Understanding Human Trafficking in the Nursing Sector – Post-Test and Evaluation


  1. Please read carefully the enclosed article “Understanding Human Trafficking in the Nursing Sector.”
  2. Complete the post-test, evaluation form and the registration form.
  3. The post-test; completed registration form; and evaluation form.

The post-test will be reviewed. If a score of 70 percent or better is achieved, a certificate will be sent to you. If a score of 70 percent is not achieved, a letter of notification of the final score and a second post-test will be sent to you. We recommend that this independent study be reviewed prior to taking the second post-test. If a score of 70 percent is achieved on the second post-test, a certificate will be issued.

If you have any questions, please contact the Ohio Nurses Association’s CE department at info@ce4nurses.org or call 1-800-735-0056.


The red number two just clicked to a three on the digital clock that sits crooked on the end of the cabinet across the room. It’s now 11:53 pm. The time is difficult to read because this guy didn’t even bother to turn off the lights when he came in to see you; the numbers are faint. The rank smell of the sheets is infiltrating your senses as your face is being thrust into the bed. A headache ensues as you taste the dry smell of cigarette smoke that permeates the fabric from years of people ignoring the “no smoking” sign. Click. The clock changes again, one of the lights is dim but you can tell it is a four. This comes with relief because you know there are only six minutes left before you can go take the shower you were promised. The hot water will feel good because this man makes you feel even dirtier than the others you had to see that night. He is in his late 50’s and overweight, much like your grandpa Pap who used to rock you to sleep when you were scared of thunderstorms. His waxy skin engulfing your body makes you feel more trapped than the pimp outside the door, waiting to take his money for the service you’re providing. When his awful grunting stops resounding in your ear you can tell the old man just ejaculated and the deed is done. You can finally take a breath as the pressure of his massive body on top of yours is lifted. He sits on the edge of the bed for a minute before getting dressed. He collects his watch and keys, and walks out without so much as a word spoken or a glance your way.

At this point it is two minutes after midnight. The pimp enters, you’re still naked but these days you don’t even bother to cover yourself anymore. He tells you “That guy paid me what he owed but said you didn’t do good enough. You better re-learn how to put on that happy face for the next one or else I’ll give you something to be sad about!” Knowing another beating would result if you ignore his instructions you smile at him. It’s less than half hearted; smiling now means nothing more than facial tension. “That will have to do,” he says, “now go clean your filthy body whore. The next guy is going to be here in 20 minutes.”

This sounds like a nightmare concocted from one of those tragic stories you’ve heard maybe once or twice, but never really allowed yourself to believe could be real, or happen to anyone you love. Unfortunately this is not a terrifying dream. This is a depiction based off of survivor testimonies about just one night in the life of a sex trafficking victim.

The Crime of Human Trafficking

Sex trafficking accounts for the largest portion of victims and profits in the ever-present tragedy of human trafficking. Human trafficking is more commonly referred to as Modern Day Slavery because it exists when men, women, and children are forced into physically laborious situations to profit another individual.  The U.S Department of Health and Human Services reports that globally human trafficking is the second largest form of organized crime and fastest growing (The U.S. Department, 2011).

This criminal enterprise is tied with arms dealing (illegal weapon sales) and second only to the dealing of illegal drugs worldwide (The U.S. Department, 2011). The Trafficking in Persons Report of 2010 tells us that the major forms of trafficking in persons include: Forced Labor, Bonded Labor (including Debt Bondage Among Migrant Laborers), Involuntary Domestic Servitude, Forced Child Labor, Child Soldiers, Forced Prostitution (Sex Trafficking), and The Commercial Sexual Exploitation of Children (including Child Sex Tourism) (U.S. Department of, 2010). These categories are all roughly placed into two different groups; that of Sex Trafficking and Labor Trafficking. The estimated global annual profits made from the exploitation of all trafficked persons or forced labor is $150 billion based on U.S. currency (The International Labour Organization 2014).

Breaking Down the Definition

Generating a solid understanding of the definition of human trafficking is important as this crime involves many forms of abuse and related offenses. Deciphering the parties involved (the perpetrators, victims, and sometimes customers) and their role in the crime of human trafficking presents a challenge. Traffickers use unique ways of recruiting, trapping, and exploiting their victims so the crime can easily go un-recognized or misinterpreted as another. The Victims of Trafficking and Violence Protection Act of 2000 (TVPA) clearly states the definition of human trafficking as a recognized illegal activity (Department of Health, 2003).

The term ‘‘severe forms of trafficking in persons’’ includes the following:

Sex Trafficking: A commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age (U.S. House of Representatives, 2008).

In the United States there are aspects of the commercial sex industry that are legalized like strip clubs, forms of pornography, and areas of prostitution. This can make separating the individuals who are legally involved in the sex industry from those who are trafficked difficult. Each trafficking situation involves a unique individual and corresponding story. When contemplating if a patient you are treating is a victim of trafficking, utilize the TVPA’s definition by looking at the five areas of focus: Force, Fraud, Coercion, Definition of “commercial sex act”, and Age.

1.) Force: Any physical restraint or causing serious harm (U.S. House of Representatives, 2008). An example would be a woman physically overpowered, tied down to a bed, or locked in a hotel and raped by a trafficker or customer (more commonly referred to as a “John”).

2.) Fraud: According to the TVPA, fraud refers to a false promise made to the victim by a trafficker to lure or entrap the victim as a means of control (U.S. House of Representatives, 2008). Examples of fraud include false promises for specific employment, promises of a certain amount of money that is never paid, being told he or she would receive legitimate immigration documents that are never obtained (U.S. House of Representatives, 2008).

3.)  Coercion: Threats of serious harm to or physical restraint against any person; any scheme, plan, or pattern intended to cause a person to believe that failure to perform an act would result in serious harm to or physical restraint against any person; the abuse or threatened abuse of the legal system (U.S. House of Representatives, 2008).

4.) “Commercial Sex Act”: Any sex act (prostitution, stripping, and pornography) on account of which anything of value is given to or received by any person (U.S. House of Representatives, 2008). Your role as a nurse is to decipher if there was anything of value exchanged for a sex act. Was there money, drugs, or valuables traded because of a sexual encounter?

5.) Age: The TVPA directly states that if a minor is caught in a commercial sex act, then they are automatically considered to be a victim of Human Trafficking. This is because in no other circumstance can that individual consent to a sexual encounter.

Labor Trafficking: The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery (U.S. House of Representatives, 2008).

This is the most recognizable form of Modern Day Slavery as it can be more easily compared to the slavery of past times. It is essentially the same as people who are made to work physically or at a specific trade without pay or freedom of movement. These victims have been found and rescued from agricultural areas, factories, restaurants, hotels, and family homes. There are various ways labor traffickers entrap their victims and utilize them for their personal profit but debt bondage is most commonly used. This is when a trafficker establishes an inflated fee (based on transportation and living costs) that the victim must pay back before they obtain freedom. A trafficker may insist that a young man pay him $1,200 US dollars as reimbursement for the cost of the van ride, meals, and apartment stay when crossing a border. The trafficker will then not pay the young man for his migrant work, claiming he is taking his cut of the debt incurred.

This essay will address occurrences of Labor Trafficking and its reproductions but not in extensive detail. The primary focus of this essay will be to provide education about sex trafficking as it is the type most common in our society. More importantly, the victims of this type of trafficking are knowingly and unknowingly being treated in our nation’s medical centers on a daily basis. The health care provider plays a key role in their rescue and rehabilitation using the specific skills s/he possesses and the opportunities available through their facilities.

The Prevalence of Human Trafficking in the United States

The Statue of Liberty, the American Flag, and the Constitution of the United States represent the freedom and justice for all citizens on our soil. Men and women have fought and died to honor and protect these principles for which our nation exists.

Understanding our society’s value of freedom makes it easier to see how the issue of human trafficking is largely hidden.  ‘Slavery’ is often considered to be a term of the past. Most people cannot fathom that there are currently people in our country who have no element of choice or freedom in their lives. Human trafficking is modern day slavery. Times and technology have changed the way people are exploited and controlled. For example, women were once sold legally at town auctions to work on plantations. Today, women are sold to the highest bidder over the internet. The methods of sale and control have advanced but not the underlying issue – that the woman is being sold against her will and used for another person’s profit.

The rate at which slavery exists in our country is astounding. Due to the inconspicuous nature of this crime, the numbers are difficult to track. Regardless of the challenge, research has provided some figures concerning prevalence of human trafficking.  The most conservative estimate given by the International Labor Organization, found that there are at least 12.3 million people in forced labor worldwide (Belser, 2005).  Although the accepted estimate is thought to be more realistic, there are currently 27 million people living in slavery (Bales, 2007). The Trafficking in Persons Report (TIP) shows that between 600,000 and 800,000 individuals are trafficked across international borders every year (U.S. Department of, 2010). Annually 18,000 to 20,000 persons are trafficked into the U.S. (U.S. Department of State, 2003). Those numbers of course do not include our own U.S. citizens who are also controlled and exploited. We know from the Center for Missing and Exploited Children that there are at least 100,000 US children caught up in commercial sexual exploitation (CSE), with the belief that there are upwards to 300,000 minors victimized (Allen, 2010).

The only way to prioritize this subject when screening patients is to recognize that, behind every one of these numbers, is a person. These are not just statistics, these are lives. These men, women, and children have been brutalized to the highest degree, yet they can still think, feel, love others, and build lives. Take for example Samantha, a client of The Salvation Army of Central Ohio’s Anti Human Trafficking Program. Samantha is a kindhearted spirit who has overcome tremendous trauma in her life with a remarkable ability to care for others. Samantha was trafficked in Florida when she turned 18 after deciding to experience life in a new state. Invited into an apartment by a man claiming to show her the city, Samantha became a victim of forced prostitution that very night after receiving her first assault and beating. This would become routine in the 11 months that would follow.

During one of Samantha’s pimp’s violent rages he threw her out of a three story window. These injuries brought her to the area hospital where she finally found sanctuary. This was the first time in almost a year Samantha was able to feel safe. This hospital stay became her opportunity to become free. With the help of the nursing staff, she was treated and reconnected with her family. Today, 36 years have passed since this horrifying ordeal and Samantha embodies what it means to be a survivor. Samantha feels blessed to be able to be a full time wife and mother of five children. She embraces the needy with philanthropic work and personally when friends are in distress. Samantha raises awareness about the reality of domestic minor sex trafficking in efforts to save other girls from this terrible fate.

Human Trafficking in the Health Care Setting

Health care facilities can be a place of refuge and restoration for victims of trafficking. The traffickers know there is opportunity for their crimes to be exposed in these settings. Thus trafficking victims are typically brought into hospitals and clinics only when injuries and ailments are life threatening or debilitating enough to affect the victim’s ability to make money.  One European study showed that 28% of Human Trafficking victims came into contact with the health care system at least one time during their captivity (Family Violence Prevention, 2005). Regrettably not one of these encounters resulted in the trafficking victim being rescued. This is most likely attributed to a lack of training necessary to understand this crime and its victims. A recent study shows the need for health care providers to be educated in our country. The study surveyed emergency room staff where 23% of those surveyed were nurses, learned that although 29% thought it was a problem in their emergency department population, only 13% felt confident or very confident that they could identify a trafficking victim, and less than 3% had ever had any training on recognizing trafficking victims (Chisholm-Strike, & Richardson, 2007).

These studies represent crucial missed opportunities to save people from immense suffering. Luckily this problem has an easy solution. Simply educating yourself and your health care facility’s staff on the issue of Human Trafficking will help with victim identification and rescue. As a health care provider (HCP) you have a golden opportunity to reach out to victims. The health care system is one of only four fields where workers are likely to encounter a victim of trafficking while they are still in captivity (The others are clergy, law enforcement, and school systems) (Crane, & Moreno, 2011). That is why the duration of this essay will discuss the signs and symptoms trafficking victims typically present when accessing treatment. You will gain an understanding of the victim’s situation which affects their mindset. Knowing this will directly affect your ability to move forward in treating the victim and aiding in their rescue.

The Mindset of the Victim

Anytime a person experiences trauma, their attitude is severely altered which is then linked to behavior change. Trauma can be broken into two areas, physical and psychological.  Medically speaking trauma is “a serious injury or shock to the body” (The American Heritage Dictonary, 2000). Psychologically it is “an event outside your control in which you experienced or witnessed a severe physical threat” (Najavits, 2002). The vast majority of human trafficking victims experience both forms. One study that interviewed 207 survivors of trafficking showed the following:  76% had experienced physical violence, 90% experienced sexual violence, and 71% experienced both during the time they were trafficked (Barrows, DO, MA (Bioethics), & Finger, MD, MPH, 2008). That is why being conscious of the victim’s trauma and sensitive in your questioning and response is extremely important.

Adult Victims

Adult victims of human trafficking are typically overlooked. This is because outsiders (friends, social service providers, family, and HCPs) assume that since they are adults they are able to freely make good decisions for themselves. When outsiders do not take a second look to see what is guiding the adult’s decisions, they tend to make negative assumptions which leads to stigma. For example many times a patient may come into a hospital who is a known sex worker. Nursing staff may assume “that’s a filthy lifestyle and she has a bad attitude, she’s getting herself into trouble and abusing the system.” When the patient picks up on the judgmental undertone of the nurse, they will completely shut down due to shame and anger — shame because the life consists of daily sexual assault and anger because the nurse lacks understanding of the patient’s circumstance. Did the nurse stop to think about how someone would end up in this profession? If the nurse would take that time, he or she would find that most likely the “lifestyle” was introduced to the patient as a child. The U.S. Department of Justice Child Exploitation and Obscenity Section conducted a nationwide study which found that as many as 70% of women involved in prostitution are introduced to the commercial sex trade in early adolescence (11-14 years of age) or early childhood (U.S. Department of Justice).

The most conservative estimates suggest between 75% – 90% of adult female prostitutes are under the complete control of a pimp (sex trafficker) (Farley, Baral, Kiremire, & Sezgin, 1998). By federal definition, this makes them victims of sex trafficking because pimps/sex traffickers use both physical and psychological torture to control “their” women (Williamson, 2008).  Pimps/sex traffickers will rape, beat, verbally abuse, and threaten the lives of people whom the women love. Such tactics consistently lead to complete obedience and a breakdown of personal agency and autonomy (Williamson, 2008), thus making it easier for the pimps to profit off of the women they control. The pimp is the one who will receive all or most of the allocated money (or thing of value: drugs, food, etc) for the sexual service the woman provided, or rather ‘endured’.

The routine beatings and rapes do not leave these women unscarred. The victims may appear to adapt to their situations but it is only a defense mechanism used to evade further pain. Victims learn ways to negotiate favor amidst the violent environment where pain and fear are imposed upon them whenever they break a rule or attempt escape (Crane, & Moreno, 2011). Restricted movement, isolation, and battery distort the woman’s reality. Victims survive by making cognitive changes which allow them to believe their situation is better than it really is compared to other life experiences they witness or imagine. Most will reach a point of complete mental defeat as they give up hope for a better life (Crane, & Moreno, 2011).

Post Traumatic Stress Disorder (PTSD) is an anxiety disorder that results after one sees or experiences a traumatic event. The symptoms that result include acute anxiety, depression, insomnia, persistent flashbacks of the event, physical hyper-alertness and self-loathing that is long-lasting and resistant to change (Bisson, & Andrew). One research study interviewed prostituted women from nine different countries. They found the level of PTSD in these women to be at 68%, which is the same range as that of combat veterans (Farley, 2003). The damaging effects of trauma infiltrate almost every aspect of trafficking survivors’ lives. Trauma causes women to become consumed by PTSD symptoms and the abusers teach women to distrust the world and feel worthless.

Since women in the sex industry are surrounded by people who control them, sexually exploit them, or judge them, they rarely have a concept of a healthy human relationship. My experience in working directly with adult survivors of sex trafficking and prostitution has shown me that the confusion about healthy relationships lead to the greatest challenges in recovery. Humans are relational creatures and sex is the ultimate act of intimacy. Though we can argue the varying affects, it is evident that sex dramatically shapes ones attitude toward relationships. For women trapped in the sex industry this can be the heart of the dysfunction.  These women are made to enter into complete intimacy with strangers, sometimes up to 7 days a week. The actions of “John’s” and the indoctrination of traffickers construct the identity of a woman as purely sexual. If you are engaged in the sex industry, almost 100% of your time is consumed by sex. You are having sex, surrounded by it, or recovering from it.

Therefore no time passes before you begin to believe the lie that your only source of value is in your sexuality. This lie breaks down a woman completely because there is no greater way to dehumanize an individual than objectifying them to nothing more than flesh. Tania, a survivor from Eastern Europe, says “They {traffickers and clients} didn’t see us as human beings, but just as whores, just as flesh that they could use. That’s all” (“Interview tania,” 2006). Once sexual violence brings a woman to this point, the real psychological collapse begins. Survivors of sex trafficking are left with major emotional burdens that include severe depression, immense feelings of shame and grief, overwhelming anxiety, self destructive behaviors (self mutilation/suicide) as well as disassociated ego states that result in mind/body separation (U.S. Department of, 2009).

Minor Victims

When children are violently stripped of their innocence through painful labor and sexual aggression, they are left with an equal burden of psychological damage. The crime of human trafficking involves kidnapping, restraint, brainwashing, ongoing sexual molestation, depravation of physical needs (proper sleep, medical care, nutrition), and over use of the body from a developmental standpoint. The core symptoms that result from these forms of trauma result in thought patterns which include: Shame, Powerlessness, Betrayal, and Ambivalence. These core concepts were identified by Megan Crawford, a licensed Social Worker who counsels minor victims of sex trafficking in Columbus Ohio, in combination with theories from Dr. Dan B. Allender.

Shame: Girls who are trafficked feel shame. The shame exists despite the fact that it is produced by situations which are not their fault and more importantly out of their control. The girls are made to believe that they enjoy the sexual activity and are willing participants – threatening her well being if she doesn’t cooperate, but vocalizing that she is obtaining pleasure from the act as a “good” adult woman should. This coercion works well at the developmental stage of childhood and adolescence. Many times actual sexual arousal happens despite the fear. This mixed with the natural desire for love and intimacy creates conflict. The girls hate and mistrust their hunger for male relationships as all previous relationships have been damaging.

In reality, the shame and pain felt results from failed trust. However, children are not able to process this truth so in attempts to protect them from further pain, girls begin to blame themselves and develop self-loathing behaviors.  Girls often listen to the lies and decide that they are the source of their own misery. This is easier than attempting to understand the magnitude of the abuse they are suffering at the hands of those who are supposed to care for them properly.

Powerlessness: Minor victims feel powerless which results in despair and becoming emotionally dead to the surrounding world. This happens because there is a major “loss of self” (Allender, 2008).  Girls feel like strangers in their own skin as they’re disconnected from their bodies as a result of trauma. When you are a victim of trafficking, you are owned by someone else. As a young victim, you become bonded to that abuser and your identity is what they create. You don’t have your own likes or dislikes. What type of things you like; the places you go, what clothing you wear are all decided by the pimp. Stunting this growth process is very damaging because adolescence is the crucial stage of development when identity is formed.

Therefore, you typically become molded for life with the individuality generated by the one exploiting you (Crawford, 2011). It becomes hard to differentiate the lies from the truths. More often then not, the negative coercion will overpower the truth and girls develop hardened hearts, self hatred, aggressive attitudes, distrust of others, and identity confusion. Girl may wholeheartedly adopt the belief that they are “stupid or naïve,” “worthless or stained,” “completely used and discarded,” and undeserving of kindness (Crawford, 2011). That is until someone can come in and guide them to view themselves with compassion.

Betrayal: Girls feel the major effects of betrayal because they are betrayed by people who promise to protect them. The costs of this are destructive and the following are produced:

Hypervigilance – When a person is constantly tense and “on guard.” A person experiencing this symptom of PTSD will be motivated to maintain an increased awareness of their surrounding environment with the goal to never be surprised (Tull, 2009).

Suspiciousness– A haunting feeling of mistrust that motivates a person to engage with someone and then pull away in fear of harm (in relation to PTSD) (Lanham, & Charette).

Distortion & Denial– The victim/ survivor will live in a haze and lack objectivity (Allender, 2008).

Loss of a Hope for Strength & Justice– gives up hope for protection, goodness, independence (Crawford, 2011).

Loss of the Hope for Intimacy– Comes to believe that intimacy with another person is either dangerous or unreal (Allender, 2008).

The betrayal can also be used as another mechanism of control by the traffickers. One negative encounter with a social service professional, or lie about them, can set future precedent. For example, hospital staff or law enforcement may treat them as a delinquent teen rather than a victim, reinforcing the idea that there is no one who understands or cares about their pain.

Traffickers will use any opportunity to highlight a truth or a lie that will make the victims feel as if they are betrayed by the system (meaning social services, hospitals, law enforcement) so they become hopeless and more dependent on the trafficker(Crawford, 2011).

Ambivalence: Girls feel ambivalent towards their individual situations. This means they feel two contradictory emotions at the same moment. When minors are trafficked, “Traumatic Bonds” may form; positive feelings/loyalties to the abuser (trafficker) (Allender, 2008). Dr. Allender is quoted as saying “central to understanding ambivalence is the fact that the very thing that was despised also brought some degree of pleasure.” It makes sense that a girl who was starved for love and attention her whole life received those to some degree from her trafficker. In the back of a girl’s mind she knows that the very person who is abusing her has the power to save and protect her from worse harm. This Traumatic Bond becomes a form of “love language” that they use to relate to other people. Due to this effect, after a child victim attains freedom they may sometimes return to the trafficker/pimp because their sense of self is so engrained in that individual (Crawford, 2011).

Secondary effects of trafficked girls drastically affect their behaviors and future health. Many surface in unusual ways like: sexual promiscuity, addiction, complete or loss of sex drive. Regardless of where they lie on the spectrum, all minor victims of trafficking have a broken, distorted view of sex because everything in their lives was at one point prematurely sexualized (Allender, 2008). Sexual addiction can become a way of normalizing the unwanted actions that were done to them previously.

Other compulsive disorders exist because of the survivor’s desire to regain a control that was previously taken. Many girls will struggle with substance abuse, eating disorders, perfectionism, Obsessive Compulsive Disorders, and self-mutilation in the aftermath of their trauma (Allender, 2008). It can also mean taking power of one’s out of control emotions.

International Victims

International victims of trafficking face many barriers that prevent them from becoming free. Foreigners trafficked into the U.S. are not only traumatized but are completely out of the comfort of their home culture. These victims do not understand the people, language, or cultural norms of the United States. Traffickers feed false realities (to those they control) about professionals (law enforcement, social services, and health providers) so those they control will distrust those systems and not seek help (Crane, & Moreno, 2011). A 15 year old Nigerian girl trafficked as a domestic servant was told by her family that doctors in American hospitals would give her medicine that would paralyze her. Therefore, when the girl was identified in an East Side Columbus Hospital she fought nurses and refused medication.

Traffickers will also cultivate distrust of authorities by playing on the victim’s fear of arrest and deportation. The victims are made to believe that they are the criminals as they are engaging in unlawful activity in a country in which they do not legally reside. Documentation is often taken or destroyed to further ingrain this belief (Crane, & Moreno, 2011). In order to rescue international victims, it is essential to enlist the trust of translators to bridge the communication barriers and dispel the myths that victims are convinced are true.

The Role of the Nurse

As a nurse you are given an opportunity that few other professionals have to free victims of human trafficking. Health care providers are among only four professions where you are likely to encounter a victim while they are still in captivity (the others being clergy, law enforcement, and school teachers) (Barrows, DO, MA (Bioethics), & Finger, MD, MPH, 2008).  In a study of survivors from San Francisco, Los Angeles, and Atlanta areas, researchers found that although 28% came into contact with health care providers during their captivity, the providers didn’t realize their patients were being trafficked (Family Violence Prevention Fund, 2005).

Upon entering a patient’s room, begin an initial assessment of the patient’s medical issues and demeanor. Both government agencies and Nongoverment Organization (NGO’s) have developed a list of clues that a victim of trafficking may exhibit. Assess for the following (U.S. Department of, 2008) (Hughes, 2003):

  • The patient is accompanied by another person who seems controlling.
  • The accompanying person insists on giving health information.
  • The patient acts unusually fearful or submissive.
  • The patient does not speak English.
  • The patient speaks some English, but someone else is speaking for him or her.
  • The patient has recently been brought to this country from Eastern Europe, Asia, Latin America, Canada, Africa, or India.
  • The patient lacks a passport, immigration, or identification documentation.
  • The person doesn’t seem to know where she or he is.
  • The person has no spending money.
  • The person appears to be under the control and supervision of someone who never leaves the person alone.
  • There are signs of malnutrition, dehydration, drug use or addiction, poor general health, or poor personal hygiene.
  • There are signs of physical abuse or neglect, such as scars, bruises, burns, unusual bald patches, tattoos that raise suspicion (for example, “Property of—” or gang-like symbols), or untreated medical problems.
  • The person appears depressed, frightened, anxious, or otherwise distressed.
  • The person’s story about what she or he is doing in this country or on the job doesn’t make sense.
  • The person lives with an employer or at the place of business and can’t give you an address.If you answer “yes” to any of the questions above, you should investigate further as there could be trafficking involved. None of these solely indicate if there is trafficking but raise the possibility. Further questioning may lead to the discovery of another form of abuse the patient is enduring. It is vital that we begin to put human trafficking on our radar as we automatically screen for domestic violence or sexual abuse in hospitals. Presenting medical issues can also be indicators of a trafficking situation. Victims of this crime typically receive health care only when their conditions become life threatening or dramatically affect their ability to work (Barrows, DO, MA (Bioethics), & Finger, MD, MPH, 2008). Preventative care is almost nonexistent for pre-existing conditions (Cole). This is because entering a health care setting presents a high amount of risk to the trafficker about exposing their crimes (Barrows, DO, MA (Bioethics), & Finger, MD, MPH, 2008) (Isaac, Solak, & Giardino, 2011)( Zimmerman C, Yun K, Watts C, 2003):
  • Bodily injuries from extreme physical stress (cigarette burns, fractures, bruises, contusions)
  • Hepatitis (as well as other bloodborne diseases)
  • Reproductive and genitourinary issues
  • Multiple Sexually Transmitted Disease infections (Including HIV/AIDS)
  • Tuberculosis
  • Malnourishment
  • Poor dental hygiene
  • Older broken bones that did not heal properly
  • Traumatic Brain Injuries
  • Pregnancy and abortion-related complications (for women and pubertal female children)
  • Chronic back, visual, or respiratory problems from working in dangerous manual labor conditions
  • Drug and alcohol dependency
  • Abnormal menstrual cycles (unusual discharge, chronic vaginal and cervical infection, pelvic inflammatory disease) leading to pain during intercourse and an unpleasant odor from infections

A study published in 2014 included 107 survivors of domestic sex trafficking, ages 14-60, from 12 cities across the U.S. including Ohio. These survivors shared their health concerns. The majority (88%) of these survivors stated they had contact with the healthcare system while being trafficked.

Common forms of violence/abuse included: forced sex (82%); punched (74%); beaten (69%; kicked (68%); forced unprotected sex (68%); threatened with a weapon (66%); strangled (54%); abused by a person of authority (51%).

Common health problems included: Any physical health problem (99%); neurological (92%); general health (86%); injuries (69%); cardiovascular/respiratory (69%); gastrointestinal (62%); dental (54%).

Psychological health problems included: depression (89%); flashbacks (68%); shame/guilt (82%); PTSD (55%); attempted suicide (42%).

Best Practices for Communicating with Victims

The key to utilizing this power is to identify the victim on your own.  You cannot expect the victim to self-identify. It is extremely rare that a victim of trafficking will vocalize their needs because they do not realize they are victims. Additionally, victims live in fear of being discovered as the threats regarding exposure are immense.  For example, before entering a hospital a victim may be told by her trafficker, “If anyone in there finds out what you’re doing, I am going to make sure your friend doesn’t eat for a week”. This is why asking the right questions in the proper ways are so imperative.

The first step in overcoming these obstacles is to build trust and rapport with the potential victim. Ideally you will have the time it takes to generate this trust through ongoing personal encounters, but most likely this will need to be done at a rapid pace. Upon beginning to treat a victim, give them respect and some degree of control through choice. If they are a victim of trafficking, they have no power or ability to choose what happens to them on a daily basis. Therefore any element of choice you can give them will allow the victim to see you as a nurse who they can trust. Having the victim make a decision about what type of drink they would like, when they prefer to take medicine (if that is an option), if they would like the curtains open or closed, or when they want the specialists to come by will help make them feel powerful. At no point can you take for granted what the victim may be deprived of and how that has devastated their self worth.

Good interviewing and questioning begins with the understanding that asking direct questions will most likely not lead you to connect with the potential victim or gain the truth of their story. Victims are often “coached” by traffickers on how to answer these direct questions and have stories prepared to deter any suspicions of abuse. A victim of trafficking will not connect with the term “human trafficking” due to unfamiliarity with the term; being unaware that it is a crime, and disbelief that their unique circumstance could fall under the specifications of a crime because of self blaming.

Asking questions surrounding the issues you suspect will give you the answers to your initial concerns. If you ask directly “are you involved with prostitution?” the patient will feel embarrassed, exposed, and immediately shut down.  A survivor of trafficking involved in The Salvation Army of Central Ohio’s Anti Human Trafficking Program, I’ll call Ann, describes one of her short encounters with the heath care field. She encourages nursing staff to be sensitive with questioning. Ann was forced into street prostitution at age 17; she had a violent pimp who deprived her of all human rights. Ann became extremely ill and was finally escorted to a medical clinic. The doctor informed her that she had tumors covering her fallopian tubes. Ann remembered the doctor being kind and how much that helped her see the hospital as “a way out.”

However, this dream was temporarily cut short once the physician asked “Ann, are you taking hard drugs? Are you walking the streets?”Ann admitted that the direct questioning made her “clam up” because there was implied judgment that she was doing bad things and that she had gotten herself into that situation. Years after this opportunity for freedom was missed, Ann said she still wishes the doctor would have taken the same time to simply ask “Are you alone? Are you afraid?” Ann said that she realized his abilities were limited as he was a doctor, safely on to the next patient, but also saw him as an opportunity. Ann said all it would have taken was for the doctor to say “Is there anything that I can do to help other than perform surgery?” to give her the confidence to say she was trapped, as the woman waiting in the lobby was sent by the trafficker to watch her every move.

This real life example demonstrates the need for nurses to be sensitive to what is unknown about the patients they come in contact with regularly. A more sensitive approach for interviewing would be asking a series of related questions in which a discussion can grow; “What do you do to make money?”, “How many sexual partners have you had in the past 30 days?”, “Is there someone who is making you do something you don’t wish to do?”, “What are the obstacles that are preventing you from getting off of the streets?” The answers to these can help paint the picture of the patient’s life without making them feel judged or threatened.

Generating an environment where the patients feel comfortable talking with you is also necessary if you want to receive the truth. Isolating the victim from anyone who accompanies them is the first step. This must be done in a non-suspicious manner because even the most unlikely person can be a trafficker or someone who is loyal to the trafficker. Informing all who came with the patient that it is the facility’s protocol that the patients only interact with staff during the first exam has been noted to be simple and successful.

The second step is enlisting the skills of a translator or social service professional (like a hospital social worker) if necessary. Typically too many new people can be overwhelming, but if the patient does not speak English or is a minor, the additional social supports may be necessary to foster good communication. It is at this point that you must stress confidentiality and safety. Inform patients of their rights of confidentiality according to your facility’s guidelines. In general potential victims will want to know that the information they say will not leak to the trafficker under any circumstances.  This is not to override honesty. Almost all victims would rather hear a hard answer than a lie because they have been fed false truths so much. A disappointing but genuine answer will speak volumes to you as a nurse as it allows them to trust your words. For example let the patient know that if you assess there is potential that the victim could be further harmed, they will need to tell authorities to protect them from further abuse.

Once you move into the information gathering stage of assessment, after the immediate medical needs are met, carefully craft your questions. You can utilize the list of questions below. These were generated to help guide you to some understanding of your patient’s situation without directly confronting the issues they fear will become exposed.

  • What type of work do you do and can you leave that situation if you want?
  • Are you paid for your work? If so, how much do you keep for yourself?
  • When you are not working, can you come and go as you please?
  • Have you been threatened with harm if you try to quit?
  • Has anyone threatened your family?
  • What are your working or living conditions like?
  • Where do you sleep and eat?
  • Do you have to ask permission to eat, sleep or go to the bathroom?
  • How did you come to this facility? City? State?
  • Is there anyone who has your identification?

Simultaneous with questioning is counter messaging the negative thoughts of the victims. Victims of trafficking feel trapped and scared as their lives are constantly threatened. Even though as a nurse you’re offering help, they will see your questioning as something that will lead them into trouble. While you are asking these questions, keep in mind that you need to speak past the brainwashing. As noted, victims are fed lies about hospitals and will initially believe the lies over what you say for the majority of your encounter.

Messages to convey while communicating with potential victims (Barrows, DO, MA (Bioethics), & Finger, MD, MPH, 2008):

  • We are here to help you, you deserve to be free of abuse
  • We will not judge you for anything you say or any situation you have been in before
  • Our first priority is your safety
  • We are not in the business of deportation
  • We will give you the medical care that you need
  • We want to make sure what happened to you doesn’t happen to anyone else
  • No one deserves to be suffering abuse at the hands of another
  • You are entitled to assistance, We can help you get assistance
  • If you are a victim of trafficking, you can receive help to rebuild your life safely in this country

If a patient keeps denying all accusations or becomes disengaged, but you still feel like something is not right, keep pursuing. Your instincts as a nurse are key. If you’re uneasy about a person’s attitude, then it is worth the time to investigate further. As a nurse your role is not to discern the whole truth about the patient’s life or trafficking situation, but to assess the need for medical intervention and follow up care.

Safety Concerns

Security is an important issue when identifying a patient who may be a victim of trafficking. There may be an immediate or potential safety concern for the patient as well as the staff. Best practice is to review the potential safety concerns now, to avoid the confusion that could ensue when encountering a potential trafficking patient. These safety concerns should then be discussed with your safety officer and supervisors, and have a plan of action in place.

If there is an immediate concern, dial 911 immediately and provide a safe place for the patient. If there is not an immediate concern for the safety of the patient or staff, you may call the national hotline or your local human trafficking hotline for further advice on the best response to the situation at hand. When you call the national hotline, you may be referred to your local coalition, with local resources and advice on how best to address this patient’s immediate needs.

Follow up care

So what happens if your instincts are correct and your patient is a victim of human trafficking? There is much that needs to happen to rescue and restore the victim. There are many people, like therapists and social workers, who will play a part. The needs of trafficking victims upon rescue are great. Immediate assistance includes medical care, housing, food, clothing, and safety. Mental health follows with trauma counseling and therapy. Income assistance and legal status present challenges as well (Barrows, DO, MA (Bioethics), & Finger, MD, MPH, 2008). In order to not be overwhelmed, focus on what you can offer as a skilled nurse. You have three main tasks:

1.)     Treating the medical needs (ideally with follow up care)

2.)     Identifying the victim and fostering their rescue through questioning and assessing

3.)     Making the proper referrals (social services, law enforcement, safe family member, etc.)

Your skill base as a medical professional is to treat and ideally heal the presenting medical issues upon arrival. Concurrently, by taking the time to understand the patient’s emotional needs and life circumstances, you can instill in them the desire for freedom. Just as important as giving them hope for a better life, you are able to foster that hope with your status as a health care professional. As a nurse you are a valued and trusted member of society who has the power to contact others that can help the victim attain safety. When you begin to make the referrals you see necessary, make sure they are all discussed with the patient. Patients will feel great anxiety if they are unaware of their surroundings or next steps forward. You must come mutually to the decision to call outside supports. If you find it necessary regardless of their consent (for example a minor where you are mandated to call children services), you must explain in detail why you came to that decision, who you are informing , when they will arrive, and your best idea of what will happen when more people hear their story.

If you have any doubts about your assessment of a patient, you can confidentially call the National Human Trafficking Hotline for guidance at 1-888-373-7888. This operates 24 hours a day seven days a week.  This can also be a way to help the victim if your best attempts to rescue them fall short due to circumstances outside your control.

Giving the phone number to someone you may believe to be trafficked on an inconspicuous note card can give the victim the opportunity to seek help when the time is right. Do not be disheartened because more often than not, this may be all you can do to help someone. However, it is not to be underestimated. Just by offering a trafficked victim respect, the knowledge that there are people out there who want to help and the power to help themselves (having them hold onto a hotline of which the trafficker is unaware) is invaluable.

As a nurse the number one thing you can offer these victims is Hope. You may be the only person who ever tells them that they have worth and the possibility of a better life. The attention you show as a nurse to the victim’s needs, both physically and emotionally will not go unnoticed. They will hold onto the security you offer with your affection and trust that the facility you work in can offer them freedom. When nurses utilize the skills listed throughout this paper and understand the mindset of a trafficking victim, they can ultimately give more than nursing care, they can offer hope.


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Understanding Human Trafficking in the Nursing Sector

  • Evaluation Were the following outcomes met? Yes or No