A distraught young woman enters your ED accompanied by a man who is reluctant to leave her alone even for a few minutes.
She appears disoriented and when questioned her story does not make sense. Her English is poor and she cannot provide any identification or proof of insurance.
Signs of physical abuse, such as scars, bruises and unusual bald spots, are visible. In addition, she suffers from a chronic illness, like diabetes, that appears to have gone untreated.
While alone these indicators can have a variety of explanations, together they could be red flags that this woman is being trafficked.
The realization that the U.S. is not immune to the horrors of human trafficking has gained momentum in recent years and professionals, especially in healthcare, are taking notice.
"Healthcare workers are on the frontlines of this problem and often come face to face with the most brutalized victims," said Nancy Walsh Henson, MSN, RN, CPCE.
Nurses are in a unique position. Not only do they have the chance to identify and help human trafficking victims, their knowledge and expertise can also be used to inform others.
Men, women, and children can fall victim to human trafficking and are, according to the the U.S. Department of Health and Human Services (HHS), "subjected to force, fraud, or coercion, for the purpose of sexual exploitation or forced labor."
The U.S. Department of State estimates that 600,000 to 800,000 victims annually are trafficked across international borders worldwide.
Through increased awareness and education a nationwide shift in perceptions has taken shape.
Victims trafficked into the U.S. generally come from Asia, Central and South America, and Eastern Europe. However, there are domestic victims as well, oftentimes children.
Law enforcement, healthcare workers, and the general public are recognizing that the victim is not to blame. The focus is on helping them and prosecuting the perpetrators.
The first step in this process is identifying potential victims, which often falls to nurses.
As some of the first individuals to come in contact with a victim, nurses must be aware of the telltale signs of human trafficking and familiar with the steps that should be taken following identification.
According to Walsh Henson and Donna Sabella, PhD, RN, assistant dean of health sciences at Arcadia University's College of Global Studies, Glenside, PA, indicators of potential human trafficking, include, but are not limited to patients with:
- limited English proficiency;
- confusion about where they are;
- no identification;
- untreated chronic illnesses;
- signs of malnutrition and/or dehydration;
- drug use;
- signs of physical abuse; and
- tattoos that could be a form of branding.
"While not all of these indicators are absolute it is imperative that nurses be aware of the possibility of human trafficking," said Sabella, "Without an understanding and knowledge of the issue, opportunities to help could be lost."
She stresses that these indicators are not absolute and the population must be taken into consideration.
For instance, a domestic victim will speak the language and will probably know where they are. Also, signs of sexual intercourse may not always be a red flag when dealing with an adult, but should always raise suspicions when dealing with a child.
While victims often end up in the ED because their traffickers only seek medical attention when absolutely necessary, nurses in other specialties, especially those related to women's health, must also remain alert.
Beyond the ED
"Nurses working in the ED are very aware that human trafficking is here in the U.S.," Walsh Henson said.
"Other areas of nursing are less informed, but that is changing. AWHONN and American Congress of Obstetricians and Gynecologist have both made it a priority to inform nurses, who specialize in OB/GYN areas, because our patients often bypass the ED."
Victims may come in for STD treatment, an abortion, or seek care for a pregnancy. Therefore, it is critical that healthcare professionals in these areas are aware of the red flags as well.
"Eighty percent of human trafficking victims are females, so any female related health issue could be a potential contact that leads to a rescue," Walsh Henson added.
In addition, school nurses can play a vital role in the identification of child victims. "There are kids who are trafficked who may go to school or have long absences, even if they are domestic," said Sabella "They will show up with expensive jewelry or show some of the physical signs of trafficking."
Once a potential victim has been identified, a nurse should follow the policy outline by his or her facility. If no such policy is in place, a phone call to the National Human Trafficking Resource Center hotline should be made, 1-888-3737-888. There are individuals on call 24/7 who will provide step by step instructions.
"Most hospitals do not have policies specific for human trafficking yet, so policies that deal with rape are often utilized, even if the trafficking victim was not sexually assaulted," said Walsh Henson.
"Human trafficking victims and rape victims are emotionally, mentally and psychologically fragile, so this should be respected during care and medical documentation."
Discretion is key. Nurses should avoid doing anything to make the trafficker nervous.
"One has to be very careful because if you make too big a scene he can just pull her right out of there and we can't really do anything," Sabella said. "And he might take her back and start beating on her."
A nurse should take any opportunity they can to separate the victim from their trafficker, but help cannot be forced upon them. Even if an individual admits to being trafficked, they may be too scared to leave. Threats of violence against a victim's family are often used to ensure they do not attempt to escape.
Except in certain cases, such as involvement of a minor, a nurse cannot detain an individual unwilling to stay. Nurses are valuable in cases of human trafficking because they have the chance to offer comfort and support while building trust.
"Nurses are the trafficking victim's first contact because nurses complete the admission assessment. The impression that the nurse gives will stay with them," Walsh Henson stressed.
"Trafficking victims are not likely to confide until the third encounter and only if the nurse has gained their trust."
Sabella suggests casually mentioning that it is policy to call the individual the next day to check-up on their status or discretely offering them a card with the hotline's number.
But she emphasizes that anything given to the victim should not attract the attention of their trafficker.
"But after that you let go. You cannot go after people."
In addition, a good relationship with police and other law enforcement can be a helpful resource, especially when dealing with underage victims. The fight against human trafficking requires teamwork across disciplines and professions.
Government involvement and support for victims was minimal until the passage of the Victims of Trafficking and Violence Protection Act of 2000 (TVPA).
TVPA aims to prevent trafficking, protect victims, and prosecute offenders, according to Sabella's article, "The Role of the Nurse in Combating Human Trafficking," found in the February 2011 issue of the American Journal of Nursing.
Under the new law, the "T" visa was established, which provides victims with temporary residency. After three years permanent residency is possible, states the article. Victims of human trafficking, who agree to cooperate with law enforcement and testify, if necessary, are eligible for this visa.
Trafficking victims, especially foreign ones, are often taught to fear the authorities, which may make them to reluctant to cooperate. This is another reason why nurses are critical. As some of the first authority figures victims come in contact with, their behavior can build a foundation of trust.
Nurses interested in learning more on their role in identifying and helping victims of human trafficking have a variety of resources to choose from. AWHONN and the ENA both sponsor meetings that address human trafficking, said Walsh Henson who has spoken at such events.
"Education is key," Walsh Henson emphasized.
Healthcare providers across the board need to be aware of human trafficking and the impact they can have.
A University Forensic Program is a resource for those looking for more formal training. For instance, Xavier University's Forensic MSN program includes human trafficking in its curriculum.
Online resources are also available, such as the U.S. Department of Health and Human Services website, which offers a tool kit for healthcare providers.
The number of nongovernmental agencies combating human trafficking has risen in last decade, according to Sabella, such as the "Coalition Against Trafficking in Women" and "Free the Slaves."
Sabella, is the founder/director of "Project Phoenix," a Philadelphia based organization that aims to help victims and educate the public. These programs offer valuable information as well.
Facility based education programs are a means to educate staff as a whole. Examples include St. Elizabeth Hospital in KY and Grady Memorial Hospital in Atlanta.
Information is at healthcare professionals' fingertips and now the task at hand is harnessing this knowledge so that these victims can receive the care they need.
Great strides have been made in raising awareness and public understanding of human trafficking, but momentum must not be lost. Healthcare providers, especially nurses, are poised to lead the way. Nurse managers and supervisors must ensure that a plan is in place, even if it is simply to call the hotline.
"Be informed and have a plan," said Sabella. "And always remember, this doesn't apply just when we are at the office. Nurses can look for this wherever they are, whether it is their next door neighbor or at a supermarket. The chances to make a difference are endless."
Catlin Nalley is editorial assistant at ADVANCE.