Introduction

Violence and human trafficking are frequently paired. "I've been hit, punched, kicked, beaten, whipped with a belt, forced to have sex, threatened with a weapon, shot at, and had my head split open," said Nicole, a trafficking survivor (Lederer & Wetzel, 2014). Human trafficking insidiously violates human rights and is a complex, global health issue. Victims are extremely valuable to a trafficker, as each one has the potential to net six figures per year (United Nations Office on Drugs and Crime, 2020). Traffickers will not relinquish this revenue stream willingly and will employ threats, violence, and forced drug use to maintain control (Polaris, 2021). These tactics, along with the illegality of human trafficking, make identifying victims difficult.

The business of trafficking is thriving and generates an estimated $150 billion in annual revenue (U.S. Department of State, 2021). Human trafficking is the third largest organized crime, behind illegal drugs and arms, because of high demand and large profit margins (Lamb-Susca & Clements, 2018). In fact, the Global Report on Trafficking in Persons found that traffickers were able to purchase potential victims for as little as $36 and up to $23,600, with a monthly return on investment of $5,000-$10,000 (United Nations Office on Drugs and Crime, 2020). The difference between selling humans as opposed to drugs and guns is the ability for traffickers to repeatedly sell the product (Peters, 2013).

Trafficking survivors report seeking medical care for women's services, physical abuse, mental health, and gastrointestinal issues while being held in captivity (Chisolm-Straker et al., 2016; Lederer & Wetzel, 2014). However, the majority of healthcare providers are unaware or unprepared to intervene, thus missing the chance to identify victims during these encounters (Chisolm-Straker et al., 2016). Rehabilitation nurses are no exception. Trafficking victims may come in contact with rehabilitation nurses because of injuries or chronic disease caused by trafficking abuse.

What Is Human Trafficking?

Human trafficking is defined by the U.S. Department of Justice (2018) as the illegal act of exploiting individuals for financial gain. The term modern-day slavery is often used to describe human trafficking because traffickers profit from stealing victims' freedom. Exploitation happens by recruiting, sheltering, or moving people through the use of coercion, control, or manipulation (U.S. Department of Justice, 2018).

Human trafficking is an umbrella term that covers many types of exploitation, such as forced labor, sex trafficking, debt bondage, involuntary domestic servitude, or child soldiers (U.S. Department of State, 2011). However, the United States acknowledges the two categories that represent the overwhelming majority of victims-forced labor (or labor trafficking) and sex trafficking (U.S. Department of State, 2021). The Trafficking Victims Protection Act (TVPA) of 2000 categorized both sex and labor trafficking as severe forms of trafficking in persons if the criteria in the definition are met. The definition states:

Sex trafficking [i.e. the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act] in which a commercial sex act is induced by force, fraud or coercion; or in which the person induced to perform such act has not attained 18 years of age; or the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery. (TVPA, 2000, pp. 10-12)

In 2000, the TVPA made trafficking a federal crime. The TVPA provides a framework to combat human trafficking by focusing on prosecuting traffickers, creating preventative programs, and protecting victims (Wells, 2019). The act also offers specific definitions for trafficking offenses and assigns steep penalties, provides restitution for victims, and establishes an interagency trafficking task force to assist victims (Wells, 2019). Since its inception, the TVPA has been amended five times to meet current and changing needs, with the last reauthorization enacted in 2019. In the last decade, policy ratification has advanced significantly, and all 50 states and the District of Columbia have passed laws banning human trafficking. However, funding to execute these laws and to provide services for victims is still lacking (Orme & Ross-Sheriff, 2015).

The prevalence of human trafficking is difficult to track due in part to the illicit nature of this phenomenon. Many additional factors present challenges that affect calculating prevalence data, including the illegality of trafficking, reluctance of victims to self-identify, lack of public education, fear of law enforcement, and lack of uniform reporting tools (Chisolm-Straker et al., 2016; Fedina & DeForge, 2017; Tracy & Macias-Konstantopoulos, 2017). The International Labour Organization, the Walk Free Foundation, and the International Organization for Migration undertook the difficult task of estimating global trafficking incidents. A combined methodological approach was employed through the use of probabilistic surveys, interviews, and mining databases (International Labour Organization et al., 2017). Data were collected over a 5-year period and were analyzed using statistical methods. The report estimates that there are conservatively 40.3 million individuals worldwide trapped in modern slavery and that 99% of victims have yet to be identified (International Labour Organization et al., 2017).

Trafficking in the United States

Human trafficking is a known global public health issue. Unfortunately, the United States is not immune from the grasp of human exploitation, as victims have been identified in every state of the union (National Human Trafficking Hotline, 2020). The United States has been identified as a top origin and destination country (Baldwin et al., 2011; United Nations Office on Drugs and Crime, 2020). Origin countries are responsible for supplying trafficked persons, and victims are taken to destination countries that create the demand. In other words, the United States is deeply involved with both the supply and the demand of human trafficking.

Many of the same obstacles that make estimating the worldwide number of human trafficking victims difficult pertain to estimating the number of victims in the United States.

Confirmed cases are tracked by various government agencies as well as private organizations. The U.S. Department of Justice (2020) provides an annual Attorney General's Trafficking in Persons Report. The most recent report is from 2018 and identifies specific numbers per department. Immigration and Customs Enforcement made 1,588 criminal arrests. The Human Trafficking Prosecution Unit obtained convictions 526 times. The Federal Bureau of Investigation investigated 667 cases and made 479 arrests. The Department of Defense reported 141 cases, and human trafficking programs assisted nearly 9,000 victims. Many private organizations are also involved in the fight against human trafficking. For example, Polaris is a nonprofit organization dedicated to ending human trafficking. A national hotline has been provided and maintained by this organization since 2015 and has seen an increase in contacts every year since inception. The most recent aggregated data come from 2019 and include a 20% increase in contacts, resulting in 22,326 victims identified nationwide (Polaris, 2019).

The typology of labor and sex trafficking is extremely varied in the United States. Polaris (2017) analyzed more than 30,000 cases, spanning 9 years to more accurately classify subgroups falling under the two main categories of labor and sex trafficking. Twenty-five unique forms of trafficking were identified. Examples included escort services, illicit massage, outdoor solicitation, traveling sales crews, food service, begging, construction, landscaping, and commercial cleaning services (Polaris, 2017). Sex trafficking is the most common form of trafficking in North America and accounts for 72% of confirmed cases (United Nations Office on Drugs and Crime, 2020). The ratio of sex to labor trafficking incidents is approximately 3:1, as labor trafficking accounts for 22% of confirmed cases.

Victim Demographics

Human trafficking spans all demographics and is not biased on age, gender, socioeconomic status, country of origin, or sexual orientation. In 2019, the Counter Trafficking Data Collaborative published global data on the range of victims' ages. The youngest victims were less than a year old, whereas the oldest victims were octogenarians. Victims identified as male, female, and as a gender minority have been identified (Polaris, 2019). Victims' socioeconomic status also varies. Some victims report having no education, whereas others have a college degree (Simich et al., 2014). A common myth of trafficking is that victims are foreign-born. In truth, domestic victims in North America have been increasing, and the latest data revealed that 75% of victims are exploited on their home soil (United Nations Office on Drugs and Crime, 2020).

Although anyone can become a trafficking victim, women and girls seem to be disproportionately represented. In North America, 62% of victims are women (18 years or older) and 22% of victims are girls (17 years old or younger), whereas 13% are men (18 years or older) and 3% are boys (17 years or younger; United Nations Office on Drugs and Crime, 2020). Emerging evidence also suggests that people of color have a higher rate of trafficking incidences. For example, Black girls comprise 19% of the population in Louisiana but make up 49% of child sex trafficking victims (Bureau of Justice Statistics, 2011).

One commonality between all victims is vulnerability. Traffickers are cunning and seek out vulnerable individuals such as children in foster care, runaways, or children in dysfunctional living situations (National Human Trafficking Hotline, 2019). Additional risk factors targeted by traffickers include a history of abuse (sexual or physical), past trauma (violence, sexual assault, and discrimination), substance abuse, mental health issues, disabilities, or poverty (Fedina et al., 2019; Polaris, 2019). Individuals looking for affection and validation with inappropriate sexual boundaries or low self-esteem are also at high risk (Macias-Konstantopoulos, 2016). Traffickers exploit these vulnerabilities and maintain control with a variety of psychological and physical techniques. These include isolation, threats of violence against the victim or the victim's family, drug use, sleep deprivation, unpredictable indulgences, degrading actions, rape, physical violence, and murder (Baldwin et al., 2015). Unfortunately, the characteristics of traffickers are as diverse as the victims they target. Traffickers can be male or female and can be strangers, family, citizens of the United States, foreign nationals, or employers (National Human Trafficking Hotline, n.d.). Although the demographics of traffickers vary, traffickers often target vulnerable individuals with shared cultural or ethnic community (National Human Trafficking Hotline, n.d.).

Health Care

Access to Services

Trafficking survivors report the ability to access health care. Studies conducted in the United States show that 50%-88% of victims sought medical care while being held captive (Baldwin et al., 2011; Chisolm-Straker et al., 2016; Lederer & Wetzel, 2014; Richie-Zavaleta et al., 2020). Victims most commonly report accessing health care for obstetric/gynecologic issues, physical abuse, mental health concerns, and gastrointestinal concerns (Baldwin et al., 2011; Chisolm-Straker et al., 2016; Lederer & Wetzel, 2014; Richie-Zavaleta et al., 2020). Even though victims are seeking care, the majority are not screened, identified, or offered help during these interactions (Ijadi-Maghsoodi et al., 2016; Ravi et al., 2017; Richie-Zavaleta et al., 2020; Westwood et al., 2016). Nurses are uniquely positioned to help trafficking victims but often lack the skills and knowledge to successfully identify and treat these individuals. Critical skills nurses need for identification of trafficking victims align with the core competencies presented by the Office of Trafficking in Persons. The core competencies include understanding the nature and epidemiology of trafficking; evaluating and identifying the risk of trafficking; evaluating the needs of individuals who have experienced trafficking or individuals who are at risk of trafficking; providing patient-centered care; using legal and ethical standards; integrating trafficking prevention strategies into clinical practice and systems of care; and using a trauma- and survivor-informed, culturally responsive approach (U.S. Department of Health and Human Services, 2021).

The exact number of trafficking victims accessing health care is simply not known. However, the health consequences of trafficking are known. Survivors have provided researchers insights into the physical and mental toll caused by the trauma of trafficking (Richie-Zavaleta et al., 2020). Trafficking victims face acute health complications as well as long-term health issues. These include sexually transmitted diseases, physical abuse injuries, infectious diseases, malnutrition, dental problems, gastrointestinal conditions, headaches, pregnancy, and back pain (Baldwin et al., 2011; Chisolm-Straker et al., 2016; Richie-Zavaleta et al., 2020; Westwood et al., 2016). Many survivors describe mental health concerns such as anxiety, depression, suicidal ideations, and posttraumatic stress disorder. Survivors also report substance abuse issues after identification as forced substance use is commonly used to maintain control by traffickers (Waugh, 2018).

Victims of trafficking may endure both physical and psychological effects related to abuse. Victims can be locked away without access to sufficient food or proper hygiene (Suzanne Dworak-Peck School of Social Work, 2018). Physically, victims are at increased risk for injuries, long-lasting health problems, and communicable diseases (Lederer & Wetzel, 2014; Ravi et al., 2017). Psychologically, victims can experience isolation, anxiety, and posttraumatic stress disorder (Lederer & Wetzel, 2014; Ravi et al., 2017). In addition, the estimated life expectancy of a trafficking victim is 7 years because of violence and murder (Bales & Lize, 2005; Phoenix Rising, n.d.). The discussion about violence and murder is beyond the scope of this article. Human trafficking victims are suffering, and each time the potential for identification is missed, the suffering is extended. When nurses are educated about the process of trafficking, victims are identified more frequently and receive interventions, allowing them the chance to assimilate back into society (Egyud et al., 2017; Geynisman-Tan et al., 2017; Macias-Konstantopoulos, 2016; Peters, 2013).

Barriers to Identification of Victims in Healthcare Settings

Several barriers have been identified that hinder victims from being identified. Barriers affecting disclosure include privacy, control, fear, and healthcare provider factors. Lack of privacy is noted as problematic because traffickers accompany victims into examination rooms claiming to be friends or relatives. Survivors report that healthcare providers did not question this practice or ask if the patient wanted privacy. Westwood et al. (2016) found that 73% of survivors surveyed were never allowed to be unaccompanied while being trafficked. Traffickers' presence prohibits the privacy required for victims to disclose. The physical environment in healthcare facilities was also identified as a privacy issue. Survivors are very aware of environmental factors such as thin curtains, proximity to other patients, and people walking in the halls (Richie-Zavaleta et al., 2020). These factors make privacy difficult and victims reticent about disclosing.

Traffickers routinely use measures to maintain control of victims. In the healthcare setting, survivors report that traffickers (or chaperones) maintain control by keeping possession of identification documents, completing admission paperwork, and directing the flow of information (Baldwin et al., 2011; Richie-Zavaleta et al., 2020). Traffickers speak for the victims when interacting with healthcare staff. Survivors also report that the accompanying person lies or censors the information that is shared with providers (Richie-Zavaleta et al., 2020).

Survivors voice fear of the trafficker as a reason to stay silent while visiting with healthcare providers. Most commonly, victims are afraid that disclosing trafficking status would cause a retaliatory reaction from the trafficker (Baldwin et al., 2011; Richie-Zavaleta et al., 2020; Westwood et al., 2016). Victims worry about their safety as well as the safety of family members (Baldwin et al., 2011). Fear of stigmatization from healthcare providers and fear of criminalization also motivate victims to withhold disclosure (Ertl et al., 2020; Richie-Zavaleta et al., 2020; Westwood et al., 2016).

Trafficking survivors identify barriers related to healthcare providers. Providers may fail to use a translator when needed and rely on the trafficker to communicate (Baldwin et al., 2011; Lederer & Wetzel, 2014; Westwood et al., 2016). Survivors note that when providers have negative attitudes, discuss sensitive health information in common areas, or appear too busy, willingness to disclose wanes (Richie-Zavaleta et al., 2020; Westwood et al., 2016).

Implications for the Rehabilitation Nurse

Rehabilitation nurses are interfacing with victims who are accessing services for physical abuse, accidents, trauma (brain injuries, fractures, contusions, burns), back injuries, and injuries from weapons (Public Health Emergency, 2020). Injuries can occur at the hand of a trafficker or a solicitor, or from labor trafficking accidents. Rehabilitation nurses are uniquely qualified to handle the dynamic phenomenon of human trafficking, because patients who typically access rehabilitation care have complex health concerns. Rehabilitation nurses are also adept at working with specialists and therapists, and a collaborative effort is needed to address the ramifications of human trafficking in the rehabilitation setting.

Common Indicators That May Identify Victims

Healthcare providers' lack of understanding about human trafficking results in missed identification if trafficking signs are not recognized (Baldwin et al., 2011; Richie-Zavaleta et al., 2020). Identification begins by understanding the typical warning signs of victimization. Rehabilitation nurses should be vigilant for signs that point to exploitation. Common indicators include the following:

* reluctance of the person to speak,

* poor engagement with healthcare providers,

* inconsistent or scripted explanations about their injuries,

* presence of untreated chronic disease,

* delayed care, and

* current drug use.

Victims of trafficking can present with an array of emotions from a flat affect to shame or devotion to the trafficker and anger directed at the provider (Peters, 2013). Traffickers create an environment that keeps victims isolated and in perpetual trauma. Repeated trauma results in altered brain function. The interaction between the nurse and the patient can be affected due to emotional dysregulation or emotional numbing-the act of separating emotions from thoughts (Center for Substance Abuse Treatment (U.S.), 2014). Rehabilitation nurses should also be attuned to patient reports of hopelessness, fear, anxiety, agitation, or when patients are submissive, depressed, hypersexual, or have sleep disorders (Center for Substance Abuse Treatment (U.S.), 2014).

Nursing Interventions

Rehabilitation nurses should cautiously assess for trafficking when warning signs are present. Interviews should be conducted in private, away from visitors, as traffickers often pose as family members or friends. A victim is very valuable to a trafficker, and a trafficker will go to great lengths to keep victims from disclosing. Therefore, nurses need to evaluate each situation for personal danger as well as the patient's personal danger and only proceed with interviews when safety is assured.

Rehabilitation nurses should be educated on the use of trauma-informed care, an approach that builds a trusting relationship by maintaining dignity, remaining nonjudgmental, and demonstrating patience when communicating with the victim (Tracy & Macias-Konstantopoulos, 2017). Trauma-informed care is the ability to recognize how trauma has affected an individual's life. A trauma-informed approach requires providers to use empathy and sensitivity during interactions (Ravi & Little, 2017). There are several practical approaches that rehabilitation nurses can employ to provide trauma-informed care. Rehabilitation nurses can create a safe environment by minimizing or addressing distress, providing emotional support, sharing information, increasing patient control, and providing choices when feasible (Substance Abuse and Mental Health Services Administration, 2014). Ultimately, the goal of trauma-informed care is to assist nurses to recognize the signs and symptoms of trauma, provide safety, meet physical needs, and provide support in order to optimize trust. Without the use of trauma-informed care, nurses might retraumatize patients by labeling victims as criminals, addicts, or prostitutes (Simich et al., 2014).

Nurses should do the following:

* practice patient-centered care,

* seek educational opportunities,

* be aware of safety needs,

* develop protocols, and

* know when to report.

The overarching goal of the rehabilitation nurse is to help restore patients to independent living. Human trafficking not only strips individuals of health but also of physical independence. To combat this human rights violation, rehabilitation nurses have an ethical responsibility to be trained on victim characteristics, trafficking indicators, and trauma-informed care. Victims of human trafficking are abused and traumatized. Providers, including rehabilitation nurses, are missing the opportunity for life-saving intervention. Rehabilitation nurses can be part of the solution to this critical problem through education, assessing for warning signs, and reporting potential cases.

Conflict of Interest

The authors declare no conflict of interest.

Funding

None.

References