QUICK LESSON ABOUT ICD-9 V62.89 ICD-10 Z65.4 Author Jessica Therivel, LMSW-IPR Cinahl Information Systems, Glendale, CA Reviewers Lynn B. Cooper, D. Criminology Cinahl Information Systems, Glendale, CA Laura Gale, LCSW Cinahl Information Systems, Glendale, CA February 12, 2016 Human Trafficking Description/Etiology Human trafficking (HT) is forcing someone to perform work, most often manual labor or sex work, against his or her will by the use of coercion, typically starting with exploitation of economic vulnerability and transitioning to physical restraint, confiscation of identity documents, or otherwise creating dependence on the trafficker. The worldwide, illegal HT marketplace, in which cheap or free labor is the product traded,is second only to drug trafficking in size. Terminology used in the United Nations Convention against Transnational Organized Crime (Palermo Protocols) to describe HT includes involuntary servitude, slavery or practices similar to slavery,debt bondage, and forced labor. HT frequently is referred to as modern slavery. Despite its name, human trafficking does not necessarily involve the movement, or transportation, of persons. It may include transportation of persons within a country or across national borders, or there may be no relocation at all. Victims of HT frequently are economically vulnerable and enter into the trafficking relationship because of promises of work, stability, education, or other enticements. Victims may be homeless, escaping interpersonal violence, fleeing war or endemic violence, adults seeking economic opportunities, minors under the control of parents who sell them, foreign nationals or natives, fluent in the local language or unable to communicate in it, documented or undocumented. Traffickers often are the same nationality or ethnicity as victims and therefore better able to exploit vulnerability and build trust. Traffickers may be individuals or part of a large criminal enterprise, factory owners or employers of domestic servants, labor brokers, or pimps. Traffickers may promise high-paying jobs or a loving relationship, or they may violently kidnap the victim or make the victim dependent on drugs in order to control him or her. Sex trafficking or sexual exploitation is the subset of HT that tends to receive the most attention from the media, politicians, and global welfare groups. However, other types of HT are problematic as well. Common elements in all definitions of human trafficking are the use of force, fraud, and coercion (i.e., the use or threat of physical force or harming of others) by the traffickers. The control or threats that traffickers use include social control (e.g., stressing to victims that they have no rights, that no one will listen to them), isolation, debt bondage (i.e., the victim must work for the trafficker to pay off items given to the victim such as food or clothing), threats of violence or actual violence, threats to turn noncitizen victims over to the criminal justice system, drugs, threats to community or family, withholding documents, sexual abuse, and constant surveillance of victims. Individuals, including children, are trafficked in the United States and abroad for sexual exploitation; labor exploitation (e.g., being forced to harvest or mine commodities such as coffee, sugar, cotton, or diamonds, or to be domestic slaves); forced marriages; or to have their organs harvested. In many countries around the world children are taken from their families and sold to factory owners or farmers. In the United States it is estimated that at least 100,000 minors currently are trafficked for purposes of sexual exploitation; many are runaways. Social workers should recognize that both males and females may be victims of sexual trafficking. The Internet increases the vulnerability of juveniles because individuals with the intention of trafficking young persons can easily hide their true intentions and groom young persons into entering dangerous situations. Of the victims of human trafficking found in the United States, the U.S. State Department reports that about Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright 2016, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
half came from other countries whereas half were trafficked into servitude while already in the United States. The highest rates of trafficking are found in countries that have weak economies and insufficient anti-trafficking laws. The Polaris Project (a nonprofit, nongovernmental agency headquartered in Washington, D.C. that works globally to end human trafficking) has classified all 50 U.S. states and the District of Columbia into four tiers based on the statutes related to human trafficking that each has in place. Thirty-two states are ranked as Tier 1, indicating that they have passed significant laws or have regulations and services in place to combat trafficking that address at least 7 of 10 categories:sex trafficking provisions; labor trafficking provisions; asset forfeiture or investigatory laws; training or task force on human trafficking; hosting a hotline; having safe harbor laws; lower burden of proof for sex trafficking of minors; victim assistance; access to civil damages; and vacating convictions for victims. Eleven states and the District of Columbia are classified as Tier 2, states that have numerous laws to combat trafficking with 5 to 6 categories met. Six states are Tier 3,having only nominal laws in 3 to 4 categories. Only South Dakota is rated as Tier 4, having made minimal efforts to combat trafficking. Twelve states have passed safe harbor laws, whereby minors who have been trafficked are not subject to criminal prosecution (e.g., for prostitution). Facts and Figures Because human trafficking takes place in what is referred to as the shadow economy,determining the number of persons involved is difficult. Victims often are afraid to report traffickers to law enforcement or immigration authorities, or to be identified as victims and thus face reprisals from traffickers. Victims of trafficking who are forced to engage in illegal acts such as prostitution may be reluctant to come forward out of fear that they themselves will be charged with a crime. According to the UN s International Labour Office (ILO),in 2012 20.9 million persons around the world were subject to forced labor, including sexual exploitation,many of whom were victims of human trafficking;an estimated 44% of persons in forced labor were moved either internally or internationally;women and girls made up 55% of the total; and children (age 17 and under)made up 26% (ILO, 2013). Industrialized nations are the most common cross-border destinations for trafficking victims; top destinations are, in descending order, Italy, the United States, Germany, the Netherlands, Japan, Greece, Turkey, and Thailand (Alvarez & Alessi, 2012). The ILO 2014 report on the economics of HT estimates that forced labor contributed US$150.2 billion per year to illegal profits worldwide. Approximately $99 billion was from commercial sexual exploitation and $51.2 billion from various other forms of forced labor (e.g., domestic work, agriculture, construction). The large number of forced laborers in Asia made it the region with the most profits ($51.8 billion); the higher rate of profit per laborer in the European Union generated $46.9 billion in profits (ILO, 2014). The Trafficking in Persons report published annually by the U.S. State Department states that globally in 2014 there were approximately 10,050 prosecutions for human trafficking, 4,445 convictions, 48,900 identified victims, and 20 new or amended pieces of legislation on human trafficking passed (Department of State, 2015). In the United States, contacts with the hotline run by the National Human Trafficking Resource Center (NHTRC) in 2014 included 21,431 phone calls, 1,1149 emails, and 1,482 online tip reports. The NHTRC s evaluation of these contacts indicated 5,042 possible individual cases of human trafficking. Of those possible cases approximately 71% involved sex trafficking, 16% involved labor, 3% involved both sex and labor, and in 9% the type was not specified; 84% of cases involved adults, 17% minors; for sex trafficking alone, 61% of cases involved adults, 37% minors; and overall, the United States was the country of origin for approximately 37% of victims(national Human Trafficking Resource Center, n.d.). Risk Factors Children are at higher risk of HT than adults, especially if they have a history of early sexual abuse, poor school performance, negative family relationships, low socioeconomic status, poor peer relations, and family abuse or neglect For youth, poverty and/or being a runaway increase the risk of being trafficked Internationally, children who live in impoverished areas and have parents with little or no formal education are at a high risk for being trafficked. Often the parents are given a sum of money, told the child is going to work for a legitimate enterprise, and then the child is sold Women are at a higher risk than men for HT although men are still vulnerable, especially to labor trafficking Undocumented immigrants in the United States are at risk due to social isolation, language barriers, lack of legal status, and possible immigration-related debts
Signs and Symptoms/Clinical Presentation It is not easy to identify victims of HT; however,there are signs that social workers should know. Upon assessing a client with these signs,social workers should investigate with the client if he or she is a victim of trafficking. Signs include Clients who seem unable to come and go freely Clients who are paid very little or unpaid and/or are working excessively long or unusual hours Clients under age 18 who are providing commercial sex acts or are in the commercial sex industry Clients who have unusual work restrictions or discuss having large debts that they are unable to pay (i.e., debt bondage) Clients who were recruited to their jobs through false promises regarding what the work would be Clients who experience high security measures at work or home (e.g., locks, barred windows or doors, security cameras) Clients who are always accompanied by someone who answers questions or attempts to control the interview Social workers can also look closely at the client s behavior and mental health. Is the client fearful, anxious, depressed, submissive, or nervous? Does the client seem abnormally fearful of law enforcement? Does the client seem in poor physical health or malnourished? Is the client showing signs of physical or sexual abuse or physical restraints? Does the client have few personal possessions? Is he or she without financial records or control of his or her money? Is he or she in control of his or her documentation? Is the client allowed to speak for himself or herself? Is the client unable to clarify where he or she lives or unsure what city he or she is in? Are there numerous inconsistencies in his or her story? Social Work Assessment Client History Conduct abiopsychosocialspiritual assessment focused on the risk factors listed which might indicate that human trafficking is present Relevant Diagnostic Assessments and Screening Tools There are no specific diagnostic tests or screening tools to determine HT. A careful biopsychosocialspiritual assessment will have the best chance of uncovering if the client is a victim Questions about the client s current living situation may be used as a screening tool. Examples of such questions include, Can you leave your job or home if you want to? Can you come and go as you please? Where do you sleep and eat? Are the doors and windows locked so that you cannot leave? Have your identification papers or other documentation been taken from you? Social workers working with known victims of HT may want to utilize the Client Assessment/Outcome Matrix for HT victims. The instrument looks at client status/outcomes in various categories (e.g., shelter/food; medical, social, emotional health; employment/education; English as a second language/literacy; legal issues/immigration status; life skills). Within each category, the client is assigned a level (i.e., 1 = in crisis; 2 = vulnerable; 3 = safe; 4 = stable; 5 = thriving) Laboratory and Diagnostic Tests of Interest to the Social Worker If the client is in a medical setting and history indicates possible sex trafficking, a medical professional may need to order sexually transmitted disease screening Social Work Treatment Summary Social workers should be aware of their own cultural values, beliefs, and biases and develop specialized knowledge about the histories, traditions, and values of their clients. Social workers should adopt treatment methodologies that reflect their knowledge of the cultural diversity of the communities in which they practice Social workers need to focus on identifying clients who may be victims of human trafficking, helping victims to exit from trafficking, and helping to restore wellness and healthy functioning. Problem Goal Intervention
Client s history and presenting problems indicate that he or she is a victim of human trafficking Client is exhibiting symptoms of depression, anxiety, trauma, or other mental health issues as a result of being trafficked To help the client obtain his or her freedom and have a plan for recovery and independence To improve the client s functioning while decreasing his or her negative symptoms Identify and meet the client s basic needs first (e.g., safety, housing, food, shelter). Identify what other services the client requires (e.g., employment, finances, family reunification). Educate the client on state and federal laws that provide protections for victims of human trafficking. Advocate if necessary for the client with law enforcement, with the client s permission. Create a plan with the client on how to maintain safety. Assist the client in developing future goals. Assist the client in formulating an exit strategy Provide individual counseling, group counseling, trauma counseling, supportive therapy (e.g., music therapy, art therapy) to address mental health and emotional needs. Applicable Laws and Regulations All 50 U.S. states have statutes that criminalize human trafficking and allow the state to prosecute perpetrators instead of having to wait for federal assistance. Wyoming was the last state to enact such a statute, in February 2013. State statutes vary; social workers should be familiar with the statutes of their state of residence and practice The Violence Against Women Act (VAWA) is a U.S. federal law that provides support for female victims of trafficking Each nation has its own laws and policies regarding HT. The U.S. Trafficking Victims Protection Act (TVPA) of 2000 (with reauthorizations in 2003, 2005, 2008, and 2013) classifies nations into tiers that are used to determine economic sanctions. Tier 1 nations fully comply with the minimum standards set forth in the TVPA and are making strong efforts to combat trafficking. Tier 2 nations do not fully comply but are demonstrating an effort to eradicate or criminalize trafficking. Nations on Tier 2 s Watch List either have an increasing or steady number of victims or cannot prove that they are trying to combat trafficking. Tier 3 nations are making no effort to combat trafficking and may be subject to sanctions. If a nation has been on the Tier 2 Watch List for two consecutive years without demonstrating change, it is automatically downgraded to Tier 3 for the third year Each country has its own standards for cultural competency and diversity in social work practice. Social workers must be aware of the standards of practice set forth by their governing body (e.g., National Association of Social Workers in the United States, British Association of Social Workers in England) and practice accordingly Available Services and Resources The United Nations has a website that provides information on HT along with opportunities for individuals to assist in the fight against HT, http://www.unodc.org/unodc/en/human-trafficking/what-is-human-trafficking.html The Polaris Project advocates and acts globally to eradicate human trafficking, https://polarisproject.org/
In the United States the Polaris Project operates the National Human Trafficking Resource Center (NHTRC), which includes an anti-traffickinghotline, 1-888-373-7888 (24 hours a day, 7 days a week, in over 200 languages), and provides services and support to victims of HT, https://traffickingresourcecenter.org/ The human trafficking task force of the San Jose, California, police department offers a wide range of resources, http:// www.sjpd.org/boi/sexual_assaults/stopht/ Humantrafficking.org is a web resource providing information, press releases, and resources for combating global human trafficking, http://www.humantrafficking.org/ Food for Thought Trafficked persons can be U.S. citizens, not only foreign nationals A common misperception is that trafficking means transportation of victims. Transportation may be involved but is not a required element Physical force is only one of many types of force used to coerce victims of human trafficking. The force used often is psychological or emotional in nature Victims are not always able to self-identify as victims or seek help immediately. Trust-building is crucial in identifying clients who might be victims Social workers should engage in policy advocacy work at the state, national, and international level to fight HT Social workers should work on educating communities on how to identify and respond to trafficking. Information campaigns and increasing awareness through education can be very effective Regardless of the type of trafficking, all victims are at risk of being victimized a second time by law enforcement when the focus shifts from what the victim has suffered at the hands of another (e.g., work injury while in forced labor, sexual or physical assault during sexual trafficking) to the victim s immigration status Red Flags Social workers working with this population need to be alert to signs of secondary or vicarious traumatization. While counseling or otherwise working with victims of human trafficking, hearing about the traumas experienced can result in traumatic stress for social workers Victims often do not self-identify, so social workers need to be aware of the signs of trafficking. Social workers should be aware that they may encounter victims when they are giving birth or when their children need care. Children may come into contact with healthcare workers or school officials with different adults representing themselves as the parent(s) of the child at different times, or may not resemble the adults who are claiming to be their parents The nature of the abuses suffered by victims of HT can seem so extreme as to be unbelievable. Social workers need to be sure that they do not project an attitude of disbelief but instead are sensitive and open with clients A victim s consent given to the trafficker is irrelevant if coercion was involved. For example, if a victim agreed under coercion to enter the United States to work for a family and then was placed into a forced labor situation, her consent is not binding Minors cannot give permission for commercial sex work. Even if a minor does not acknowledge coercion, it is still present if the minor is involved with commercial sex work. Social workers may need to advocate for minor clients with law enforcement if law enforcement views minors as perpetrators of crimes (e.g., when a minor is arrested for prostitution) Discharge Planning Most victims of HT have long-term needs. Victims need to have a safety plan or feel that their safety is being addressed. The emotional and psychological needs of victims will need to be addressed in any discharge planning and supports put in place to deal with the trauma that was experienced. Victims financial and other needs must be addressed and assistance from appropriate agencies secured Survivors of HT may experience changing needs for services, discharge, and aftercare. Initial freedom may be followed by recovery and then work toward independence; victims needs will vary depending on the stage they are in Social workers may facilitate reunification of victims of HT with their families References 1. Alvarez, M. B., & Alessi, E. J. (2012). Human trafficking is more than sex trafficking and prostitution: Implications for social work. Affilia: Journal of Women & Social Work, 27(2), 142-152.
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