patient's presentation and clinical findings?

  • Does the victim appear fearful when asked questions about citizenship, country of origin, immigration status, or residence? This may indicate a fear of deportation.

  • If the victim is a minor, is s/he in school? Living with parents or relatives? If not, what reasons are given for these circumstances?

SCREENING QUESTIONS

Examples of questions to screen for human trafficking include [96,97,98]:

  • Can you tell me about your living situation?

  • Has anyone ever threatened you with violence if you attempted to leave?

  • Does anyone force/require you to have sexual intercourse for your work?

  • Has anyone ever threatened your family if you attempted to leave?

  • Does anyone make you feel scared at work?

  • Are you free to come and go as you wish?

  • Does your home have bars on windows, blocked windows/doors, or security cameras?

  • How many hours do you work?

  • Have you ever worked without receiving payment you thought you would get?

  • Do you owe your employer money?

  • Do you have to ask permission to eat, sleep, use the bathroom, or go to the doctor?

The Polaris Project has developed a flow chart for the assessment of potential trafficking victims, available at https://www.traffickingresourcecenter.org/sites/default/files/Assessment%20Tool%20-%20Medical%20Professionals.pdf. If a person is thought to be a victim, one should follow workplace protocols and/or contact the National Human Trafficking Resource Center at (888) 373-7888 for next steps.

INTERVIEWING TRAFFICKED VICTIMS: BEST PRACTICE GUIDELINES

Service providers should repeatedly weigh the risks and benefits of various actions when interviewing human trafficking victims [65,99,100]. The following interviewing recommendations were published by the World Health Organization to encourage service providers to continually and ethically promote human trafficking victims' safety during every phase of the interviewing process [93,101]:

  • Each victim and trafficking situation should be treated as unique; there are no standard templates of experiences. Listen carefully to the victim's story. Each story told is unique, and each patient will voice distinctive concerns. Believe each story, no matter how incredible it may seem. As rapport and trust build (perhaps very slowly), accounts may become more extensive.

  • Always be safe and assume the victim is at risk of physical, psychologic, social, and legal harm.

  • Evaluate the risks and benefits of interviewing before starting the interviewing process. The interviewing process should not invoke more distress. In other words, the interviewing process should not end up re-traumatizing the victim.

  • Provide referrals for services where necessary; however, it is necessary to be realistic and not make promises that cannot be kept. Trust is vital because it has been severed on so many levels for trafficking victims.

  • Victims' readiness to change will not be based on what societal defines as "ready" or social expectations. Some victims will eagerly grasp new opportunities, while others may be fearful of potential traffickers' threat and be less receptive to help.

  • Determine the need for interpreters and if other service providers should be present during the interviewing phase. Ensure that everyone involved is adequately prepared in their knowledge about human trafficking, how perpetrators control their victims, and how to ask questions in a culturally sensitive manner. Keep in mind that often times, traffickers will offer to help with the interpreting. Using interpreters from the same community of the victim should be avoided to prevent breaches in confidentiality.

  • All involved should be prepared for an emergency plan. For example, is there a set plan for a victim who indicates he/she is suicidal or in danger of being hurt?

  • Always be sure to obtain informed consent. Remember the informed consent process is going to be unfamiliar to many victims. In addition, self-determination and autonomy have been compromised by continual threats and being forced to commit dehumanizing acts. Avoid using legal and technical jargon.

It is important to use a trauma-informed approach when assessing and caring for potential victims, which requires that practitioners understand the impact of trauma on all areas of an individual's life [102]. Physical, emotional, and psychologic safety is at the heart of trauma-informed care. Providers should assume that human trafficking victims are describing their reality to the best of their ability, given the trauma they have experienced. Responses and behaviors (e.g., being guarded, defensive, belligerent) may be coping mechanisms [102].

REPORTING

If screening and assessment findings indicate that an individual may be a victim of human trafficking, one should contact the National Human Trafficking Hotline at 1-888-373-7888. A text telephone (TTY) option for people who are deaf, hard of hearing, or speech impaired can be accessed by dialing 711. Reporting by text is available by texting the National Human Trafficking Hotline at 233733. Online chat is also accessible at https://humantraffickinghotline.org.

The National Human Trafficking Hotline collects information about the location of the trafficking case and the name of the suspected trafficker. The hotline will also request non-personally identifying information, such as the city and state of the reporter and how he or she learned of the hotline; reporting can be done anonymously. Reporters and/or victims are only asked to provide information they feel comfortable sharing, and the hotline does not share information with external agencies unless permission is given or when required by law. Hotline calls are managed by anti-trafficking hotline advocates, who are specifically trained. After receiving a report of suspected human trafficking, the National Human Trafficking Hotline will assess each case individually to determine if a case should be reported to a local, state, or federal investigative and/or service agency equipped to investigate the tip and/or respond to the needs of the potential victim.

Under the child abuse laws, practitioners who are mandated reporters and who are suspicious that a minor is being abused should immediately report the abuse. Persons in Florida who know, or have reasonable cause to suspect, that a child is abused, neglected, or abandoned must immediately report such knowledge or suspicion to the Florida Abuse Hotline of the Department of Children and Families at 1-800-96-ABUSE.

INTERVENTIONS AND RESOURCES

EDUCATION AND PREVENTION

Education is believed to be a key ingredient in the prevention of human trafficking. Raising awareness through advertisements, campaigns, and other creative vehicles regarding recruitment threats, the various deception techniques employed, the different forms of human trafficking, and the consequences of human trafficking can decrease the incidence [64,103]. Because the general public often believes human trafficking is a problem that only occurs in developing countries, there is a clear need for public education about trafficking and safety for young children and women in and outside the United States [22]. The Campaign to Rescue and Restore Victims of Human Trafficking provides brochures and posters about human trafficking, which are available to be ordered (at no cost) from https://www.acf.hhs.gov/archive/otip/resource/about-rescue-restore [87]. Posting these brochures or posters increases the possibility that a trafficked victim will self-report [100].

Education about human trafficking has become a higher international priority. Innovative and creative approaches are being implemented to disseminate information about human trafficking, particularly how perpetrators recruit high-risk groups (e.g., youths with disabilities, runaways) [67]. For example, groups have used street plays to educate communities about child labor dangers in India [104].

Although the topic of human trafficking has become more common in public discourse, service providers and law enforcement authorities remain under-educated about human trafficking. They are not sure what to look for, what to ask, and what to do if they do identify individuals who are victims of human trafficking [103]. Law enforcement officials require training to identify and assess potential victims at various borders and ports of entry. If a minor is accompanied by an adult who is not the child's parent or legal guardian, this should raise a red flag [103]. Furthermore, to work effectively to identify human trafficking victims, there is a need for service providers to navigate and collaborate with a complex host of government, social service, mental health, and nongovernment legal entities [103].

MENTAL HEALTH AND SOCIAL SERVICES

Care and services provided to victims can be organized into three distinct categories: immediate and concrete services at the time of rescue; services related to recovery; and long-term services pertaining to reintegration [105]. When trafficking victims are rescued, a great deal of counseling services and practical, day-to-day assistance will be required. Housing, transportation, food, clothing, medical care, dental care, financial assistance, educational training, reunification (for those who wish to return to their homeland), and legal aid are some of the concrete services needed [71]. Practitioners should connect, coordinate, and case manage these services as much as possible. During this stage, it is also important to understand victims' needs, their strengths, and their risks and vulnerabilities [75].

Safety planning is also crucial in the immediate rescue stage. Traffickers may be continuing to try to locate some victims; placing victims in safe houses may be necessary [63]. The National Human Trafficking Hotline encourages that safety planning be based on the unique needs and circumstances of the individual.

During the recovery and reintegration stages, as discussed, human trafficking victims experience an array of mental health and psychologic issues. Mental health counseling is vital, but it is important to remember that the concept of counseling or talk therapy may be foreign to victims from non-Western cultures [65]. The expression of emotions may be in opposition to cultural values of emotional restraint, which can be intensified by feelings of shame and guilt resulting from experiences with sexual and physical assault. Beyond the paramount importance of the practitioner gaining the patient's trust, practitioners may educate patients about the counseling process and explore their patients' expectations about counseling, healing, and recovery [106]. As noted, victims' symptoms may not only be a manifestation of the trauma but also coping mechanisms to cope with self-blame, shame, and trauma [56].

Given differing cultural beliefs about healing, it is crucial that practitioners be open to alternative treatment and explore with patients the use of traditional healing methods [65]. There are many indigenous healing interventions victims may be using, including cultural rituals, faith healing, therapeutic touch, herbal remedies, and spiritual practices [107]. These interventions are multi-layered, taking into account the physical, psychologic, communal, and spiritual [107]. These healing methods are historically rooted in specific cultures, and therefore, practitioners should become familiar with traditional healing methods and how they can be integrated with Western counseling techniques [106]. For example, given many cultural groups' beliefs that unmarried girls are defiled if raped, a cultural cleansing ritual may be needed as a first step to help a community accept a returning victim who was sexually assaulted during her trafficking experience [30]. After this ritual is performed, it is possible that both the patient and her family may be more open to counseling and other services.

Other trauma interventions that might be beneficial include cognitive-behavioral therapies, eye movement and desensitization reprocessing therapies, mindfulness techniques, and expressive therapies [56,63].

Physicians, social workers, nurses, therapists, and counselors must be familiar with legal, case management, educational, job and life skills training, and housing services in the community. Human trafficking victims are not only unfamiliar with navigating the social service system, but many are also not proficient in English. Therefore, practitioners will serve as coordinators and advocates, linking necessary services. In one study, the majority of agencies had to rely on collaboration in order to refer clients [108]. Social workers and practitioners relied on word-of-mouth and community meetings to learn about services in order to better meet the needs of human trafficking victims. Furthermore, because many community organizations and agencies are not familiar with human trafficking, practitioners must take a primary role in educating colleagues about the complex dynamics of human trafficking.

It is important to remember that the evidence supporting interventions and therapies for victims of human trafficking is in its infancy [105]. Most efficacy studies of therapies and interventions do not involve experimental designs, which makes it difficult to draw definitive conclusions regarding efficacy. Future work is needed to develop and evaluate interventions that address the multilayered and complex needs of human trafficking survivors.

ADVOCACY

Physicians, social workers, nurses, allied health professionals, counselors, and psychologists will find themselves in multiple roles when working with victims of human trafficking. Advocacy is one of these roles and involves the practitioner being an agent for change. This consists of engaging in activities that alter the social conditions at the individual, family, community, and institutional levels [109]. One way to advocate on behalf of human trafficking victims is by signing petitions or joining credible organizations concerned with changing the circumstances that lead to human trafficking. Many organizations have petitions established on their websites for individuals to persuade policymakers, legislators, and government officials to advocate for the protection of human trafficking victims, create greater awareness of the problem, and prosecute traffickers, including:

LAWS AND POLICIES

Justice for Victims of Trafficking Act

In 2015, the Justice for Victims of Trafficking Act (JVTA) became law, allowing survivors formal input in federal anti-trafficking policy and providing incentives for states to enact laws to prevent the prosecution of child victims for crimes committed as a direct result of being subjected to trafficking. The JVTA provides additional bases of criminal liability for those who patronize or solicit trafficking victims for commercial sex and creates a new offense prohibiting the advertising of sex trafficking activity. It also clarifies that traffickers in child sex trafficking cases who had a reasonable opportunity to observe the victim can no longer claim ignorance about a victim's age as a defense [24]. Some provisions of this law are scheduled to expire in 2019 and 2020 [110].

Victims of Trafficking and Violence Protection Act

A wide range of laws have been established to protect human trafficking victims and to prosecute perpetrators. A general knowledge of these laws is helpful when caring for victims and seeking appropriate social services. The TVPA was enacted in 2000 and reauthorized in 2003, 2005, 2008, 2013, and 2018 by the Trafficking Victims Protection Reauthorization Acts [24]. It emphasizes the three Ps: prevention, protection, and prosecution [111]. The prevention component consists of training and awareness; the protection dimension gives trafficked victims the ability to receive services using federal funds like other refugees; and the prosecution component focuses on laws and policies for the prosecution of traffickers.

Because victims of trafficking are often viewed as criminals, this law states that victims of severe trafficking should not be penalized for any illegal behaviors or acts they engaged in as a result of being trafficked, including entering the United States with false documents or no documentation or working without appropriate paperwork [64]. This law also allows T Nonimmigrant Status (T visas) to be granted to victims of trafficking so they may remain in the United States with the purpose of collaborating with the federal authorities to prosecute the perpetrators. During this time, victims are offered a range of benefits and services, including access to the Witness Protection Program [64]. After three years, victims can apply for permanent resident status [16].

One of the criticisms of the Act is that it places the burden of demonstrating innocence and coercion on the victim [112]. The Act also fails to recognize the complex dynamics of human trafficking. For example, it focuses more on sex trafficking versus other forms [113]. Many victims have been abused and terrorized by the perpetrators, who they must now provide information and evidence against to stay in the country. Victims are continually fearful that they will be deported [112].

Victims who are of minor age are eligible for Unaccompanied Refugee Minors programs, the Children's Health Insurance program, and Temporary Assistance to Needy Families [103]. Furthermore, victims between 16 and 24 years of age are eligible for work permits and can apply for the Job Corps program [103]. However, it is important to remember that the key to this law is that the victim must have experienced a "severe form" of trafficking and the victim must be willing to assist in the apprehension and prosecution of the perpetrator to receive services [114].

Preventing Sex Trafficking and Strengthening Families Act

The Preventing Sex Trafficking and Strengthening Families Act was signed into law in 2014. In accordance with this law, child welfare agencies are required to monitor and report the number of child sex trafficking victims. Cases of suspected or known child sex trafficking must also be reported to law enforcement [37].

Trafficking Victims Protection Reauthorization Act

The Trafficking Victims Protection Reauthorization Act was introduced and signed into law in 2013. It allocated $5 million in 2009, $7 million in 2010, $7 million in 2011, and $8 million annually through 2017 to provide services to victims and to prevent human trafficking [22,115,116]. It amends the TVPA and assists foreign governments to implement programs to prevent human trafficking. Victims of human trafficking in other countries are also eligible for assistance through organizations that have grants from the U.S. government [115]. Greater monitoring of trafficking trends through databases will also be implemented. The Act also declares that it is not a defense that a defendant is not criminally liable or is subject to reduced criminal liability due to acceptance of the illicit conduct in the foreign jurisdiction.

The Prosecutorial Remedies and Other Tools to End the Exploitation of Children Today Act

The Prosecutorial Remedies and Other Tools to End the Exploitation of Children Today Act was enacted in 2003. This law maintains that all sexual activity with minors, within or outside the United States, is illegal. American citizens who engage in sex with minors in any country and who are caught will be prosecuted in the United States [64].

As of 2017, all 50 states have enacted criminal anti-trafficking laws. In addition, every state has a law on labor trafficking, and all have passed criminal statutes for sex trafficking [117].

SOAR to Health and Wellness Act

The SOAR (Stop, Observe, Ask, and Respond) to Health and Wellness Act was signed into law in 2018. It directs the Department of Health and Human Services to develop a program to train healthcare providers and practitioners to identify possible human trafficking victims, to work with law enforcement agencies, and to refer victims to services [7].

Florida House Bill 369

In 2015, The Florida Legislature passed House Bill 369, which mandates the display of a human trafficking public awareness sign in a wide range of locations, including [118]:

  • Every public rest area, turnpike service plaza, weigh station, primary airport, passenger rail station, and welcome center in the state

  • Emergency rooms at general acute care hospitals

  • Strip clubs or other adult entertainment establishments

  • A business or establishment that offers massage or bodywork services for compensation that is not owned by a healthcare professional

The sign must contain text, in both English and Spanish, regarding the steps to take if you or someone you know is the victim of trafficking, exploitation, and/or forced labor.

RESOURCES

For more information and to become involved in advocacy movements, please utilize the following resources. In some cases, the tools provided may be valuable for patient and/or peer training. In particular, the National Human Trafficking Hotline provides free, downloadable awareness materials for victims, first responders, and healthcare and mental health professionals, including a flyer available in 20 languages.

Alliance for Children in Trafficking
https://www.napnappartners.org/provider-public-resources
Coalition to Abolish Slavery & Trafficking
https://castla.org
Coalition Against Trafficking in Women
http://www.catwinternational.org
Futures Without Violence
https://www.futureswithoutviolence.org
HEAL Trafficking
https://healtrafficking.org
Human Rights Watch
https://www.hrw.org
International Justice Mission
https://www.ijm.org
International Labour Organization
https://www.ilo.org
Office of Refugee Resettlement
https://www.acf.hhs.gov/orr
National Human Trafficking Hotline
https://humantraffickinghotline.org
Polaris Project
https://polarisproject.org
Salvation Army
https://www.salvationarmyusa.org
Sex Workers Project
http://sexworkersproject.org
United Nations Office on Drugs and Crime
Human Trafficking Knowledge Portal
https://sherloc.unodc.org/cld/en/v3/htms/index.html
U.S. Department of Health and Human Services
Administration for Children and Families
https://www.acf.hhs.gov
U.S. Department of Health and Human Services
Administration for Children and Families
SOAR to Health and Wellness Training
https://www.acf.hhs.gov/otip/training/soar-to-health-and-wellness-training
Services Available to Victims of Human Trafficking: A Resource Guide for Social Service Providers
https://www.acf.hhs.gov/otip/resource/services-available-to-victims-of-human-trafficking
U.S. Department of Justice
Bureau of Justice Assistance
https://www.bja.gov
U.S. Department of Justice
Office for Victims of Crime
https://ojp.gov/ovc
U.S. Department of Labor
Bureau of International Labor Affairs
https://www.dol.gov/agencies/ilab
U.S. Department of State, Office to Monitor and Combat Trafficking in Persons
https://www.state.gov/bureaus-offices/under-secretary-for-civilian-security-democracy-and-human-rights/office-to-monitor-and-combat-trafficking-in-persons

CONCLUSION

Human trafficking is a severe human rights violation. Because the roots of human trafficking are multifaceted, no one solution exists to eliminate this problem. Unfortunately, as the problem grows, practitioners will be confronted with the issue in their patient populations. Practitioners should be committed to the collaboration amongst disciplines to address poverty, racism, discrimination, and oppression in order to reduce the vulnerable positions of human trafficking victims and their families. Because of the social justice component in the codes of ethics of professionals such as physicians, nurses, social workers, psychologists, and counselors, all practitioners can play a key role in the individual, community, and systemic levels to help address this gross abuse of power. One way to begin is to educate oneself and one's respective disciplines about the global nature of human trafficking and the complex dynamics of the problem.

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Evidence-Based Practice Recommendations Citations

1. Clinical Effectiveness Group. UK National Guidelines on the Management of Adult and Adolescent Complainants of Sexual Assault, 2011. London: British Association for Sexual Health and HIV; 2012. Available at https://www.bashhguidelines.org/media/1079/4450.pdf. Last accessed August 15, 2019.


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