by Kristin Hall & Tamara Jackson
THIS CASE STUDY: A 27-year-old female presents as a
trauma activation after being found unresponsive in the stairwell of a casino. She
has extensive swelling and bruising to her face and an obvious deformity to her
lower leg. Upon arrival to the trauma center, she is examined by the trauma
team and her belongings, which included multiple cell phones, are bagged up to
be transported with the patient upon disposition. Aside from the medical
management of this patient, do you have any other concerns about her? Without
any additional information, is this something that is reportable in your
current jurisdiction? Would you be concerned about allowing visitors to see
own a person?Can you own
a person as your property? What is human trafficking? Let’s answer some of
Human trafficking can be defined 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 act has not attained 18 years of age; or 2) the
recruitment, harboring, transporting, 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.
A few other definitions are important here:
There are three essential elements needed to institute
trafficking: the process, the means, and the end. The process includes
recruiting, harboring, moving, obtaining, or providing of a person. The means
of trafficking includes force, fraud, or coercion. Defining the end
looks at the purpose of involuntary servitude, whether it be debt bondage,
slavery or sex trafficking.
can be anyone. It can be an individual or a group of individuals including but
not limited to:
industries are commonly known for trafficking?
What makes a person vulnerable
to trafficking?There are multiple factors that contribute to trafficking and
may make individuals more vulnerable. Factors in origin areas of trafficking
include extreme poverty (particularly among women); limited social, economic,
or political stability; scarcity of legal, reasonable jobs; wars or armed
conflicts that lead to oppression; and limited education or gender
Minority groups such as indigenous persons and those in the
LGBTQ communities are also at greater risk for trafficking. Substance abuse and
mental illness are also aspects that create additional vulnerabilities and can
ease exploitations. Minors who are trafficked are often runaways or come from
an unstable family environment.
Factors in destination areas of trafficking include increase in
expenses for employers to hire workers who are legally hired; an increased
demand for commercial sex workers; and an increase in demand for cheap
laborers, particularly in agricultural or construction jobs.
What are some common misconceptions?There are many myths regarding human trafficking, here are a few
of the most common:
Trafficking requires the kidnapping or movement of people.
Reality: The exploitation of humans can be
done without physically moving them. Human smuggling is the act of transporting
persons across state lines or borders.
Trafficked persons are not compensated for the work they do, or if they entered
their situation willingly, it does not constitute as trafficking.
Reality: Trafficking survivors are often
paid, but they are forced to give the majority of the money earned to their
trafficker. In instances of labor trafficking, the victim may not be paid the
amount that was promised to them. Individuals who work in the commercial sex
trade may or may not be victims of trafficking. If they are adults in control
of their finances and their actions or movements, they are likely not being
Human trafficking only happens outside the United States, or those trafficked here are immigrants.
Reality: The United States is the biggest
consumer of human trafficking. Victims span all ages, ethnicities, and
All trafficking victims are held captive or chained to the wall to prevent them
Reality: Most trafficking victims are able
to leave their situation for short periods of time, but may not have the means
to escape permanently. Whether they are financially dependent on their
trafficker or do not have control of their documents, they are often held
mentally or emotionally captive rather than by physical means.
Traffickers prey on those that they don’t know.
Reality: Most victims of trafficking are
groomed and exploited by people familiar to them—including family members or
Women and girls are the only victims of sex trafficking.
Reality: It is estimated that almost half
of sex trafficking survivors are male. That is likely a conservative estimate,
as male victims are less likely to report or be identified.
The sex trade is responsible for most of trafficking victims.
Reality: Experts believe there are more
cases of labor trafficking worldwide, but education and awareness campaigns are
generally centered around sex trafficking.
can you identify a survivor? What are you looking for? What are some possible
indicators of human trafficking?
Identifying survivors of trafficking can be difficult as many of
them may not identify as being trafficked. Here are some signs of trafficking:
Why may victims not give the impression that they want help?There are many answers to this question, and often many reasons
why survivors may not be ready to leave their situation. Similar to those
experiencing violence from an intimate partner, they may be financially
dependent on their trafficker. Traffickers also spend time grooming their
victims and isolating them from their families, friends or support groups. They
often threaten violence towards their victims and children to prevent them from
leaving. Victims are conditioned not to trust law enforcement or the health-care
system, so it may take time before they will accept services. Survivors may
feel ashamed if they entered their situation willingly and blame
themselves for not being able to escape. They also may not see themselves as
victims and may not be aware of the options and services available to them. A
non-judgmental and victim-centered approach can help to build trust with the
survivor and assist in facilitating a path of escape.
What is your trauma-based and client-centered approach to human
trafficking?As with any other patient who may be affected by violence, their
medical needs should be addressed first. If safely able to do so, getting them
away from their situation for even a few hours can help start a dialogue. These
conversations should happen when the person is alone and away from even those
that the survivor may report as being close family members. If you are meeting
the survivor in the hospital and the controlling person refuses to leave,
taking the survivor to the bathroom, x-ray, or another location may be
If safety is an issue, consider notifying your facility’s
security and following your facility’s safety plan. Finding a safe,
comfortable, quiet, and accommodating environment can facilitate these conversations,
as well as assure confidentiality. This can also help to build rapport with the
survivor, which is essential in these cases. Those working with survivors of
trafficking should also be careful not to impose their beliefs or values onto
the survivor, as doing so can damage the rapport that was built.
Every survivor should be offered a comprehensive health
assessment and physical exam. Trafficked persons often have limited access
to health care, so capitalization on those opportunities may be vital for their
Working with your community’s resources to allow the client
interview to be performed by a forensic nurse, trauma-informed social worker,
or another medical professional is strongly recommended. The path to disclosure
and treatment should be led by the survivor, including any forensic exam or
Evidence collection by the forensic nurse in cases of
trafficking can include photo documentation of tattoos or injuries,
and swabs to collect trace evidence of DNA. Ideally, this should be done
prior to any wound cleansing or repair, but will always come second to medical stabilizing
interventions. Wound documentation and evidence collection are best performed
by a forensically trained nurse or medical professional.
In a study on the effectiveness of sexual assault nurse examiner
(SANE) programs who often work with survivors of sex trafficking, Dr. Rebecca
Campbell et al. found that SANE programs “promote the psychological recovery of
rape survivors” and can assist them in being introduced to community resources
(2005). The implementation of SANE programs in recent decades has increased the
amount of forensic evidence collected in cases of sex trafficking, which has
allowed for increased prosecution.
Once their medical needs are met, some basic interview questions
that may help with identification can include:
are some social service needs of human trafficking survivors?
What are the health-care outcomes of exploitation?The health-care outcomes of exploitation can vary depending on
the types and duration of exploitation, but we know that at best it is damaging
both psychologically and physically.
Many survivors of trafficking have substance abuse issues. A Polaris
Project report showed substance abuse was the most common risk factor for sex
trafficking in 2019. Drugs and other illicit substances may also have been used
as part of the means of trafficking, or survivors may be self-medicating with substances
to cope with the trauma associated with trafficking. This can compound the
difficulties during their road to recovery, both physically and emotionally.
Mental health is also a common risk factor for sex trafficking,
which is only exacerbated by the relentless sexual abuse. Survivors may also be
malnourished and any chronic health issues, such as diabetes or hypertension,
may have been neglected. This can contribute to higher incidence of heart
disease and strokes. Abuse in any form— emotional, physical or sexual—has been
shown to increase the prevalence of chronic health issues later in life. According
to a 2002 study on Intimate Partner Violence and Its Physical Health
Consequences, abused women had a higher prevalence of headaches, back pain,
sexually transmitted infections, urinary-tract infections, and abdominal/pelvic
pain. Strangled women also had a higher incidence of strokes and transient ischemic
attacks or “mini strokes” (2003).
discuss: Can you own a person?Unfortunately, the statistics are showing that the owning of
persons is a fast-growing, global health crisis fueled by limited awareness of
the prevalence of trafficking, as well as lucrative opportunities for
traffickers. It is estimated there are 25 million trafficked persons worldwide:
45% are females, 55% are males, 74% are adults and 26% are children. Of all the
trafficked persons in the U.S., 79% were minors at the time trafficking began.
According to the International Labor Organization, profits of the
trafficking trade are greater than five of the world’s largest tech companies
combined, equaling more than $150 billion (2014).
The intricate network of traffickers creates an army that is difficult to fight
as they are often hiding in plain sight. Many run legitimate businesses that
may be a front for trafficking or may be the actual trafficking organization
itself. Restaurants, construction companies, nail salons, massage parlors,
hotels, and cleaning companies are all frequent businesses used in sex and labor-trafficking
As many trafficking operations span multiple geographic regions,
particularly with the aid of technology, prosecution of crimes has been
difficult. The United Nations created the Protocol to Prevent, Suppress and Punish Trafficking in
Persons, Especially Women and Children, supplementing the United Nations
Convention Against Transnational Organized Crime.
It was created in 2003, has been signed by more than 150 nations around the
world and has aided in the prosecution of international trafficking
Successful legislation in the U.S. includes the Trafficking
Victims Protection Act, enacted in 2000 and reauthorized five times. This act
encouraged Congress to allocate $250 million to benefit survivors of human
There is no clear path to completely eradicate human
trafficking, but it is widely discussed that in order to effectively combat
trafficking we need to increase the availability of education and viable work
opportunities. The Polaris Project reported a 20% increase in direct contact
from survivors in 2019. Direct contact from survivors increases their
likelihood of engaging in services and also allows for better reporting.
Community education is working for survivors, though we need to continue
our outreach in our communities to address issues of human trafficking and
gender inequality. To combat labor trafficking, we need to effectively reduce
the wage gap between legal and illegal workers. And, of course, for effective
prosecution, we need to eliminate corruption of law enforcement agencies and
dismantle the trafficking networks.
This may seem impossible to accomplish, but every year more
nations around the globe join the United Nations protocol. Non-governmental
organizations have popped up and can provide survivors with food and temporary
housing. Other services include access to advocacy and legal services,
including visa application assistance for foreign-born survivors. Collaboration
of nations worldwide stops the growth of this trade. By providing the medical
assessments, forensic exams, and aftercare needed, the impact of trafficking
can take less of a toll on our survivors.
Going back to our case study, this patient was found to have
multiple facial fractures and a fracture to her ankle that required surgical
intervention. After the initial survey performed by the trauma team, the
primary nurse was able to initiate a dialogue with this patient. She built
trust with her patient, who ultimately disclosed she was being sold for sex by
her boss while working at an event-planning company. She had a fairly extensive
drug history and her boss was using that to continue to exploit her. After a
lengthy conversation with the emergency nurse and the forensic nurse, the
patient elected to have a forensic exam performed and was interviewed by law
enforcement. The patient was entered into witness protection as well as a drug-treatment
program. The suspect was formally charged with five felonies, including
aggravated exploitation of a prostitute.
you need immediate help with victim response?
About the AuthorsKristin Hall (BSN, RN, CEN) has
worked in emergency medicine for the past 14 years and currently works as a
charge nurse in the emergency department of a level I trauma center. Since
beginning her career as a forensic nurse, she has worked to expand the practice
of forensic nurses in her home state of Utah. She is the current clinical
director for the Salt Lake Area Family Justice Center SANE program and serves
as a board member of the Academy of Forensic Nursing.
Tamara Jackson (MSN, RN, SANE-A) is a
dedicated professional who has served the health-care profession for more than
20 years. Adhering to evidenced-based
practices, Jackson has developed an extensive database of health-care
professionals within Amita Health. She is recognized as a leader and is well
respected by peers, medical staff, and the patients that she serves. Jackson is
responsible for the design and implementation of a training program to further
goals and increase productivity of sexual assault nurse examiners within Amita
S. 2011. Human trafficking: A human rights abuse with global dimensions. Interdisciplinary
Journal of Human Rights Law. 6(1):27-40.
R., D. Patterson, and L. F. Lichty. 2005. The effectiveness of sexual assault
nurse examiner (SANE) programs: A review of psychological, medical, legal, and
community outcomes. Trauma, Violence, & Abuse. 6(4):313-329. https://doi.org/10.1177/1524838005280328
International Labor Organization.
2014. Profits and poverty: The economics of forced labor. h https://www.ilo.org/global/topics/forced-labour/publications/profits-of-forced-labour-2014/lang--en/index.htm
Labor Organization. 2020. 2020 Trafficking in persons report. https://www.state.gov/wp-content/uploads/2020/06/2020-TIP-Report-Complete-062420-FINAL.pdf
Polaris Project. 2020. Myths,
facts, and statistics. https://polarisproject.org/myths-facts-and-statistics/
Taliaferro, E. (producer). May 2003.
The Pandora Effect. Texas Tech Women's Health Conference Keynote Speech. http://dhss.alaska.gov/ocs/Documents/childrensjustice/strangulation/4.%20The%20Pandora%20Effect.pdf