Human trafficking is a major global public health concern (United Nations Office on Drugs and Crime [UNODC], 2015a). At the same time, human trafficking is a grave crime that constitutes a violation of human rights. Every country in the world is affected, whether as the country of origin, transit, or destination for trafficked victims. Contrary to healthcare providers' perceptions, a recent study showed that as many as 87.7% of victims of human trafficking have come into contact with the healthcare system while being trafficked (Lederer & Wetzel, 2014). In recent years, nurses and other healthcare providers have become more judicious in their identification of human trafficking (Sabella, 2011), which indicates that they may have the opportunity to intervene and aid trafficked victims. The emergency department (ED) has been identified as the most frequented setting where trafficked victims seek medical care (Peters, 2013). As a result, it is critical that healthcare providers are able to identify and appropriately manage the care of the patient who has been trafficked to achieve optimal health and legal outcomes.

In this article, the anatomy of human trafficking including the scope of the problem, definitions, and elements of human trafficking is explored. We will discuss the roles of the clinician, including ED, primary care, and forensic nurses as well as advanced practice nurses, in screening and identifying those at risk. Clinical screening tools and guidelines appropriate in the treatment of human trafficking victims are reviewed. Finally, local and international strategies and resources currently available and in place to address human trafficking are presented. For the purpose of this article, the terms "human trafficking" or "trafficking" will be used throughout.

Scope of the Problem

Next to drug trafficking, human trafficking is considered the fastest growing criminal enterprise worldwide (The Federal Bureau of Investigation, 2013). The total number of trafficked victims is unknown because of the clandestine nature of the crime. It is estimated, however, that there are approximately 21 million victims of human trafficking worldwide, with 3 of every 1,000 people being forced into labor at any given period (International Labor Organization [ILO], 2016). Recent data showed that forced labor exploitation (68%) and commercial sexual trafficking (22%) are the most common forms of human trafficking. Of these numbers, 55% of exploited victims are women and girls; 26% of which are children under the age of 17 years (ILO, 2016). Victims of sex trafficking are more likely to be Black (40%) or White (26%), whereas victims of labor trafficking are more often Hispanic (63%) or Asian (17%; U.S. Department of Justice [DOJ], 2011). Human trafficking generates an estimated illegal profit of $150 billion globally (ILO, 2016). Two thirds of the profit, or $99B per year, is generated by commercial sexual exploitation, and one third-$51.2B- is generated from forced labor exploitation (UNODC, 2015a). The Asia Pacific region is reported to have the largest number of forced laborers (56%) globally, followed by Africa (18%; ILO, 2016). The United States is not immune to this epidemic.

The United States has been identified as a source, transit, and destination country for human trafficking. The latest data from the National Human Trafficking Resource Center (NHTRC, 2016) revealed that, in 2015 alone, they received 21,947 calls related to human trafficking and 5,544 cases were reported. Of these numbers, sex trafficking accounted for 4,136 cases, labor trafficking accounted for 721 cases, and sex and labor trafficking accounted for another 178 cases. The state of California is reported to have the largest number of cases of human trafficking in the United States (NHTRC, 2016). Under the U.S. Federal Law, human trafficking victims are classified within three groups: (a) minors (under the age of 18 years) induced into commercial sex and referred to as Commercial Sexual Exploitation of Children; (b) adults aged 18 years and over who are induced into commercial sex either by force, coercion, or fraud; and (c) children and adults who are forced to perform labor against their will (The National Child Traumatic Stress Network, 2015).

What is Human Trafficking?

The terms "trafficking in person," "human trafficking," and "modern slavery" are umbrella terms used to describe "the act of recruiting, harboring, transporting, providing, or obtaining a person for compelled labor or commercial sex acts through the use of force, fraud, or coercion" (U.S. Department of State, 2015, p. 7). Human trafficking as an enterprise thrives because there is a demand. Furthermore, the activity reaps substantial monetary gain for the traffickers, and they are able to engage in the crime with a relatively low risk of detection (NHTRC, n.d.). Thus, human trafficking is a very lucrative criminal activity for traffickers (ILO, 2016).

Low detection risk by the government is the result of several factors including lack of government and law enforcement training, lack of investigations, low community or public awareness, ineffective or unused laws, limited resources for trafficked victims, and society blaming of the victims (NHTRC, n.d.). Regrettably, in some countries, the government supports the trafficking industry. For example, countries that may support trafficking are countries placed on Tier 2 or Tier 3 watch list. Countries placed on Tier 3 do not comply with the minimum standards set by the Trafficking Victims Protection Act and are not making any significant effort to do so. Tier 3 countries include Kuwait, Thailand, Zimbabwe, Russia, and Somalia, to name a few (U.S. Department of State, 2015).

Traffickers seek out the most vulnerable, and thus, the supply of victims is limitless. Those living in poverty seek out better economic opportunities and are tricked into trafficking. Similarly, there are countless numbers of homeless youth on the streets who are easy prey for traffickers. On the other hand, human trafficking will not thrive without demand (U.S. Department of State, 2015).

Pearson (2005) has identified three levels of demand in the context of human trafficking. These three levels of demand include (a) employer demand, (b) consumer demand, and (c) third parties involved in the process (e.g., recruiters, transporters, agents). There is an increasing consumer demand for cheap goods or services, thus fueling the demand for cheap labor. Women and children are most vulnerable to commercial sexual exploitation.

Traffickers maintain control over their victims by keeping their passports, money, or identifying documents, thereby preventing the individual from leaving the circumstances. At times, these victims could be in a country illegally and have no course of action against their trafficker for fear of deportation. Another way traffickers control their victims is by keeping them isolated or moving from place to place to prevent the formation of relationships, which could lead to identification (NHTRC, n.d.).

Elements of Human Trafficking

Trafficking can be carried out by different types of traffickers, which range from individuals exploiting their partners to organized criminal groups that operate transnationally or across borders (UNODC, 2014). There are three elements that constitute human trafficking: the act, the means, and the purpose (see Figure 1; UNODC, 2015a). The Act involves the recruitment, transfer, harboring, and transportation or receipt of persons. Recruitment is an essential part of the trafficking process, which often involves deception (UNODC, 2014). At the same time, victims can be abducted or sold and then transported to another country. Romantic trafficking is one way traffickers lure women into false romantic relationships for the purpose of abducting them afterward. Means are the ways by which trafficking is achieved. These include threats or the use of force, coercion, abduction, fraud, deception, abuse of power or vulnerability, or giving payments or benefits to control the person/victim. Traffickers may use drugs and/or physical and mental coercion to keep women and children entrapped. At the same time, they use threats of harm to the victim's family as a source of power over the victims. Finally, the purpose of this exploitation could include commercial prostitution, sexual exploitation, forced labor, slavery, and removal of organs (UNODC, 2015a).

Figure 1. The A-M-P Model: elements of human trafficking. Obtained from UNODC (2015a;

Types of Human Trafficking

Labor Trafficking

Labor trafficking, or forced labor, involves using force, physical threats or abuse, psychological coercion, abuse of the legal system, or other coercive means to compel someone to work (U.S. Department of State, 2015). Migrants are particularly vulnerable to this form of human trafficking. Others may fall victim to forced labor because of debt bondage including inherited debts. Higher rates of labor trafficking are found in the food service industry, domestic work, agriculture, and unspecified general labor (Polaris Project, 2015).

Sex Trafficking

Adults and children can be sexually exploited to perform commercial sex activity against their will. Adults engage in commercial sex activity because of force, threats of force, coercion, and fraud. Victims of sex trafficking could be involved in a variety of enterprises including street or Internet-based prostitution, pornography, brothel-based work, or sexualized jobs such as strippers or escorts (Alpert et al., 2014). Minors may be brokered as mail-order brides or be subjected to "survival sex" in exchange for their basic needs (Alpert et al., 2014).

Other Forms of Trafficking

Human trafficking can take many forms of exploitation and can include organ trafficking (and the illegal sale of organs) and the trafficking of children for armed combat. Young boys are often targeted and used as child soldiers, whereas young girls are targeted to serve as wives (UNODC, 2014; U.S. Department of State, 2015).

Clinical Implications

Risk Factors

Anyone can be at risk for victimization; however, women and children are the most vulnerable to being trafficked (Alpert et al., 2014). Other risk factors include a lack of education, a history of abuse or violence, family instability, being disabled and marginalized, or possessing a stigmatized gender, culture, or ethnic background. Importantly, extreme poverty is notably the highest "push" factor that increases susceptibility to human trafficking (Alpert et al., 2014; Choi, 2015).

Role of Clinicians

The ED is the setting most frequented by trafficked victims; thus, ED nurses may be the first point of contact for these victims in the healthcare setting (Peters, 2013). The ED nurse thus plays a vital role in the delivery of healthcare services for trafficked victims. Other areas of contact identified include urgent care, family planning clinics such as Planned Parenthood, and public and private offices (Dovydatis, 2010; Lederer & Wetzel, 2014). The role of clinicians in caring for these victims is threefold and includes (a) screening and identification of trafficked individuals; (b) management of acute healthcare needs; and (c) referral for health, safety, and legal resources (Peters, 2013).

Screening and Identification

Contrary to healthcare provider belief, studies have shown that victims of human trafficking have contact with healthcare professionals even while they were being trafficked (Dovydaitis, 2010; Lederer & Wetzel, 2014), with the most frequent area of contact in the ED (Lederer & Wetzel, 2014). Trafficked individuals come from all demographics. They may be of any age, race, ethnicity, or gender. Furthermore, they may not readily disclose that they are a trafficked individual and, importantly, may not even identify themselves as such (Peters, 2013). Healthcare professionals must also be cognizant of the fact that trafficked individuals may be preconditioned by their trafficker to not trust law enforcement and/or healthcare providers.

Healthcare providers, including ED nurses, forensic nurses, and advanced practice nurses, may increase the likelihood of identifying trafficked individuals by conducting a thorough patient history and assessment with the use of an approved screening tool (Mishori, 2015). Accurate and detailed documentation of the medical history and patient examination are critical to facilitate optimum health and legal outcomes for the patient who is being trafficked (Alpert et al., 2014). It is, however, imperative to understand that, although there is no one sign that can show that a person is being trafficked, there are indicators or red flags that healthcare providers should recognize (Alpert et al., 2014; Department of Homeland Security [DHS], 2015a; Sabella, 2011). Table 1 highlights some red flags/general indicators that may suggest a person is a victim of human trafficking. This list, although not exhaustive, may assist ED nurses and other healthcare professionals to recognize actual and potential victims of human trafficking.

Table 1 Red Flags for Human Trafficking

Screening Tools

Trafficking victim identification tool.

The Vera Institute of Justice (VIJ, 2014a) received a grant from the National Institute of Justice in 2011 to test and validate the Trafficking Victim Identification Tool (TVIT). In 2014, the Institute released this tool and guidelines for administration as a resource to assist healthcare providers, law enforcement, and social service agents in identifying human trafficking victims (VIJ, 2014a). The tool's validity and reliability was tested on 180 clients. Validity was established using construct validity, discriminant and convergent validity, and criterion validity. Interrater reliability and internal consistency were used to establish the tool's reliability (VIJ, 2014b). TVIT is available in short (20-item) and long versions, with both found to be highly reliable in predicting labor and sex trafficking in men and women, among U.S.-born and foreign victims. TVIT consists of questions related to personal demographics, migration to the United States for foreign-born individuals, and living/working conditions of the individual. There is also a postinterview determination that is made by the interviewer. Recommendations for use of this screening tool are to incorporate it (a) within the regular assessment process during healthcare visits or be part of enrollment for specific programs, (b) on an individual case-by-case basis, and (c) after rapport is established. Furthermore, it may not be appropriate to implement during the healthcare provider's first encounter with the patient. In addition, the tool should be implemented using its prearranged protocol (VIJ, 2014a).

Screening questionnaires.

Although TVIT is a valid and reliable tool, it may not be feasible for nurses to administer the instrument in a busy ED. There are other screening tools available to assist healthcare providers in identifying trafficked victims. The Department of Health and Human Services (n.d.) has developed some key questions that can be asked of suspected trafficked victims. Sample questions that healthcare providers may ask suspected trafficked victims are shown in Table 2.

Table 2 Sample Questions for Healthcare Providers to Ask Suspected Trafficked Victims

TVIT and other trafficking screening tools are an important resource for healthcare providers for use in identifying trafficking victims. Early identification and additional and ongoing training in the overall care of the trafficking victim are essential in delivering high-quality, comprehensive care (VIJ, 2014b).

Care Plan/Treatment

Despite the use of a valid and reliable screening tool, nurses and other healthcare providers must realize that trafficked individuals may not disclose their victimization, leave their captors, or participate with law enforcement. Fear of harm from their captor and retribution to self and or/family may play a factor (VIJ, 2014a). Furthermore, those who attempt to seek protection in highly trafficked areas may be immediately returned to their captors; thus, victims of trafficking may feel that there is nowhere to turn for assistance (U.S. Department of State, 2015). Developing a trusting relationship where the patient is believed and supported is critical when delivering care to patients who have been trafficked. It is recommended that use of the screening tool and questioning of the patient may be delayed until a second meeting or until rapport is developed (VIJ, 2014a). Asking the right question is crucial in identifying potential victims; however, it is imperative that the person be placed in a safe and confidential environment. If they are accompanied by someone who could be their trafficker, every effort should be made to separate them before asking questions. This could be done when it is time to perform physical examination of the patient. If the potential victim does not speak English, enlist the help of a staff member who speaks the language; otherwise, use an interpreter service provided by the institution. However, if the victim is a child, it is important to request the assistance of a social service specialist who is skilled in interviewing minors (Department of Health and Human Services, n.d.).

As part of this trusting relationship, it is important that, as healthcare providers, nurses disclose the legal boundaries of their practice, that is, mandatory reporting, so that the patient has informed consent when deciding whether to disclose. Healthcare providers must be cognizant to the fact that retribution by the trafficker is a reality, and by disclosing, the patient may be putting themselves or those they love at risk of harm (U.S. Department of State, 2015). It is crucial for the nurse to maintain an unbiased and nonjudgmental attitude to help facilitate a trusting and therapeutic relationship. Therefore, the goal of the nurse-patient interaction should not be "to get disclosure" from the suspected victim but rather to create a climate that is safe, secure, and caring, empowering the victim to disclose if she chooses to do so (Alpert et al., 2014).

Once a victim of human trafficking is identified, the nurse or other healthcare provider should conduct a needs assessment to assist with the development of a plan of care that addresses the physical, psychological, and safety needs of the patient (Hodge, 2014). Although the ED nurse and other healthcare professionals may be able to treat emergent physical needs, referral and consultation to specially trained mental health professionals to address acute and chronic psychological consequences associated with trafficking is critical. Furthermore, care of the trafficked victim takes a coordinated effort from several agencies such as health, law, criminal justice, and social systems. Understanding local, regional, and federal laws on trafficking, obtaining personal protective orders, and assisting with obtaining temporary shelter are all factors that play into care of the trafficked individual (VIJ, 2014a).

Health Care Needs

Human trafficking presents a plethora of health consequences that the nurse may be responsible for treating in the emergency setting. Table 3 presents a compilation of some identified health consequences of human trafficking.

Table 3 Common Health Problems of Human Trafficked Victims

Safety Needs

The highest priority of care is to ensure the safety of both the victim and the healthcare provider(s). The American Colleges of Obstetricians and Gynecologists (2011) recommend safety measures for healthcare providers caring for patients who are victims of human trafficking (see Table 4). These measures do not guarantee absolute safety; however, these actions could buy healthcare professionals some time should they be confronted with a potentially dangerous situation.

Table 4 Safety Measures for Healthcare Professionals Caring for Victims of Human Trafficking

Implications for Forensic Nurses: Adoption of "BLUE" Strategies

As healthcare providers, it is imperative that nurses become aware of, and participate in, the local and global initiatives in the fight against human trafficking. The color blue has become the international color for trafficking awareness and helps identify global antitrafficking initiatives (UNODC, 2014). The Blue Heart, the Blue Campaign, the Blue Blindfold, and the thin Blue line are some of the "BLUE" global efforts on antitrafficking (Department of Homeland Security, 2015b; UNODC, 2015a). Furthermore, a worldwide strategic approach to combat human trafficking is composed of three interdependent and complementary components: (a) research and awareness, (b) promotion of protocols and capacity building, and (c) strengthening of partnership and coordination (UNODC, 2015a). These components are referred to as the 4Ps-prevention, protection, prosecution, and partnership (DOJ, Health and Human Services, and Homeland Security, 2014; UNODC, 2015a).

Prevention

Over the last several years, a variety of national and international training and research initiatives have been implemented with the purpose of engaging in efforts to prevent human trafficking. The Institute of Medicine and National Research Council (2013) published the report Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the US. This document is intended to increase awareness and understanding of sex trafficking, outline emerging strategies in prevention and identification, and offer a path forward for those committed to combating sex trafficking in the United States.

The UNODC first launched the Blue Heart Campaign to appeal to the global audience "to open their heart" to help stop human trafficking. It is then that the Blue Heart became the international symbol against human trafficking (UNOCD, 2015b). In 2012, President Obama declared January to be "Human Trafficking Awareness Month" (Office of the Press Secretary, The White House, 2012). During this month, events are expected to take place in an attempt to increase public awareness of human trafficking.

On May 29, 2015, the "Trafficking Awareness Training Health Care Act" was passed (Public Law No. 114-22; Congress.gov, 2015). This Act asked for training of healthcare professionals to recognize and respond to victims of human trafficking (Congress.gov, 2015). This training will be through a grant awarded by the Health Resources and Services Administration to accredited schools of medicine and nursing to (a) develop evidence-based practices for healthcare professionals and (b) design and implement a pilot program to test these best practices and educational materials developed for identifying victims of human trafficking (Public Law No. 114-22, 2015).

Protection and Prosecution

The Blue Blindfold initiative was first launched in the United Kingdom in 2007 as a strategy to help protect victims of human trafficking. This concept is used by the UK law enforcement community as well as other European countries. The focus of the program is to encourage people to "don't close your eyes" to human trafficking (Blue Blindfold, 2012).

The Victims of Trafficking and Violence Protection Act, passed in 2000 and later renamed Trafficking Victims Protection Act, created a visa category (T status or T-visa) specifically for trafficked individuals. This visa protects trafficking victims by allowing them to legally reside in the United States and to have access to healthcare services in return for their participation with law enforcement in the prosecution of their traffickers (Siskin & Wyler, 2013).

In regard to prosecution, one of the goals of UNODC (2015b) is to increase the number of convictions for human traffickers globally. In the United States, human trafficking constitutes a crime against the Thirteenth Amendment to the U.S. Constitution (U.S. DOJ, 2015). In 2007, the Human Trafficking Prosecution Unit, part of the Criminal Section of the Civil Rights Division, was created to assemble the country's expert prosecutors on human trafficking. These Human Trafficking Prosecution Unit prosecutors work closely with the Assistant U.S. Attorney to streamline fast-moving trafficking investigations (U.S. DOJ, 2015).

Partnerships

Local, national, and international partnerships display a unified front to criminals and promote team, rather than individual, effort. The Blue Campaign by the DHS (2015b) raises awareness of human trafficking by leveraging partnerships with law enforcement agencies, government and nongovernment agencies, and private organizations. The Blue Campaign logo represents collaboration among several agencies in the fight against human trafficking. The logo conveys unity, strength, and innovation (DHS, 2015b).

Conclusion

Human trafficking is a crime against humanity that can have potentially devastating health consequences to its victims. Poverty and the promise of better earning opportunity are two risk factors that can make someone very vulnerable to being exploited. At the same time, human trafficking will not exist without demand. The 4Ps - prevention, protection, prosecution and partnership - are key strategies in the fight against human trafficking. This can be achieved through collaborative partnership between law enforcement and healthcare professionals locally and worldwide. Nurses, particularly ED and forensic nurses as well as advanced practice nurses, are at the frontline of caring for these victims; therefore, it is imperative for these nurses to be trained in screening and case finding.

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