Rebecca Puchkors; Jeanne Saunders; David Sharp

Learning Objectives

By the end of this section, you will be able to:

Define human trafficking
Identify resources for prevention and awareness
Discuss nursing responsibilities related to human trafficking

Human trafficking is a serious public health emergency affecting an estimated twelve to thirty million people every year in the United States, including more than five million children (Byrne, Parsh, & Parsh, 2019). It is a grave and disturbing global crisis, transcending borders and affecting countless lives. For nurses and clients, understanding and addressing human trafficking is of paramount importance.

This section will explore the facets of human trafficking, from its underlying causes to the psychological and physical trauma it inflicts on its victims. It will also offer insights into how psychiatric-mental health nurses can actively engage in preventing and combating this crime. By delving into the interconnectedness of mental health and human trafficking, future nurses will be able to recognize signs, provide compassionate care, and collaborate with multidisciplinary teams to support survivors on their path to recovery. Understanding this issue is not only essential for delivering holistic health care, but also for advocating for the vulnerable and marginalized individuals who often bear the brunt of human trafficking’s devastating consequences.

Human Trafficking Defined: Force, Exploitation, and Vulnerability

Human trafficking involves the illegal trade of people, typically for forced labor or commercial sexual exploitation, using coercion, fraud, or force. This grave violation of human rights involves the recruitment, transportation, harboring, or receipt of victims for the purpose of exploitation. It is a global criminal enterprise that thrives on the vulnerability of its victims, exploiting their socioeconomic, personal, or psychological vulnerabilities to maintain control and profit from their suffering. Human trafficking is a complex and multifaceted issue that demands attention from health-care workers, law enforcement, policymakers, and organizations dedicated to combating this form of exploitation.

Force, exploitation, and vulnerability are interconnected elements that characterize human trafficking. The physical or psychological violence used to control victims, including threats, abuse, or confinement is called force. Perpetrators employ force to instill fear and compliance, making it difficult for victims to escape their situations. The numerous different ways in which traffickers financially benefit from their victims’ labor or sexual services is called exploitation. For example, this can involve coercing victims into prostitution, pornography, or other forms of commercial sex work and then taking the majority of their earnings. A person’s vulnerability, or ability to be harmed or influenced, plays a critical role in the recruitment and control of victims. Those who are vulnerable due to poverty, homelessness, substance addiction, or a history of abuse are often targeted by traffickers who exploit these vulnerabilities to manipulate and control their victims.

Table 27.1 provides examples of different types of human trafficking.

Type	Definition
Child soldiering	Child soldiering refers to the practice of recruiting and using children, typically under the age of eighteen, for armed conflict or warfare. These children are often forcibly abducted or coerced into joining armed groups, where they are subjected to combat roles, including fighting, spying, or serving as support personnel.
Debt bondage	Debt bondage is a form of forced labor in which individuals are trapped in a cycle of debt, often due to borrowing money or receiving advances from employers, and are subsequently compelled to work for low or no wages to repay the debt. Victims of debt bondage are often subjected to exploitative working conditions and find it challenging to escape the cycle of debt and exploitation.
Labor trafficking	Labor trafficking refers to the illegal practice of recruiting, harboring, transporting, or obtaining individuals through force, fraud, or coercion to engage in various forms of labor, often in degrading or exploitative conditions. Victims of labor trafficking are typically subjected to involuntary servitude, forced labor, or other forms of labor exploitation, and they may be trapped in situations where their freedom and basic rights are severely restricted.
Sex trafficking	Sex trafficking is the illegal act of recruiting, harboring, transporting, or obtaining individuals through force, fraud, or coercion for the purpose of engaging them in commercial sexual exploitation, including prostitution or pornography. Victims of sex trafficking are often subjected to violence, manipulation, and severe exploitation, and they are denied their basic human rights and autonomy.

Table 27.1 Types of Human Trafficking

Educating Those Affected

Providing education to survivors of human trafficking is a crucial component of holistic recovery and empowerment. Survivors often face physical and psychological health challenges resulting from their traumatic experiences, and nursing education can play a pivotal role in helping them regain control over their lives.

First and foremost, nursing education for survivors involves a trauma-informed approach. Understanding the impact of trauma on survivors’ mental and physical health is essential. Nurses should create a safe and nonjudgmental environment that fosters trust, allowing survivors to disclose their experiences at their own pace. Education should encompass knowledge about common health issues associated with trafficking, including sexually transmitted infections, substance misuse, and mental health disorders.

Empowering survivors with health-care knowledge is also crucial. This includes teaching basic self-care skills, recognizing signs of illness, and accessing health-care services. Many survivors have limited access to health care during their exploitation, and providing them with the tools to navigate the health-care system empowers them to seek care when needed. Additionally, addressing the long-term effects of trauma and promoting self-care strategies, such as mindfulness and stress management, can aid in their emotional healing.

Nursing education should extend beyond just health care. It should also encompass life skills, such as financial literacy, job readiness, and social support networks, to help survivors reintegrate into society successfully. By equipping survivors with education and resources, nurses play a vital role in helping them reclaim their lives, regain independence, and break the cycle of exploitation. Ultimately, nursing education for survivors of human trafficking is a step toward restoring their dignity and enabling them to lead healthier, more fulfilling lives.

Link to Learning

The U.S. Department of State has compiled a list of twenty ways to help fight human trafficking. It contains resources, tools, and tips for helping victims of human trafficking.

Available Resources for Prevention and Awareness

For human trafficking victims and the nurses who assist them, a range of essential resources are available to provide support and aid in recovery. Government agencies, such as the U.S. Department of Health and Human Services (HHS) and the Office for Victims of Crime (OVC), offer comprehensive information, grants, and programs aimed at addressing the needs of trafficking survivors as well as professional development opportunities. Social services, including local shelters and nonprofit organizations like Polaris and the National Human Trafficking Hotline, offer emergency housing, legal assistance, counseling, and other vital services tailored to the unique needs of victims. Additionally, specialized training and resources for health-care professionals, including nurses, are available through organizations like HEAL Trafficking, equipping them with the knowledge and skills to recognize, assist, and advocate for trafficking survivors within the health-care system.

Government Agencies

Several government agencies in the United States provide resources and support for human sex trafficking victims and work to combat trafficking. Some of the key agencies include:

Office on Trafficking in Persons (OTIP): Part of the U.S. Department of Health and Human Services, OTIP is responsible for providing comprehensive services to trafficking victims, including shelter, legal assistance, and social services. It also offers grants to organizations working to combat human trafficking.
The Department of Justice (DOJ): DOJ’s Civil Rights Division houses the Human Trafficking Prosecution Unit, which focuses on prosecuting traffickers and assisting victims. It also provides grant funding to local law enforcement agencies and service providers through the Office for Victims of Crime (OVC).
The Federal Bureau of Investigation (FBI): The FBI investigates and combats human trafficking as part of its mission. It works on both domestic and international cases, targeting traffickers and networks involved in the trade.
U.S. Immigration and Customs Enforcement (ICE): ICE has a Homeland Security Investigations (HSI) unit dedicated to investigating transnational human trafficking cases. It also provides victim assistance through the Victim Assistance Program.
Department of State - Office to Monitor and Combat Trafficking in Persons (TIP Office): This office produces the annual Trafficking in Persons Report, which assesses global efforts to combat trafficking and ranks countries on their antitrafficking efforts.
U.S. Department of Labor (DOL): DOL’s Wage and Hour Division investigates labor trafficking cases, ensuring that workers are protected and paid appropriately. It also provides support and resources to victims of labor trafficking.
U.S. Customs and Border Protection (CBP): CBP plays a role in preventing trafficking at the borders, identifying victims, and working to dismantle trafficking networks involved in illegal border crossings.
Child Exploitation and Obscenity Section (CEOS): Part of the DOJ’s Criminal Division, CEOS focuses on prosecuting child exploitation cases, including child sex trafficking.
The National Human Trafficking Hotline: While not a government agency, this hotline is funded by the Department of Health and Human Services and is a critical resource. It provides assistance, referrals, and information to victims of trafficking and concerned individuals. The hotline can be reached at 1-888-373-7888.

These agencies work together to combat human trafficking, provide support to victims, prosecute traffickers, and raise awareness about the issue. They often collaborate with nongovernmental organizations (NGOs) and local service providers to deliver comprehensive assistance to survivors.

Social Services

There are many private agencies that also aid victims and survivors of human trafficking. Many receive either federal or state funding to assist their operations.

Polaris Project: Polaris operates the National Human Trafficking Hotline, 888-373-7888 (National Human Trafficking Hotline, 2023). This hotline provides assistance, resources, and referrals to trafficking victims and concerned individuals. Polaris Project also engages in advocacy efforts to combat trafficking.
ECPAT-USA (End Child Prostitution and Trafficking): ECPAT-USA focuses on preventing the sexual exploitation of children and advocating for their rights. It offers educational resources, conducts research, and works to shape policies that protect children from trafficking.
Covenant House: Covenant House provides shelter, food, and support services to homeless and trafficked youth in several U.S. cities. It offers a comprehensive range of services, including mental health support, job training, and legal assistance.
CAST (Coalition to Abolish Slavery and Trafficking): CAST offers comprehensive services to survivors of trafficking, including shelter, legal assistance, and case management. It also engages in policy advocacy and community outreach.
GEMS (Girls Educational and Mentoring Services): GEMS is dedicated to empowering young women and girls who have experienced commercial sexual exploitation and domestic trafficking. It provides counseling, educational support, and opportunities for personal growth.
Dignity Health’s Human Trafficking Response Program: Dignity Health offers a comprehensive program aimed at identifying and providing care to trafficking victims in health-care settings. It trains health-care professionals to recognize signs of trafficking and connects victims with support services.
The Salvation Army: The Salvation Army operates several programs and shelters across the country that provide support to trafficking victims. It offers emergency shelter, counseling, and case management services.
Safe Horizon: Safe Horizon offers a range of services to victims of crime and abuse, including trafficking. It provides legal assistance, counseling, and advocacy for survivors in the New York City area.

Nursing Care: Assessment and Intervention

The identification of and intervention for potential victims of human trafficking represent critical aspects of a nurse’s role. Table 27.2 serves as a comprehensive guide for nurses engaged in the assessment and intervention process when encountering clients suspected of being victims of human trafficking. Acknowledging the complex nature of this issue, the table outlines key indicators for identification, such as physical and behavioral signs, and provides information that is crucial for initiating a trauma-informed conversation. Furthermore, it offers insights that are helpful with collaborating with multidisciplinary teams, reporting mechanisms, and culturally sensitive approaches. By equipping nurses with signs and evidence of trafficking, the aim is to enhance their ability to recognize, respond, and advocate for the well-being of individuals subjected to this form of abuse.

Signs of Trafficking	Evidence of Trafficking
Physical signs	Evidence of physical abuse, including bruises, burns, or other injuries Signs of malnourishment or untreated medical conditions Tattooing or branding, which traffickers sometimes use to mark their victims
Behavioral signs	Fear, anxiety, depression, or other emotional distress A sudden change in demeanor or behavior, such as becoming withdrawn or submissive An inability to speak freely or make eye contact Displaying a lack of control over their own finances, identification documents, or personal belongings
Controlled communication	A third party who appears to be exerting control over the individual, speaking for them, or monitoring their interactions Inconsistent or scripted responses when asked about their situation
Working conditions	Being unable to leave their job or working excessively long hours with no breaks Living at their workplace or in overcrowded, unsanitary conditions
Lack of identification	Not possessing identification documents, such as a driver’s license or passport Having false identification documents
Restricted movement	Being closely monitored or accompanied at all times An inability to come and go freely
Sexual exploitation	Having a history of engagement in commercial sex work when they are underage or showing signs of being controlled by a third party
Age and vulnerability	Appearing significantly younger than their stated age Having a history of child abuse or neglect, making them more vulnerable to exploitation
Fear and independence	Expressing a profound fear of authorities or retaliation from traffickers Demonstrating a strong emotional attachment to their trafficker or controller, often due to Stockholm syndrome or coercive tactics
Online presence	Evidence of advertisements for commercial sex services on online platforms or social media accounts that suggest control by a third party

Table 27.2 Identifying Victims

Registered nurses with two or more years of clinical experience (especially in emergency nursing, maternal/child health, or critical care) may become certified as a Sexual Assault Nurse Examiner (SANE). The International Association of Forensic Nurses provides more information on this certification.

Clinical Judgment Measurement Model

Recognize Cues: Possible Signs of Human Trafficking

Recognizing cues involves identifying that which is abnormal with the client. For example, the nurse might notice that their client is fearful in the presence of their partner, has multiple bruises, and seems reluctant to answer questions. These abnormal findings require action. To learn more, the nurse may ask the client questions such as:

Have you experienced harm or received threats when attempting to leave your current situation?
Have threats been made against your family members?
Is your place of residence the same as your workplace?
Could you please describe your living and dining arrangements?
Are you indebted to your employer in any way?
Do you possess your passport or identification, and if not, who is in possession of it?

The client’s responses can guide the nurse on what actions to take next. For urgent cases, the nurse should contact emergency services at 911. The National Human Trafficking Hotline is 1-888-373-7888 and can be contacted to report a tip, connect with antitrafficking services, for training, general information, or antitrafficking resources.

Mandated Reporting and Trauma-Informed Care

Mandated reporting and trauma-informed care are two crucial aspects of nursing practice when it comes to addressing human trafficking. These concepts are intertwined and play a significant role in identifying and assisting trafficking victims while minimizing further trauma.

Nurses, like many other health-care professionals, are mandated reporters. This means they are legally obligated to report suspected cases of abuse, neglect, or exploitation of children or vulnerable adults, which includes human trafficking. When a nurse encounters a client who exhibits signs or discloses information suggesting involvement in trafficking, they have a legal and ethical duty to report their suspicions to the appropriate authorities, such as Child Protective Services or law enforcement. The agency to which the professional must report the suspected abuse differs by state; nurses must be familiar with the law where they are practicing. Mandated reporting is essential for several reasons:

It helps protect vulnerable individuals, especially minors, from further harm.
It allows law enforcement and social services agencies to investigate and intervene in trafficking cases.
It holds traffickers accountable for their actions.
It contributes to a broader effort to combat human trafficking and bring perpetrators to justice.

Recognizing the trauma that survivors of human trafficking have experienced is essential for health-care professionals, including nurses. The approach that acknowledges the prevalence of trauma and its effects on an individual’s mental, emotional, and physical well-being is trauma-informed care. Key principles of trauma-informed care include:

understanding the potential triggers and emotional responses that trauma survivors may exhibit
creating a safe and nonjudgmental environment that fosters trust and open communication
prioritizing the survivor’s autonomy and choice in their care and treatment
being aware of the potential retraumatization that can occur if care is not delivered with sensitivity to a survivor’s history
collaborating with trauma-informed mental health professionals to provide appropriate psychological support

When working with victims of human sex trafficking, trauma-informed care is essential because many survivors have experienced severe physical and psychological abuse. When nurses provide care that is sensitive to the trauma, they can better establish rapport, gain the survivor’s trust, and facilitate disclosure of their experiences. Additionally, this approach helps survivors feel more comfortable accessing health-care services, which is often their first step toward recovery.

Client Referral and Support

Client referral and support are fundamental aspects of nursing care when addressing human trafficking. Nurses play a crucial role in connecting trafficking survivors with the necessary resources and services while providing ongoing support to facilitate their healing and recovery.

In the realm of client referral, nurses play a pivotal role in ensuring that survivors of human trafficking receive the comprehensive care they need. This includes immediate attention to their physical well-being, where nurses may provide referrals to medical specialists, facilitate forensic examinations when necessary, and address sexual and reproductive health concerns. Given the often-profound mental health challenges faced by survivors, nurses also connect them with mental health professionals and therapists specializing in trauma-informed care. Moreover, nurses collaborate with social workers to provide referrals to social services agencies, enabling survivors to access housing assistance, financial support, food, and other resources. Nurses can also guide survivors toward legal aid organizations or attorneys specializing in human trafficking cases, offering assistance with restraining orders, immigration matters, or pursuing restitution from traffickers. Lastly, for survivors grappling with substance misuse issues, nurses facilitate referrals to addiction treatment programs and support groups to address these specific challenges comprehensively.

Client support requires a multifaceted approach in nursing care for trafficking survivors, encompassing trauma-informed care to establish trust, emotional support involving active listening and empathy, safety planning to prevent revictimization, education about rights and resources, crisis intervention for acute distress, advocacy within the health-care system, and empowerment to regain control over their lives, participate in their recovery decisions, and promote autonomy and self-efficacy.

Nurses’ Reactions and Care for the Caregiver

Nurses who care for survivors of human trafficking often face unique challenges and emotional reactions due to the nature of the work. Providing care for survivors of such traumatic experiences can take a toll on the mental and emotional well-being of health-care professionals. Nurses who care for survivors of human trafficking may experience compassion fatigue or vicarious trauma. Compassion fatigue occurs when nurses become emotionally exhausted due to their empathetic responses to survivors’ suffering, and vicarious trauma refers to the emotional toll that exposure to the trauma of others can have on health-care providers. These reactions can lead to symptoms, such as anxiety, depression, and burnout. Likewise, nurses may experience a range of emotional responses when caring for trafficking survivors, including sadness, anger, frustration, and helplessness. It is crucial for nurses to acknowledge and manage these emotions effectively to prevent them from negatively impacting their care. Nurses also may have preconceived notions or biases about human trafficking, which can affect the care they provide. Recognizing and addressing these biases are essential to ensure that survivors receive nonjudgmental and compassionate care. Caring for survivors can also lead to secondary trauma, where health-care providers experience symptoms similar to those of trauma survivors. This can include intrusive thoughts, nightmares, and hypervigilance. Recognizing these symptoms and seeking support is essential for nurses’ well-being. To address these challenges and ensure that nurses are equipped to provide the best care possible, “care for the caregiver” is crucial:

Self-care: Nurses must prioritize self-care, which includes practices like exercise, mindfulness, seeking support from colleagues or therapists, and setting boundaries to prevent burnout.
Supervision and support: Health-care organizations should provide supervision and support for nurses caring for trafficking survivors. Regular debriefing sessions and access to mental health professionals can help nurses process their emotions and manage vicarious trauma.
Education and training: Ongoing education and training on trauma-informed care and the unique needs of trafficking survivors can help nurses feel more prepared and confident in their roles.
Peer support: Encouraging peer support and creating a culture where nurses can openly discuss their experiences and challenges can be highly beneficial.
Supervision and team collaboration: Nurses should collaborate with other health-care professionals, social workers, and organizations specializing in trafficking to provide holistic care to survivors and share the emotional burden of their work.

27.2 Human and Sex Trafficking