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1 Human Trafficking: Implications for Healthcare Professionals This course has been awarded 2.0 (two) contact hours Original Course: March 25, 2018 Expires: March 31, 2021 Copyright 2018 by AMN Healthcare All Rights Reserved Reproduction and distribution of these materials is prohibited without an Rn.com content licensing agreement.

2 Acknowledgements RN.com acknowledges the valuable contributions of.... Kim Maryniak, PhD, MSN, RNC-NIC, NEA-BC Conflict of Interest and Commercial Support RN.com strives to present content in a fair and unbiased manner at all times and has a full and fair disclosure policy that requires course faculty to declare any real or apparent commercial affiliation related to the content of this presentation. Note: Conflict of Interest is defined by ANCC as a situation in which an individual has an opportunity to affect educational content about products or services of a commercial interest with which he/she has a financial relationship. The author of this course does not have any conflict of interest to declare. The planners of the educational activity have no conflicts of interest to disclose. There is no commercial support being used for this course.

3 Purpose The purpose of this course is to provide information about human trafficking for healthcare professionals. An overview of the problem, identification and interventions for victims of human trafficking will be discussed. Objectives After successful completion of this course, the participant will be able to: 1. Identify the types of human trafficking 2. Describe risk factors for becoming victims of human trafficking and how to identify victims 3. Explain community resources available to assist victims of human trafficking 4. Discuss reporting of human trafficking victims legal implications

4 Introduction Human trafficking occurs when a victim is forced or coerced into performing actions against his or her will, including labor or sexual acts. It is a problem worldwide, and is a form of slavery. Globally, it is estimated that there are 20.9 million human trafficking victims. Of those, 68% are in forced labor, 55% are female, and 26% are children (Polaris, 2018a). In the year 2017, there were 4,460 reported cases in the United States and U.S. Territories of human trafficking to the National Human Trafficking Hotline (2017). Victims can be adults, adolescents, or children, and male or female Many victims of human trafficking require some form of health care. o One study of sex trafficking survivors showed that 87.8% of the participants had been in contact with a health care provider while they were being abused (Lederer & Wetzel, 2014) Types of Human Trafficking There are three main categories of human trafficking, each with variations of what may occur: Sex trafficking: The recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act (Department of Health and Human Services, n.d., para 2) o These acts are not consensual or abusive o Induced by force, fraud, or coercion; and/or o The act is induced to be performed by an individual less than 18 years of age Labor trafficking: The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services (Department of Health and Human Services, n.d., para 2) o Induced by force, fraud, or coercion; and/or o For the purpose of subjection to involuntary servitude, debt bondage or slavery Organ harvesting: Involves trafficking people in order to use their internal organs for transplant (National Crime Agency, 2018, para 7) o Induced by force, fraud, or coercion o Kidneys are in high demand due to transplant waiting lists (Department of Health and Human Services, n.d.; Interpol, 2018; National Crime Agency, 2018) Sex Trafficking Sexual exploitation involves sexual acts which are not consensual and/or abusive, and are performed without the permission of the victim. This may include prostitution, escort work, and pornography. Victims include women, men, and children. Exploitation may also include victims who consent to engage in providing sexual services, particularly those who are legally unable to consent (National Crime Agency, 2018). This is a widespread form of trafficking which is seen worldwide with various source, transit, or destination countries. Women and children are generally from developing

5 countries or socio-economically vulnerable in developed countries. Victims are often lured by promises of generous employment, and leave to pursue what they believe will be a better life. Forged travel documents and organized networks are usually present to transport victims to the destination country. Once at the destination, victims are forced into sexual slavery, kept in cruel conditions, and experience continuous fear through violence and abuse (Interpol, 2018). This crime type has been most noted in Asia, Africa, Central America, and South America. Inconsistent laws and inexpensive travel increase the risk for sex trafficking, particularly with children (Interpol, 2018). Labor Trafficking Labor trafficking is also a prevalent problem, with victims coming mainly from developing countries. Victims are recruited and trafficked using coercion and deceit, and end up held in conditions of slavery in various jobs. Victims include men, women, and children, and they are usually engaged in manual labor as well as domestic servitude (Interpol, 2018). Victims are forced to work very long, difficult hours, often in demanding conditions without training and equipment. If there are any wages, victims are also forced to give most, if not all, of their wages to their traffickers. The jobs and work environments are often described as dirty, degrading, or dangerous. There is use of coercion, lack of freedom, with verbal or physical violence to ensure compliance (National Crime Agency, 2018). Victims of labor trafficking have been found in industries such as manufacturing, entertainment, travel, farming, and construction, and there has been a significant increase in reported numbers in recent years. Housing accommodations often include placing large numbers of people in small or single dwellings (National Crime Agency, 2018). Labor trafficking may also include domestic servitude, in which victims are forced to work in private households. Duties generally include household tasks, such as cooking, cleaning, and child care. Again, there is lack of freedom for the victims. Victims often experience isolation with minimal privacy and comfort, such as sleeping on a mattress on the floor in an open part of the house (National Crime Agency, 2018). Organ Harvesting Trafficking individuals in order to use their tissue, cells, or organs is quickly growing as a criminal pursuit. Lengthy waiting lists for transplants exist in many countries, and exploitation of the desperation of patients and potential donors occurs. The health and lives of victims are at risk from procedures carried out in illegal and inappropriate conditions without medical supervision or care (Interpol, 2018).

6 The illegal commerce of organ harvesting is dominated by demand for kidneys. Kidneys are the only major organs that can be completely transplanted with comparatively few risks to the life of the donor (National Crime Agency, 2018). Test Your Knowledge Which of the following describes labor trafficking? A. Sexual act B. Forced to work long hours C. Unauthorized removal of tissue for transplant D. Consensual escort services Rationale: Victims are forced to work very long, difficult hours, often in demanding conditions without training and equipment. If there are any wages, victims are also forced to give most, if not all, of their wages to their traffickers. The jobs and work environments are often described as dirty, degrading, or dangerous. There is use of coercion, lack of freedom, with verbal or physical violence to ensure compliance Methods of Trafficking: Force There are different methods that are used by offenders to subject victims to trafficking. Traffickers use force, fraud, and coercion to compel their victims to engage in activities. Force can include the use of physical restraint or causing severe physical harm. Physical violence such as rape, assault, and restriction of movement or physical confinement is often used as a way to control victims. This is especially performed during the early stages of victimization, in which the resistance of the victim is broken down by the trafficker. (Department of Health and Human Services, n.d.; Interpol, 2018; National Crime Agency, 2018) Methods of Trafficking: Fraud Fraud can involve promises which are not truthful, usually regarding employment, wages, working conditions, or other subjects. For example, persons may be promised a high paying position in another country, but when they arrive they find themselves manipulated into forced labor. Other individuals may respond to advertisements promising modeling, nanny, or service jobs overseas, but are then forced into prostitution once they arrive at their destination. (Department of Health and Human Services, n.d.; Interpol, 2018; National Crime Agency, 2018) Methods of Trafficking: Coercion Coercion can be comprised of variety of elements. The act of coercion may be threats of serious harm to or physical restraint against the victim. A scheme, plan, or pattern intended to cause the victim to believe that failure to perform an act would result in severe harm to or physical restraint against that person is also coercion. The actual or threatened abuse of the legal process is another form of coercion. (Department of Health and Human Services, n.d.; Interpol, 2018; National Crime Agency, 2018)

7 Methods of Trafficking: Debt Bondage Debt bondage, or peonage, occurs when traffickers demand labor of the victim as a means of repayment for a real or alleged debt. The offenders do not reasonably apply a victim s wages toward the payment of the debt. Another strategy of the offender is to limit or define the type and length of the debtor s services. The victims may actually be charged fees by the traffickers, such as money for transportation, rooms, food, incidentals, interest, fines, and other charges such as those for bad behavior. Wages may be withheld or excessively reduced that even violate previously made agreements. Debt bondage ensnares a victim in a debt cycle that he or she can never pay down. This method can also be part of a larger scheme of psychological cruelty. (Department of Health and Human Services, n.d.; Interpol, 2018; National Crime Agency, 2018) Methods of Trafficking: Other Strategies Other strategies for trafficking may include the retention of identity documents, including passports. This ensures that the victim cannot leave nor prove his or her identity status. The threat of reporting to the authorities can also occur, regardless of whether or not the worker holds legal status in the country where he or she is held. (Department of Health and Human Services, n.d.; Interpol, 2018; National Crime Agency, 2018) Test Your Knowledge A woman travels to Mexico, believing that she will be starting as a model. Once there, she is forced into performing sexual acts. This method of trafficking is: A. Debt bondage B. Force C. Coercion D. Fraud Rationale: Fraud can involve promises which are not truthful, usually regarding employment, wages, working conditions, or other subjects. For example, persons may be promised a high paying position in another country, but when they arrive they find themselves manipulated into forced labor. Other individuals may respond to advertisements promising modeling, nanny, or service jobs overseas, but are then forced into prostitution once they arrive at their destination. The A-M-P Model The Action-Means-Purpose model, or AMP model, demonstrates how human trafficking occurs. The action ( A ) is when a trafficker either induces, recruits, harbors, transports, provides, or obtains. Means ( M ) are used by the trafficking through force, fraud, or coercion. And the purpose ( P ) is for commercial sex, labor, or services. At least one element from the action, means, or purpose must be present to determine if a situation involves human trafficking. One exception is that a minor person (less than 18 years of age) who is induced into commercial sex, regardless of any means, is

8 considered to be a sex trafficking victim (National Human Trafficking Resource Center (NHTRC) Polaris Project, 2012). A visual representation of the model can be found at Human Smuggling Although there is a connection to human trafficking, human smuggling is another issue. Smuggling is the illegal transport of a person across a country s border, and is transnational. With smuggling, individuals consent to being smuggled. Rather than a crime against a particular individual, this is a crime that is committed against a country. Criminals take advantage of the desperation and humanitarian crises for financial gain. Human smuggling may result in trafficking, but are considered two separate crimes. (Department of Health and Human Services, n.d.; Interpol, 2018) Risk Factors of the Victim Victims of human trafficking come from diverse socioeconomic, education, and cultural backgrounds. Victims may be located in suburban or rural locations. All age groups, male, female, and transgender individuals are represented in victims. However, there are some risk factors which may make individuals more vulnerable to becoming victims of human trafficking. These factors may include: Runaways and homeless youths Foreign nationals (either documented or undocumented) Individuals with a past history of violence, trauma, discrimination, neglect, or abuse Other social, personal, and environmental factors (National Center on Safe Supportive Learning Environments, 2018; National Human Trafficking Hotline, n.d.) Risk Factor: Runaways and Homeless Youths Runaway and homeless youths do not have a network of support and may end up in unfamiliar environments, which puts them at risk of becoming a victim of trafficking. Human traffickers may approach runaway youths in public, including transportation depots or bus stops, shelters, or on the streets. These types traffickers pretend to be a person who cares about the individual, using false affection and manipulation to coerce sexual or other services from the victim (Dignity Health, 2017; National Center on Safe Supportive Learning Environments, 2018; National Human Trafficking Hotline, n.d.) Risk Factor: Foreign Nationals Foreign nationals who are trafficked within the United States may be more vulnerable to trafficking and exploitation. Approximately 32 percent of hotline calls involve foreign nationals (National Human Trafficking Hotline, n.d.). Traffickers recruit victims in home countries, and then require large recruitment and travel fees. These fees place the victims in a large debt and creates a dependency on the new employer or trafficker. Traffickers also control and manipulate their victims by leveraging the inability to transfer many work visas, unfamiliarity with surroundings, lack of knowledge about laws and rights, language fluency, and cultural understanding. Even foreign nationals who

9 are legally in a country are vulnerable, as legal documents of the victim may be held by the traffickers for control (National Crime Agency, 2018; National Human Trafficking Hotline, n.d.). Risk Factor: Past History of Violence Individuals who have a history of exposure to violence and trauma are more vulnerable to future exploitation. This is a result of the psychological effects of the trauma, which can be ongoing and difficult to overcome. Victims who have experienced domestic or sexual violence, war and conflict, neglect, physical or emotional abuse may be targeted by traffickers, who recognize vulnerability. Victims of various forms of trauma may create a normalization of violence and abuse or low self-esteem or self-worth, which causes a susceptibility to human trafficking (Dignity Health, 2017; National Center on Safe Supportive Learning Environments, 2018; National Human Trafficking Hotline, n.d.). Risk Factor: Social, Personal, and Environmental Factors Social factors which may increase vulnerability to human trafficking include poor or no social support and social isolation. Those who have been bullied or discriminated against, such as ethnic and cultural differences, learning or other disabilities, sexual preference or gender identity differences, and religious beliefs are also at risk. Personal and environmental factors may involve poverty, unstable home environments, substance abuse, personal or family mental illness, and emotional distress. Relationships with individuals who are already involved in commercial sex is also considered a risk factor (Dignity Health, 2017; National Center on Safe Supportive Learning Environments, 2018; National Human Trafficking Hotline, n.d.). Test Your Knowledge Which of the following may be a risk factor for human trafficking victims? A. Past violence B. Middle class socioeconomic status C. Strong social support D. High self-esteem Rationale: Individuals who have a history of exposure to violence and trauma are more vulnerable to future exploitation. This is a result of the psychological effects of the trauma, which can be ongoing and difficult to overcome. Victims who have experienced domestic or sexual violence, war and conflict, neglect, physical or emotional abuse may be targeted by traffickers, who recognize vulnerability Identifying Victims As stated earlier, many victims of human trafficking seek out health care at some point, usually as a result of conditions suffered as a victim. It is important to recognize signs that an individual may be a victim of human trafficking. This involves both physical recognition and assessment as well as asking many questions. There are many

10 indicators that a person could potentially be a victim of trafficking. These indicators can be divided into the following categories: General indicators Labor trafficking indicators Sex trafficking indicators Physical indicators Mental indicators Social and developmental indicators (National Human Trafficking Resource Center [NHTRC], n.d.; Polaris, 2018b) General Indicators Some general indicators includes a person verbalizing a history which sounds scripted or is inconsistent, or if he or she is hesitant or not willing to answer questions about an injury or illness. If a person is unable to give his or her address, or is not oriented to date, time, or place, these might be other indicators. If the person is accompanied by someone who does not let the patient speak for him or herself, is not willing to leave the patient s side, or who interprets for him or her. If there is evidence of controlling or dominating relationships, such as expressing many concerns about pleasing another person, this could be a general indicator. Other indicators could be if a person does not have his or her identification documents, is not in control of his or her money, or indicates that he or she is not being paid or has withheld wages. Additional signs may be if the individual appears fearful or nervous, avoids eye contact, resists assistance, or demonstrates hostile behavior (National Human Trafficking Resource Center [NHTRC], n.d.; Polaris, 2018b). Labor Trafficking Indicators With asking appropriate questions, indicators of labor trafficking can be identified. Indicators may include if the patient has ever been abused at work or threatened with harm by an employer or supervisor. Other red flags are if the person is not allowed to take sufficient breaks, food, or water while at work, or if he or she is not provided with appropriate personal protective equipment for hazardous work. Another indicator is if an individual states he or she was recruited for different work than he or she is currently performing. Other indicators are if the person is required to live in housing provided by his or her employer, or if he or she has a debt to employer or recruiter that he or she cannot pay off (National Human Trafficking Resource Center [NHTRC], n.d.; Polaris, 2018b). Sex Trafficking Indicators There are also specific indicators that could signify a victim of sex trafficking. One indicator is if a patient is under the age of 18 and admits to being involved in the commercial sex industry. Another indicator is if a person has a form of branding, such as a tattoo, which indicates that he or she is for sale or is the property of another person. Another red flag is if the person acknowledges that he or she has had remarkably high numbers of sexual partners. Other indicators may include use of language that is common in the commercial sex industry, or if he or she does not have

11 appropriate clothing for the weather or social situation (National Human Trafficking Resource Center [NHTRC], n.d.; Polaris, 2018b). Test Your Knowledge A possible indicator that a person is a victim of sex trafficking is: A. A patient is able to give a clear, complete history B. A patient states he has been working at the same job for five years C. The patient admits to working in the commercial sex arena D. You note a tattoo on a patient which reads Managed by Pete Rationale: Another indicator is if a person has a form of branding, such as a tattoo, which indicate that he or she is for sale or is the property of another person. Physical Indicators There are also physical indicators that may suggest a patient is a victim of human trafficking. Physical indicators may include signs of physical abuse or unexplained injuries, such as bruises, cuts, wounds, burns, fractures, broken teeth, blunt force trauma, or even signs of torture. Neurological conditions can be physical indicators, such as headaches or migraines, memory loss, vertigo, difficulty sleeping or concentrating, or traumatic brain injury. Conditions of the cardiovascular, respiratory, or gastrointestinal systems that seem to be caused or worsened by stress are also indicators. Examples include cardiac arrhythmias, hypertension, respiratory distress, chronic constipation, or irritable bowel syndrome. Dietary concerns may also be apparent, such as malnutrition, loss of appetite, anorexia, or severe weight loss. Conditions involving the reproductive system may also be indicators, such as sexually transmitted diseases, genitourinary issues or trauma, multiple unwanted pregnancies or abortions, sexual dysfunction, or retained foreign bodies. Other physical issues may include substance use or abuse, effects from extreme temperatures or industrial exposures, or multiple somatic complaints (National Human Trafficking Resource Center [NHTRC], n.d.; Polaris, 2018b). Mental Indicators Mental indicators may include suicidal ideation or actions, self-harm, anxiety, nightmares, or flashbacks. Flat affect, feelings of shame or guilt, over-cautious behavior, or hostility may also be indicators. Victims may voice feelings of depersonalization, such as being an outside observer of themselves, emotional or physical numbness, distorted perception of time, or feelings of alienation. Development of mental disorders may occur, such as depression, post-traumatic stress disorder, attachment disorders, or dissociate disorders (National Human Trafficking Resource Center [NHTRC], n.d.; Polaris, 2018b). Social and Developmental Indicators There are also social and developmental indicators that may identify human trafficking victims. Increased engagement in high risk behaviors can be an indicator, such as a youth who has a history of running away or early sexual experiences. There may be difficulty with social skills, or in forming or maintaining healthy relationships. Physical or

12 cognitive developmental delays may be seen. There may also be observations of dysfunctional relationships between the victim and the trafficker, such as trauma bonding (also known as Stockholm syndrome) (National Human Trafficking Resource Center [NHTRC], n.d.; Polaris, 2018b). Test Your Knowledge A possible mental indicator that a person is a victim of human trafficking is: A. Presence of a sexually transmitted disease B. Voiced statements of feeling depersonalized C. Developmental delays with a patient D. History of running away Rationale: Mental indicators may include suicidal ideation or actions, self-harm, anxiety, nightmares, or flashbacks. Flat affect, feelings of shame or guilt, over-cautious behavior, or hostility may also be indicators. Victims may voice feelings of depersonalization, such as being an outside observer of themselves, emotional or physical numbness, distorted perception of time, or feelings of alienation Assessment of Patients It is often difficult for victims of trafficking to discuss their situation in healthcare settings, so it is vital that healthcare professionals approach this carefully. Developing rapport and engaging patients is essential in a safe, therapeutic environment. Assessment of potential safety risks that may occur with sensitive questions and inquiry is needed prior to discussion. The goal of this interaction is not to force disclosure of information or necessitate rescue of the patient, but rather to establish a secure and non-judgmental environment which will assist in the identification of trafficking indicators and support the patient (National Human Trafficking Resource Center (NHTRC) Polaris Project, 2011; NHTRC, n.d.). Assessment Considerations Considerations for appropriate assessments include: Speak with the patient privately, in an appropriate place at a suitable time without another person accompanying the patient Provide the patient a choice between speaking with a male or female healthcare professional Use official interpreters as needed; do not use individuals that are with the patient Allow time to develop trust and rapport with the patient Ensure the patient understands information about confidentiality policies, practices, and mandatory reporting laws, and verify that understanding Ensure that multidisciplinary resources are used, such as social workers and spiritual care Reference any facility protocols for victims of abuse or sexual abuse Be aware of community resources to assist healthcare professionals in conducting appropriate assessments of human trafficking victims and determining next steps

13 (National Human Trafficking Resource Center (NHTRC) Polaris Project, 2011; NHTRC, n.d.) Test Your Knowledge An important consideration when asking questions of a potential human trafficking victim is: A. Speak with him or her privately B. Have a person accompanying the patient translate C. Interview the patient quickly D. Reassure the patient that you will notify the authorities Rationale: Considerations for appropriate assessments include: Speak with the patient privately, in an appropriate place at a suitable time without another person accompanying the patient Provide the patient a choice between speaking with a male or female healthcare professional Use official interpreters as needed; do not use individuals that are with the patient Assessment Tools: Commonalities There are various assessment tools which are available to assist healthcare professionals identify potential victims of human trafficking. There are commonalities with these tools. Healthcare professionals should pay particular attention to vulnerable populations, such as children, adolescents, and those who have identifiable risk factors. Assessment involves a series of questions that assist in soliciting information that can indicate if a person is a victim of human trafficking. The questions can initially be framed around the purpose ( P ) identified in the AMP model, to determine if a patient is involved in commercial sex or labor and services. If asking direct questions is not successful, it may be beneficial to ask open-ended questions of the patients. This may be helpful to determine to elicit the information needed for victim identification (Dignity Health, 2017; National Human Trafficking Resource Center (NHTRC) Polaris Project, 2011; NHTRC, n.d.) Assessment Tools: Labor Trafficking Questions There are many questions that can assist with assessment. Further questions explore the actions and means sections of the AMP model. Some questions specific to labor trafficking include: What are your hours of work? Are you paid for your work? What is your wage? Are you able to come and go as you please? How frequently do you see your family and friends? Are you able to have private conversations with others? Do you owe money to another person, such as your employer or recruiter? Do you feel safe? Where do you live, eat, and sleep? What is the environment and surroundings like?

14 What do you sleep on- a bed, a cot, or on the floor? Has anyone ever denied you food, water, sleep, medicine, or health care? Do you live at the place where you work? Does anyone threaten or hurt you? Did someone give you instructions on what to say today? If the person is a foreign national: Did you have to pay a fee to come to the United States? Do you have your own identification documents, like your passport or work documents? Or does another person hold on to them? This list is not all-inclusive. (Dignity Health, 2017; National Human Trafficking Resource Center (NHTRC) Polaris Project, 2011; NHTRC, n.d.) Assessment Tools: Sex Trafficking Questions Some questions specific to sex trafficking include: Do you feel safe at home? And at school (if applicable)? Do you feel safe with your significant other, or spouse (as appropriate)? Do you feel safe with your friends and peers? Does anyone threaten or hurt you? Does anyone pressure you to do something you don t want to do? Does anyone threaten or hurt your family, your children, or friends? Does anyone force you to have sex with others or to perform sex acts for money, food, clothing, drugs, or housing? Has anyone ever pressured or forced you into working as a stripper, an escort, or a prostitute? Has anyone ever tricked you into meeting with them, entering into a relationship, or to run away from home, and then asked or forced you to perform a sexual act for money? Has anyone ever taken a photo of you that made you feel uncomfortable? Was the picture posted on a website for classified ads, possibly for massage or escort services? This list is not all-inclusive. (Dignity Health, 2017; National Human Trafficking Resource Center (NHTRC) Polaris Project, 2011; NHTRC, n.d.) Test Your Knowledge Which of the following is an appropriate question to screen for a potential victim of sex trafficking? A. What is your sexual orientation? B. Do you have access to medical care? C. Do you owe money to your employer? D. Have you been tricked into being an escort? Rationale: Has anyone ever pressured or forced you into working as a stripper, an escort, or a prostitute? Has anyone ever tricked you into meeting with them, entering

15 into a relationship, or to run away from home, and then asked or forced you to perform a sexual act for money? Assessment Tools There are established and validated assessment tools that can be used to identify victims of human trafficking. These tools are important to use, as they were created using evidence and have been shown to be effective. A comprehensive human trafficking assessment tool, provided by the National Human Trafficking Resource Center Polaris Project (2011) is available at Assessment.pdf A trafficking victim assessment tool created by the Vera Institute of Justice (2014) is available at Other assessment tools, protocols, and resources can be found on the National Human Trafficking Hotline website (2018), available at Support Hotlines: United States There are also hotlines that are available for victims, healthcare professionals, and other concerned individuals. These hotlines can provide valuable information about identifying and assisting victims of human trafficking. National Human Trafficking Hotline (from the National Human Trafficking Resource Center) o o Website: o Available 24 hours per day, seven days a week. Can provide assistance in more than 200 languages. Department of Homeland Security Blue Campaign o o Website: o Available 24 hours per day, seven days a week. Support Hotlines: Worldwide Globally, there are hotlines available in most countries. These can be found at The CNN Freedom Project o Website: European Commission o Website: Test Your Knowledge One human trafficking hotline available in the United States is through the:

16 A. Centers for Disease Control and Prevention B. American Nurses Association C. National Human Trafficking Resource Center D. Department of Health and Human Services Rationale: There are also hotlines that are available for victims, healthcare professionals, and other concerned individuals. These hotlines can provide valuable information about identifying and assisting victims of human trafficking. National Human Trafficking Hotline (from the National Human Trafficking Resource Center) o o Website: o Available 24 hours per day, seven days a week. Can provide assistance in more than 200 languages. Department of Homeland Security Blue Campaign o o Website: o Available 24 hours per day, seven days a week. Sharing Information Information about patients are upheld through the Health Information Portability and Accountability Act (HIPAA). If patients disclose they are victims of human trafficking or there are multiple red flags indicating this type of situation, there are concerns that the victim may be in danger for repercussions. Confidentiality is vital to maintain, and permission and consent is needed before disclosing any personal information about the patient to others, including other healthcare professionals and service providers. HIPAA regulations can also impact the ability to report potential trafficking situations on the patient s behalf. Contacting the National Human Trafficking Resource Center (NHTRC) can facilitate a report to specialized law enforcement trained to handle human trafficking cases. When contacting the NHTRC or other local resources, HIPAA must be upheld (NHTRC, n.d.; NHTRC, 2016a). Reporting Victims There are specific legal requirements for each state regarding mandatory reporting of human trafficking. There may be situations which require mandatory reporting under related statutes, such as child abuse or domestic violence. Cases of human trafficking may fall into mandatory requirements based on those state statutes. It is important to know what your local and state laws are, as well as your facility policies (NHTRC, n.d.). Test Your Knowledge Reporting victims of human trafficking is: A. Always a mandatory reporting situation B. Variable, depending on state statutes C. May be mandated by HIPPA

17 D. Never required Rationale: There are specific legal requirements for each state regarding mandatory reporting of human trafficking. There may be situations which require mandatory reporting under related statutes, such as child abuse or domestic violence. Cases of human trafficking may fall into mandatory requirements based on those state statutes. It is important to know what your local and state laws are, as well as your facility policies Next Steps for Identified Victims A victim-centered response is recommended, as each situation of human trafficking is different and unique. Victims may or may not be comfortable in disclosing their situation. Even those victims who do disclose may not be ready to seek or allow assistance from resources, including healthcare professionals and law enforcement. If a patient has disclosed that they are a victim of human trafficking, it is appropriate to provide the patient with a hotline number. It is important to encourage him or her to call the hotline if he or she wants to talk to someone and is ready for help. If there is a situation involving immediate, life-threatening danger, it is important to follow your facility s policies for reporting to law enforcement. When it is possible, ensure that the patient is a partner in the decision to contact law enforcement (NHTRC, n.d.; NHTRC, 2016a). Documentation It is essential to accurately document any information regarding the patient s injuries and treatment. Remember that documentation of abuse can assist to build a case against a trafficker, but information about the victim can also be used against them in a court proceeding (NHTRC, n.d.). Referral to Legal and Social Services Healthcare professionals should be familiar with the resources available within their facility, as well as those in the community. The patient should be provided with options for community resources and services. Planning for safety should also be included in discharge planning. In the United States, the National Human Trafficking Resource Center (NHTRC) is another important resource to be aware of. The NHTRC has a network of over 3,200 referral contacts which can help victims of human trafficking. These contacts include anti-trafficking organizations, shelters, legal service providers, law enforcement, and local social service agencies (NHTRC, n.d.). Types of Social Services Public and private social services are available as referrals for victims for rescue, food, clothing, and shelter. Coordination between healthcare professional and these services is essential. These referrals should address basic, legal, emotional and social, and safety and security needs. Needs to be addressed include:

18 Basic o Clothing o Food o Housing o Transportation o Work and employment o Health care o Interpreter services Legal o Immigration services o Marital or child custody o Prosecution of the trafficker(s) o Legal charges against the victim, such as prostitution or other offenses Emotional and social o Case management and social work o Advocacy services o Crisis intervention o Behavioral health care and counselling o Occupational and life skill training o Education o Reconnecting with family and friends Safety and security o Planning for safety o Shelters and safe environments o Protective orders (NHTRC, 2016b) Conclusion Human trafficking is a devastating reality in today s world. Dedicated individuals and organizations are fighting this travesty every day. Healthcare professionals such as nurses are in a unique position of identifying and intervening for victims. It is important for nurses to understand how to assess and recognize victims and be aware of resources to help in these situations. References Dadi, F., & Thimsen, K. (2015). Identifying human trafficking in health care settings. Retrieved from HT pdf Department of Health and Human Services. (n.d.). Human trafficking. Retrieved from Dignity Health. (2017). Human trafficking response program shared learnings manual. Retrieved from Health_HTRP_SharedLearningsManual_ pdf

19 Interpol. (2018). Types of human trafficking. Retrieved from Lederer, L., & Wetzel, C. (2014). The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Annals of Health Law, 23(1), National Center on Safe Supportive Learning Environments. (2018). Human trafficking in America s schools: Risk factors and indicators. Retrieved from National Crime Agency. (2018). Types of modern slavery crime. Retrieved from National Human Trafficking Hotline. (n.d.). The victims. Retrieved from National Human Trafficking Hotline. (2017). Hotline statistics. Retrieved from National Human Trafficking Hotline. (2018). Assessment tool. Retrieved from National Human Trafficking Resource Center (NHTRC). (n.d.). Identifying victims of human trafficking: What to look for in a healthcare setting. Retrieved from uring%20a%20medical%20exam%20-%20final%20-% docx.pdf National Human Trafficking Resource Center (NHTRC). (2016a). Framework for a human trafficking protocol in healthcare settings. Retrieved from %20Trafficking%20Protocol%20in%20Healthcare%20Settings.pdf National Human Trafficking Resource Center (NHTRC). (2016b). Recognizing and responding to human trafficking in a healthcare context. Retrieved from National Human Trafficking Resource Center (NHTRC) Polaris Project. (2011). Comprehensive human trafficking assessment. Retrieved from Assessment.pdf National Human Trafficking Resource Center (NHTRC) Polaris Project. (2012). Understanding the definition of human trafficking: The Action-Means-Purpose A-M-P model. Retrieved from Polaris. (2018a). Human trafficking: The facts. Retrieved from Polaris. (2018b). Recognizing the signs. Retrieved from Vera Institute of Justice. (2014). Screening for human trafficking: Guidelines for administering the Trafficking Victim Identification Tool (TVIT). Retrieved from

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