The National Association of Nurse Practitioners in Women’s Health (NPWH) recognizes the critical role of women’s health nurse practitioners (WHNPs) and other nurse practitioners (NPs) who provide healthcare for adolescent and adult females in terms of identifying, assessing, and responding to the needs of trafficked female individuals. Adolescent and young adult females comprise the majority of trafficked persons in the United States and globally, most specifically as victims of sex trafficking. NPs must be well prepared to identify, assess, and provide care for these individuals and have access to the resources to do so.¹ 

Many trafficked persons are seen in healthcare settings, yet they remain unidentified.² Healthcare providers (HCPs) either are not aware of or do not respond to signs, when present, that a patient may be a victim of sex trafficking. A validated screening tool is not yet available. However, NPs can 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 addition, NPs can consider practice recommendations from colleagues in social service, advocacy, healthcare, and law enforcement who have expertise in human trafficking identification and intervention.

NPWH supports a comprehensive, coordinated, multidisciplinary approach to meet sex-trafficked individuals’ complex needs and help them address the challenges they face. To that end, NPWH supports research initiatives to develop a validated screening tool to better identify patients who are victims of sex trafficking, as well as to better understand the most effective manner in which to meet their emergency, short-term, and long-term healthcare needs.

Legislation and regulatory policies should focus on eliminating the demand for trafficked individuals in the first place, and on targeting persons and agencies that condone human trafficking. NPWH supports the development of legislation, regulatory policies, and advocacy efforts that protect the safety, rights, dignity, and cultural values of trafficked individuals.

NPWH will provide leadership and collaborate with other organizations and agencies to deliver NP education, develop policies, and conduct or support research in a concerted effort to increase knowledge and provide resources for NPs to identify, assess, and respond to the needs of trafficked female individuals.

Background

In 2000, the U.S. Trafficking Victims Protection Act (TVPA) updated post-Civil War slavery statutes to further guarantee freedom from slavery and involuntary servitude.³ For this purpose, sex trafficking was defined as the recruitment, harboring, transportation, provision, or obtaining of a person, through force, fraud, or coercion, for the purpose of commercial sex act.³ Severe forms of trafficking in persons was defined as sex trafficking in which the person induced to perform such 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.³ The TVPA was re-authorized most recently in 2013.⁴ Today, the terms modern slavery, trafficking in persons, and human trafficking are used as umbrella terms meeting the TVPA definition.

Accurate statistics for the incidence and prevalence of human trafficking are elusive because of the clandestine nature of the crime and trafficked individuals’ reluctance to identify themselves. Worldwide, it is estimated that 20.9 million persons are victims of trafficking and that among this group, 4.5 million (22%) are victims of forced sexual exploitation.⁵ Within the U.S., trafficked individuals may be transported across borders from other countries or they may already reside here. Data from a Bureau of Justice Statistics report for January 2008 through June 2010 identified 527 confirmed victims of trafficking, with 80% of these cases being classified as sex trafficking, 10% as labor trafficking, and 10% as undetermined.¹ Eighty-three percent of the sex-trafficked individuals in this report were U.S. citizens, with 94% of them being female. The commercial sexual exploitation of minors comprised 64% of the cases. Of note, these data reflect only reported and investigated cases; the numbers may greatly under-represent the true extent of the problem. In 2015, the National Human Trafficking Resource Center (NHTRC) hotline received 21,957 calls across all states, with 4,314 calls reporting sex trafficking.⁶ 

Females at high risk for being victims of sex trafficking include those who are young, live in extreme poverty, have limited education and work opportunities, engage in drug use, and/or have a history of instability or abuse in their families of origin. They may be more vulnerable if they have mental or physical disabilities. Adolescent females who are runaways and/or homeless are particularly vulnerable.^2,7

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 U.S.; have language barriers; distrust authority figures; feel they do not have any options; be ashamed of their situation and the stigma they believe it carries; or have a criminal record. Traffickers may use monitoring devices to track these individuals’ every move to deter them from seeking help. In addition, some trafficked individuals may not under-stand the concept of coercion or that they are victims of an illegal activity.2

Patients who have been trafficked are at high risk for long-term physical and mental health con-sequences related to inflicted trauma and depriva-tion of their basic needs for survival. Health conse-quences may include unintended pregnancies; sexually transmitted infections (STIs), including HIV; poor dentition compounding malnutrition; depression; post-traumatic stress disorder (PTSD); and suicidal ideation. Commonly reported physi-cal symptoms include fatigue, headaches, back pain, and weight loss.8

Implications for women’s healthcare and WHNP practice

WHNPs and other NPs who provide women’s healthcare should be aware of indicators that raise suspicion that an individual presenting to a healthcare setting may be in an exploitative circumstance. Warning signs identified by anti-trafficking experts include:

• Hypervigilant, fearful, or submissive demeanor; evidence of being controlled;

• Provision of vague answers to questions or a script-like recitation of her 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 her injuries;

• Accompaniment by another person who answers questions for the individual and refuses to leave her alone during the visit;

• Inability to produce identification documents;

• Signs of physical abuse (e.g., cigarette burns, bruising), sexual abuse, medical neglect, torture, depression, PTSD, and/or alcohol or substance use disorder;

• Tattoos or other markings indicating a claim of ownership by another;

• Recurrent STIs;

• Trauma to her genitals or rectum; and/or

• History of repetitive abortions or miscarriages.^2,7,9,10

WHNPs are particularly qualified through their educational preparation to recognize and provide needed healthcare services and referrals for adolescent and adult females who are victims of sexual, physical, and/or emotional abuse. Trauma-informed care for these patients places an emphasis on helping the individual feel safe and reclaim control of her life and decisions. 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.²

No official guidelines are available regarding the most effective manner in which to provide for the emergency, short-term, and long-term healthcare needs of trafficked patients. However, expert opinion supports 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 the patient and/or her family members if she reports the crime.

• Incorporate safety planning for both the patient and staff.

• Use a trauma-informed approach in assessment and treatment.

• Provide care for any immediate needs (e.g., treat STIs, diagnose a pregnancy).

• Provide culturally appropriate services.

• Mitigate language barriers; provide a professional interpreter when needed.

• Establish a list of local resources for collaboration that provides wraparound services for the individual.

• Contact the NHTRC hotline at 1-888-373-7888 for guidance on the next steps and referrals if needed.^2,7,11

The NHTRC provides detailed information for HCPs concerning identification, assessment, and response to the needs of patients who have been trafficked.

Recommendations

WHNPs and other NPs who provide healthcare for adolescent and adult females should:

• 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 the patient and staff;

• Establish partnerships with local social service providers, mental health providers, religious leaders, legal advocates, and law enforcement representatives for comprehensive services;

• Serve as change agents in their communities through mentoring programs for at-risk youth, advocacy for policy changes to aid recovery of trafficked individuals, and engagement in activities that will promote greater cultural awareness of gender inequalities; and

• Assess their own learning needs with regard to the unique and complex needs of trafficked individuals and seek continuing education as appropriate.

NPWH will provide leadership and resources to ensure that:

• Educational programs for NP students with a population focus that includes adolescent and adult females impart evidence-based knowledge and skill building for the development of competencies to identify trafficked individuals and provide healthcare and appropriate referrals for them; and

• Continuing education programs are available for NPs to obtain evidence-based knowledge and competencies to identify and provide healthcare and appropriate referrals for trafficked individuals.

References

1. Banks D, Kyckelhahn T. Characteristics of Suspected Human Trafficking Incidents, 2008-2010. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics; 2011. 

2. 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 Preven-tion, Massachusetts Medical Society; 2014.

3. 106th U.S. Congress. Victims of Trafficking and Violence Protection Act of 2000, Public Law 106-386. 2000. 

4. U.S. Department of State. U.S. Laws on Trafficking in Persons. 2016. 

5. International Labor Organization. ILO 2012 Global Estimate of Forced Labor: Executive Summary. 2012. 

6. National Human Trafficking Resource Center. 2015 NHTRC Annual Report. 2016. 

7. Clawson H, Dutch N, Solomon A, Grace L. Human Trafficking Into and Within the United States: A Review of the Literature. U.S. Department of Health and Human Services, Office of the Assistant Secretary of Planning and Evaluation; 2009. 

8. World Health Organization. Understanding and Addressing Violence Against Women: Human Trafficking. 2012. 

9. Baldwin SB, Eisenman DP, Sayles JN, et al. Identification of human sex trafficking victims in health care settings. Health Hum Rights. 2011;13(1):36-49. 

10. National Human Trafficking Resource Center. Identifying Victims of Human Trafficking: What to Look for in a Healthcare Setting. 2016. 

11. Dovydaitis T. Human trafficking: the role of the health care provider. J Midwifery Womens Health. 2010;55(5):462-467.