Exploitive Environments

When healthcare workers encounter potential victims of trafficking, a detailed work history and social history will assist in identifying red flags. A better understanding of most common areas where persons are targeted for exploitation will help practitioners assess a potential victim.

Victims of labor trafficking tend to be near farms, fisheries, factories, or businesses such as nail salons, massage parlors, restaurants, and areas with high immigrant populations. Traveling sales crews, begging rings, landscapers, construction workers, domestic workers, nannies, elder adult caregivers, and those in retail have a heightened risk of being labor trafficked. Immigrants may lack the power of communication due to language barriers which enable handlers from a similar background to approach them. 

Sex trafficking can be hotel or motel based, street-based, or in residences functioning as brothels. Commercial-front brothels, escort services, truck stops, bars, and strip clubs can be places where sex trafficking occurs. Sex trafficking can happen at home with parents, intimate partners, or other family members as the perpetrators. Victims may not see themselves as victims, and may refer to the trafficker as their “daddy” or "boyfriend." [25][21][19]

Labor Trafficking Considerations

Common presenting complaints of victims of human trafficking are much like those of intimate partner violence but may vary depending on if a victim of labor versus sex trafficking. Labor traffickers prey on specific vulnerabilities to entice individuals to accept substandard working conditions. Workers in the agriculture industry, factories, and domestic servitude sectors are vulnerable to human trafficking due to their work visa and immigration status being controlled by one employer. This power over the individual and fear of deportation allows the trafficker to manipulate the worker, leading to victimization. 

Agricultural and industrial workers who are forced to work long hours with substandard wages may be isolated, confined by the use of dogs, armed guards, barbed wire or other fences, and locks. The seasonal nature of their work and movement from place to place heightens their vulnerability due to regularly being subjected to unfamiliar surroundings. 

Domestic workers are also isolated, forced to live on the premises, and may lack access to cell phones and other communication devices. Language barriers add to vulnerability, coupled with this inability to communicate. Traveling sales crews, begging rings, and peddlers are vulnerable due to homelessness and working in unfamiliar settings. If left behind in an unknown city, they may resort to "survival sex." 

Workers in strip clubs and bars may have fraudulent work visas and ties to organized crime, rendering them vulnerable to trafficking. Drug and alcohol are used as a manipulation tool. Labor laws may not apply to subcontractors or independent contractors, thus increasing vulnerability risk. A common theme originates between persons who are exploited and traffickers: Keep the victim isolated by proximity or language, vulnerable due to immigration status, without resources and owing debts, and without the protection of labor laws and increase the ability to control and manipulate. 

Trafficking in persons for labor exploitation may put a patient at risk for malnutrition, communicable diseases such as hepatitis and tuberculosis, pesticide and chemical burns, or exposure and work-related injuries due to lack of safety equipment such as safety belts, gloves, goggles, and masks. 

Labor Trafficking Red Flags

Stop, Observe, Ask, and Respond (SOAR) will guide practitioners in determining whether red flags indicate a potential case of human trafficking. Healthcare providers must determine if a crime occurred or if all three elements of trafficking in persons exist: force, fraud, and coercion. The provider's role is to recognize a potential case of human trafficking, empower the person being exploited, educate the victim on resources and established support structures, and provide a framework for a trauma-informed, victim-centered approach to healthcare.

Observing for verbal and nonverbal clues as well as asking open-ended questions in a private, non-judgmental way will allow caregivers to determine a potential case of human trafficking. Questions to ask regarding labor trafficking suspicions may include and not be limited to the list below.

1. Are you being paid the wages that were part of the initial agreement?
2. Can you change jobs if you want to?
3. Would anything happen to you if you did quit your job?
4. Can you come and go as you please, take bathroom breaks, eat when you want?
5. Do you live with others? What are the home conditions and where do you sleep? Do you have a bed? Do you sleep on the floor? Is it too cold or too hot?
6. Did you pay a fee to get your job? Do you owe a debt to your employer?
7. Do you have access to your money, your identification? 
8. Has your employer ever threatened you? 
9. Did you have eye protection, a mask, a safety harness? Personal protective equipment such as gloves? Respirators?
10. Does your employer provide your housing? 
11. Are you working in the job you were hired to do? 
12. Are you concerned about your safety? Your family or children's safety?
13. How many hours do you work a day? How many days per week?
14. Have you moved around a lot? Do you know your address? Can you give me directions or a location of your house?
15. Do you take care of others?
16. Are there locks on the doors or bars on the windows? Can you leave freely?[26]

Barriers to Identification of Victims

Healthcare providers, for a variety of reasons, may fail to stop, observe, and ask questions to identify a potential victim of human trafficking. The absence of protocols, myths, stereotypes, biases, fear of no available resources, lack of education regarding human trafficking red flags, time constraints, lack of privacy, or an inability to separate the person from the potential trafficker all may play a part in the inability to identify victims. The victim declining to give a history and self-identify is a factor [23].

Diagnostic Overshadowing

A patient who presents with multiple visits for a pain complaint that has no organic cause, a frequent flyer as labeled by some, may be a victim of trafficking but stereotyped and overlooked. Those problematic patients that present with stress-related issues on multiple visits or those who return over and over with psychological holds for overdoses or suicidal ideations may be victims of trafficking. Each time, there is the risk that they will be released back into the trafficking situation and victimization. Providers must recognize the potential for "diagnostic overshadowing" and be attuned to their own emotions and potential for bias.[27]  Traffickers can pose as parents, grandparents, or spouses. As providers, practitioners must stop, observe, ask and respond[4].

As front-line participants in the battle to combat human trafficking, healthcare workers must be aware of these potentials barriers to victim identification. Often, rushing from patient to patient or exam room to exam room, being caught between documentation and hands-on assessment and care, and treating patients in hallways, lobbies, or corridors adds to the potential for a missed opportunity. 

Sex Trafficking Red Flags 

According to the National Human Trafficking Resource Center (NHTRC) and hotline, general indicators or red flags of trafficking in persons may include but not be limited to the following with some modifications:

1. Inconsistent history or a history that appears coaxed. May be difficult to determine if a language barrier is present.
2. Resistant to answer questions about the injury or incident.
3. Avoids eye contact, is nervous, fearful of touch.
4. No idea of address or general area where they live.
5. No control over their finances and lacks decision-making capacity.
6. Accompanied by a controlling companion or family member that refuses to let the patient speak for themselves or be alone for care or insists on being the translator.
7. Exhibits bizarre, hostile behavior. Resistant to care and assistance. May have initially consented but changes mind after asked to undress for an exam.
8. No identification or the companion has it in their possession.
9. Under age 18 and involved in a commercial sex act.
10. Tattoos or branding signs. Markings may say "daddy" "for sale," imply ownership, or read as an advertisement for a product.
11. Multiple sex partners.
12. Inappropriate attire for the environmental conditions of the area.
13. Attempt to reason away bruises or ligature marks by claiming a bruising or rare blood disorder.
14. Silent, afraid to speak, cringes at the sound of a loud voice.
15. Uses trafficking "lingo" such as "the life" or other words common in the commercial sex industry.
16. Has addiction issues such as opioids.
17. Admits to a forced sexual encounter or being forced into sex acts.[21][28][29]
18. Has a cover story to avert suspicion, but details may vary or be inconsistent with a query. Law enforcement may refer to this as a "legend."

Head-to-Toe Assessment

Conducting a head-to-toe, full assessment in this patient population is of vital importance. An examination may prove difficult due to the emotional and psychological state of the victim. These patients may appear as uncooperative or vague and give an inconsistent history. These reactions are manifestations of their trauma. Provider frustration or stereotyping may arise, leading to the desire to exit the room quickly, with a quick determination of probable diagnosis and treatment. As discussed above, the potential exists for "diagnostic overshadowing." As with any trauma patient, a high index of suspicion should be present for co-existing conditions and comorbidities.

Conduct the assessment in private, not allowing anyone accompanying the patient to be present. A chaperone may be present and a certified interpreter, if required, to facilitate a feeling of trust and establish rapport. Provide a same-sex provider for the physical exam/assessment if at all possible with the staffing mix currently available. During the exam, the patient may seem emotionally absent, hyperventilate, and not verbalize feelings of discomfort. Be alert to nonverbal signs. Reassure frequently and promote a relaxed, non-rushed atmosphere. Avoid interrogating the victim, ask only direct, pertinent, open-ended, yet neutral questions. Maintain eye contact with the victim, barring cultural considerations, and avoid writing while the victim is speaking. Ensure the victim is completely undressed and in a gown so a complete trauma assessment can be initiated. Specifically, examine for the following:

• Bruising; old, healing or new lacerations; hematomas; signs of acute or chronic head trauma or a headache; missing hair or bald spots.
• Trouble hearing; damage to the auditory canal or eardrum; signs of trauma to the oropharynx such as lacerations or burns, blood in the mouth, ulcerations, tooth decay, broken teeth, gingival irritation, tongue abnormalities; signs of anemia or dehydration in the oral mucosa.
• Visual defects, sudden or of gradual onset; tattoos or brands in the hairline or on the neck; signs of strangulation such as bruising.
• Signs of chest trauma, murmurs; cigarette burns; tattoos that imply ownership; bruising in various stages of healing; signs of stress-related cardiovascular issues such as arrhythmias or high blood pressure.
• Respiratory issues that would indicate inhalation injuries from chemical exposure, toxic fume exposure, asbestos exposure, or mold exposure.
• Signs of tuberculosis such as night sweats, coughing up blood, fever, weight loss.
• Signs of stress-related respiratory or gastrointestinal problems.
• Damage to lung tissue due to prolonged exposure to chemicals or pesticides, aspiration pneumonia or other inhalation injuries; meth lab exposure can produce burning to the eyes, nose, and mouth, chest pain, cough, lack of coordination, nausea, and dizziness.
• Hypothermia or hyperthermia from environmental exposure from working in damp, cool, poorly insulated factories or buildings; mold exposure signs/symptoms.
• Signs of gastrointestinal issues such as nausea, vomiting, diarrhea, constipation, or abdomen pain; rectal pain, itching, trauma or bleeding; parasites in the feces or signs of abdominal trauma.
• Bruising to the back or scarring; tattoos that imply advertisement, ownership, or are sexually explicit in the pubic hair.
• Obstetrical and gynecological complaints such as sexually transmitted infections or recurrent STI’s (An STI, especially if recurrent, in a minor may be the first and only sign of sexual abuse; repeated unwanted or unplanned pregnancies or forced abortions; anogenital trauma; evidence of retained foreign bodies such as in the vagina from packing during menstruation, vaginal bleeding, discharge, rashes, itching, signs of injury or forced sex.[30][30][31]
• Number of sexual partners; condom use; genitourinary symptoms present such as burning, frequency, odor, dark urine or history of frequent urinary tract infections.
• Signs of bruising or lower back scarring from repeated beatings; musculoskeletal issues such as signs of repetitive trauma; work-related injuries or injuries such as back problems from wearing heels for hours walking the streets or neck and jaw problems from frequent, forced oral ses.
• Fractures, old or new, any contractures. Cigarette or scald burns. Ligature marks/scars around ankles or wrists. Signs of scabies, infestations (scalp or body). Impetigo. Fungal infections.
• Signs of nutritional deficits such as Vitamin D deficiencies from lack of exposure to sunlight, anemia, mineral deficiencies, brittle or fine hair.
• Signs of anorexia, bulimia, loss of appetite, malnutrition, severe electrolyte abnormalities.
• Children may have growth and development abnormalities and dental cavities or misaligned poorly formed teeth. 
• Neurological issues such as seizures, pseudo-seizures, numbness or tingling, migraines, inability to concentrate, vertigo, unexplained memory loss, seizures.
• Insomnia, nightmares, waking up frequently.
• Signs of opioid or other addiction.

Signs of Physical or Psychological Torture

Signs of physical torture may present on a dermatological evaluation such as abrasions over bony prominences, scratches or linear abrasions from a wire, or "road rash" to extremities from being thrown from or drug by a vehicle. Ropes and cords can leave elongated, broad-type abrasions. Ropes may leave areas of bruising mixed with abrasions. Belts or cords may have loop marks, parallel lines of petechial with central sparing. Tramline bruising, two parallel lines of bruising, can result from being beaten with a heavy stick or baton. Cigarette burns tend to be circular with a 1 cm diameter and can fade in a few hours or a few days. Burns, in general, tend to take the shape of the object that inflicted the burn.

Trafficking victims may be beaten or subjected to torture for a variety of reasons.  By the guerilla pimp as a result of not meeting a quota or set of established rules, by a customer who is displeased or is just acting out a part of the sex act, or for no apparent reason other than to maintain control on the part of the trafficker. Bruises, lacerations, marks, or scars may be present on the lower back where they are hidden more easily and do not disfigure the product/victim and inadvertently make the person being trafficked less marketable. 

It is important to note that some cultures practice cupping therapy and may have bruising and scars from this practice. Correlate this finding with a detailed history as well as the presence of other red flags. 

Psychological and Mental Status Examination

Mental health indicators of trafficking in persons may be missed or explained away as a panic attack. Again, one must stop and take an in-depth look, considering the flags. Look for signs such as depression, suicidal ideations, self-mutilation injuries, anxiety, post-traumatic stress disorder (PTSD), and feelings of shame or guilt. Shame may keep a victim bound to a trafficking situation, often used as a control tool by a trafficker. Does the patient report nightmares, flashbacks, irrational fears, irritability, social isolation, suicidal ideations, or depression? 

A trafficking victim may describe a situation as if they were an outsider looking in, a mind-body separation , creating a safe, alternate reality to cope with the atrocities they are facing and feelings of shame and guilt. They take a third-person, omniscient point of view in their storyline since this is the most trusted viewpoint. Sometimes patients exhibiting this behavior are categorized as impersonal or devoid of emotion, numb to their surroundings, or detached. This is their survival mechanism.

Addiction issues may be present and result in withdrawal. The addiction may be fueled by the trafficker for control or by the victim to cope with the physical or emotional pain surrounding the trafficking situation. 

Documentation of Assessment Findings

Documentation of physical findings is important and may assist the victim in prosecuting their trafficker at a later date if health records get subpoenaed. Follow established documentation guidelines and reporting requirements based on state and local statute or federal law as addressed previously. Photo documentation may prove vital. Follow any protocols/policies specific to your institution regarding the taking of photos and their storage and obtain all required consent forms.[3][32][33]

Recognition and Intervention

Once a practitioner identifies a potential trafficked person, it is imperative to establish a private, quiet, safe place to assess the patient further, much like in cases of child or elder abuse. Building rapport and providing an opportunity for the victim to feel empowered is of utmost importance and builds trust. Do not start a dialogue until you can establish a safe, private, and secure place.

In this era of mobile devices where a smartphone is always within easy grasp, ensure cell phones are off and not nearby. Cell phones can be another way the traffickers control the victim. The victim may have arrived alone but is always on her cell phone. The cell phone may be the trafficker's way of " keeping tabs" or listening to everything going on in the room. 

Maintain eye contact during conversation, speak slowly and quietly, and avoid looking down at the potential victim. Instead sit in a nearby chair where on-level eye contact, unless contrary to the patient's cultural norms, is possible. Ensure an environment where the victim can establish a sense of power and control. This empowering zone of safety may allow them to open up and admit they are victims, but more importantly, it may provide a venue for resources, opportunity, and the realization they are not alone and that help is available if they choose to accept it. 

Ask the patient if it is safe to talk now and if it is alright if you are the one in the room or whether they would prefer someone else. Never assume it is safe for the victim; they must confirm that it is safe. Safety is critical for the victim, staff, and nearby patients. Trafficking protocols will guide your care and determine a preset location that is readily available for an interview or a few minutes alone with the patient. A bereavement room set up for family notification in the event of trauma or sudden death may be one such place.

Inform the potential victim of trafficking that you are mandated by law to report certain disclosures. Monitor their verbal and nonverbal cues. Be alert to your facial expressions, body language, and any nonverbal cues you are exhibiting. Avoid stereotyping and revictimizing the potential victim as they disclose information. 

Communicating with Potential Victims

Communicating with victims of human trafficking can be intimidating for health-care providers. The Department of HHS created a resource called Messages for Communicating with Victims of Human Trafficking as part of their Rescue and Restore Campaign in 2016. These messages assist healthcare providers in building a rapport with the victim and promoting a trusting environment.[34][35]

Sample Messages to Ease Communication

Sample messages for communicating with a victim of human trafficking according to the Department of HHS.[36][37]

1. We are here to help you, and our priority is your safety. We can keep you safe and protected.
2. We can provide you with the medical care you need as well as find you a place to stay. 
3. Everyone has the right to live without being abused or hurt, and that includes you. 
4. You deserve a chance to live on your own and take care of yourself, be independent, and make your own choices. We can help you with that. 
5. We can get you help to protect your family and your children. 
6. You have rights and deserve to be treated according to those rights.
7. You can trust me. I will do everything within my power to help you. Assistance is available for you under the law, and there are special visas to allow you to live safely in this country.
8. No one should have to be afraid all the time. We can help.
9. Help us, so this does not happen to anyone else. 
10. You can decide what is best for you, but let me provide you with a number to call for help 24-hours a day. You do not even have to tell them your name if you do not want to. They are there to help you anytime day or night. The National Human Trafficking Resource Center hotline number is 1.888.3737.888. 

Do not make false promises. Only offer what you can access provide. 

Providers are not required to determine if a crime or a prosecutable offense has taken place. However, they can foster an empowering, caring environment to identify a victim for a potential rescue and provide invaluable resources to assist in restoring their lives and help them to begin healing emotionally and physically. 

Creating an Opportunity for Intervention

The trafficker may be the accompanying family member that declines to leave the patient alone. Similar to intimate partner violence, the provider creates an opportunity to take the patient to the bathroom for a urine sample or to radiology for an x-ray or CAT scan, informing the family member that they cannot go with the patient. Another way to get the victim alone is to notify the alleged family or significant other that hospital policy requires you to interview and examine everyone alone. 

Before you separate the potential victim from the family member or controlling individual, make sure you or a dedicated, trained staff member has the time to conduct an interview/assessment at that moment. 

Traffickers can be parents, "boyfriends," husbands, women, men, friends, and those you would otherwise see as protectors. If privacy cannot be obtained to interview the suspected victim alone, do not confront the situation. The trafficker may cause the victim serious bodily injury after removing them from the facility if alerted to the fact that the healthcare provider is suspicious of the situation.

Safety

Assessment of the level of danger or threat to the patient and staff is imperative. Pay attention to your immediate area and follow preset protocols by your institution in notifying law enforcement and security personnel. 

The NHTRC can assist you in threat level assessment, danger risk, and the contacting of law enforcement if the patient consents. Is the trafficker still nearby? How will the trafficker act if the victim does not return? Are there minors or other family members that are in danger? Is the patient a minor? 

an interprofessional approach is best, if available, with a trained social worker nearby as predetermined in your trafficking protocol. Follow preset policies and procedures regarding abuse and neglect at your institution and according to local and state statute. The NHTRC hotline offers invaluable assistance with resources, assessment, and best courses of action. 

Much like intimate partner violence, ensure the patient has a safe place to go upon discharge. 

Reporting

If a patient reveals they are a victim of human trafficking, ask the patient if it is alright to call the NHTRC hotline number. Encourage the patient to call and provide them with the phone number. It may be dangerous for them to keep the number on hand, so ask them if they can memorize it or give them a "shoe" or "key" card that can be hidden in their shoe or other discrete location. 

The National Human Trafficking and Resource Center hotline number is available around the clock and is confidential to the extent of the law. The NHTRC is a tip hotline, a place to find out about services and to ask for help. The hotline can translate and communicate with individuals in more than 200 languages. A caller does not need to disclose any personal information to the hotline; it can be anonymous.

The NHTRC is available to help healthcare providers in the event of a potential trafficking case when no protocols are available. Healthcare providers can gain information in social referrals such as anti-trafficking organizations, shelters, local social services agencies, legal services, and law enforcement numbers. Tip reporting is available. The hotline provides training information and technical support on their website. The NHTRC can guide a provider in an assessment of a potential victim. 

• Report Online or Access Resources & Referrals: www.traffickingresourcecenter.org
• Call: 1-888-373-7888 (24/7) Email: nhtrc@polarisproject.org

Mandatory Reporting/HIPAA Considerations

Guidelines for the reporting of suspected cases of human trafficking for adults and children will vary depending on facility, location, state and federal laws. Adults may not want to report the incident; thus, a consideration made in the decision to alert law enforcement based on predetermined protocols and local or state laws coupled with patient wishes. Some states mandate reporting if serious bodily injury or a firearm is involved. 

It is essential to consider Health Insurance Portability and Accountability Act (HIPAA) concerns. The practitioner must obtain permission from an adult victim of human trafficking to release any protected health information (PHI) or personally identifiable health information to the NHTRC. The NHTRC may be contacted and provided general information for a consult as long as no protected, identifiable health information is released. If the victim is under the age of 18 and involved in a commercial sex act, follow mandatory state reporting laws for child abuse and institutional child abuse policies. 

HIPAA will permit the release of protected health information under certain circumstances such as suspected injury or abuse. For example, if the law mandates a disclosure as in the case of child abuse or neglect, elder abuse or neglect, and in cases reportable to the medical examiner. Reporting is permissible under HIPAA regulations if the disclosure involves a crime in an emergency, any disclosures necessary to prevent harm if the patient consents to the disclosure, and any situation where local, state, or federal law requires reporting. However, follow institutional guidelines and policies in place for HIPAA reporting requirements.

Trafficking Health Implications

Labor and sex trafficking carry inherent health risks and need exploration. Research studies in South Africa and West Bengal, India regarding the effects of sex trafficking and HIV risk determined that women and girls who experienced forced sexual encounters through being trafficked were 50% more likely to acquire HIV. One reason suggested that immature cervical epitheliums or cervical ectopy might lead to breaks in the vaginal mucosal and subsequent inflammation which increases the chance for HIV to spread during repeated sexual assaults in younger victims, but more research is [38]required [38][21][38].  

Vulnerability and inexperience may lead to HIV and other sexually transmitted infections due to inadequate condom use and repeated exposure to older adult males throughout the trafficking lifespan. 

Sex Trafficking Health Implications

When treating these potential victims, screening for injury and sexually transmitted infections (STI) such as HIV/AIDS, herpes, syphilis, gonorrhea, chlamydia, trichomonas, hepatitis, and molluscum contagiosum needs consideration. If a recent forced sexual encounter, emergency contraception, and STI prophylaxis are considerations, following preset institutional guidelines. 

Sexual assault kits may need to be obtained. Follow sexual assault collection of evidence protocols in your local area and per institutional policy. Project Help, Rape Crisis, and women's shelters may be a resource. Pain from daily forced sexual encounters and trauma may be an issue. Problems with urinary tract issues may warrant a urinalysis or culture. A urine sample that is not a clean catch, often referred to as "dirty urine," may be obtained to test for a sexually transmitted infection such as chlamydia. A pregnancy test may be useful. Toxicology studies may be needed, and alcohol levels and withdrawal issues addressed. 

Complications surrounding forced tampon use or "packing of the vagina" by traffickers to facilitate sexual encounters (unnoticeable to customers) while victims are menstruating may be of concern. Foreign debris may be present in the vagina on pelvic examination, and cervical cultures are a possibility if any discharge is present. That "lost tampon" patient may be a victim of trafficking and require a more in-depth assessment, asking open-ended, neutral questions to spot red flags.

Labor Trafficking Health Implications

Labor trafficking victims may experience severe dehydration or malnutrition due to being forced to work long hours in construction, on farms, at factories, or in "sweatshops." Heat exhaustion or hypothermia may present in these trafficking victims.  

According to the 2016 Global Report on Trafficking in Persons, Southeast Asia is emerging as a destination for short, medium, and long-distance trafficking. Increasing in frequency, these individuals are made to endure long ocean voyages as they are smuggled into the United States and other countries on cargo ships. These overcrowded, unsanitary conditions have infectious disease ramifications.[39][40]

Communicable or infectious diseases such as silicosis, tuberculosis, HIV, and typhoid may be an issue. Scabies, lice, and bacterial and fungal skin infections may be a concern. Malaria, Chagas disease, cysticercosis, toxoplasmosis, toxocariasis, and trichomoniasis also may be risks. Asbestos concerns exist for miners who are victims of labor trafficking[41]

Migrant workers who are being trafficked in the fishing and seafood industry may suffer from exposure to Vibrio vulnificus and subsequent necrotizing fasciitis with septicemia if left untreated. Vibrio vulnificus, found in warm climates with shallow, coastal waters, can infect a person through lacerations or breaks in their skin 

Labor trafficking victims may suffer from injuries related to poor ergonomics, such as back and neck injuries, vision problems, carpal tunnel syndrome, and headaches. 

Intimate Partner Violence

Domestic violence or intimate partner violence (IPV) takes many forms and involves the maltreatment of another within a romantic union or partnership. Men, women, teenagers, heterosexuals, gay, lesbian, bisexual, and transgender may be affected. Domestic violence may include emotional, physical, sexual, economic, spiritual, or psychological insults. IPV involves one partner in the relationship subjecting the other to some form of abuse to exert power and control over them. 

Domestic violence, much like human trafficking, is a significant public health issue that plagues millions of people. Individuals subjected to IPV, especially as teenagers, are vulnerable to practicing risky behaviors such as drug use and sexual promiscuity. These vulnerabilities place them in high-risk situations to be victims of human trafficking. Traffickers feed off this opportunity to exert power and control over a victim. Power and control manifestation takes many forms of abuse on the part of the trafficker.

The Human Trafficking Power and Control Wheel

The Human Trafficking Power and Control Wheel finds its basis in the power and control wheel for domestic violence. The wheel for human trafficking depicts the different types of abuse inflicted on trafficking victims at the hands of traffickers. Power and control, the wheel center, represent the primary weapon a trafficker uses to the manipulate a victim and keep them bound to the trafficker.[42][43][44]

Other tools in the arsenal to demoralize and dehumanize a victim involve coercion and threats. 

1. Intimidation: Intimidation is another tactic used by the trafficker and involves physical violence inflicted upon children, pets, or other victims. It may include threats with a weapon or actual weapon use, destruction of property, and misleading information regarding police.
2. Emotional Abuse: Emotional and psychological abuse can be particularly devastating to a victim. The trafficker humiliates the victim in front of others, calls them names, blames the victim for the situation, and convinces them that they would be all alone if the trafficker did not love and take care of them. The exploiter tells the person under their control repeatedly how worthless they are and that they are too weak to survive outside the existence the trafficker has created for them. The may threaten to expose or shame the victim by releasing sex tapes, nude photos, drug addiction, or participation in violence or sex acts against other victims. 
3. Isolation: A trafficker may keep a victim isolated by confinement, frequently move so the victim cannot become familiar with their surroundings or keep them cut-off from others by a language barrier. A victim may be isolated from family and friends or be accompanied by the trafficker while in a public place. The trafficker may not allow the victim access to routine, preventative medical care. Thus, medical problems may be exacerbated and overall health compromised.
4. Minimizing, Denying, and Blaming: A trafficker often blames the victim and denies there is anything wrong with the situation, minimizes their involvement in the abuse or exploitation, and lets the victim think the victim is the reason for their current circumstance: the victim is the one that ran away, reached out to them on social media, went to that party or hotel room.
5. Sexual Abuse: Sexual assault may be useful to the trafficker as a means of power and control. The victim is treated as a sex object, only as good as the money he or she brings in. They may be forced to submit to sex with multiple partners daily or risk the wrath of the trafficker. Forced abortions, threats to end a pregnancy or violence during pregnancy are control tactics. Unwanted pregnancies, either through forced sexual assault or consensual sex, are a way to control a victim.
6. Using Citizenship or Residency Privilege: The trafficker may use privilege or superiority as a means of control. The trafficker may hide or threaten to destroy immigration papers such as work visas, passports, or other forms of identification. A victim might be used as a servant or as a pawn to entice others into trafficking. The trafficker or pimp may threaten the family, threaten to report to immigration.
7. Economic abuse: Debt bondage is employed as a tool to manipulate and control. The victim may get charged enormous interest rates that they can never repay. They are restricted from leaving their situation because they have no access to money, are allowed only a small allowance, or have any earnings confiscated.
8. Coercion and Threats: Threats of or actual physical abuse is another manipulation tool used to exert power and control over the victim. It may involve shoving, punching, hitting, kicking, and strangulation injuries. Torture can take the form of cigarette burns or branding or withholding basic needs such as food, water, and clothing. Threats to harm a child bind the victim to the trafficker for fear of no food or shelter or the actual threat of physical harm to the child. They may threaten to contact the Department of Children and Families or law enforcement. Traffickers may use drugs as a form of control over the victim. Either, the introduction of drugs to the victim, or the threat to withhold drugs from a victim that is already struggling with addiction issues. These addiction issues may have led the person trafficked to the initial point of contact with the trafficker or be a result of trying to cope with the trafficking situation.

Victim-Centered Approach

A victim-centered approach is paramount in the delivery of care to a victim of human trafficking. Defined as the precise focus of attention, catering to the needs of the victim to ensure delivery of care in a compassionate, culturally sensitive, linguistically appropriate, non-judgmental, and caring manner. A victim's wishes, safety, and well-being are considerations. 

The heart of a victim-centered approach ensures a victim does not suffer re-victimization or re-traumatization. Trauma, as it relates to an individual from an initial insult, is a series of events or stressors that the individual experiences as either emotionally or physically life-threatening and has lasting ramifications on social, physical, mental, and spiritual well-being.

Trauma-Informed Approach

Human trafficking care must involve a trauma-informed approach where the healthcare provider recognizes the scope of the impact of the trauma on an individual victim’s lifespan and lessens any chance of inflicting more injury on this victim. Provider understanding of the signs of trauma, verbal and nonverbal cues, and their response by following predetermined protocols for identification, treatment, and appropriate referrals are essential elements of trauma-informed care.

Trauma-informed care involves the entire healthcare team and the incorporation of shared decision-making practices using an interdisciplinary, collaborative approach. Safety, transparency, and collaboration with peers and agencies are vital. It is essential that the approach accounts for culture and gender equality, LGBTQ considerations and support, and most importantly, an empowering environment.[45]

Empowerment

Empowerment allows the victim to seek out resources and take the first steps towards self-identifying. Empowerment of staff is important for them to recognize the red flags of human trafficking and feel comfortable in their training and knowledge to offer appropriate resources and follow up care to trafficking victims. 

The goal is for providers to enable others to champion change and advocate for protocol development, ensuring the incorporation of the Power and Control Wheel for Human Trafficking into the identification of the victim and subsequent polytrauma complex care that will be needed to empower the survivor to become a productive, functioning member of the community. 

Human Trafficking Protocols

Providers must know the local resources available ahead of time and establish a human trafficking protocol much like the one for intimate partner violence or alleged sexual assaults.

Local resources such as Project Help, rape crisis centers, women's shelters, homeless shelters, addiction centers, and churches can provide needed materials and support services for these victims and clarify any rules, such as pet policies.

Know the resources available for potential victims of human trafficking through local law enforcement or task forces?

Human trafficking protocols need to include specific vital elements such as indicators, red flags, ways to separate the potential victim from the trafficker, interview procedures, ways to maintain and ensure safety for the victim, staff, and potentially other victims and referral information.

Mandatory reporting requirements that address local, state and federal laws need to be incorporated in a protocol. Referral information must be accurate and easily understood by the victim and translated appropriately based on language needs. 

Provide NHTRC Hotline information. Incorporate follow-up data into a protocol. Another part of a protocol might include a critique of staff performance and ways to improve. Mandatory staff education will play a vital role in protocol implementation. 

Recognize that everyone plays a role in stopping human trafficking and identifying those at risk: social workers, case managers, customer service representatives, nurses, physicians, physician assistants, nurse practitioners, nursing assistants, medical assistants, nursing students, medical students, educators, dental assistants, law enforcement, security guards, support staff, and the community.

Referral Considerations

Long-term psychological impacts must be taken into consideration when referrals for treatment of these complex trauma patients get enacted into the treatment plan. Multifarious conditions exist emotionally and physically, rendering approaches to future care a challenge for healthcare providers [46]. 

According to the findings of a study of male and female survivors of trafficking in England conducted between 2013 to 2014, healthcare, including physical, mental, and sexual healthcare, must be a fundamental component of post-trafficking care. Follow-up care coordinated with multiple disciplines is essential. Basic needs of clothing, food, safe shelter, and transportation must be discussed. Ensure language barriers are addressed and provide resources on free classes to learn the local language. Discuss medical issues and refer to appropriate subspecialists.

Transitioning from Victim to Survivor - Potential Referrals

• Dietician consults in cases of severe malnutrition.
• Infectious disease consults for communicable diseases and sexually transmitted infections.
• Referral to obstetrics/gynecology for infertility concerns related to forced abortions, repeated trauma, or frequent miscarriages or medical problems such as prenatal concerns, addiction issues, torch infections, originating from lack of preventative care or poor access to care may need investigation. Hormone replacement therapy concerns must be met for lesbian, gay, bisexual, transgender and questioning (LGBTQ) victims.
• Surgical or dermatology referrals for removal of unwanted tattoos or brands or to treat burns and other injuries.
• Consultations with gastroenterologists for stress-related issues.
• Children often suffer developmental delays and need assistance with transitioning into a healthy life. 
• Social stigma implications of forced homosexuality can play a role in future psychological care. Crisis intervention teams and case managers will have a role in successful integration practices.[47][48][49]
• Perpetrators often use substance abuse to control victims, or victims use it as a form of escape from the abusive environment. Addiction and sobriety considerations will need implementing into daily routines. Community-based organizations, support groups, and faith-based programs may ease this transition period and lessen the impact of psychological stressors.
• Legal services referrals made for child custody issues, immigration assistance, protective/restraining orders, assistance with any offenses, and with the successful prosecution of the trafficking entity. 

Survivor's Role

Cultural shock impacts and language barriers play a role in the recovery period and successful transition into society as a survivor and not a victim. Survivors of human trafficking can offer much-needed insight into the thoughts, feelings, and interactions with members of the healthcare team and guide care and training programs going forward with this vulnerable patient population .

In 2015, a study conducted in New York City’s Rikers Island jail suggested that survivor-based input was essential in addressing healthcare concerns and improving care in this patient dynamic. Themes originated from these victims regarding healthcare providers such as victims feeling intimidated, judged, and stereotyped. They suggested providers and front-line personnel pay attention to their body language and nonverbal cues they are displaying as they walk into the treatment room, up to the front desk, or after disclosure. This interaction, if negative, can impact a victim feeling safe enough to open up and not be judged. These victims emphasized an approach that was not one of interrogation but asking straightforward, normalized, direct questions in a compassionate, nonjudgmental way that reinforced a feeling of safety and confidentiality. [2][43][18]

Further research is needed in this area for conclusive results as this crime comes "out of the shadows," and researchers look beneath the surface, but survivors should play a role in the education of healthcare providers 

The Language of Trafficking

Languages are essential to the understanding of different cultures, environments, enterprises, and socioeconomic groups. Human trafficking and smuggling have a dialect, unique to traffickers and victims. Exploration of "trafficking vocabulary" will help practitioners relate to and understand patients who have been trafficked. 

It is imperative in a victim-centered approach, much like a patient-centered approach, to communicate effectively with a potential victim or patient. The following are legal definitions and terms or "lingo" used by traffickers and victims or as they relate to human trafficking. This list continues to grow as we achieve a better understanding of human trafficking victims. Other terms may become recognizable as jargon unique to a trafficking situation. 

Trafficking "Lingo"

• Daddy: The word a victim is required to call their pimp/trafficker.
• Gorilla Pimp: A trafficker or pimp that resorts to violence to control a victim 
• Romeo/Finesse Pimp: The trafficker that uses a false romance; a false promise of money, clothing or other gifts; or false hope of marriage to lure victims. Often referred to as "boyfriend."
• Branding: A carving, tattoo, or mark on a victim that implies ownership by a pimp/gang/trafficker. The tattoo may say, "Daddy," "Property of...," or "For sale." 
• Quota: The amount of money expected from their trafficker/pimp each night. If quotas go unmet, the victim may be beaten, tortured, or made to work exorbitant hours until the expected amount has been delivered.
• Circuit: A series of places where prostitutes/victims get moved. Keeping them in unfamiliar surroundings increases their vulnerability and facilitates the trafficker's control over the individual.
• Date: The time and location where the sex act is to take place. The buyer or "john" meet them at this pre-determined site.
• The Life: Sex-trafficking victims refer to their situation as being in "the life."
• Bottom: A victim who is chosen by the pimp or trafficker to "handle" the other victims. They may train the new victim, post ads/control social media posts, inflict punishment if rules get broken, and book the "date." This individual victim may feel tremendous shame and guilt because of her actions and treatment of other victims. The pimp may further control the "bottom" by threatening violence, increased quotas, or reporting her to the authorities. The "bottom" may be required to entice others into servitude by posing as a student, a concerned friend, a mother-figure.  

Trafficking Victims Protection Act Definitions

• Coercion: Threats of serious harm to or physical restraint against any person; any scheme, plan, or pattern intended to cause a person to believe that failure to perform an act would result in serious harm to or physical restraint against any person; or the abuse or threatened abuse of the legal process [22 U.S.C. 7102 (3)(a)(b)(c)].
• Commercial Sex Act: Any sex act on account of which anything of value is given to or received by any person [22 U.S.C. 7102 (4)] 
• Debt Bondage: The status or condition of a debtor arising from a pledge by the debtor of his or her personal services or of those of a person under his or her control as a security for debt, if the value of those services as reasonably assessed is not applied toward the liquidation of the debt or the length and nature of those services are not respectively limited and defined [22 U.S.C. 7102 (5)].
• Involuntary Servitude: Any scheme, plan, or pattern intended to cause a person to believe that, if the person did not enter into or continue in such condition, that person or another person would suffer serious harm or physical restraint [22 U.S.C. 7102 6 (a)].
• Labor trafficking: The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purposes of subjection to involuntary servitude, peonage, debt bondage, or slavery (22 USC § 7102).
• Sex trafficking:  The recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purposes of a commercial sex act, in which the commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age (22 USC § 7102).

Human trafficking care must involve a trauma-informed approach where the healthcare provider recognizes the scope of the impact of the trauma on an individual victim’s lifespan and lessens any chance of inflicting more injury on this victim. Provider understanding of the signs of trauma, verbal and nonverbal cues, and their response by following predetermined protocols for identification, treatment, and appropriate referrals are essential elements of trauma-informed care.

Trauma-informed care involves the entire healthcare team and the incorporation of shared decision-making practices using an interprofessional, collaborative approach. Safety, transparency, and collaboration with peers and agencies are vital. [45]