Sex trafficking is a global crime enslaving persons of all ages and across all borders, and providers can be challenged to locate and recognize victims. Trafficked victims present with varied and complex healthcare needs requiring unique and tailored interventions. This investigative project sought to situate the existing literature with experiences described by professionals who work with trafficking survivors. Findings from the report indicate that many survivors report seeking care and receiving treatment from nurses while trafficked yet failing to be identified by nurses or other healthcare providers as a trafficking victim. This article addresses the scope of sex trafficking, indicators used to recognize victims of sex trafficking, the critical need for nursing to be knowledgeable of sex trafficking, and concludes with a discussion of nurses’ responsibility to address victims’ diverse needs.
Key Words: human trafficking, sex trafficking, child sexual abuse, domestic abuse, adult sexual abuse, child prostitution, child brides, adult prostitution, nursing care of abuse victims, victimization, TVPRA.
Trafficked victims present with varied and complex healthcare needs requiring unique and tailored interventions.Human trafficking of adults and children is often described as modern-day slavery. Human trafficking law is categorized three ways: labor trafficking, child sex trafficking, and adult sex trafficking. Most victims are female although approximately one third to one fourth are male (Polaris, 2018). According to Raney (2017), “The Global Report on Trafficking in Persons” estimates that 27% of all victims detected globally are children and one in three victims are boys.
Human trafficking law is categorized three ways: labor trafficking, child sex trafficking, and adult sex trafficking.Human trafficking is a crime that historically has been overlooked and more recently has garnered the attention of law enforcement and human rights advocates (U.S. Department of Justice, 2021). Globally, there are approximately 24.9 million victims of human trafficking (U.S. Department of State, 2019). Experts estimate that human trafficking produces approximately 150 billion dollars a year with $99 billion earned from sexual exploitation alone (Human Rights First, 2017a). According to the United Nations Office on Drugs and Crime [UNODC] (2009), approximately 79% of human trafficking victims are sexually trafficked. Sex trafficking crosses age, gender, and global boundaries.
The United States Federal Anti-Trafficking Laws defines sex trafficking as, “the recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purpose of a commercial sex act, in which the 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” (Alliance to End Slavery & Trafficking[ATEST], 2017).
Anti-Trafficking Laws define sex trafficking comprising three components of action, means, and purpose. Anti-Trafficking Laws define sex trafficking comprising three components of action, means, and purpose. Action is recruiting, harboring, providing, or soliciting. Means include use of force, fraud, or coercion. Purpose is identified as a commercial sex act. However, for a victim younger than 18 years of age, sex trafficking is a crime regardless of how the victim was manipulated or recruited, and therefore, the use of force, fraud, or coercion is not a requirement for the crime.
Locating the Human Trafficking Victim
Victims of sex trafficking can be found in many locations such as imposter massage businesses, escort services, brothels, truck stops, strip clubs, hotels, online advertisements, child brides, and literally, in the streets. Sex traffickers are often thought of as strangers but, occasionally, the traffickers are family members, friends, or neighbors who use various strategies to recruit victims. According to the International Organization for Migration [IOM] (2017), nearly half of the child trafficking cases involve a family member manipulating the child into sexual exploitation.
Some of the methods traffickers use include physical violence, threats, false promises of employment or marriage, or as restitution for providing for victims’ basic needs of food and shelter (Polaris, 2021a). Traffickers may search for victims through websites, social media or gatherings, business establishments within the local community, or through personal interaction with others. The more victims a trafficker has, the greater the financial reward; narcotics and weapons can be sold only once, but a person can be sold repeatedly providing limitless financial gain.
Recognizing The Human Trafficking Victim
Recognizing victims of sex trafficking is difficult for nurses and other healthcare providers. According to Leslie (2018), up to 80% of current victims visit a health care provider yet, most are not identified as sex trafficking victims and the opportunity to rescue is lost. Victims often do not self-identify as trafficking victims when they present for healthcare. Therefore, it is imperative nurses are knowledgeable of signs of human trafficking. Barriers contributing to victim nondisclosure include a sense of shame, fear of retaliation from the trafficker, fear of arrest, threats of harm, and fear of the healthcare system.
Recognizing victims of sex trafficking is difficult for nurses and other healthcare providers.It is critical for nurses to be aware of red flags victims may display and seek to communicate and build a foundation of trust, thereby, reducing anxiety and providing the opportunity for victim disclosure. The purpose of this investigative project is to examine extant literature and information from professionals working with trafficking survivors in order to provides strategies for identifying victims and to examine nurses’ roles in recognizing and addressing victims’ physical, psychological, and safety needs.
Investigative Project Method
The goals of this investigative project were to: 1) assess the scope of sex trafficking, 2) identify indicators for recognizing the sex trafficking victim, and 3) examine the role and responsibility of nurses in addressing the victim needs. The process integrated extant literature with data gained from discussions with professionals who work with survivors. Interviews and questionnaires were completed with professionals at four social service agencies that provide care to victims of human trafficking. Two interviews were conducted via email question and answer responses, one interview occurred via telephone, and one interview was in-person. Interview questions were open-ended and focused on: the various red flags that sex trafficking victims exhibit, the interaction of the nurse with the victim, and the immediate and long-term needs of the sex trafficking victim. The data gathered from the interviews was analyzed for common themes using content analysis procedures.
Additional insights were gleaned from a review of the research published between 2013-2019 related to sex trafficking and the role of the nurse in the clinical management of the victim. A total of 34 publications were selected for inclusion from the following databases: Pubmed, MEDLINE, Expanded Academic, Google Scholar, Polaris Project, NIH.gov, MissingKids.com, Unicef.org, UNODC.org, NIJ.gov, HHS.gov.
Interviewees represented individuals who are professionally engaged in Upstate South Carolina social service agencies that serve victims of sex trafficking. Interviewees included: executive directors of agencies, program directors of agencies, and ministerial volunteers. Emails, phone calls, and interviews were analyzed using content analysis procedures to identify themes. Collectively, the interviewees emphasized similar red flags that sex trafficking victims present (see Table 1). Four themes emerged from the interviews, literature, and analysis: 1) sex trafficking is global in scope and crosses all boundaries, 2) healthcare providers lack awareness and consequently fail to identify the sex trafficking victim, 3) the sex trafficking victim is a trauma victim displaying a variety of red flags, and 4) nurses have a responsibility to address the immediate and long-term physical and psychological needs of the victim.
Table 1. Red Flags to Identify Victims of Sex Trafficking
Red Flags that a victim may present on admission to a healthcare facility:
â— Branding or tattoos on the back of the neck or under the arms or breast tissue
â— Tattoos indicating ownership (e.g., dollar signs, property of, the life, or a specific name)
â— Bald patches on the head where the hair has been pulled out
â— Bite marks
â— Strangulation marks on the throat
â— Petechiae in various locations such as the wrist
â— Wounds in various stages of healing
â— Vaginal or rectal trauma
â— Sponges or cloths stuffed in the vaginal canal
â— Untreated infections
â— Broken bones
â— Burn marks
E. Counts (personal communication, September 26, 2018).
Theme 1: Scope of Sex Trafficking
...sex trafficking victims comprise all ages, gender, ethnicities, and racial backgrounds...The interviews and the literature attest that sex trafficking victims comprise all ages, gender, ethnicities, and racial backgrounds, yet possess the common thread of vulnerability. According to Wyatt and Sinutko (2018), “Traffickers prey on an individual’s vulnerability by initially offering to provide for a need, for example, buying a meal or clothing, offering a place to sleep, or paying for transportation” (p. 283). Traffickers will also pretend to cultivate a romantic relationship with the victim to foster trust. Then, when the victim begins to trust in the relationship, the traffickers demand restitution for the “kindness” shown. As mentioned by Toney-Butler, Ladd, and Mittel (2021), traffickers present themselves as a “rescuer” to the vulnerable victim offering the chance for a better life, yet, in reality, the trafficker is a “profiler” searching for victims to translate into profit. Vulnerability is the tool used to gain control of the victim. After the trafficker provides for the victims' needs, they force the victim into enslavement as repayment.
Child trafficking. Under United States Federal law, any child or adolescent younger than 18 years of age, who is involved in the sex industry is considered a sex trafficking victim, regardless of how they were recruited (Becker & Bechtel, 2015). In an open letter, the National Center for Missing and Exploited Children (NCMEC) reported the average age of children entering the sex trade in the United States as 15 years of age (Clark, 2020). Additionally, the National Center for Missing and Exploited Children (2018) estimates that 1 in 7 U.S. runaways are at risk of becoming sex trafficking victims. Moreover, runaway teens are often recruited by traffickers within 48 hours of leaving their homes. The sex trafficker preys on the child that is vulnerable: the runaway, the child estranged from their family, the homeless, the abused, and the child with substance abuse issues.
The child’s unmet needs are tools the trafficker uses to gain trust and control of the child. According to Greenbaum (2017), a child may also become a victim of sex trafficking because their parent is a victim. One example is the child whose parent is already working within the sex trade. According to Lo and Zoia (2018), one million children globally are involved in the commercial sex industry. The prevalence of child brides under the age of 15 is as high as 22% in Bangladesh and 30% in Chad (UNICEF, 2021). Often young girls are sold by their families into marriage with an adult male and it is not uncommon for them to be trafficked for sex if they attempt to flee the marriage. In Nepal, most of the 13,000 individuals who are sex trafficking victims were recruited as children (Lo & Zoia, 2018).
Characteristics of sex traffickers. Sex traffickers are always looking for new recruits since the more victims a trafficker has equates into a higher profit margin (Lundstrom & Henderson, 2018). Sex trafficking is market driven based on the premise of supply and demand. It is the trafficker who profits monetarily from providing a victim for sexual activity. The individual seeking and obtaining sexual gratification from the victim is referred to as the “John.” Unfortunately, it is the victim who pays the highest cost with physical abuse, psychological abuse, loss of freedom, victimization and in some cases, death.
Characteristics of sex trafficking victims. Sex trafficking victims often refer to their enslaved situation of being under the control of a trafficker as “the life.” Yet, it is a life of fear, intimidation, loss of freedom, violence, brutality, deprivation, physical abuse, substance abuse, emotional abuse, sexual assault, and starvation. According to Baldwin, Fehrenbacker, and Eisenman (2015) (as cited in Wyatt & Sinutko 2018), traffickers are relentless in their use of verbal insults, threats, and other forms of abuse intended to humiliate, shame, embarrass, and belittle, in addition to physical abuse that may include repeated rape and beatings to intimidate and force the victim into submission. The physical and psychological abuse results in devastating scars that take years of therapy to heal after rescue. Sex trafficking victims are victims of the crimes of power, domination, and control. Usually, victims are only brought to a healthcare facility related to issues that require treatment such as sexually transmitted infections, pregnancy, abortion procedures, infections, or neglected injuries.
Theme 2: Lack of Awareness among Healthcare Providers
Up to 87% of sex trafficking victims intersect with a healthcare provider during their trafficking experienceUp to 87% of sex trafficking victims intersect with a healthcare provider during their trafficking experience (Leslie, 2018; Wyatt & Sinutko, 2018). Some reasons why clinicians fail to identify the sex trafficking victim include lack of education regarding sexual trafficking, the rush of a typical patient assessment, the absence of evidence-based screening protocols for trafficking victims, lack of privacy with the victim, and personal biases. According to the Arizona State Board of Nursing (2014), most nurses lack understanding of the scope and presenting symptoms of sex trafficking. Lack of awareness among healthcare providers results in a lost opportunity to identify and aid victims (Washburn, 2018; Wyatt & Sinutko, 2018).
Need for sex trafficking education. Within the last 10 years, healthcare institutions have acknowledged the need for more education related to sex trafficking, but research suggests a lack of educational offerings. In a study by Beck et al. (2015) (as cited in Greenbaum, 2017), 63% of healthcare providers reported that they have never received training related to the identification of sex trafficking victims. In a survey study of 166 nurses, Ramnauth, Benitez, Logan, Abraham, and Gillum (2018) discovered that 84% had never received training related to sexual trafficking yet, 12% of the respondents had provided care to a patient who may have been a victim. In a mixed methods study, Powell, Dickins, and Stoklosa (2017) found that most healthcare providers were unaware of how to provide care to sex trafficking victim. Brace, Sanders, and Oommen (2018) discovered that inadequate training results in healthcare providers possessing misconceptions regarding sex trafficking (e.g., how a victim may appear, or the lack of rights denied to the victim by the trafficker). This lack of knowledge can result in missed opportunities for identification and rescue.
Theme 3: Trauma Victims and Red Flags
Sex trafficking victims may present to the healthcare facility with mutilations, malnutrition, dental issues, and tuberculosis. According to E. Counts (personal communication, September 26, 2018) the red flags are often physical and psychological (see Table 1). Other red flags include malnutrition, scripted stories or reported explanations that do not match the injury, resistance to touch, gaps in memory, inability to identify a home address, lack of identification, or the avoidance of eye contact (Sinay, 2017). Since violent injuries are not uncommon for the victim to experience, prior injuries that have healed without treatment may be discovered when X-rays or scans are completed.
The victim is often instructed to refer to the individual accompanying her or him as, “my Daddy” or “that’s my boyfriend” to prevent identification as a sex trafficking victim. In some cases, victims are not allowed to speak and may look to the individual accompanying them during the clinical workup. On occasion, a victim may be accompanied by a woman claiming to be a friend or relative who could be the “Bottom.” The woman designated as the bottom helps recruit, supervise, and control the victim and reports directly to the trafficker.
The victim may be without legal identification since these items are usually taken by the trafficker and may be unable to provide a home address since they are sometimes moved from one location to another (Becker & Bechtel, 2015). Answers given by the victim may seem vague or coached since traffickers often threaten their victims with the possibility of physical harm if they reveal their status as a sex trafficking victim. During the interview, the victim may exhibit a flat affect as if they are discussing another person. As discussed in Toney-Butler et al. (2021), “They take a third-person, omnipresent view…”. Separating themselves emotionally from the situation is a coping behavior. Conversely, the behavior that a nurse may witness in an adult is different from that of a child. The child may be belligerent or withdrawn and those could be behaviors s/he has adopted to survive living in a hostile environment (Greenbaum, 2017).
Nursing interventions. During the interview portion of the clinical workup, it is essential for the nurse to allow the interview to be led by the victims’ response and to speak with the victim alone to ensure their safety and confidentiality. If the victim does not speak English, the nurse should secure a professional translator, therefore, avoiding the use of the individual accompanying the victim. It is essential that both the nursing examination and interview occur in a comfortable and non-threatening location with the nurse sitting beside or at the same level as the victim, maintaining a conversational tone and seeking first to meet the victims' primary need including the most physiologically basic: toileting, warmth, and hydration. It is important for the nurse to remember that the goal is to create a safe environment to ensure safety, rapport, and trust building that can lead to disclosure (Conrad & Downing, 2018). To facilitate a trusting relationship, the nurse should never make promises that cannot be kept since the victim has already endured deceitfulness; therefore, trust is difficult for the victim to grant.
Victims usually do not self- identify as sex trafficking victims...Victims usually do not self- identify as sex trafficking victims due to the fear of being beaten by the trafficker. In some cases, victims may be so mentally battered that they may believe that the trafficker is the only person who cares. It is vital for the nurse to demonstrate caring and patience and to display a nonjudgmental approach. According to Dr. Rapp (personal communication, August 10, 2018), “The most difficult thing will be to establish trust with the victim.” Establishing trust is critical toward providing for the victims’ needs and the opportunity of the disclosure.
By moving through the assessment slowly, using the victims’ reaction as a guide, and explaining the reason for each step the nurse will assist in reducing the anxiety of the victim. The nurse should provide a reason for each step of the physical examination since the victim has already endured the trauma of sex trafficking, may have been beaten and/ or raped, and have an aversion to touch. It is important to reduce the anxiety of the physical assessment by ensuring that the sex of the examiner is the same as that of the victim. The victim may appear guarded or seem emotionally absent and these may be learned coping behaviors. Currently, there are no validated screening tools to assess for human trafficking, but there are suggested screening questions found in the literature that may provide the opportunity for identification of the victim (see Table 2). Using open-ended, broad base questioning may impart information allowing for disclosure, e.g., “Tell me about your living situation” (Paton, 2020). Most importantly, the nurse should recognize when something does not feel right and continue to screen the victim.
Table 2. Screening Questions for Suspected Sex Trafficking
Suggested questions to use in screening a patient for suspected sexual trafficking:
Nurses’ Responsibility to Address Immediate and Long-Term Needs
Victims younger than 18 years of age must be reported to law enforcement. The Federal Child Abuse and Protection Act (CAPTA) was amended in May 2017 (Child Welfare Information Gateway, 2019) to state that “a child shall be considered a victim of ‘child abuse and neglect’ and of ‘sexual abuse’ if the child is identified … as being a victim of sex trafficking … or a victim of severe forms of trafficking in persons” as described in the Trafficking Victims Protection Act” (English, 2017, p.3). As explained by Dr. D Rapp, (personal communication, August 10, 2018), “If the trafficking victim is a child, s/he would be turned over to the Department of Social Services and be placed into either a safe house or foster care where they will receive the medical help that they need.” It is important that facility policies regarding notification of security, law enforcement, and child protective services are followed. Nurses should have at their disposal the National Human Trafficking Resource Center [NHTRC] hotline phone number for information and guidance in the provision of care to sex trafficking victims.
Adult trafficking victims. If an adult self-identifies as a trafficking victim, the nurse must obtain permission from the victim to notify law enforcement and should begin referrals to community agencies for housing and support. If the adult victim does not wish to leave the trafficking situation, the nurse should provide information regarding local resources in the community and their contact information if the victim should decide to exit trafficking situation in the future. Again, it is important that facility policies regarding notification of security and law enforcement are followed to be mindful of safety needs of victims and staff. If the victim does not desire to exit the trafficking situation, the nurse should offer the National Human Trafficking Hotline and, if necessary, place the information discreetly within the victims' shoes or the victims clothing for privacy. Advising about resources within the community that can provide for the security of the victim may motivate the victim to exit the trafficking situation. As with many violent situations, exiting the trafficking situation can place the victim and the nursing staff in imminent risk of harm from the trafficker.
Team approach to interventions. Sex trafficking victims have endured multiple traumas: sexual abuse, physical and psychological trauma, enslavement, substance abuse, and other violent situations. The mental health disorders experienced by sexual trafficking victims are comparable to those experienced by prisoners of war. A team approach is necessary to meet the holistic needs of the victim. As stated by Judge (2018, p.293): “Case management is a critical component of recovery services for human sex trafficking.” Victims desirous of leaving the trafficking situation may need referrals for mental health evaluations, substance abuse treatment, specialist physicians, legal services, and transfer to safe houses. All referral agencies should be alerted to the victims' status as a sex trafficking survivor.
Victim-centered approaches to care are vital for recovery. Victim-centered approaches to care are vital for recovery. Care delivery should be individualized, culturally appropriate, compassionate, and nonjudgmental, with measures taken to reduce the repeated recitation of traumatic events to professionals. Appropriate treatment should ensure consideration of immediate and long-term needs of the victim. Nurses should be thoroughly versed in the resources available within their local communities as it is through the local community that long-term needs of the victim will be met.
Educational needs. The most important thing that the nurse can do is to recognize the victim, meet their needs, and offer them the opportunity to leave the trafficking situation. Many victims leave healthcare encounters unrecognized and return to the horrific situation of sex trafficking. Unfortunately, due to lack of education and other factors, nurses are failing to recognize sex trafficking victims. Nurses are called upon to advocate for patients, yet, in the case of sex trafficking victims, nurses serve the important role of a rescuer as well.
Currently, the education of nurses related to sex trafficking is intermittent and insufficient. Nurse leaders and educators should provide educational opportunities for nursing students and staff regarding methods to recognize the sex trafficking victim in addition to appropriate interventions to address the victim’s physical and psychological needs. Often, nurse educators associate sexual trafficking with mental health, and pediatric and emergency nursing care, but sex trafficking victims can be found in any healthcare encounter.
Nurse education should include content related to human sexual trafficking and the care of the victim in medical nursing, mental health nursing, pediatric nursing, maternal newborn nursing, and community nursing care. Each state licensure board should include content regarding identification and nursing care of the sex trafficking victim as part of their licensure renewal contact hours. It is imperative that nursing leadership in all arenas of nursing provide in-depth educational programs addressing sex trafficking and appropriate interventions to meet both the immediate and long-term needs of the victim.
A nurse could be a critical link between the sex trafficking victim and freedom... Human sex trafficking is complex, misunderstood, and underreported. The sex trafficking victim could be a young child, a teen, a young mother, a pregnant patient, or an older adult who presents for healthcare. Traffickers may be family members or strangers feigning affection with the goal of exploiting the victim for profit. Human sex trafficking is global in scope, yet it can be found in the smallest of communities. It is a multifaceted crime that crosses all boundaries with no single Arizona victim profile. Many victims of sex trafficking who have been rescued testify to treatment by nurses or other healthcare providers while they were in the trafficking situation yet were not identified as a trafficking victim. The nursing profession needs to ensure that the needs of sex trafficking victims be included within the education of every nurse. A nurse could be a critical link between the sex trafficking victim and freedom from the life of sexual bondage.
Deborah Jacks Camak, MSN, RNC-MNN, FCN, C-EFM
Deborah Jacks Camak is currently a nursing faculty member with Piedmont Technical College in Greenwood, South Carolina teaching associate degree nursing students and practical nursing students. She includes in her instruction to her students the responsibilities of the nurse in meeting the needs of the human trafficking and domestic violence patient. Deborah Jacks Camak supports and volunteers at local agencies addressing the needs of victim of sexual trafficking.
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