The Hard Truth About Human Trafficking

Abstract

Human trafficking is a vicious crime against a person’s human rights and has been denoted as a form of modern-day slavery. Globally, it has become a $12 billion industry and about 14,500–17,500 victims are trafficked in the United States annually. Trafficked victims are subjected to physical, sexual, and psychological abuse through forced labor, commercial sex, and slavery–like practices. Traffickers sell, trade, and exploit victims using violence and coercion as their means of control. Healthcare providers, especially forensic nurses, are one of the few groups of professionals likely to interact with trafficked victims while they are still in captivity.
Forensic nurses have the best opportunity to screen, identify, intervene, and rescue these victims. Once identified, victims should be referred to systems and supports where they can obtain the much needed physical and psychological care. More research on the field of human trafficking is needed in order to collect empirical data and continued the development of practices for effective development of policies, victims’ response, and service model approaches among health care providers and law enforcement agents.

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t’s estimated that 14,500 to 17,500 individuals
are trafficked in the United States each year;
globally, this crime is a $12 billion industry.1,2
Traffickers sell, trade, and exploit victims
using any means of control, subjecting them
to isolation, violence, and intimidation.
Traffickers may lure victims with empty
promises of employment and a dreamlike
life, when in reality, victims are forced,
defrauded, or coerced into commercial sex or
involuntary labor.
Modern day slavery
The United Nations defines human trafficking as:
“The recruitment, transportation, transfer, harboring
or receipt of persons, by means of the 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 exploi-
tation. Exploitation shall include, at a minimum, the
exploitation of the prostitution of others or other forms
of sexual exploitation, forced labour or services, slavery
or practices similar to slavery, servitude, or the
removal of organs.”3
I
By Rosario Sanchez,
RN, CCRN, FN-CSA,
and Sharon W. Stark, PhD,
RN, ANP-BC, CPG, GNP-BC
human
traffic
king
2.0
CONTACT HOURS
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The hard truth about human trafficking
20
January 2014 • Nursing Management www.nursingmanagement.com
The underground nature of this
crime must be revealed to the public
and healthcare workers, especially
forensic nurses who can take a lead
role in identifying, interviewing,
and advocating for victims.1
Trafficker/victim dynamic, stages
Force, fraud, and coercion are the
methods used by traffickers to com-
mit the crime of human trafficking.
The process includes attaining and
maintaining control of victims for
the purpose of servitude, slavery,
and debt bondage.4 Force may
include rape, beating, captivity,
and/or isolation to control the victim.
The early period of victimization is
often referred to as the “seasoning
process” in which the traffickers
gain total control through violence.5
Victims are often terrified and
succumb at the hands of their
traffickers.1
Fraud involves false offers of
employment and promises of a
better life. For instance, women and
adolescents may be promised legiti-
mate opportunities such as mar-
riage, modeling careers, or jobs as
a nanny in another country.6 Once
they arrive, victims are forced into
activities such as sexual slavery,
domestic servitude, agricultural
labor, sweatshop factory work, and
panhandling.1
Coercion often involves threats,
debt-bondage (when a trafficker has
control of the victim until a trans-
portation fee from another country
is paid), and psychological manipu-
lation. A victim may be threatened
with injury or death if he or she
doesn’t comply with the traffickers’
demands. Traffickers generally take
away all of their victims’ travel
documents, and keep them isolated
to make escape nearly impossible.6
Traffickers use isolation to manipu-
late victims, making them psycho-
logically vulnerable due to lack of a
support system.7 In addition, many
victims don’t seek assistance or
ask for help because they lack the
knowledge and/or language to do
so. Victims learn survival skills in
order to make a better life for them-
selves at the hands of their traffick-
ers, but at some point victims reach
total mental defeat and hopelessness.8
Traffickers work cautiously to
entangle victims and secure their
dependency. The progression of
human trafficking can be described
in a couple of stages. The first stage
is the “process of initiation.” Traf-
fickers spend time developing the
submissive and workable victims
who are easier to control.5 The
second stage is “indoctrination,”
during which traffickers use their
authoritarian status to further retain
control and build a community with
its own rules. Preference may be
displayed to some victims within
the group to manipulate and retain
victims’ loyalties.9 (See Table 1.)
Legal framework
In 2000, Congress passed the human
trafficking legislation, the Traffick-
ing Victims Protection Act (TVPA),
which set forth a clear definition and
Table 1: Stages of human trafficking
Stage I: Initiation
Emotional coercion includes pretense of love of the victim and presenting gifts
such as clothes or a phone call to family.
Once emotionally involved, victims are vulnerable to manipulation by the traf-
ficker or trafficking partner to perform sexual acts for love and monetary needs.
Victims are brainwashed to believe that their treatment and living conditions
are normal, so they become more submissive.
Little resistance by victims leads to emotional and physical abuse.
Traffickers use pejorative remarks to demoralize victims and belittle self-worth.
New victims are forced to watch physical abuse, forced sexual acts, rape, and
torture of other victims to ensure adherence and obedience.
Victims’ lives are out of their control so the means to their survival is to do
as they’re told.
Coercive acts of physical abuse/torture keep victims fearful and easy to control.
Stage II: Indoctrination
Authority of traffickers retains control as community is built with own rules.
Trafficker’s display favoritism to certain victims in a group to manipulate and
retain victims’ loyalties. (Trafficker may rotate favorites to create confusion and
discord among victims.)
To ensure unbreakable control, the trafficker diminishes trust and friendship
between victims.
Victims are kept emotionally and physically on edge to create an invisible
bond, where the trafficker may be seen as the potential source of comfort and
humiliation at the same time.
Adapted from:
Buncab I, Heirendt A. Human trafficking. In: Ledray LE, Burgess AW, Giardino AP. Medical Response to Adult Sexual
Assault: A Resource for Clinicians and Related Professionals. Saint Louis, MO: STM Learning Inc.; 2011:357-396.
Crane PA, Moreno M. Human trafficking: what is the role of the health care provider? Journal of Applied Research on
Children: Informing Policy for Children at Risk. 2011;2(1):1-27.
Demir O. Methods of sex trafficking: findings of a case study in Turkey. Global Crime. 2010;11(3):314-335.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

www.nursingmanagement.com Nursing Management • January 2014
21
outlined the differences between
human trafficking and smuggling at
the federal level. Since its induction,
it has been reauthorized to become
an affirmative victim-centered law.10
In addition to increasing criminal
fines for human trafficking and pro-
viding immigration relief to victims,
it also created a set of benefits for
undocumented victims. As a result,
undocumented victims are entitled
to the trafficking victim protection
visa (T-visa). A T-visa allows traf-
ficking victims the right to live and
work in the United States for 3 years,
after which they may be eligible to
apply for a permanent visa. Under
this bill, victims are also eligible for
physical and mental health services,
housing, food stamps, education,
and legal services.10
Many advocates of TVPA support
the federal level benefits, but a gap
in the legislation still remains at
the state level. For example, a sex-
enslaved victim may be charged
with prostitution when arrested by
law enforcement and prosecuted at
the state level. Subsequently, the
victim is caught in legal limbo as a
victim of human trafficking under
federal law, but charged with pros-
titution under state law. Therefore,
the creation of state antitrafficking
legislation such as the “Safe Har-
bor” laws are imperative to aid in
the investigation and prosecution
of traffickers by local and state law
enforcement.10 Some states are legis-
lating criminal statutes addressing
human trafficking, but much more
work is still needed to expose this
inhumane crime.
At the international level, the
Department of State Office to
Monitor and Combat Trafficking in
Persons leads the U.S. global com-
mitment to fight against human
trafficking. Effective international
policies to combat human traffick-
ing include partnering with foreign
countries such as Cyprus and Costa
Rica.11 The Office to Monitor and
Combat Trafficking in Persons
supports the fight against human
trafficking through its recommen-
dations in the annual Trafficking
in Persons (TIP) Report. These rec-
ommendations are country-specific.
The TIP Report is the U.S. govern-
ment’s diplomatic tool to involve
foreign governments in human
trafficking issues; it’s the world’s
most complete resource of antihu-
man trafficking efforts and reflects
the U.S. commitment to global
leadership on crucial human rights
injustice and law enforcement
issues.12
Health issues
Human trafficking victims rarely
seek medical care. However, when
medical care is needed, the ED is
often the primary choice for treat-
ment. An ED visit might be the
only opportunity to identify victims,
meet their immediate needs, and
develop a plan with the interdisci-
plinary healthcare team and law
enforcement officials to rescue the
victim and hopefully apprehend
the trafficker.13
Victims of human trafficking are
exposed to numerous health issues.
Most victims present with some
kind of physical trauma usually
resulting from forced manual labor
or from direct physical violence by
the trafficker or his or her clients in
order to control the victim.9 Any
form of bodily injury may be a
result of extreme physical stress.
Cigarette burns, fractures, bruises,
contusions, and other burns are
common injuries secondary to
physical violence.1 Nonetheless,
healthcare providers should pay
close attention to any bodily injury
that doesn’t correlate with the his-
tory provided by the victim. Many
victims have tattoos that clearly
brand them to a particular traf-
ficker.14 This might expose victims
to infection with hepatitis and
other bloodborne diseases.
Also, victims may present to
the ED with complaints of a genito-
urinary and reproductive nature.
Adult and children victims of
sex trafficking are at high risk for
acquiring multiple sexually trans-
mitted diseases, including HIV
infection.2 In addition, female vic-
tims with their menstrual period
may be forced to insert cotton,
sponges, or mattress stuffing into
their vagina to block menstruation
and continue working at the expense
of their health. Such practices can
cause victims to have abnormal
discharges, chronic vaginal and
cervical infections, and pelvic
inflammatory disease.14
Victims tend to live and work in
filthy conditions. Overcrowding
and improper sanitation place them
at risk for various respiratory and
other infections such as tuberculo-
sis. Victims may have food with-
held and/or be subjected to inade-
quate diets, leading them to have
physical signs of malnutrition.10
Many of the mental health issues
suffered by female victims are due to
the frequent psychological abuse at
the hands of their traffickers. Female
survivors suffer from increased inci-
dences of acute anxiety and stress
disorder, depression, and personal-
ity disorders, along with low self-
esteem, suicidal ideation, disassocia-
tion, and poor interpersonal relation-
ships.9
Implications for nursing
Healthcare providers, especially
forensic nurses, are one of the few
groups of professionals likely to
interact with trafficked victims
while they’re still in captivity.2
Thus, forensic nurses have the best
opportunity to screen, identify,
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

The hard truth about human trafficking
22
January 2014 • Nursing Management www.nursingmanagement.com
intervene, and rescue these victims.
Once identified, victims should be
referred to support systems where
they can obtain important physical
and psychological care, as well as
material support to enable them to
move beyond victimization. One
system is the Department of Health
and Human Services National
Human Trafficking Resource Center;
a 24/7 hotline that connects victims
of trafficking with local organiza-
tions that provide support services.1
As previously mentioned, traf-
ficked victims are likely to suffer
a wide spectrum of health risks that
reflect the unique circumstances
and experiences in a trafficked vic-
tim’s life. They may have cuts,
burns, bruises, and fractured bones,
or show signs of anxiety, depression,
substance abuse, and malnutrition.7
Victims most often comply and
don’t attempt to escape or seek help
for fear of their safety and/or that
of their family members. Threats
of harm to family members are one
of the most powerful tools used
against trafficking victims.
Fear and distrust of all profes-
sionals—healthcare providers, gov-
ernment, law enforcement—diminish
the possibility of victims seeking
help. Traffickers brainwash victims
to believe that law enforcement will
arrest and deport them. They’re told
not to say anything to healthcare
professionals because of police
involvement.10 This isolation allows
the trafficker to control the victim’s
life and sets the stage for total
dependency on the trafficker.10
Forensic nurses are in a unique
position to build trust with traffick-
ing victims. Taking the time to listen
and develop rapport is critical. Sus-
pected victims should always be
screened in private to ensure confi-
dentiality and safety, particularly if
they appear submissive, hesitant,
or fearful of questions. Requesting
time alone with a patient shouldn’t
be done in such a way as to arouse
suspicion from the trafficker.7 The
person accompanying the victim
can be gently asked to assist with
paperwork at the front desk. In a
sexual assault case, the forensic
nurse can ask the person to remain
in the waiting room while a speci-
men is obtained in another room.
It’s vital to understand the risk
these victims may take by disclos-
ing their plight. An individualized
plan of care for the immediate
needs of the victim at the particular
moment must be implemented.8
This plan must be enacted and
understood not only by the health-
care team but also by law enforce-
ment and immigration services. The
forensic nurse should be aware of
the human trafficking laws at the
federal and state level in order to
provide victims with possible legal
options. The plan must include a
coordinated response that can pro-
vide safety to the victim as well as
the apprehension of the trafficker
whenever possible.8 Meeting the
victims’ physical, mental, and emo-
tional needs must be part of the plan.
Education
Nurses are poorly educated about
issues of human trafficking. Most
of the education is based in practice
experiences if a victim is seen for
other health issues. Nursing educa-
tion programs need to inform stu-
dents about human trafficking,
recognizing victims, and how to
intervene on their behalf. Nurses
should be wary when the patient
isn’t allowed to be alone with the
healthcare provider; someone else
speaks and intervenes in all aspects
of care for the patient; there’s a
language barrier; there are signs of
physical and/or mental abuse, mal-
nutrition, anxiety, and/or depres-
sion; no documents of identification
are available; or the patient doesn’t
know where they are or live and
can’t provide information about
where they work or what they do.15
Another area where forensic
nurses can be very influential is
community education to raise
awareness of these less obvious
victims.9 Topics should include the
strengthening of human right laws,
prevention practices against human
trafficking, the possible physical and
mental signs and symptoms the
trafficking victims may present with,
information about resources avail-
able within the community, and cul-
turally sensitive skills. Additionally,
because of their background, foren-
sic nurses can educate other nursing
colleagues about indicators of
human trafficking and teach them
assessment skills to screen for signs
and symptoms common among traf-
ficking victims.8 The Department of
Health and Human Services Office
of Refugee Resettlement offers a
variety of online Rescue and Restore
Toolkits for healthcare professionals
to use to identify victims of human
trafficking.16
Wake-up call
The business of human trafficking
is lucrative for exploiters, and
unlike drugs and weapons, victims
can be sold over and over for profit.
Collaboration is key to creating an
effective response team to battle the
crime. Sexual assault victim advo-
cates, domestic victim advocates,
sexual assault forensic nurse exam-
iners, law enforcement officers, and
community social service providers
are important members in identify-
ing and assisting trafficked victims.
Forensic nurses need to extend
their practice to include research on
the field of human trafficking to
collect empirical data and continue
the development of practices for
effective improvement of policies,
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

www.nursingmanagement.com Nursing Management • January 2014
23
victims’ response, and service
model approaches among health-
care providers and law enforcement
agents. Future considerations for all
healthcare professionals should
include education to inspire nurses
to join their state’s coalition against
human trafficking to uncover the
hard truth of human trafficking to
our nation’s blinded eyes.
N
M
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Rosario Sanchez is a critical care nurse at
Centrastate Medical Center in Freehold, N.J.
She’s also a SANE on call for the Monmouth
County Prosecutor’s Office. Sharon W. Stark is
associate dean and coordinator of the nurse
practitioner and forensic nursing programs at
Monmouth University, N.J.
The authors and planners have disclosed no
potential conflicts of interest, financial or
otherwise.
DOI-10.1097/01.NUMA.0000440630.41142.66
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