Human Trafficing 2 PDF

HUMAN TRAFFICKING
DANA BARTLETT, BSN, MSN, MA, CSPI
Dana Bartlett is a professional nurse and author.

His clinical experience includes 16 years of ICU
and ER experience and over 20 years of as a
poison control center information specialist. Dana
has published numerous CE and journal articles,
written NCLEX material, written textbook
chapters, and done editing and reviewing for
publishers such as Elsevier, Lippincott, and
Thieme. He has written widely on the subject of
toxicology and was recently named a contributing editor, toxicology section, for Critical Care
Nurse journal. He is currently employed at the Connecticut Poison Control Center and is
actively involved in lecturing and mentoring nurses, emergency medical residents and
pharmacy students.
ABSTRACT
Human trafficking has become a growing social concern worldwide. Despite

efforts to prevent it, human trafficking (human slavery) is an abuse that
affects all age groups, genders, and ethnicities. Health professionals are
increasingly required to be aware of the problem of human trafficking, to
recognize it and to know how to intervene. Although the laws and law
enforcement agencies combat human trafficking, health agencies are
increasingly confronted with the demoralizing and crippling effects this abuse
has on individuals, whole families and communities.
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all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 2 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
Statement of Learning Need
Many health clinicians do not realize that the abuse of human trafficking will
be encountered in healthcare sites before it is recognized by social or law
enforcement agencies. Health clinicians need to be prepared to investigate
by asking the right questions and to recognize a victim of human trafficking,
as well as how to report when an individual has identified forced labor and
other coercive acts against them.
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Course Purpose
To help health clinicians identify victims of human trafficking or those

exposed to abusive, coercive acts and forced labor.
Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and

Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Dana Bartlett, BSN, MSN, MA, CSPI, William S. Cook, PhD,

Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC
all have no disclosures.
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge, on

page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
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1. Human trafficking is best described as a crime in which the victim
is
a. moved or smuggled from one country to another.

b. working in an illegal business or industry.
c. forced, defrauded or coerced to engage in sex or forced labor.
d. under the age of 18.
2. True or False: Although human trafficking is present in the United

States, it is an aberration.
a. True
b. False
3. In the United States, soliciting a person 17 years of age, for the

purposes of performing commercial sex, is a crime
a. if some form of force was used.

b. only if there is coercion.
c. in all cases.
d. if the person did not give his or her consent.
4. It is estimated that at any given time, there are almost

______________ people who are victims of forced labor
worldwide.
a. 21 million
b. 2.1 million
c. 5 million
d. 40,000,000
5. A person with financial obligations to an employer, which have

accumulated past their ability to repay, can effectively make the
worker a slave, which is technically known as
a. migrant worker status.

b. employer patronization.
c. modern-day slavery.
d. debt bondage.
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Introduction
Human trafficking is a modern-day form of slavery. Human traffickers prey

on the weak and vulnerable and every year all over the world, millions of
women, children, and men are compelled into prostitution or forced labor by
violence, coercion, deception, or a combination of all three. The victims are
from many different backgrounds but the common denominators they all
share are their desperation and their limited resources. The perpetrators of
human trafficking target people who simply cannot fight back, and human
trafficking places these people into situations from which there is little
chance of escape.
Human Trafficking Defined
The Victims of Trafficking and Violence Protection Act of 2000, a law passed
by the United States Congress in 2000, defines human trafficking as 1) sex
trafficking in which a commercial sex act is induced by force, fraud, or
coercion, or in which the person induced to perform such an act has not
attained 18 years of age, 2) 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, 3) a victim need not be
physically transported from one location to another, for the crime to fall
within these definitions, and 4) involuntary servitude, peonage, debt
bondage, or slavery.
The above definitions are in accordance with the United Nations Protocol to
Prevent, Suppress and Punish Trafficking in Persons, especially Women and
Children, which states the following.
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"Trafficking in persons" shall mean the recruitment, transportation,
transfer, harboring or receipt of persons, by means of the threat or
use of force or other forms of coercion, of abduction, of fraud, of
deception, of the abuse of power or of a position of vulnerability or of
the giving or receiving of payments or benefits to achieve the consent
of a person having control over another person, for the purpose of
exploitation. Exploitation shall include, at a minimum, the exploitation
of the prostitution of others or other forms of sexual exploitation,
forced labor or services, slavery or practices similar to slavery,
servitude or the removal of organs. The consent of a victim of
trafficking in persons to the intended exploitation set forth in
subparagraph (a) of this article shall be irrelevant where any of the
means set forth in subparagraph (a) have been used.
The recruitment, transportation, transfer, harboring or receipt of a
child for the purpose of exploitation shall be considered "trafficking in
persons" even if this does not involve any of the means set forth in
subparagraph (a) of this article; "Child" shall mean any person under
eighteen years of age.19
It is important to note that these definitions clearly state that trafficking

does not necessarily mean moving or smuggling of persons. Trafficking is
the dealing or sale of humans as a commodity for profit.
Social Trends And Causes Of Human Trafficking
In a modern, wealthy country such as the United States it would be easy to

assume that incidents of human trafficking would be an aberration, however,
it is not. The United States Department of State issued a recent report
entitled, Trafficking in Persons Report (June 2016). The report stated that:
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The United States is a source, transit, and destination country for
men, women, transgender individuals, and childrenboth U.S. citizens
and foreign nationals subjected to sex trafficking and forced labor.
Trafficking can occur in both legal and illicit industries, including in
commercial sex, hospitality, sales crews, agriculture, manufacturing,
janitorial services, construction, shipyards, restaurants, health and
elder care, salon services, fairs and carnivals, peddling and begging,
and domestic service.20
The statement above emphasized key points about human trafficking.

Human trafficking does include the popularly reported incidents where young
women are forced into prostitution. While sex slavery involving young
women is a large part of human trafficking, children and men are also
victims of human trafficking.
Human trafficking is not limited to illegal businesses or the underground.

Human trafficking can be found in a wide variety of legal businesses,
industries, and services. In addition, human trafficking does not always
involve the moving or smuggling people from one country to another; the
victims are often citizens and residents of the country in which the violation
occurs. These conditions, which are important aspects of human trafficking,
clearly underscore a chilling point about this crime human trafficking and
its victims are often hidden in plain sight.
Statistics of Human Trafficking
Statistics about a crime like human trafficking will always be imprecise, and
some experts feel that the incidence of human trafficking has been
underestimated while some feel it has been overestimated. The U.S. Justice
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Department has estimated that 14,500 17,500 foreign nationals are
trafficked into the Unites States every year. Recent (2015) information from
U.S. organizations involved in the fighting of human trafficking reported over
24,000 calls to their hotlines. It has been estimated that at any given time,
there are almost 21 million people who are victims of forced labor
worldwide.
Variations Of Human Trafficking
If a minor, which is defined by Federal law as someone under age 18, is

employed, encouraged, harbored, lured, recruited, transported, or solicited
for the purposes of commercial sex, force and/or coercion are not necessary
for this to be considered a crime. Worldwide and in the United States,
countless numbers of children are forcibly employed or sold to others for
forced employment. United States law prohibits importation of any goods
that were manufactured using forced child labor.
Debt Bondage
Debt bondage is a form of human trafficking that involves the use of debt to
hold someone in servitude. Debt bondage is especially common for migrant
workers and foreign nationals who travel for employment.
Once these people are in a situation where their financial obligations to an

employer have accumulated past their ability to repay, debt bondage can
effectively make the worker a slave and or prevent them from leaving. It
also makes them vulnerable to be used as a commodity or possession, being
bought and sold.
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Domestic Service
Domestic service is a common form of human trafficking in the United States

and around the world. Foreign nationals can easily be hidden inside a private
residence from authorities, they are often the only employee, they do not
speak the native language, and they have no support. In addition, money,
personal identification, and resources are withheld and the employer (a
loosely used term in this situation) can always threaten to have the victim
exposed to the Immigration and Naturalization Service and deported.
Forced Labor
If someones labor is obtained by force, threats, physical restraint, or serious

harm, or if someones labor is obtained by a plan that is intended to cause
that person to believe he/she will come to harm, that is forced labor.
There is a wide variety of ways people can be coerced or deceived into

forced labor. Much of it is centered in activities that are low-skilled, seasonal
in nature, or undervalued, or in work that no one would voluntarily do. Jobs
that are dirty and dangerous or performed in very poor conditions are often
done by forced labor.
Forced Marriage
Forced marriage is different from arranged marriage. In the United States

forced marriage occurs when a young girl is taken from her home, returned
to the country of her family and forced to marry. Resistance or refusing to
marry puts her at risk for physical abuse and even death, and forced
marriage is associated with increased rates of domestic violence, rape, and
suicide.
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Organ Trafficking
Organ trafficking can take one of three forms. The victim can be forced or
deceived to relinquish an organ, the victim may agree to sell an organ but
will not be paid, or the victim may be fraudulently treated for an ailment and
the organ unnecessarily removed.
Sex Trafficking
In some countries prostitution is not illegal or it is considered a crime of

relatively minor importance. But when someone prostitutes herself/himself
because he/she has been coerced and/or forced to do so or the use of fraud
or threats is involved, this is sex trafficking and it is a crime. In those
circumstances, anyone who has enticed, harbored, patronized, recruited,
transported, or solicited another person for sexual activity is guilty of sex
trafficking.
Sex trafficking predominantly affects girls and women, and in many parts of
the world their lack of legal rights and the economic disparities attached to
their gender make girls and women especially vulnerable. Girls and women
are promised jobs with relatively good wages and once away from home and
family, then they are exposed to isolation, threats, and violence that hold
them prisoners.
Victims Of Human Trafficking
Many victims of trafficking are girls and women, but such victims can be
children, men, older adults, citizens of the country or foreign nationals, legal
or illegal aliens. But regardless of gender, age, or background, the victims of
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human trafficking all share one thing - vulnerability. There are numerous
examples of vulnerable individuals listed below.
Runaways are frequent victims of human trafficking.

Transgender individuals are a population vulnerable to this crime.
Homeless youth can easily become coerced or forced into a human
trafficking situation.
Foreign nationals are far away from home, may not speak the
language, have no support systems, and may be in the country
illegally.
People who come from politically unstable countries, countries in which
there is war or widespread violence; citizens of these countries are
desperate to leave and can easily be exploited.
Anyone who is poor or comes from a country in which there is
significant economic instability.
People who have disabilities.
Victims of domestic violence and/or sexual abuse.
Victims of child sexual abuse.
Native American, Alaskan American individuals are particularly
vulnerable to human trafficking.
Consequences Of Human Trafficking
The obvious consequence of human trafficking is of course loss of freedom.

Human trafficking, as was stated earlier, is modern slavery, people held in
bondage and exploited for financial gain. But the loss of freedom is simply
the underpinning for the severe psychological and physical consequences of
human trafficking.
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Psychological Consequences
Human trafficking depends on coercion,

emotional abuse, fear, lying,
manipulation, threats essentially any
harmful and negative emotions. This
treatment, combined with the loss of
freedom and the hopelessness
experienced by human trafficking victims,
has profound emotional consequences.
Human trafficking victims frequently
suffer from a wide variety of
psychological problems, such as those
listed below.
Addiction
Anxiety
Depression
Eating disorders
Emotional dysregulation
Hostility
Hypervigilance
Insomnia
Low self esteem
Normalizing of sexual violence
Shame
Suicide
Posttraumatic stress disorder
Traumatic bonding
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Emotional dysregulation is a condition in which an individuals emotional
response to a situation is considered very abnormal. Emotional dysregulation
is a common feature of posttraumatic stress syndrome (PTSD).
Traumatic bonding is a relationship in which the bond between two people is

based on intermittent cycles of fear and pain with pleasure. This relationship
is complex but it essentially involves isolation, complete (or perceived to be
complete) power by one person over another, a real or perceived threat to
kill or harm the victim, and occasional acts of kindness by the perpetrator.
Humans are programmed to form attachments and although the bond of a

human trafficker to the victim is grossly abnormal, the victim has no one
else. The victim needs the trafficker because the trafficker supplies the
basics to sustain life and because the trafficker provides some level of
pleasure, albeit very small and intermittent. The victim soon learns that to
survive it is psychologically better to become attached to the enslaver.
Posttraumatic stress disorder is a psychological condition that is caused by

living through or witnessing an extremely traumatic event, particularly an
event that causes fear and helplessness. People who have PTSD suffer from
a variety of signs and symptoms such as depression, flashbacks, and intense
mood swings. The risk of suicide has been reported to be very high for
victims of human trafficking. Lederer, et al., (2014) found an incidence of
attempted suicide of 41.5% during the experience of human trafficking and
20.5% after human trafficking.
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Physical Consequences
The physical consequences of human trafficking affect every organ system.

These are identified as:
Musculoskeletal: Fractures, pain

Neurological: Memory loss, disorientation
Pulmonary: Tuberculosis
Skin: Bites, bruises, burns lacerations, scars
Reproductive/sexual: Abortion, genital trauma, pregnancy, and
sexually transmitted infections.
Sexually transmitted infections are very common in women and men who
are victims of sex trafficking. The rate of human immunodeficiency virus
(HIV) infection in male and female prostitutes is especially high, and there is
no reason to believe that this would not be the case for victims of sex
trafficking. Women who are victims of sex trafficking can suffer ectopic
pregnancy, pelvic inflammatory disease, unsafe and unsanitary abortions,
and infections with antibiotic-resistant sexually transmitted diseases.
Methods Of Human Trafficking
Human trafficking depends on vulnerability. Vulnerability would be caused by

an individuals cultural, economic, social, and personal circumstances.
Traffickers exploit these weaknesses to both establish and maintain power
over the victim, and they do so not through simple physical force. In the late
1950s, a sociologist named Albert Biderman studied interrogation techniques
that had been used to manipulate prisoners of war and make them
compliant and accepting, and his work can be applied to human trafficking.
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Biderman identified eight techniques used for coercion and to maintain
power over the other person, which are highlighted below.
Isolation
Isolation, both physical and psychological, is a very common theme in

human trafficking and it is essential for human trafficking to succeed.
Victims are deliberately kept from the outside world, sometimes not even
being allowed outside. Isolating the human trafficking victim is one the most
important steps of creating a victim and in keeping him/her in that status.
Isolation prevents a victim from seeking help, and it is physically and
psychologically disorienting; and, isolation is an essential part of the process
of traumatic bonding.
Because the trafficker/traffickers are often the only personal and social
contact for the victim, some degree of emotional and psychological
dependency on the person who is exploiting the victim is almost inevitable.
Humans want and need relationships. This a deep part of our nature and
even though the trafficker-victim relationship is horribly abusive, a victim
may unconsciously decide that any human contact is preferable to none and
he/she will develop a psychological attachment to the trafficker.
Degradation
Degrade means to break down and this is one of the primary goals of human
traffickers; to break down the humanity of their victims. Victims of human
traffickers are continually and ceaselessly degraded by emotional, physical,
and psychological abuse.
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Degradation forces the victims to exist only for the most basic instincts and
needs, and it creates a sense of hopelessness. It also forces that person to
live in fear, and fear creates obedience. And, degradation also creates or can
reinforce a sense of worthlessness, a complete lack of self-esteem,
diminishing the victims ability to resist. Many human trafficking victims had
a diminished sense of worth prior to this, so they are particularly vulnerable
to this technique as it reinforces a core belief that they have no self-worth,
no value. It is a sentiment that the trafficker is happy to reinforce.
Omnipotence
The human trafficker does everything he/she can to appear omnipotent.

They control every aspect of the victims life, and they often do have the
power of life and death. Combined with the other psychological techniques
traffickers use, the synergistic effect of total control over the victims life has
profound psychological consequences.
Monopolizing Perception
Monopolizing perception is a commonly used technique of human traffickers,

which is brutal, disorienting, and exhausting. The victims attention is
constantly and forcibly directed on the trafficker, his/her demands, and the
tasks the victim must do. The victim literally has no time to think of anything
else except the trafficker and the work.
Indulgences
Day after day a human trafficking victim will be abused and degraded, given
only what is essential to keep him/her alive. But every so often the trafficker
offers a small kindness or some personal recognition of the victim. These
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indulgences may seem spontaneous but they are not; they are part of the
plan to create complete dependency on the part of the victim. They are done
periodically, the frequency is deliberately unpredictable, and they are never
associated with anything the victim does, or does not do.
Since the natural human instinct associates rewards with behaviors - and
rewards for the victim are so few and so minimal he/she will become even
more fixated on ways to please the trafficker even though that is not
possible.
Indulgence is the easiest method of control to understand. And in the case

of human trafficking a threat is highly effective as well because in most
cases, the trafficker has the power to carry out any threat, up to and
including death. The victims and their families can be subject to threats and
a threat is a simple way to ensure long-term obedience.
Trivial Demands
The concept of trivial demands is closely related to degradation and

omnipotence. The trafficker constantly makes demands that are very trivial
and pointless; someone in forced domestic service may be required to
arrange cans of food in a cupboard alphabetically, then next day by size, and
then next day by manufacturer. Being compelled to perform these
meaningless and useless tasks sends a clear message to the victims that the
abuser can do anything they want to the victim, even things that no
reasonable person would agree to do. This technique also engrains the habit
of unquestioning obedience.
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Inducing Debility
Inducing debility has to do with conditions where people are easier to control
when they are hungry, tired, thirsty, sleep-deprived, or weak. Traffickers will
often deprive victims of physical necessities and the induced debility makes
people far more controllable.
There are of course many other ways a victim of human trafficking can be
abused and controlled, such as debt accumulation, deception, forced use of
drugs, refusal to provide needed medical care. However, the goal is always
the same - control of another human for economic gain.
Recognizing Human Trafficking Individuals
Human trafficking is common but identification of the victims is not. This is

of course primarily because of the nature of the crime and because of the
isolated and fearful circumstances in which the victims live. Working in a
factory or a sweatshop 14 hours a day, doing agricultural labor on a rural
farm, employed as a sex worker, or being in debt bondage as a domestic
and never allowed to leave the house are examples of such damaging
conditions.
The victims of human trafficking do have contact with people outside

their world. Some forms of this modern-day slavery involve being out in
public, i.e., construction job sites, agricultural work which is not done in
remote areas, and studies have shown that healthcare professionals,
particularly in the emergency room (ER), encounter human trafficking
victims. These studies did not involve large numbers but Chisolm-Straker, et
al., (2014) found that 87.8% of the sex trafficking victims they surveyed
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had contact with a healthcare professional, and slightly more than 63% had
visited an ER at least once.
Yet, if people who are being trafficked are occasionally in the public domain
and occasionally interact with someone aside from other victims or the
traffickers, why arent they recognized? Human trafficking after all is a
horrible crime that causes devastating consequences. Why dont people, and
especially healthcare professionals, identify the victims? The answer to the
last question can be summed up in a simple phrase: dont know and dont
tell.
Healthcare professionals may not have sufficient awareness of the problem.

If they are not aware they will not look, there may not be any strong cues
that provide incentive to look, and there are countless reasons why the
victims will not tell them.
Studies have shown that healthcare professionals do not have extensive

knowledge about human trafficking. It is also clear that even though human
trafficking victims often seek healthcare they are almost never recognized by
healthcare professionals. Lack of knowledge of human trafficking and an
inability to recognize the victims can be due to lack of education, no
validated assessment tools that can be used to identify these victims, the
patients complaint can easily be explained as being caused by something
else, and, unlike other people who come to an ER, the victims are not
forthcoming about how and why they became injured or sick.
As previously mentioned, there are countless reasons why a human

trafficking victim wont reveal his/her status, and some of these are listed
below in Table 1.
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Table 1: Reasons for Non-Disclosure of Human Trafficking Status
Criminal record
Cultural inhibitions
Fear
Lack of opportunity
Language barrier
Psychological/physical disorientation
Sexual orientation
Shame
Unaware/unsure of legal rights
Unaware of victim status
These reasons for nondisclosure may all seem obvious but when they are
examined closely, it is clear why human trafficking victims do not ask for
help. Consider the following case studies.
Case Study 1
An 18-year-old woman living in Thailand is kidnapped and smuggled into the

United States. She does not speak English, she has no identification, and she
is forced into prostitution. Beatings, periodic rapes, and threats from the
captors to harm her family and to turn her over to the police are common
occurrences.
When she develops a venereal disease or an injury from one of her captors
or an abusive customer, she is brought to a clinic where the staff is paid off -
and threatened - to look the other way. Also for her, the examinations are
strange and embarrassing, and they further her shame about what she has
been forced to do.
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Case Study 2
A 25-year-old woman has been recruited to leave her family in Mexico and
come to the United States for a well-paying factory job; her entry into the
country is illegally arranged. The job is real, but she is told that due to the
conditions of her recruitment she must repay $25,000 to the people who
brought her here. At her current salary, this debt can never be repaid. In
addition, the promised living arrangements have not been provided, she is
forced to buy food from captors (at exorbitant prices), she is only allowed to
go to work and then is returned to a communal home to sleep, and she is
forced to work 16-18 hours a day.
These inhuman conditions are enforced by occasional physical violence,

constant threats of violence, and threats to turn her over to the Immigration
and Nationalization Services. When she needs healthcare, she is brought to
an ER by one of her captors. Although she speaks sufficient English to make
her problems understood, she is instructed to act as if she cannot speak the
language, and the captor pretends to interpret for her.
In these situations, it is evident why a human trafficking victim would not

and often cannot ask for help. They do not have the emotion, financial, or
social resources to do so. Their circumstances make it virtually impossible
for them to ask for help. And finally, the real or perceived cost of trying to
break free is far more than anyone would be willing to pay.
Identifying Human Trafficking Victims
Identifying a victim of human trafficking has many similarities to recognizing

a victim of intimate partner violence. Although there are validated
assessment tools for identifying people who are being trafficked, there are
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certainly clues and signs that should alert the health clinician to the
possibility.
The injury or the illness cannot be explained.

The explanation cannot logically or factually account for the
injury/illness.
Medical care is sought long after it seems reasonable to have done so.
There are injuries that suggest intentional harm, i.e., bruises on the
face or around the neck, intentional burn marks, puncture wounds,
trauma to the genitals.
Someone who seeks medical attention is accompanied by a friend who
insists on always being with that person, and he/she is very
controlling, and answers for the individual who is injured or sick; and,
the injured or sick party seems hesitant and fearful when the friend is
nearby.
The same person is seen multiple times for the same illnesses or
injuries. Examination of their records may show no voluntary follow-up
care for these problems and/or no compliance with recommended
treatments both of which require time and money, neither of which
the victim possesses.
The patient is exceptionally fearful and nervous while being questioned
and examined.
The complaints always involve injuries, issues surrounding drug use,
or are related to sexual activity.
The patients complaint seems as if it was memorized or scripted.
The patient has no identification.
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If human trafficking is suspected, a focused private interview should be the
next step. The questions should be nonjudgmental, open-ended, and framed
in a way that encourages the patient to talk.
Interviews with human trafficking victims found that the victims would be
more likely to be open and candid if the healthcare professional appeared to
be knowledgeable about trafficking, if he/she was respectful, and a
nonjudgmental attitude was perceived. The following section includes
examples of questions that may be helpful during the interview process.
Interview Questions for Suspected Human Trafficking
Work History
How many hours do you work in a week? How much are you paid? Do you
get to keep the money you earn? Do you get time off? Could you quit your
job if you wanted to? How did you get this job? Do you feel that you were
lied to about your job, the pay, and the working conditions? What would
happen to you if you complained about your job? Are you forced to do things
that are dangerous? What happens if your employer is angry at you? Has
your employer ever hit you or threatened you?
Perceptions of Safety
Do you feel safe right now? Do you feel safe answering these questions? Is
there anyone who has threatened you at home or at work? Is there anyone
who has hit you or abused you at home or at work? Do you have people in
your life who frighten you? What would you do if you needed help of any
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type? What would make you feel safe right now? Has anyone ever
threatened you or threatened your family?
Personal History
Are you free to do what you want? Do you have to ask permission to go out?
Are you allowed to go out? Do you need permission to speak to other
people? Were your identification papers/documents taken from you? Have
you ever been forced to have sex? Have you ever been forced to have sex in
exchange for money? Have you ever been pressured to do something you
didnt want to do? What would happen if you refused? Do you get enough to
eat? Has anyone punished you by withholding food? What would you do if
you were sick and needed help?
The categories were arbitrarily chosen and there is clearly overlap between
them. The goals are to encourage the interviewee to open up and provide
basic details about his/her life. These details would not be particularly
important for most patients but are crucial in these circumstances.
This interview process can be delicate and difficult, as trying to get someone
who is a victim of human trafficking to talk about his/her status is potentially
very dangerous for them and requires an enormous level of trust. The
healthcare clinician who asks the human trafficking victim to reveal his/her
status is saying in effect: If you take this risk I can help you and you will be
safe.
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The following excerpt is from a 2017 American Medical Association (AMA)
Journal of Ethics article and elucidates the obligation of health clinicians in
situations of suspected human trafficking.
risks to trafficking victims associated with a mandatory reporting

system, especially one that fails to achieve its intended purposes, are
significant. If trafficking victims and survivors youth or adults are
aware of a reporting requirement, it could possibly deter them from
seeking care or disclosing sensitive information, because they fear
reprisal by their traffickers, prosecution by law enforcement (i.e., for
prostitution), or deportation by immigration authorities. If reporting
resulted in access to real protections and meaningful services,
knowledge of that might overcome the reticence of trafficked persons
to reveal their situation and have it disclosed.18
Reporting Human Trafficking
Certain consequences of human trafficking like gunshot wounds, stab

wounds, child abuse, intimate partner violence, sexual assault, or immediate
threats to a patient are covered by mandatory reporting laws, and these
situations should be reported to the police. However, the requirements for
mandatory reporting of human trafficking itself vary from state to state. For
example, some states have requirements for reporting sex trafficking and
some for reporting labor trafficking.
Unless required to by local laws or unless there is a reportable consequence

of human trafficking, instances of suspected human trafficking cannot be
reported to legal authorities if the patient is competent and has not given
his/her permission to do so. This situation would seem to be the worst of
25
both worlds; knowing about or suspecting the presence of a particularly
horrible crime but being prevented from interceding.
Patient safety is the priority and if there is no immediate danger, the

administrative and/or legal departments of the healthcare facility should be
consulted. A valuable resource is the National Human Trafficking Resource
Center (NHTRC) at https://humantraffickinghotline.org/. The NHTRC
operates a hotline that is available every day, 24 hours, 1-888-373-7888.
The NHTRC can provide information, guidance, and resources for healthcare
clinicians who have questions about human trafficking.
Reporting Human Trafficking
Call 911 if there is an immediate threat to the patients health or life.
Follow mandatory reporting laws if the situation involves child abuse,

gunshot wounds, intimate partner violence, sexual assault, or stab wounds.
Follow your state mandatory human trafficking requirements.
Do not report human trafficking if the victim is competent and refuses to

give permission to do so.
Consider providing the victim with the NHTRC hotline number.
26
Summary
Human trafficking is common in the United States but it is often referred to

as a crime that is hidden in plain sight. Traffickers exploit those who are
especially vulnerable, the victims are young, old, male, female, native-born
and foreign, and they are enslaved in forced labor, domestic service, and
prostitution, and may other forms of involuntary servitude. The physical and
psychological consequences of human trafficking are often quite severe.
Healthcare professionals often do not have adequate knowledge of human

trafficking. In addition, it has been shown that human trafficking victims
have frequent contact with the healthcare system, yet they are seldom
recognized.
Reporting human trafficking can be complicated. Although there are

mandatory reporting laws for many of the consequences of human
trafficking, not all states have mandatory reporting laws for the crime itself
and the laws that exist vary from state to state. Asking a victim of human
trafficking to reveal his/her status represents a huge issue of trust and risk.
Health clinicians should always remember that patient safety is the priority.
Patient confidentiality must be protected as the resources available for
consultation are accessed, and the mandatory reporting laws are followed
relative to human trafficking, child abuse or sexual assault.
Please take time to help NurseCe4Less.com course planners evaluate

the nursing knowledge needs met by completing the self-assessment
of Knowledge Questions after reading the article, and providing
feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course

requirement.
27
is
a. moved or smuggled from one country to another.

b. working in an illegal business or industry.
d. under the age of 18.

a. True
b. False

a. if some form of force was used.

b. only if there is coercion.
c. in all cases.
d. if the person did not give his or her consent.

worldwide.
a. 21 million
b. 2,100,000
c. 5 million
d. 40,000,000

a. migrant worker status.

b. employer patronization.
c. modern-day slavery.
d. debt bondage.
28
6. Domestic service is a common form of human trafficking
a. in the United States.

b. around the world.
c. involves foreign nationals.
d. All of the above
7. Jobs that are dirty and dangerous or performed in very poor

conditions are
a. often done by domestic help.

b. often done by forced labor.
c. called seasonal jobs.
d. not part of human trafficking.
8. True or False: Forced marriage is different from arranged

marriage.
a. True
b. False
9. Organ trafficking is not present if
a. the victim agreed to sell the organ.

b. force was not used to remove the organ.
c. the victim was being treated for an alleged ailment.
d. None of the above
10. _______________________ is a condition in which an

individuals emotional response to a situation is considered very
abnormal.
a. Posttraumatic stress syndrome (PTSD)

b. Traumatic bonding
c. Emotional dysregulation
d. Patronization
29
11. A situation in which a person (real or perceived) threatens to kill
or harm a victim, and then shows occasional acts of kindness to
the victim is an example of
a. emotional dysregulation.
b. patronization.
c. traumatic bonding.
d. hypervigilance.
12. True or False: In countries where prostitution is legal, sex

trafficking cannot occur.
a. True
b. False
13. A human trafficker will control or try to control every aspect of a

victims life, including the power of life and death over the
victim, in order to appear
a. omnipotent.
b. indulgent.
c. debilitating.
d. hypervigilant.
14. A trafficker who constantly makes demands on the victim that

are pointless is practicing the concept of
a. hypervigilance.
b. indulgence.
c. debilitation.
d. trivial demands.
15. A reason why a victim of human trafficking may not reveal his or
her status is
a. the victim may have a criminal record.

b. language barriers.
c. psychological disorientation.
d. All of the above
30
16. True or False: Recognizing a victim of human trafficking has
many similarities to recognizing a victim of intimate partner
violence.
a. True
b. False
17. Reporting a case of human trafficking
a. is mandatory in all cases.

b. may require the consent of the victim.
c. is not required even if there is a reportable crime.
d. is not dependent on the patients safety.
18. Indulgences, or small acts of kindness shown to a human

trafficking victim, are
a. spontaneous acts of kindness.

b. associated with the actions of the victim.
c. planned to create complete dependency on the part of the victim.
d. deliberate and predictable to give the victim a modicum of hope.
19. If a healthcare clinician suspects a patient may be a victim of

human trafficking, the next step for the clinician should be
a. to contact law enforcement.

b. tell the victim to consent to disclosure of the crime.
c. a focused, private interview.
d. to let family or friends know of the suspected situation.
20. True or False: All consequences of human trafficking require the

victims consent before the circumstance may be reported to law
enforcement.
a. True
b. False
31
CORRECT ANSWERS:

is
Human trafficking [is defined] as 1) sex trafficking in which a

commercial sex act is induced by force, fraud, or coercion, 2)
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.

b. False
In a modern, wealthy country such as the United States it would

be easy to assume that incidents of human trafficking would be an
aberration. It is not.

c. in all cases.
If a minor, which is defined by Federal law as someone under age

18, is employed, encouraged, harbored, lured, recruited,
transported, or solicited for the purposes of commercial sex, force
and/or coercion are not necessary for this to be considered a
crime.

worldwide.
a. 21 million
It has been estimated that at any given time, there are almost 21
million people who are victims of forced labor worldwide.
32
d. debt bondage.
Debt bondage is a form of human trafficking that involves the use

of debt to hold someone in servitude. Debt bondage is especially
common for migrant workers and foreign nationals who travel for
employment. Once these people are in a situation where their
financial obligations to an employer have accumulated past their
ability to repay, debt bondage can effectively make the worker a
slave and or prevent them from leaving.
6. Domestic service is a common form of human trafficking
a. in the United States.

b. around the world.
c. involves foreign nationals.
d. All of the above [correct answer]
Domestic service is a common form of human trafficking in the

United States and around the world. Foreign nationals can easily be
hidden inside a private residence from authorities, they are often
the only employee, they do not speak the native language, and
they have no support. In addition, money, personal identification,
and resources are withheld and the employer (a loosely used term
in this situation) can always threaten to have the victim exposed to
the Immigration and Naturalization Service and deported.
7. Jobs that are dirty and dangerous or performed in very poor

conditions are
b. often done by forced labor.
There is a wide variety of ways people can be coerced or deceived

into forced labor. Much of it is centered in activities that are low-
skilled, seasonal in nature, or undervalued, or in work that no one
would voluntarily do. Jobs that are dirty and dangerous or
performed in very poor conditions are often done by forced labor.
33
8. True or False: Forced marriage is different from arranged
marriage.
a. True
Forced marriage is different from arranged marriage.
9. Organ trafficking is not present if
a. the victim agreed to sell the organ.

b. force was not used to remove the organ.
c. the victim was being treated for an alleged ailment.
d. None of the above [correct answer]
Organ trafficking can take one of three forms. The victim can be
forced or deceived to relinquish an organ, the victim may agree to
sell an organ but will not be paid, or the victim may be fraudulently
treated for an ailment and the organ unnecessarily removed.
10. _______________________ is a condition in which an

individuals emotional response to a situation is considered very
abnormal.
c. Emotional dysregulation
Emotional dysregulation is a condition in which an individuals

emotional response to a situation is considered very abnormal.
Emotional dysregulation is a common feature of posttraumatic
stress syndrome (PTSD).
11. A situation in which a person (real or perceived) threatens to kill

or harm a victim, and then shows occasional acts of kindness to
the victim is an example of
c. traumatic bonding.
Traumatic bonding is a relationship in which the bond between two

people is based on intermittent cycles of fear and pain with
pleasure. This relationship is complex but it essentially involves
isolation, complete (or perceived to be complete) power by one
person over another, a real or perceived threat to kill or harm the
victim, and occasional acts of kindness by the perpetrator.
34
12. True or False: In countries where prostitution is legal, sex
trafficking cannot occur.
b. False
In some countries prostitution is not illegal or it is considered a

crime of relatively minor importance. But when someone prostitutes
herself or himself because she or he has been coerced and/or
forced to do so or the use of fraud or threats is involved, this is sex
trafficking and it is a crime.
13. A human trafficker will control or try to control every aspect of a

victims life, including the power of life and death over the
victim, in order to appear
a. omnipotent.
The human trafficker does everything he/she can to appear

omnipotent. They control every aspect of the victims life, and they
often do have the power of life and death.
14. A trafficker who constantly makes demands on the victim that

are pointless is practicing the concept of
d. trivial demands.
The concept of trivial demands is closely related to degradation

and omnipotence. The trafficker constantly makes demands that
are very trivial and pointless;.
15. A reason why a victim of human trafficking may not reveal his or
her status is
a. the victim may have a criminal record.

b. language barriers.
c. psychological disorientation.
d. All of the above [correct answer]
Reasons for Non-Disclosure of Human Trafficking Status: Criminal

record; Cultural inhibitions; Fear; Lack of opportunity; Language
barrier; Psychological/physical disorientation.
35
16. True or False: Recognizing a victim of human trafficking has
many similarities to recognizing a victim of intimate partner
violence.
a. True
Recognizing a victim of human trafficking has many similarities to

recognizing a victim of intimate partner violence.
17. Reporting a case of human trafficking
b. may require the consent of the victim.
However, the requirements for mandatory reporting of human

trafficking itself vary from state to state. For example, some states
have requirements for reporting sex trafficking and some for
reporting labor trafficking. Unless required to by local laws or unless
there is a reportable consequence of human trafficking, instances of
suspected human trafficking cannot be reported to legal authorities
if the patient is competent and has not given his/her permission to
do so.
18. Indulgences, or small acts of kindness shown to a human

trafficking victim, are
c. planned to create complete dependency on the part of the victim.
These indulgences may seem spontaneous but they are not: they
are part of a plan to create complete dependency on the part of the
victim. They are done periodically, the frequency is deliberately
unpredictable, and they are never associated with anything the
victim does, or does not do.
19. If a healthcare practitioner suspects a patient may be a victim of

human trafficking, the next step for the practitioner should be
c. a focused, private interview.
... there are certainly clues and signs that should alert the
practitioner to the possibility [of human trafficking].... If human
trafficking is suspected, a focused private interview should be the
next step. The questions should be nonjudgmental, open-ended,
and framed in a way that encourages the patient to talk.
36
20. True or False: All consequences of human trafficking require the
victims consent before the circumstance may be reported to law
enforcement.
b. False
Certain consequences of human trafficking like gunshot wounds,

stab wounds, child abuse, intimate partner violence, sexual assault,
or immediate threats to a patient are covered by mandatory
reporting laws, and these situations should be reported to the
police.
References Section
The References below include published works and in-text citations of

published works that are intended as helpful material for your further
reading.
1. Alpert EJ, Ahn R, Albright E, Purcell G, Burke TF, Macias-

Konstantopoulos W. (2014). Human Trafficking: Guidebook on
Identification, Assessment, and Response in the Health Care Setting.
2014 Massachusetts General Hospital and Massachusetts Medical
Society. Retrieved online at http://www.massmed.org/Patient-
Care/Health-Topics/Violence-Prevention-and-Intervention/Human-
Trafficking-(pdf)/.
2. Atkinson HG, Curnin KJ, Hanson NC. (2016). US state laws addressing
human trafficking: education of and mandatory reporting by health
care providers and other professionals. J Hum Trafficking.
2016;2(2):111-138.
3. Baldwin SB, Eisenman DP, Sayles JN, Ryan G, Chuang KS. (2011).
Identification of human trafficking victims in health care settings.
Health Hum Rights. 2011;13(1): E36-E49.
37
4. Biderman AD. (1957). Communist attempts to elicit false confessions
from Air Force prisoners of war. Bull N Y Acad Med. 1957;33(9):616-
625.
5. Chisolm-Straker M, Richardson LD, Cossio T. (2012). Combating
slavery in the 21st century: the role of emergency medicine. J Health
Care Poor Underserved. 2012;23(3):980987.
6. Chisolm-Straker M, Baldwin S, Gaigbe-Togbe B, et al. (2016).
Healthcare and human trafficking: we are seeing the unseen. J Health
Care Poor Underserved. 2016;27(3):1220-1233.
7. English A. (2017). Mandatory reporting of human trafficking: Potential
benefits and risks of harm. AMA J Ethics. 2017;19(1):54-62.
8. Gibbons P, Stoklosa H. (2016). Identification and treatment of human
trafficking victims in the emergency department: A case report. J
Emerg Med. 2016;50(5):715-719.
9. Grace AM, Lippert S, Collins K, et al. (2014). Educating health care
professionals on human trafficking. Pediatr Emerg Care.
2014;30(12):856-861.
10. Hachey LM, Phillippi JC. (2017). Identification and management of
human trafficking victims in the emergency department. Adv Emerg
Nurs J. 2017;39(1):31-51.
11. Kerr PL, Dash R. (2017). Ethical considerations in mandatory disclosure
of data acquired while caring for human trafficking survivors. AMA J
Ethics. 2017;19(1):45-53.
12. Lederer LJ, Wetzel CA. (2014). The health consequences of sex
trafficking and their implications for identifying victims in healthcare
facilities. Ann Health Law. 2014;23, 61.
13. Powell C, Dickins K, Stoklosa H. (2017). Training US health care
professionals on human trafficking: where do we go from here? Med
Educ Online. 2017;22(1):1267980. doi:
10.1080/10872981.2017.1267980.
14. Ross C, Dimitrova S, Howard LM, Dewey M, Zimmerman C, Oram S.
(2015). Human trafficking and health: a cross-sectional survey of NHS
professionals' contact with victims of human trafficking. BMJ Open.
2015 Aug 20;5(8):e008682. doi: 10.1136/bmjopen-2015-008682.
15. Shandro J, Chisolm-Straker M, Duber HC, et al. (2016). Human
trafficking: A guide to identification and approach for the emergency
physician. Ann Emerg Med. 2016;68(4):501-508.
16. Stoklosa H, Grace AM, Littenberg N. (2015). Medical education on
human trafficking. AMA J Ethics. 2015;17(10):914-921.
17. Todres J. Physician encounters with human trafficking: Legal
consequences and ethical considerations. AMA J Ethics. 2017;19(1):16-
22.
38
18. English A. Mandatory reporting of human trafficking: Potential benefits
and risks of harm. AMA J Ethics. 2017;19(1):54-62.
19. United Nations. Protocol to Prevent, Suppress, and Punish Trafficking in
Persons, especially Women and Children, 2000.
20. U.S. Department of State (2016). Trafficking in Persons Report.
The information presented in this course is intended solely for the use of healthcare
professionals taking this course, for credit, from NurseCe4Less.com.

The information is designed to assist healthcare professionals, including nurses, in addressing
issues associated with healthcare.

The information provided in this course is general in nature, and is not designed to address any
specific situation. This publication in no way absolves facilities of their responsibility for the
appropriate orientation of healthcare professionals.

Hospitals or other organizations using this publication as a part of their own orientation
processes should review the contents of this publication to ensure accuracy and compliance
before using this publication.

Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold
NurseCe4Less.com, including its parent(s), subsidiaries, affiliates, officers/directors, and
employees from liability resulting from the use of this publication.

The contents of this publication may not be reproduced without written permission from
NurseCe4Less.com.
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HUMAN TRAFFICKING

DANA BARTLETT, BSN, MSN, MA, CSPI

Dana Bartlett is a professional nurse and author.

Human trafficking has become a growing social concern worldwide. Despite

Continuing Education Credit Designation

Statement of Learning Need

To help health clinicians identify victims of human trafficking or those

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and

Course Author & Planning Team Conflict of Interest Disclosures

Dana Bartlett, BSN, MSN, MA, CSPI, William S. Cook, PhD,

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on

a. moved or smuggled from one country to another.

2. True or False: Although human trafficking is present in the United

3. In the United States, soliciting a person 17 years of age, for the

a. if some form of force was used.

4. It is estimated that at any given time, there are almost

5. A person with financial obligations to an employer, which have

a. migrant worker status.

Human trafficking is a modern-day form of slavery. Human traffickers prey

Human Trafficking Defined

It is important to note that these definitions clearly state that trafficking

Social Trends And Causes Of Human Trafficking

In a modern, wealthy country such as the United States it would be easy to

The statement above emphasized key points about human trafficking.

Human trafficking is not limited to illegal businesses or the underground.

Statistics of Human Trafficking

Variations Of Human Trafficking

If a minor, which is defined by Federal law as someone under age 18, is

Once these people are in a situation where their financial obligations to an

Domestic service is a common form of human trafficking in the United States

If someones labor is obtained by force, threats, physical restraint, or serious

There is a wide variety of ways people can be coerced or deceived into

Forced marriage is different from arranged marriage. In the United States

In some countries prostitution is not illegal or it is considered a crime of

Victims Of Human Trafficking

Runaways are frequent victims of human trafficking.

Consequences Of Human Trafficking

The obvious consequence of human trafficking is of course loss of freedom.

Human trafficking depends on coercion,

Traumatic bonding is a relationship in which the bond between two people is

Humans are programmed to form attachments and although the bond of a

Posttraumatic stress disorder is a psychological condition that is caused by

The physical consequences of human trafficking affect every organ system.

Musculoskeletal: Fractures, pain

Methods Of Human Trafficking

Human trafficking depends on vulnerability. Vulnerability would be caused by

Isolation, both physical and psychological, is a very common theme in

The human trafficker does everything he/she can to appear omnipotent.

Monopolizing perception is a commonly used technique of human traffickers,

Indulgence is the easiest method of control to understand. And in the case

The concept of trivial demands is closely related to degradation and

Recognizing Human Trafficking Individuals

Human trafficking is common but identification of the victims is not. This is

The victims of human trafficking do have contact with people outside

Healthcare professionals may not have sufficient awareness of the problem.

Studies have shown that healthcare professionals do not have extensive

As previously mentioned, there are countless reasons why a human

An 18-year-old woman living in Thailand is kidnapped and smuggled into the

These inhuman conditions are enforced by occasional physical violence,

In these situations, it is evident why a human trafficking victim would not