Human Trafficking: A tragic public safety issue- victims need care

Nurses are considered mandatory reporters for suspected minor age (under 18) human trafficking victims.

"....and a crime against humanity..." Cheryl Green MSN, RN, CNL

"...many victims suffer from chronic untreated diseases, such as tuberculosis, diabetes or asthma, as well as infestations, poor dentition, dehydration, and malnutrition."

"Victims who are immigrants were probably told that authority figures are the enemy and will seek to arrest or deport them."

Although Republicans are obstinately resistant to progressive changes in the US immigration laws, the facts are accumulating to show how human trafficking is becoming a public safety issue and even tangentially related to illegal immigration, because victims often feel like they're criminals. In fact, while illegal immigrants are worried about being deported, the victims of human traffiking are frightened, because they must hide in the shadows or face criminal charges, plus deportation. Moreover, many of them are physically and emotionally ill, suffer from post-traumatic stress disorder and are victims of domestic violence.

A nurse may be a victim's only point of contact outside of captivity. It's mandatory for nurses to report human trafficking of minor age children.

In other words, human trafficking is the darkest side of the illegal immigration issue. Worse, it's unlikely the trafficking will stop, just because immigration reform happnes to be resolved.

Public health is at risk for infectious diseases with this growing trafficking problem, because the victims of are usually living in poverty, or worse, and not receiving the benefit of medical care. They're a lost population. 

In the magazine, American Nurse Today, an article by Cheryl Green, MSN, RN, CNL, defines the human trafficking issues.
She calls it a "crime against humanity". 

IN MOST WAYS, human trafficking (modern slavery) is no different from slavery of ancient times: it's brutal, highly profitable business with  no regard for its victims. Trafficking is a crime but it's often difficult for medical providers to recognize the victims and to identify how to help them.

Human trafficking falls into two broad categories:
1.  Labor trafficking- typically is either forced hard labor, usually in agriculture or textile sweatshops; or domestic labor, such as working as a nanny or house servant.
2.  Sex trafficking - involves forced work in strip clubs, massage parlors, pornography production or prostituion. It also may involved  mail-order brides.  

"Human trafficking: Preparing for a unique patient population", by Green describes the most prevalent form of slavery in the United States being "sex trafficking". 

An estimated 14, 500 to 17,500 people are trafficked into the US annually and 100,000 to 200,000 American minors are exploited in the sex industry. Worlwide, 2 million children and young women are trapped in sex slavery.  

Consequences for the victims 
Human trafficking victims face grave physical and emotional dangers every day. Research suggests initial gang rape is a common method of recruitment into slavery. Threats of repeated rape, if the victim doesn't comply with demands, are common.  Some victims rescued from the sex trade report customers who didn't like condoms and paid extra to avoid using them.  This puts victims at great risk for sexually transmitted infections, unplanned pregnancy and physical trauma from rape.

Physical abuse, rampant in the trafficking business, is a primary means of forcing victims to comply. A study of European trafficking victims found about 75 percent were kicked, punched in the face, burned with cigarettes, hit with objects, dragged by their hair or struck in the head. More than half had post-traumatic stress (PTSD) disorder. Also, many victims then abuse or become addicted to the drugs or alcohol, given to them by their traffickers (sometimes by force) to control them. What's more, many victims suffer from chronic untreated diseases, such as tuberculosis, diabetes or asthma, as well as infestations, poor dentition, dehydration, and malnutrition.

These facts underscore the immediate and imperative need for healthcare advocacy for victims. Unfortunately, caregivers, nurses, the public at large or public safety professionals may have limited knowledge about how to identify victims of human trafficking, especially in the healthcare setting.

Helping to rescue victims
A nurse may be the trafficking victims only point of contact with the environment outside of captivity. To help rescue victims from a horrific life they didn't choose, healthcare providers need to become knowledgeable about this crime against humanity.

Implications for nurses
In 2014, Katherien Chon, senior adviser on Trafficking in Persons, for the US Dept. of Health and Human Services, testified before Congress that roughly 75 percent of trafficked women saw a healthcare provider while they were in captivity. In most cases, this provider was in an emergency department (ED). Indeed, they are obviously seen in the most expensive emergent care setting without opportunity for follow up or access to primary preventive care.

Nevertheless, many trafficking victims can be identified in other settings where health clinics, acute-care hospital units, dental offices and jails.  This encounter may be a victim's only possible entry point into the social safety nets, yet many many trafficking victims aren't identified as such in healthcare settings. Once this opportunity to identify them is lost, it may never arise again, because traffickers typically don't allow visits to care providers unless a victim's health is so precarious that she or he can't work.

Even victims who seek care may go unrecognized or be mistaken for domestic violence victims, drug addicts or prostitutes.  

Failure to identify a trafficking victim in a health care facility can lead to tragic consequences or even death for that person.  

Nurses are front line caregivers and therefore have the opportunity to identify victims and refer them to appropriate resources.

Recognizing trafficking victims
Although human trafficking and domestic violence victims share some common presentations, important differences exist. For example, domestic violence victims usually fear one abuser, whereas trafficking victims may fear many people because they may have multiple abusers.  (If a victim is assessed for having poorly healed fractures or signs of repeated strains, this is an assessment for trafficking....)

Victims who are immigrants probably have been told that authority figures are the enemy and will seek to arrest or deport them.

Consequently, they may fear a uniform, including a nurses uniform. Also, trafficking victims tend to be more isolated than domestic violence victims, to suffer disease or malnutrition and to have little or no family contact. Also, they're more likely to be victims of substance abuse.  

Some victims, although cognitively intact, may be unable to verbalize their current location, if asked. This is especially true of those trafficked into the United State from other countries. Not only are the victims in unfamiliar surroundings, but they may see little of their outside world and may not even know where they are.

Be aware that adults and children who've been coerced into prostitution in the United States aren't (not!) considered criminals. On the contrary, they're victims of human trafficking and protected under the federal Trafficking Victims Protection Act. 

In fact, persons younger than age 18 who are involved in commercial sex exploitation fall into the legal criteria for minor sex trafficking, their traffickers are prosecutable under the law. Nurses are considered mandatory reporters for suspected minor (under 18) human trafficking victims.

Approaching a suspected victim
If you suspect a person or patient of yours is a trafficking victim, consider how to best approach him or her. Never ask outright if she or he is a trafficking victim, especially if a companion is present. Most victims probably don't know what the term "trafficking" means. What's more, few people, no matter how dire their circumstances, want to be called a victim, because they're trying to retain as much dignity as possible. 

If a patient doesn't speak English, call for a medical interpreter.
Be prepared for the companion to insist that he or she can interpret, but decline this offer, explaining that facility policy allows only for certified medical interpreters. Also, consider cultural factors. For example, female victims from patriarchal cultures typically are unwilling to speak for themselves, the same, of course, for minors.

Anticipate that victims will resist help. Feelings of intense fear, shame, and helplessness may even compel some to try to leave the facility without treatment. In some cases, a companion who senses that authorities suspect the true nature of the situation may force the victim to leave. Therefore, if you suspect trafficking, make sure a staff member stays with the victim at all times. (In fact, one way to assess the risk of a person being a trafficking victim is the sense that he or she is under surveillance, at all times.)  Keep in mind, of course, that many immigrants and other foreigners can't read, write or speak Englsh and are accompanied to the hospital by companions who speak for them, yet are not trafficking victims. Consequently, be careful not to base a trafficking assessment solely on these characteristics -  but diligence to the issue will alert the nurse to any unusual interacton or situation.

Human trafficking victims don't receive preventive helth care, so by the time emergency or clinic providers encounter them, many health conditions may have become serious and vcitims may be in dire health circumstances. With this in mind, conduct a head-to-toe nursing assessment, providing as much privacy & comfort as possible.  

Asking certain questions can help determine if the patient is a trafficking victim, without causing fear or alienation.

Be aware that repeated violent penetration may  cause vaginal or anal fistulas. Even young women may have bowel or bladder incontinence, or both.  Many trafficking victims have positive drug screens, infectious diseases, live or scabies infestations or tattoos with brands of gang symbols, trafficker initials or even barcodes.


Psycho-social issues are prevalent among this population. Although victims may have pronounced anxiety or panic, some may even be stoic, almost to the point of complete withdrawal.

Finally, lack of trust may lead victims to suspect you're trying to trap them into revealing information as a test of loyalty to the trffficker, putting the victim, or the victims's family, in danger. Establishing trust is difficult but crucial (!) because the trafficker most likely is the only person the victim feels they can trust and rely on.

Cheryl Green is a cardiac/medical-surgical nurse at Cone Health Alamance Regional Medical Center in Burlington, North Carolina.

The National Human Trafficking Resource Center is a resource for more information:  1-888-373-7888,  Consider posting the phone number where patients can see it.