Human trafficking is a form of modern-day slavery and is a significant pediatric healthcare problem in the United States. The term "human trafficking" encompasses both sex and labor trafficking. Sex trafficking, especially child sex trafficking, has received significant lay and professional attention. However, few efforts have focused on learning more about youth experiencing labor trafficking in the United States. Although the exact number of child labor trafficking victims in the United States is difficult to quantify, over 5 million children worldwide are victims of child labor trafficking (International Labor Organization, 2012). Pediatric healthcare providers, including forensic nurses, are likely to encounter victims of child labor trafficking in their practice (Greenbaum, 2018). A basic understanding of child labor trafficking will assist forensic nurses in timely identification of and appropriate intervention for victims. In this article, child labor trafficking is discussed in terms of definition, epidemiology, history, risk factors, consequences, identification of, and implications for practice.

Definitions

The Trafficking Victims Protection Act of 2000 was the first federal legislation to address human trafficking, both sex and labor trafficking, in a comprehensive manner. The Trafficking Victims Protection Act defines labor trafficking as the use of force, fraud, or coercion to recruit, harbor, transport, provide, or obtain a person for labor or services for the purposes of subjection to involuntary servitude, peonage, debt bondage, or slavery (U.S. Government, 2000). Child labor trafficking involves the trafficking of persons who are 18 years old or younger (Development Services Group, Inc., 2016). The definition of child labor trafficking requires the presence of force, fraud, and/or coercion (Administration on Children, Youth and Families, 2013). The use of force can include the use of physical restraint or harming a victim. Fraud involves intentionally deceiving victims regarding certain aspects of their employment such as job tasks, payment, and work conditions, and examples of coercion include threatening physical or mental harm to victims or their loved ones or threats of abuse of the legal system such as deportation (Office on Trafficking in Persons, 2015). It is important to note that the use of force, fraud, or coercion is not required to meet the definition of child sex trafficking. This difference in requirements for identification as a victim of child labor trafficking versus child sex trafficking may be because of the fact that children can legally work in the United States under certain stipulations yet they cannot consent to involvement in commercial sex acts (Owens et al., 2014). It is important that forensic nurses understand that a child can be a victim of labor trafficking and sex trafficking simultaneously, such as being forced to work in a nail salon to pay off a debt with job duties also including engaging in sexual contact with the customers (National Human Trafficking Resource Center, n.d.).

A basic understanding of terms is necessary to further understand child labor trafficking. In lay terms, involuntary servitude refers to an individual forced through some sort of coercion to work for another person. The coercion could involve threats of physical or legal harm to the individual or another person. Peonage or debt bondage is the pledge of a person's labor or services to pay off a debt. A person could also pledge the labor of a person under their control, such as a child, for payment of said debt (National Human Trafficking Hotline, n.d.). Assessment of the monetary value of the labor is not reasonable or applied toward payment of the debt.

It is important to understand the differences between legal child employment, child labor, child labor exploitation, and child labor trafficking. State law defines legal age, hours, and specifics for child employment in that state. Child labor exploitation occurs when a child is working legally yet denied basic legal rights such as fair pay (Owens et al., 2014). Child labor involves a child under the legal working age engaging in illegal work and/or work that causes potential harm to their health, development, or education (Owens et al., 2014). Child labor trafficking involves many aspects of child labor and child labor exploitation but is only child labor trafficking if force, fraud, or coercion is involved (Development Services Group, Inc., 2016).

Child Labor Trafficking Settings

Child labor trafficking occurs in a variety of settings in the United States, especially in informal employment settings (Greenbaum et al., 2017). Small businesses, organized crime, gangs, and even families may exploit victims (U.S. Department of Health & Human Services, 2012). Common employment sectors in which youth are trafficked include domestic service, agriculture, construction, cleaning services, door-to-door magazine sales, drug trafficking, beauty services, begging, and hotels and restaurants (Polaris Project, 2015; U.S. Department of Health & Human Services, 2012).

Although many child labor trafficking victims in the United States are foreign nationals, American-born youth primarily experience exploitation in two industries: door-to-door sales and drug trafficking (Murphy, 2016; Polaris Project, 2015). In a study of American-born homeless youth (aged 12-24 years) in 10 U.S. cities, two forms of labor trafficking emerged as common: forced drug dealing and unpaid and/or fraudulent commission-based sales jobs (Murphy, 2016). Forced drug trafficking was more common than fraudulent sales jobs with 81% of labor-trafficked youth reporting forced drug sales. Youth reported feeling psychologically coerced into drug dealing and physically threatened to continue dealing when they expressed interest in quitting (Murphy, 2016). Familial and cultural coercion occurred with 38% of labor-trafficked youth reporting being forced by their parents or other family members to work in the drug trade (Murphy, 2016). Nearly half of labor-trafficked youth stated that they were coerced into drug dealing because of gang involvement. The following factors related to gang involvement describe force and coercion equivalent to labor trafficking: Gang initiation typically occurred at a very young age, initiation tended to be violent, and threat of violence was involved with exiting the gang. Traffickers running sales crews often target economically disadvantaged youth promising a fun job, travel, and high pay. In reality, unreasonable sales quotas exist and youth experience negative consequences for not meeting them such as confiscation of pay, verbal or physical abuse, and denial of food and shelter. Often, youth work very long hours from early morning until the evening and are in a new city or neighborhood separated from their families and familiar surroundings feeling helpless and dependent on their traffickers.

Other industries target primarily foreign-born children for involvement in labor trafficking. Children work in agriculture to harvest crops and care for livestock as members of the migrant and seasonal workforce. They work very long hours for little or no pay, most often alongside their parents with whom they travel to find work. As work is seasonal, families often live transient lives. Living and work conditions are often unsuitable and unsanitary. Child labor trafficking victims working in agriculture are typically undocumented immigrants or foreign nationals with temporary H-2A work visas (National Human Trafficking Resource Center, n.d.). Children also work as domestic workers providing services such as cooking, cleaning, childcare, elder care, gardening, and other household work. The children may work for one or more families and may live in the home with their employer. Long hours are worked with little to no pay and without opportunity to attend school or have any external interactions (National Human Trafficking Resource Center, n.d.). Again, children working in domestic service are most often undocumented immigrants or foreign nationals on a temporary visa. Children are also exploited in the health and beauty industry working at nail and hair salons for long hours with little or no pay. These children are most often undocumented immigrants and foreign nationals on temporary work visas.

Epidemiology

Accurate statistics on the number of child labor trafficking victims within the United States are not readily available. There are many reasons that contribute to making a single estimate of child labor trafficking victims difficult, if not impossible. Trafficking is a covert business; traffickers tend to guard their victims closely and/or isolate them to their workplace (Clawson et al., 2009). Fear of physical/emotional harm or even deportation may make trafficking victims reluctant to disclose to healthcare providers, law enforcement, or child protective services (CPS) (Farrell et al., 2008). Discrepancies in definitions of, and beliefs about child labor trafficking, also make the scope of the problem difficult to define; a migrant labor-trafficked child may be labeled as an illegal immigrant instead of a child labor trafficking victim (Gouty, 2015). In addition, evidence suggests that deficits in the ability of CPS and law enforcement (Farrell et al., 2012) as well as healthcare providers (Greenbaum et al., 2017) to identify child labor trafficking victims exist.

However, data exist that may provide some insight into the scope of the problem of child labor trafficking. It is estimated that 5.5 million children experience labor trafficking worldwide (International Labor Organization, 2012). Koegler et al. (2019) described demographic characteristics of potential human trafficking victims from tips reported to a social service agency in a Midwestern city from 2008 through 2017 (213 tips and 82 potential victims). Seven percent of labor trafficking victims were less than 18 years old, and 23% of sex trafficking victims were less than 18 years old. Nearly all (95%) labor trafficking victims were foreign born, whereas over half (59%) of sex trafficking victims were from the United States. Banks and Kyckelhahn (2011), in a Bureau of Justice statistics report using state and local law enforcement data, found that 13.9% of trafficking investigations in the United States between 2008 and 2011 involved labor trafficking. Two hundred fifty-seven cases of child trafficking were found; five involved labor trafficking, and 248 involved sex trafficking. The National Human Trafficking Resource Center (2015) concluded that 15.8% of labor trafficking cases reported to the National Human Trafficking Hotline involved children. Murphy et al. (2015) explored sex and labor trafficking among homeless youth in New Orleans. Ninety-nine clients of a shelter for homeless youth were interviewed regarding their trafficking experiences. Sex trafficking (11%) was more common than labor trafficking (5%). Four (two male and two female) of the five youth who reported labor trafficking victimization had been forced to sell drugs. All reported entry into drug trading by their teen years, with 9 years being the youngest reported age of entry. One youth reported labor trafficking occurring in a factory in Mexico. In summary, numbers suggest that child sex trafficking is more prevalent than child labor trafficking (Development Services Group, Inc., 2016). However, the extent of child labor trafficking may be masked by current deficits in identification.

History and Prosecutions

The United States has a long history of exploiting children for labor; child labor trafficking is not only a modern-day American problem. Indentured servants first arrived in America the decade after the founding of Jamestown in 1607 (Walts, 2017). Indentured servitude was a system of bonded labor where a worker was under contract to an employer for a fixed period in exchange for their transportation, food, clothing, shelter, and other necessities (Walts, 2017). From the early 17th century to the early 20th century, large numbers of people, including many children and youth from Europe, came to America via a system of indentured servitude in exchange for the cost of their transportation. The mortality rate for these indentured servants was very high, and servitude periods were often extended for various arbitrary reasons (Mintz, 2006).

By the mid-1600s, Black Africans, adults and children, were brought to America to work in the fields and inside homes, first as indentured servants, which evolved into slavery (Walts, 2017). Children and their families were the property of their owners. Treatment was at the whim of their owners; children could be sold resulting in separation from parents and were beaten, starved, and generally not allowed to be educated. This practice continued until the late 1800s. The early 18th century brought along another example of the exploitation of children for labor-the practice of padrones in the United States. Padrones were men who lured young boys, most often from Italy but also Greece, China, Japan, and Mexico, with promises of a good life in America and put them to work for their personal profit (Walts, 2017). These children were not offered any education or life skills training to live independently. They were stranded in a foreign country without family and forced to work for their padrone or risk physical harm.

The early 20th century brought about legislation to address child labor in the United States. The Fair Labor Standards Act of 1938 is the federal law defining minimum wage, recordkeeping, overtime pay, and child labor in the United States (National Human Trafficking Resource Center, 2016). The Fair Labor Standards Act states that a child must be at least 14 years old to work in nearly all industries, except agriculture. The law also provides protections for the number of hours per week a child can work. Children younger than 14 years can work in agriculture as long as there is compliance to statutory criteria. There is no limit to the number of hours a child can work in agriculture other than the work must be performed outside school hours.

The 2000s have brought about increased prosecution of child labor trafficking perpetrators. The following cases were successfully prosecuted and illustrate that children continue to be exploited for labor in the United States. The United States v. Garcia Botello et al. involved over 40 Mexican farmworkers, including children, who were recruited to work on farms in New York State and were forced into debt bondage with deplorable working and living conditions (U.S. Department of Justice, 2002). The United States v. Abdelnasser Eid Youssef Ibrahim (2006) involved a man and his wife who purchased a 10-year-old girl from Egypt to work in their California home cleaning, cooking, and caring for children without pay; verbally and physically abusing her; and denying access to school and religious services (U.S. Department of Justice, 2006). The United States v. Akouavi Kpade Afolabi et al. (2009) is a case in which 20 young girls ranging in age from 10 to 19 years were smuggled from Togo and forced to work at hair braiding and nail salons in New Jersey up to 14 hours a day, 7 days a week without pay (U.S. Immigration & Customs Enforcement, 2010).

Risk Factors

Child labor trafficking victims come from diverse ethnic and demographic backgrounds, and a standard profile of a labor trafficking victim is nonexistent. However, certain populations have an increased vulnerability to victimization (see Box 1). Although most children/youth trafficked for sex within the United States are American born (Greenbaum, 2018), depending on the industry and circumstances, both U.S.-born and foreign-born youth are vulnerable to child labor trafficking victimization (Koegler et al., 2019). Both boys and girls are at risk for labor trafficking (Hopper & Gonzalez, 2018; Koegler et al., 2019), but boys may be more likely to experience labor trafficking than sex trafficking. Children from impoverished backgrounds are also at an increased risk for child labor trafficking.

Box 1. Child Labor Trafficking Risk Factors.

United States born

Foreign born

Unaccompanied foreign-born minors

Undocumented foreign-born youth

Children of foreign-born parents living in the United States

Poverty

LGBTQ children and youth

Runaway/thrown away/homeless youth

Child welfare involvement

Trauma exposure

(Sources: Developmental Services Group, 2016; Hopper & Gonzalez, 2018)

Childhood trauma exposure increases vulnerability to entry into child labor trafficking for U.S.- and foreign-born youth (Hopper & Gonzalez, 2018). The National Child Traumatic Stress Network (2018) defines a traumatic event as a dangerous or distressing experience outside the range of usual human experience, which overwhelms an individual's ability to cope and frequently results in intense emotional and physical reactions, as well as feelings of helplessness and terror, and threatens serious injury. Unfortunately, many children live lives filled with trauma. It is estimated that up to 90% of children experience some form of traumatic experience in their lives (Heinzelmann & Gill, 2013). According to Jennings (2004), child maltreatment is the most common form of complex trauma; however, prolonged traumatic exposure can also occur in the context of long-term family or community violence or dysfunction (Fratto, 2016; refer to Box 2). Factors that decrease a parent's ability to adequately parent, such as household domestic violence, parental drug, alcohol, or mental health concerns, are sources of trauma exposure for children and increase their vulnerability to child trafficking. Experiencing child maltreatment may increase the risk for experiencing sex trafficking greater than labor trafficking (Hopper & Gonzalez, 2018). Hopper and Gonzales (2018), in a sample of trafficking survivors, found 65% of sex trafficking victims endorsed experiencing some form of child maltreatment, versus only 18% of labor trafficking victims. Childhood trauma can predispose a youth to homelessness, running away from home or being thrown out of the home. Lesbian, gay, bisexual, transgender, and queer youth are also at risk to experience strife and stress at home secondary to parental nonacceptance of their sexuality. Parental nonacceptance makes lesbian, gay, bisexual, transgender, and queer youth vulnerable to being "throw away youth," evicted from their home by their parents (Development Services Group, Inc., 2016). Homeless, thrown away, and runaway youth are vulnerable to labor trafficking, in both legal and illegal industries, because of the need for money for basic needs (Clawson et al., 2009).

Box 2. Psychosocial Trauma Exposures/Familial Psychosocial Assessment.

Child maltreatment

Sexual abuse

Physical abuse

Emotional abuse

Neglect

Exposure to domestic violence

Caregiver drug and/or alcohol concerns

Caregiver mental health concerns

Depression

Anxiety

Bipolar disorder

Schizophrenia

Low functioning/cognitive delays

Previous familial involvement with child protective services

Foster care

Out-of-home placement

Previous familial involvement with law enforcement

Financial concerns

Exposure to community violence

(Source: Hornor et al., 2019)

Youth who are not U.S. citizens can be especially vulnerable to labor trafficking (Mostajabian et al., 2019). Foreign children traveling to the United States alone or with their families are at an increased risk, as well as undocumented migrant youth and other children of foreigners (Walts, 2017). These youth often come to America to escape poverty and/or violence in their countries of origin. Their desire to support themselves and their families makes them vulnerable to labor trafficking (Office of Trafficking in Persons, 2015). Youth may be forced into exorbitant debt bondage by smugglers to repay them for transporting them into the United States (Uehling, 2008). The threat of deportation can be used to manipulate youth. Foreign-born youth, especially unaccompanied minors, are particularly vulnerable to a multitude of trauma exposures including labor trafficking (Hopper & Gonzalez, 2018). These youth are far from home, often do not speak the language, and have no understanding of their basic human rights, making them extremely vulnerable to labor trafficking.

Consequences

Child labor trafficking victims experience significant physical and psychological trauma. Their trauma experiences are complex. Child labor trafficking victims are dependent on their traffickers for food, shelter, and basic existence. Despite inhumane treatment at the hands of their traffickers, cognitive distortions form where victims develop positive/thankful feelings for their traffickers. Victims are simultaneously fearful of and grateful to their traffickers for their survival (Sanchez et al., 2019). Trauma bonding is defined as the invisible strong emotional tie that develops between two individuals, despite one person frequently beating, threatening, abusing, harassing, or intimidating the other (Hopper & Gonzalez, 2018). Victims are also emotionally dependent on their traffickers. Control may be maintained via physical violence or psychological manipulation, such as threats of deportation. These feelings of dependence on the trafficker lead to the belief that leaving the trafficker will cause more harm than good. Conflicting feelings toward the trafficker exist, savior versus slave driver, making it a difficult struggle for youth to find the courage to leave. It is not unusual for youth to leave and return multiple times before finally making a clean, complete break. Despite this, youth most often leave trafficking situations through their own means (Murphy, 2016).

Child labor trafficking can result in a variety of negative physical and psychosocial health consequences for victims (see Box 3). Child victims of labor trafficking are often significantly malnourished, resulting in stunted growth, poorly formed or decayed teeth, and reproductive problems as they mature (U.S. Department of Health & Human Services, 2012). Labor trafficking victims may experience physical abuse at the hands of their traffickers, resulting in a variety of physical injuries including bruises, abrasions, fractures, burns, abdominal trauma, head trauma, and even death (Greenbaum et al., 2017). Victims of labor trafficking often work in unsafe work environments. Unsafe work environments place children at a high risk for preventable work-related injuries, including any of the physical injuries described above, and also chemical burns, vision problems, or respiratory problems from contact with topical or inhaled irritants; hearing loss from exposure to loud noises; and chronic back or other musculoskeletal pains (National Human Trafficking Resource Center, n.d.). Access to timely health and dental care is lacking, resulting in an exacerbation of illness severity, for both chronic and acute conditions. Symptoms of illness have often significantly progressed upon presentation for care (Greenbaum et al., 2017). Sexual abuse/assault as well as sex trafficking may be experienced by child labor trafficking victims, resulting in sexually transmitted infections, unplanned pregnancies, and anogenital injuries (Hopper & Gonzalez, 2018).

Box 3. Consequences of Child Labor Trafficking.

Physical abuse/assault/physical injuries

Bruises/abrasions/other cutaneous injuries

Fractures

Blunt force trauma

Abdominal trauma

Head trauma

Broken teeth

Burns

Work-related injuries

Chemical burns/poisonings (cutaneous exposure to toxic substances)

Limb amputations (unsafe work environment)

Respiratory symptoms (exposure to toxic gases/substances)

Hearing loss (chronic unprotected exposure to loud noises)

Visual problems (exposure to toxic gases/substances)

Sexual abuse/assault/sex trafficking

Sexually transmitted infections

Unplanned pregnancy

Anogenital injury

Chronic malnutrition

Stunted growth

Dental complications

Reproductive problems

Limited access to timely medical/dental care

Dental injuries/dental decay

Mental health

Posttraumatic stress disorder

Depression

Anxiety

Suicidal ideation/attempts

Nonsuicidal self-injury

Traumatic bonding

Sources: Greenbaum et al., 2017; National Human Trafficking Resource Center, n.d.

Child labor trafficking can also result in a variety of mental health consequences for victims including depression, suicidal ideation, nonsuicidal self-injury, posttraumatic stress disorder, anxiety, and traumatic bonding (Hopper & Gonzalez, 2018). Victims may report symptoms of depression such as sleep disturbance, sadness, guilt/worthlessness, fatigue, and concentration problems (Hopper & Gonzalez, 2018). Feelings of helplessness, shame and humiliation, shock, denial, and disbelief may develop (National Human Trafficking Resource Center, n.d.). Anxiety symptoms are not uncommon, and panic attacks may also be experienced.

Identification

Forensic nurses are in a unique position to identify potential victims of child labor trafficking. Forensic nurses often provide care to child victims of sexual abuse or sexual assault and other vulnerable children. The possibility of child labor trafficking must not be ignored. Unfortunately, no validated tools exist for the identification of child labor trafficking victims in the healthcare setting (Bespalova et al., 2016). As previously discussed, child labor trafficking can result in a multitude of physical and mental health consequences for victims. Victims may present for care in a variety of healthcare settings, both inpatient and outpatient. It is important that all pediatric healthcare providers, including forensic nurses, be aware of labor trafficking red flags (refer to Box 4).

Box 4. Child Labor Trafficking Red Flags.

Delay in seeking medical care/symptoms progressed at presentation

Unwilling or hesitant to answer questions about the injury or illness

Recent immigration history (especially if they lack access to documentation)

Unfamiliar with location (city or town)

Inconsistent history of injury or illness

Work-related injuries

Not in possession of their identification documents

Appears intimidated by person accompanying them

Accompanying person appears overly dominant (does not let patient answer questions, refuses to provide privacy for patient, insists upon interpreting for patient, and resistant to use of an interpreter)

Lives in housing provider by employer

Lives with employer

Lacks basic work-related protective gear

(Sources: National Human Trafficking Resource Center, n.d.; Zimmerman & Borland, 2009).

Forensic nurses must understand that child labor trafficking victims do not often disclose trafficking in the clinical setting. It is crucial for forensic nurses to be thoughtful about how they engage with patients for whom possible child labor trafficking is suspected, using trauma-informed care practices. Trauma-informed care is a method of caring for trauma-exposed individuals that acknowledges the presence of trauma symptoms and its effects on the lives of victims (Substance Abuse and Mental Health Services Administration, 2015). Trauma-informed care emphasizes the need for all pediatric healthcare providers to recognize the effects of violence and trauma on an individual's health, behavior, and development (Elliott et al., 2005). Safety is paramount to trauma-informed care-safety for the patient, the patient's family, and the healthcare providers. Creating a safe space to discuss labor trafficking concerns is paramount. As the patient may be accompanied by the trafficker or an associate of the trafficker and threatened with harm to themselves or their families were they to disclose information regarding trafficking, this can be particularly challenging. It is critical to find a time and place to speak with the patient privately. If a language barrier is noted, the utilization of a professional interpreter is indicated (National Human Trafficking Resource Center, n.d.). It is also critical to assess potential safety risks of asking sensitive questions to the patient (National Human Trafficking Resource Center, n.d.). The goal of the healthcare interaction with the patient is not disclosure or rescue but rather to provide health care while creating a nonjudgmental space that is conducive to identification of trafficking indicators to assist the patient.

The principles of trauma-informed care also endorse the importance of empowerment, choice, and transparency (Substance Abuse and Mental Health Services Administration, 2015). It is important to provide the patient with choices whenever possible, for example, asking if they would feel more comfortable talking to a male or a female provider. Rapport building is essential; thus, it is essential to take time to establish a connection with the patient to facilitate patient comfort with being open to discussing difficult, sensitive subject matter. The importance of transparency is also warranted, particularly in relation to confidentiality practices and limitations. Patients need to be informed that, if they share information that raises a concern for their safety, that you are legally obligated to report to CPS to ensure their ongoing safety. The use of multidisciplinary resources, such as social work, can facilitate the care of the patient. Existing institutional protocols for physical or sexual abuse can also assist to guide care. If the healthcare institution does not have a protocol for the response to child labor trafficking victims and/or the forensic nurse is not familiar with local child trafficking resources, the National Human Trafficking Resource Center (United States) hotline is available 24 hours a day, 7 days a week to provide assistance (1-888-373-7888).

Implications for Practice

Forensic nurses are uniquely positioned to both identify potential victims of child labor trafficking and intervene appropriately. Understanding possible physical and mental health consequences and "red flags" is a crucial first step in identifying potential victims. Knowledge of basic screening questions (see Box 5) to ask patients when concerns for possible child labor trafficking arise can assist the forensic nurse to decide when it is appropriate to involve other members of the healthcare team, such as social work. Principles of trauma-informed care should be used with all pediatric patients, but especially those for whom child labor trafficking is a concern.

Box 5. Screening Questions for Child Labor Trafficking.

Labor trafficking

1. Tell me about where you live/who you live with.

2. Tell me about where you work.

3. Is the job what you expected, or is it different than what you were told or expected?

4. Does anyone at work scare or hurt you or threaten to hurt you or your family?

5. Can you leave the place you work?

6. Do you go to school?

7. Has anyone ever threatened you or your family if you were to leave your place of employment?

8. Have you ever worked without getting paid when you thought you would?

9. How many hours do you work a week?

10. Do you owe your boss money?

Sex trafficking

1. Have you ever been asked or had to have sex in exchange for something you wanted or needed (shelter, food, clothes, transportation, money)?

2. Has anyone ever wanted you to have sex with someone else?

3. Has anyone forced you to do something you did not want to do?

4. Has anyone taken sexual pictures/videos of you and posted them on the Internet?

(Sources: Byrne et al., 2017; Hackey & Phillippi, 2017).

Regardless of answers to screening questions, a thorough physical examination is indicated (Leslie, 2018). Child labor trafficking victims may experience physical trauma as the result of physical abuse/assault or work-related injuries. Forensic nurses should be particularly concerned if physical injuries appear inconsistent with the history provided by the patient. A head-to-toe cutaneous examination with detailed written and photo documentation of injuries including descriptions of size, shape, color, location, and pattern of bruising; contusions; scars; lacerations; or other evidence of physical trauma should be conducted (Hachey & Phillippi, 2017). A thorough oral examination to note any dental/oral injuries or decay should also be performed. The forensic nurse must note that child labor trafficking victims may also experience sex trafficking or other forms of sexual abuse/assault. Dependent on patient history of sexual abuse/assault as well as patient assent and tolerance of examination, an anogenital examination following a sexual assault protocol is indicated. Testing for sexually transmitted infections and pregnancy may also be necessary. A thorough health and psychosocial history along with a physical examination should be conducted, along with a plan of care to address any identified acute or chronic physical and mental health concerns.

Care of potential child labor trafficking victims requires thorough assessment of their safety. If screening interview and/or physical examination reveals concerns of child labor trafficking, physical abuse/assault, or sexual abuse/assault or raise safety concerns for a minor, a report to CPS and law enforcement is crucial. CPS and law enforcement investigations result in protective measures for youth at risk for child labor trafficking as well as prosecution of traffickers (English, 2017). It is important for all forensic nurses to be familiar with local and state resources available for child labor trafficking victims and make appropriate linkages. The Human Trafficking Resource Center Hotline (1-888-3737-888) can provide immediate information regarding local resources available to victims in the United States. Communities may have specialized case management services and/or residential treatment facilities that provide trauma-informed mental health care, access to education, and basic life skills programming. Local child advocacy centers and Children's Hospital child abuse programs are also sources of information, services, and referral.

Forensic nurses must champion the development of comprehensive trauma-informed, multidisciplinary protocols to assist in the identification and management of child labor trafficking victims within their institutions (Hachey & Phillippi, 2017). Forensic nurses must also become active in local and state advocacy efforts to battle the problem of child trafficking. Exploring the efforts of local or statewide human trafficking taskforces, increasing their own personal knowledge regarding child labor trafficking, and becoming a voice to ensure identification and appropriate intervention to meet the healthcare needs of children who are victims of child labor trafficking are all important roles for forensic nurses to embrace. In addition, educating other healthcare providers regarding both child labor and child sex trafficking is an important role for forensic nurses. A multidisciplinary healthcare team working seamlessly with a multidisciplinary community team (CPS, law enforcement, local advocacy agencies, and legal/judicial services) is necessary to meet the complex needs of child labor trafficking victims. Forensic nurses possess the passion, knowledge, and skills to play a pivotal role in the elimination of child labor trafficking. Forensic nurses can truly make a difference in the lives of child labor trafficking victims.

References