"Money may be able to buy a lot of things, but it should never, ever be able to buy another human being."U.S. Secretary of State, John F. Kerry
Trafficking in persons, also referred to as modern-day slavery, is a phenomenon affecting nearly every country in the world-one that is increasingly recognized as a global public health concern, a violation of human rights, and above all, a heinous crime (CdeBaca & Sigmon, 2014). A simple Internet search using the term "human trafficking" yielded 20,300,000 results; "trafficking in persons" yielded 40,100,000 results, whereas "sex trafficking" garnered another 13,800,000 results. However, since the debut of the Journal of Forensic Nursing in 2005, only two articles addressing human trafficking have been published: the first in 2006, a brief column entitled "The High Cost of Human Trafficking" (Moynihan, 2006), and the second, a review article in 2015 entitled "Risk Factors for Domestic Minor Sex Trafficking in the United States: A Literature Review" (Choi, 2015). Given the magnitude of this issue, the consequences for victims, and the implications for nursing, it is perplexing that we have not received more manuscripts on this topic, especially when the Journal of Forensic Nursing is the official journal of the International Association of Forensic Nurses.
In December of this past year, I had the opportunity to discuss human trafficking with Dr. Donna Sabella, a nurse expert in human trafficking. In recent years, nurses have become more astute in their understanding of human trafficking, showing skill in both identification and intervention. Yet, large numbers of trafficked victims continue to fall through the cracks-invisible to the healthcare providers they encounter-and as a result, opportunities to intervene are lost (CdeBaca & Sigmon, 2014; Sabella, 2011, 2016). Although not intended to be a comprehensive expose, my personal objective in interviewing Sabella for this editorial was twofold: (a) to heighten awareness of this global phenomenon; and (b) to challenge forensic educators, clinicians, researchers, and policy makers working with persons who are, or who have been, trafficked to consider writing for the Journal of Forensic Nursing.
What is Human Trafficking? How Do You Define It?
At its most basic, Sabella describes human trafficking as forcing people to do something against their will. Although a number of definitions of human trafficking exist, perhaps one of the most commonly cited definitions is from the United Nations (2000)Protocol to Prevent, Suppress and Punish Trafficking in Persons.
"Trafficking in persons" shall mean the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs. (p. 3)
Although a complex definition, Sabella retorts that the three key words to keep in mind are "force," "fraud," and "coercion." Simply stated, trafficking in persons is about the exploitation of people to provide some sort of service (through force, fraud, and/or coercion). The two major categories of trafficking of persons are (a) sex trafficking and (b) labor trafficking. Not surprisingly, trafficking is known as a "gendered" crime; those who are trafficked into the sex industry and as domestic servants are more likely to be women and children, whereas men and boys are more commonly trafficked for various forms of labor (World Health Organization and Pan American Health Organization, 2012). Sabella was quick to point out that, in the case of a child (under 18 years old) who is being sex trafficked, proving force, fraud, or coercion is not necessary for the offense to be considered human trafficking. Labor trafficking takes many forms: forced labor, bonded labor or debt bondage, domestic servitude, child labor, and unlawful recruitment and use of child soldiers (U.S. Department of State, 2015). Regardless of whether one is forced into sex trafficking or labor trafficking, "all trafficking victims share one essential experience: the loss of freedom" (Polaris Project, n.d.).
How Did You Get Involved in This Area of Practice?
With a background in mental health nursing, Sabella frequently met with clients in Philadelphia (where she practiced) who experienced substance abuse issues and comorbid mental health diagnoses. Through careful interviewing, she soon learned that many of her clients were involved in prostitution to feed their addictions. Not only were they experiencing addiction issues, they frequently presented at appointments with unexplained injuries, and when she probed further regarding their injuries, she was often provided with vague and implausible answers. That was 2005-2006, and she wanted to learn how to work more effectively with the clients she was seeing. At that time, programs to assist women attempting to transition from prostitution were nonexistent in Philadelphia. She started searching online for resources, and through shear persistence, she managed to visit a program called DIGNITY (Developing Individual Growth and New Independence Through Yourself), located in Phoenix, Arizona. Funded through Catholic Charities, and founded and operated by a woman with lived experience as a prostitute and addict, there, Sabella learned how often prostitution and trafficking in persons are intertwined. Upon her return to Philadelphia, she was instrumental in the development of a residential recovery program for trafficked women-Dawn's Place (http://ahomefordawn.org/index.php)-where she was a founding member and served as the Program Director. She is currently founder and Director of Project Phoenix (http://www.projectphoenixwebsite.com), an outreach program that provides support and facilitates groups for prostituted and trafficked women both in and out of prison in Philadelphia. She holds an academic post as an Associate Professor with Widener University, School of Nursing, and continues in her role as Coordinator of the Human Trafficking Certificate Program at Drexel University (see Table 1).
What Should Nurses Know? In General, How Should They Respond?
Sabella responded candidly to this question, claiming that, first and foremost, nurses need to know that trafficking in persons exists. Nurses can no longer hide behind their naivete, believing that this sort of thing only happens elsewhere-wherever that may be. More often than not, persons who are being trafficked pass through the healthcare system seen by nurses who either did not recognize the signs or did not know what to do. CdeBaca and Sigmon (2014) state that "training must go beyond raising awareness of the plight of victims and recognizing the signs of human trafficking. Training should also cover guidance on interacting with potential victims, interviewing techniques, recommended responses, and resources" (p. 264). Sabella, however, is also a realist and recognizes that nurses have a limited amount of time for continuing education, but having said this, she also emphasized the importance of focusing on their own areas of practice. For example, who might you see in the emergency department? What about in pediatrics? In schools? What about nurses who work in jails and correctional facilities? Sadly, women are often recruited while they are incarcerated. For those who are being trafficked, whether in sex trafficking or labor trafficking, they "typically only see health care when their condition becomes serious" (Sabella, 2011, p. 32).
What are Some of the Health Consequences of Human Trafficking?
Regardless of whether one is sex trafficked or labor trafficked, the consequences of human trafficking are persistent and severe.
Sex Trafficking
* Women frequently experience sexually transmitted diseases; vaginal and rectal trauma; unintended pregnancies; and physical injuries, including bite marks, cigarette burns, knife wounds, and broken bones, inflicted by their customers or their pimps. Sabella further noted that, as oral sex sells very well, women frequently experience temporomandibular joint disorder as they are often forced to meet an oral sex quota.
* Mental health and addiction issues prevail, particularly depression, anxiety disorders, and posttraumatic stress disorder. Women are often further exploited through coerced drug and alcohol addiction, which allows the pimp to hold more power over them.
* Sadly, Sabella observed that women may be branded by their pimps or may intentionally get a tattoo, often on their torsos, to be identified by their family or loved ones should they end up dead in a field or a canal.
* Children are particularly vulnerable to both sex trafficking and labor trafficking. Children are easy to transport, and people (johns) will pay more to have sex with a child. Countries known for sex tourism include Brazil, Cambodia, Thailand, and the Dominican Republic. Sadly, children in some countries may be intentionally maimed and disfigured to secure more money begging.
Labor Trafficking
* Persons who are labor trafficked also experience physical violence, psychological violence, and imposed social isolation.
* Depression, anxiety disorders, and posttraumatic stress disorder are also common.
* They are forced to live in cramped, often locked, settings with poor ventilation, poor sanitation, and exposure to the elements. Infectious diseases in such quarters can be rampant.
* Exposure to chemicals and airborne contaminants is common, and protective clothing (boots, safety glasses, masks, etc.) are nonexistent.
* Exploitation of drug and alcohol dependence is also common.
* CdeBaca and Sigmon (2014) report that commercial sexual exploitation of men and boys has been reported in Kenya, Southeast Asia, Spain, and the United States and warrants further investigation, as it is believed to be significantly underreported.
For more information on health consequences, see Sabella (2011, 2016), the U.S. Department of State (2015), and the World Health Organization an Pan American Health Organization (2012).
How Might Interested Nurses Become More Involved in This Area?
Of course, there are lots of ways that nurses can get involved. First and foremost, Sabella encourages connections with "like-minded souls." In her experience, "once you start walking down the path, you will find other people along the path, too." According to the U. S. Department of Justice (2015), "responses to human trafficking are most effective, coordinated, and efficient when they are multidisciplinary and collaborative in their problem solving" (p. 1).
Clearly, the partnerships that forensic nurses develop will depend on what is available in their communities. The importance of seeking out and exploring other sectors cannot be overemphasized. According to Sabella, like-minded souls can be found through exploring a variety of resources and sectors, including law enforcement, faith-based organizations, justice systems, education systems, and domestic violence shelters, to name a few. Explore what is available in your community. What resources exist? What is needed in your community? Become more informed. Forensic nurses, after all, are ideally situated to show leadership in this area. Develop a seminar, give a Webinar, and invite others who have expertise to give an in-service or speak at a community event. Determine what is needed and wanted. Such partnerships can have a real domino effect; not only do they lead to increased community education and awareness, such collaborations can also lead to the identification of potential victims and traffickers, prosecution of traffickers, protection and assistance for victims, and the prevention of trafficking from occurring (CdeBaca & Sigmon, 2014; U.S. Department of Justice, 2015).
Finally, is There One Thing That All Nurses Should Know About Trafficking in Persons? One Take-Away Point?
Surprisingly, her answer to my final question was particularly simple. It really is all about the nursing process-and it starts with assessment. Nurses need to have an understanding of what to look for; if they do not recognize it, they will never assess it, never develop appropriate nursing diagnoses and plans, never implement those plans, and never evaluate their outcomes. I would refer readers to some key resources found in Table 1 and Sabella's (2011, 2016) publications for further information. She also wanted to pay homage to Dr. Mary deChesnay, whose work in sex trafficking is pivotal to any discussion on trafficking in persons (see Table 1).
Closing Thoughts
It is impossible for any single agency, organization, or discipline to respond to the comprehensive needs of the diverse nature of human trafficking victims. I am confident, however, that forensic nurses, regardless of where they hang their hats, will show leadership in their workplaces. I look forward to hearing from potential authors. The Journal of Forensic Nursing publishes original articles, review articles, case reports, and letters to the editor. Feel free to email me at [email protected] should you wish to discuss your ideas further.
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