The National Association of Nurse Practitioners in Women’s Health (NPWH) affirms the essential role of women’s health nurse practitioners (WHNPs) and other advanced practice registered nurses (APRNs) who provide women’s and gender-related healthcare for adolescents and adults in identifying, assessing, and responding to the needs of trafficked individuals. Victims of trafficking include all ages and gender identities. However, adolescent and young adult females comprise the majority of trafficked persons in the United States and globally, most specifically as victims of sex trafficking.¹

A majority of victims of sex trafficking have had contact with a healthcare provider (HCP) while in captivity, yet most remained unidentified during these encounters.^2–4 Missed opportunities for intervention occur because HCPs either are not aware of or do not respond to signs, when present, that a patient may be a victim of sex trafficking.^2–4 NPWH asserts that WHNPs and other APRNs who provide women’s and gender-related healthcare for adolescents and adults have a responsibility to know and attend to indicators that a patient may be a victim of sex trafficking and have access to resources for assessment and care.

A comprehensive, coordinated, multidisciplinary approach is needed to meet the complex needs of victims of sex trafficking and to help them address the challenges they face. All encounters must protect their safety, rights, dignity, and cultural values. A trauma-informed approach is critical in all aspects of care to prevent re-victimization, reduce adverse outcomes, and promote the health and wellbeing of individuals who are or have been victims of sex trafficking.

Research is needed to better understand the most effective manner by which to meet the emergency and short-and long-term needs of victims of sex trafficking. Legislation and regulatory policies should target traffickers, persons, and establishments that participate in or condone sexual exploitation as a major focus on the prevention of trafficking. NPWH advocates for a concerted effort to understand and tackle the root causes of human trafficking. It is a large but crucial endeavor to address the social, economic, legal, and cultural environments that promote and sustain trafficking.¹

NPWH provides leadership and collaborates with other organizations and agencies to deliver education and skills training for WHNPs and other APRNs who provide women’s and gender-related healthcare and develop evidence-based practices and resources to improve identification, assessment, and response to the needs of trafficked individuals.

Background

In 2000, the US Trafficking Victims Protection Act (TVPA) updated post-Civil War slavery statutes to further guarantee freedom from slavery and involuntary servitude.⁵ Today, modern slavery, trafficking in persons, and human trafficking are used as umbrella terms meeting the TVPA definition for involuntary servitude. The TVPA defined sex trafficking as the recruitment, harboring, transportation, provision, or obtaining of a person through force, fraud, or coercion for the purpose of a commercial sex act.⁵ Severe forms of trafficking were defined as sex trafficking in which the person induced to perform such an act has not attained 18 years of age or sex trafficking for the purpose of subjection to involuntary services, servitude, peonage, debt bondage, or slavery.⁵ Most recently reauthorized in 2019, the TVPA maintains these definitions and continues with the purpose of facilitating prevention of trafficking, protection and assistance for victims, and prosecution and punishment of traffickers.⁶

Accurate statistics for the incidence and prevalence of human trafficking are elusive because of the clandestine nature of the crime and the reluctance of trafficked individuals to identify themselves. Worldwide, it is estimated that 24.9 million persons are victims of trafficking, of whom 4.8 million (19%) are victims of forced sexual exploitation. Women and girls constitute 99% of these victims of forced sexual exploitation.¹

Some of the most extensive data on US human trafficking come from the National Human Trafficking Resource Center (NHTRC) hotline. In 2019, the hotline reported 22,327 individual communications with victims and survivors of trafficking through phone calls, texts, online chats, and emails across all states, with 14,597 of these communications reporting sex trafficking. NHTRC notes that this likely represents only a small subset of the totality of human trafficking in the US.⁷

Individuals at increased risk for being victims of sex trafficking include those who live in extreme poverty, have limited education and work opportunities, have experienced childhood sexual abuse, are refugees without lawful immigration status, and those with substance use disorders. They may be more vulnerable if they have mental or physical disabilities. Adolescents who are runaways, homeless, in the child welfare or juvenile justice system, and those who identify as lesbian, gay, bisexual, transgender, or questioning are particularly vulnerable.^2,7–13

Victims of sex trafficking are at high risk for long-term physical and mental health consequences related to inflicted trauma and deprivation of their basic needs for survival. Health consequences may include unintended pregnancies, sexually transmitted infections (STIs), including HIV, malnutrition, substance use/misuse, traumatic brain injury, depression, post-traumatic stress disorder (PTSD), and suicidal ideation. Commonly reported symptoms include muscle pain, headaches, other chronic pain, impaired memory, impaired concentration, insomnia, and fatigue.^{4,8,10,12,14,15}

Trafficked individuals face numerous barriers to disclosing their situation to HCPs. They may fear harm to themselves, family members, or friends; fear deportation if not legally in the US; have language barriers; distrust authority figures; believe they do not have any options; be ashamed of their situation and the stigma they think it carries; or have a criminal record. Traffickers may use monitoring devices to track every move of their victims to deter them from seeking help. In addition, some trafficked individuals may not understand the concept of coercion or that they are victims of an illegal activity.^10,13,15

Reliable and valid screening tools for use with adults and adolescents in healthcare settings are beginning to emerge.^3,10,14,16 HCPs can also draw from existing evidence in related areas—especially intimate partner violence, sexual assault, homeless and runaway youth, child abuse and neglect, and individuals experiencing trauma in general—for clinical guidance in identifying victims of sex trafficking. In addition, HCPs can consider practice recommendations from colleagues in social service, advocacy, healthcare, and law enforcement who have expertise in human trafficking identification and intervention. The goal of screening is not disclosure but understanding the individual’s life experiences so that they can be connected to resources that will best serve their current and future needs.^11,12

Implications for women’s and gender-related healthcare

WHNPs and other APRNs who provide women’s and gender-related healthcare for adolescents and adults should be aware of indicators that raise suspicion that an individual presenting to a healthcare setting may be in an exploitative circumstance. Warning signs described by experts in the identification and care for trafficked individuals include:

• Hypervigilant, fearful, or submissive demeanor; evidence of being controlled;
• Provision of vague answers to questions or a script-like recitation of personal health history;
• Delay between the onset of an injury or illness and the seeking of healthcare, in context with other indicators;
• Discrepancies between an individual’s explained cause and the clinical presentation of injuries;
• Accompaniment by another person who answers questions for the individual and refuses to leave the patient alone during the visit;
• Inability to produce identification documents;
• Signs of physical abuse (eg, cigarette burns, patterned injuries, bruising), sexual abuse, medical neglect, depression, PTSD, and/or alcohol or substance use disorder;
• Tattoos or other markings indicating a claim of ownership by another;
• Gang involvement;
• Recurrent STIs;
• Trauma to the genitals or rectum; and/or
• History of repetitive abortions or miscarriages.^4,8,12,13,15

WHNPs and other APRNs who provide women’s and gender-related healthcare for adolescents and adults need to provide trauma-informed healthcare and make appropriate referrals for patients who are victims of trafficking. Goals of a trauma-informed approach in care are to avoid re-traumatization, to emphasize the patient’s strengths and resilience, to support development of healthy short-and long-term coping mechanisms, and to promote healing and recovery.¹³

No one set of all-encompassing guidelines is available regarding the most effective manner by which to provide for the emergency and short-and long-term healthcare needs of trafficked patients. However, published recommendations based on expert opinion and research to date support these approaches:

• Foster trust and relationship building, which includes an assurance of confidentiality.
• Ensure privacy prior to discussing potential trafficking with the patient.
• Recognize potential danger to patients and/or family members if they report the crime.
• Incorporate safety planning for both patient and staff.
• Use a trauma-informed approach in assessment and treatment.
• Provide care for any immediate needs (eg, treat STIs, diagnose a pregnancy).
• Provide culturally appropriate services.
• Mitigate language barriers; provide a professional interpreter when needed.
• Listen to what the patient defines as their own needs.
• Establish a list of local resources for collaboration that provides wraparound services for the individual.
• Contact the NHTRC hotline for guidance on the next steps and referrals if needed.^8,11–13,15

Recommendations

NPWH recommends that WHNPs and other APRNs who provide women’s and gender-related healthcare for adolescents and adults:

• Be familiar with and educate staff about warning signs indicating that a patient may be a victim of sex trafficking;
• Establish a plan in the healthcare setting for safety of both patient and staff;
• Establish partnerships with local social service providers, mental health providers, legal advocates, and law enforcement representatives for comprehensive services;
• Serve as change agents in their communities through support of mentoring programs for at-risk youth and advocacy for policy changes to aid recovery of trafficked individuals and;
• Assess their own learning needs with regard to the unique and complex needs of victims of sex trafficking and seek continuing education as appropriate.

NPWH will provide leadership to ensure that:

• Continuing education programs and resources are available for WHNPs and other APRNs to obtain evidence-based knowledge and competencies to identify and provide healthcare and appropriate referrals for individuals who are victims of trafficking.
• Public health policy and legislation promote the rights, health, and safety of individuals who have been or are victims of sex trafficking.
• Research progresses in all aspects for the prevention and reduction of harms from sex trafficking.

References:

1. International Labour Organization. Report. Global estimates of modern slavery: forced labour and forced marriage. International Labour Office (ILO), Geneva, September 19, 2017.
2. Hornor G, Sherfield J. Commercial sexual exploitation of children: health care use andcase characteristics. J Pediatr Health Care. 2018;32(3):250-262.
3. Greenbaum VJ, Livings MS, Lai BS, et al. Evaluation of a tool to identify child sex trafficking victims in multiple healthcare settings. J Adolesc Health. 2018;63(6):745-752.
4. Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law. 2014;23(1):61-91.
5. 106th United States Congress. Victims of Trafficking and Violence Protection Act of 2000.
6. Wells K; Polaris Project. The 2019 Trafficking Victims Protection Reauthorization Act: a topical summary and analysis of four bills. January 14, 2020.
7. Polaris Project. 2019 Data Report. The U.S. National Human Trafficking Hotline.
8. Greenbaum J. Identifying victims of human trafficking in the emergency department. Clin Pediatr Emerg Med. 2016;17(4):241-248.
9. US Department of State, Office to Monitor and Combat Trafficking in Persons. 2020 Trafficking in Persons Report: United States.
10. Haney K, LeBeau K, Bodner S, etal. Sex trafficking in the United States: a scoping review. J Evid Based Soc Work. 2020;17(6):714-748.
11. Erickson L. Office of the Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services. Office of Human Services Policy. 2018 HHS Health and Human Trafficking Symposium–Takeaways and Next Steps. October 2019.
12. National Human Trafficking Resource Center. Identifying Victims of Human Trafficking: What to Look for in a Healthcare Setting. 2016.
13. Alpert EJ, Ahn R, Albright E, et al. Human Trafficking: Guidebook on Identification, Assessment, and Response in the Health Care Setting. Waltham, MA: MGH Human Trafficking Initiative, Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, and Committee on Violence Intervention and Prevention, Massachusetts Medical Society; September2014.
14. Bespalova N, Morgan J, Coverdale J. A pathway to freedom: an evaluation of screening tools for the identification of trafficking victims. Acad Psychiatry. 2016;40(1):124-128.
15. Lepianka C, Colbert AM. Characteristics and healthcare needs of women who are trafficked for sex in the United States: an integrative literature review. J Forensic Nurs. 2020;16(1):6-15.
16. Vera Institute of Justice. Screening for human trafficking. Guidelines for administering the trafficking victim identification tool (TVIT). June 2014.

Resources:

A. National Center for Missing and Exploited Children

B. National Human Trafficking Hotline: 1-888-373-7888

C. Polaris Project: National Human Trafficking Resource Center

D. Safe Horizon Anti-Trafficking Program and 24-hour hotline: 1-800-621-HOPE (4673)

E. SOAR National Human Trafficking Training and Technical Assistance Center

Approved by NPWH Board of Directors: January 2017Updated and reaffirmed by the Board of Directors: June 29, 2021