Course excerpt from Human Trafficking: Identification and Intervention
Potential Indicators of Human Trafficking
Victims and survivors of human trafficking rarely self-identify in the healthcare setting (Alpert et al. 2014) and may be unaware that they are a victim/survivor of human trafficking (Polaris, 2017). Therefore, it is critical for healthcare providers to be knowledgeable about potential indicators of human trafficking.
Various indicators of human trafficking have been identified by different sources, including that the individual:
- Is not free to leave or come and go as he/she wishes.
- Is under 18 and is providing commercial sex acts.
- Is in the commercial sex industry and has a pimp/manager.
- Is unpaid, paid very little, or paid only through tips.
- Works excessively long and/or unusual hours.
- Is not allowed breaks or suffers under unusual restrictions at work.
- Owes a large debt and is unable to pay it off.
- Was recruited through false promises concerning the nature and conditions of his/her work.
- High security measures exist in the work and/or living locations (e.g. opaque windows, boarded up windows, bars on windows, barbed wire, security cameras, etc.).
- Is fearful, anxious, depressed, submissive, tense, or nervous/paranoid.
- Exhibits unusually fearful or anxious behavior after bringing up law enforcement.
- Avoids eye contact.
- Appears malnourished.
- Shows signs of physical and/or sexual abuse, physical restraint, confinement, or torture.
- Has few or no personal possessions.
- Is not in control of his/her own money, no financial records, or bank account.
- Is not in control of his/her own identification documents (ID or passport).
- Is not allowed or able to speak for themselves (a third party may insist on being present and/or translating).
- Claims of just visiting and inability to clarify where he/she is staying/address.
- Lack of knowledge of whereabouts and/or do not know what city he/she is in.
- Loss of sense of time.
- Has numerous inconsistencies in his/her “story.”
Additionally, these have been identified as indicators of human trafficking in the clinical setting, specifically:
- Delayed presentation for medical care.
- Discrepancy between the stated history and the clinical presentation or observed pattern of injury.
- Scripted, memorized, or mechanically recited history.
- Stated age older than visual appearance.
- Subordinate, hyper-vigilant, or fearful demeanor.
- Inability to produce identification documents.
- Documents in the possession of an accompanying party.
- Reluctance or inability to speak on one’s own behalf.
- Accompanying individual who answers questions for the patient or otherwise controls the pace and content of the encounter.
- Companion or accompanying individual who insists on providing translation.
- Companion who refuses to leave.
- Evidence of a lack of care for previously identified or obviously existing medical conditions.
- Tattoos or other marks or insignias that may indicate a claim of “ownership” by another.
- Evidence of any kind of physical violence including torture.
Red Flag Indicators
Specific red flag indicators of sex trafficking, or of labor trafficking with concomitant sexual exploitation/abuse, include:
- Recurrent sexually transmitted infections.
- Multiple or frequent pregnancies.
- Frequent or forced abortion.
- Frequent relocation to avoid detection.
- Labor trafficking should be suspected in patients of any age who present with injuries or ailments that could be due to lack of proper protective gear, excessively long work hours, heavy labor with restricted access to food/drink, or physical abuse, for example:
- Occupational-type injuries without evidence of legitimate employment (e.g., overuse injuries, chemical exposures, exposure to extreme or adverse climate conditions, head injuries).
- Physical ailments (e.g., dehydration, malnutrition, chronic fatigue), especially when accompanied by vague references to being related to a work situation.
Given that foreign-born nationals are more likely than U.S. citizens to be trafficked for the purpose of forced or bonded labor, the above indicators are especially relevant to patients for whom English is not the primary language.
Indicators of Exploitation of Children
Commercial sexual exploitation should be suspected if children or adolescents (or, in certain circumstances, young adults) present with any of the following features:
- Presentation to the health care setting with non-guardian or unrelated adults.
- Access to material possessions that one would reasonably doubt the patient could afford.
- Over-familiarity with sexual terms and practices.
- Seemingly excessive number of sexual “partners.”
- History of school truancy or recurrent episodes of running away.
- Reluctance to talk about a particular tattoo.
- Fearful attachment to a cell phone (often used for monitoring or tracking) (Alpert et al., 2014, p. 18-19).
The following have been identified as potential additional indicators of the commercial sexual exploitation of children, specifically:
- History of emotional, sexual, or other physical abuse.
- Signs of current physical abuse and/or sexually transmitted diseases.
- History of running away or current status as a runaway.
- Inexplicable appearance of expensive gifts, clothing, or other costly items.
- Presence of an older boyfriend/girlfriend.
- Drug addiction.
- Withdrawal or lack of interest in previous activities.
- Gang involvement (The Polly Klaas Foundation, n.d.).
Further, indicators of familial trafficking are unique. Because the trafficking takes place within family networks, “the trafficker may begin grooming the victim at an early age, using their close proximity to take advantage of the child’s developmental stage and inability to verbally express concerns or safety issues” (U.S. Department of State, 2021, Navigating the Unique Complexities in Familial Trafficking, para. 3). In these cases, the traffickers take advantage of the child’s reliance on the family structure, for both attachment and to meet their basic needs (U. S. Department of State, 2021).
When Human Trafficking is Suspected
Upon recognizing one indicator (or more) of human trafficking during a healthcare encounter or when a client has disclosed being trafficked, a provider’s next responses are critical. “Do not try to rescue your patient if you are not yet linked to the protection system available for trafficked persons in your country or area, and do not have proper information on existing referral networks and available services” (International Organization for Migration, 2009, p. 81).
If a health care provider suspects their client/patient is being trafficked, it is important for them to speak with the client/patient privately, particularly since anyone accompanying them may also be involved in their trafficking. Private conversations also help to foster a safe space for clients/patients to share information about what they may be experiencing (Texas Health & Human Services: Texas Human Trafficking Resource Center, 2024).
Human trafficking, commonly discussed under the two broad categories of sex trafficking and labor trafficking, is a pervasive public health issue, globally and in the United States. Human Trafficking: Identification and Intervention is a 1-hour online continuing education (CE) course that will examine the various forms of human trafficking, including the commercial sexual exploitation and trafficking of domestic minors and children who are foreign nationals, the commercial sexual exploitation and trafficking of adults, and the labor trafficking of adults and minors. Estimates of the prevalence and scope of these crimes will be discussed. The course will also explore how providers may recognize indicators of human trafficking in healthcare settings and provide trauma-informed intervention. Resources available to assist providers and those impacted by human trafficking will also be examined.
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