Human Trafficking Prevention Training for Texas Healthcare Practitioners

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will have the current, evidence-based information and tools necessary to accurately recognize and intervene in suspected instances of human trafficking. Specific learning objectives to address potential knowledge gaps include:

• Define the concepts and elements that constitute human trafficking.
• Recognize the dynamics and vulnerability factors for human trafficking.
• Articulate the scope and impacts of human trafficking.
• Identify the “red flags” that may indicate human trafficking.
• Describe assessment tools and strategies that can be used in clinical settings to identify human trafficking victims.
• Discuss the importance of using a trauma-informed approach when screening victims of human trafficking.
• Explain the role and actions that healthcare professionals can take to respond and follow up with patients who are trafficked.
• List human trafficking resources, including contact information.

WHAT IS HUMAN TRAFFICKING?

Human trafficking is a crime involving the exploitation of someone through the use of force, fraud, or coercion for the purposes of compelled labor or a commercial sex act. Human trafficking affects individuals across the world, including in Texas. It affects people of all ages, genders, ethnicities, and socioeconomic backgrounds. Human trafficking robs individuals of their basic human rights and can occur across and within state and international borders.

Human trafficking steals freedom for profit. It is a multibillion-dollar criminal industry that victimizes an estimated 29.9 million people around the world. This crime occurs everywhere, and victims may be found in such industries as healthcare, childcare, agriculture, nail salons, trucking, and hotels or motels. All trafficking victims have a common experience: the loss of freedom (Polaris, 2020a).

Since the Thirteenth Amendment to the Constitution was ratified in 1865, involuntary servitude and slavery—such as human trafficking—have been prohibited in the United States (Interactive Constitution, 2020).

The Trafficking Victims Protection Act (TVPA) was first passed in 2000 and has since been amended and reauthorized many times by Congress. The TVPA provides the infrastructure for the federal response to human trafficking. A multi-agency approach is founded on a framework that focuses on the “3 Ps”: prevention, protection, and prosecution.

Federal agencies such as the U.S. Department of Homeland Security and the Federal Bureau of Investigation investigate human trafficking cases. The Justice Department prosecutes federal cases and funds the formation of state and local human trafficking task forces. The Department of Health and Human Services is involved in community education and awareness efforts, prevention, and funding the National Human Trafficking Hotline (Polaris, 2020b).

The U.S. Department of Health and Human Services has identified human trafficking as a public health issue. As such, healthcare professionals are key to responding to the problem. Access to healthcare is often difficult for trafficking survivors due to issues such as lack of identity documents, lack of finances or insurance, shame, and fear. Survivors often contend with health issues such as depression, trauma, sexually transmitted infections, chemical dependency, injuries, and poor nutrition. Survivors require both acute and long-term responses to their healthcare needs.

Because human trafficking is a hidden crime, it is easy to miss identifying a patient as a survivor unless the clinician understands risk factors and develops a rapport that will allow the survivor to disclose their needs. It is essential that healthcare professionals are educated on the recognition of human trafficking, referrals and resources, and the nuances of providing trauma-informed care. They can offer support to patients who disclose maltreatment or abuse, homelessness, and financial need. By listening carefully to the patient, healthcare professionals are in a position to help a patient leave a situation in which they are being exploited (Gardner, 2023).

Types of Human Trafficking

There are different types of human trafficking, also known as trafficking in persons. Human trafficking may predominantly involve commercial sex, it may be specific to labor, or it may include both sex and labor. Human trafficking can be domestic or international and does not require crossing international or state borders.

SEX TRAFFICKING

Sex trafficking encompasses many sex crimes. The victims may be adults or children of any gender and may be domestic or foreign residents.

According to the TVPA, sex trafficking is 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. Under federal law, any minor under the age of 18 who is involved in commercial sex is considered to be a trafficking victim.

Force, fraud, or coercion are key elements used to identify trafficking, but they do not need to be present if the trafficking victim is under the age of 18. However, the use of force, fraud, or coercion on adults is what distinguishes sex trafficking from consensual commercial sex.

LABOR TRAFFICKING

According to U.S. federal law (22 USC § 7102), labor trafficking is 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. As with sex trafficking, force, fraud, or coercion do not need to exist if the labor trafficking victim is under the age of 18.

Labor trafficking victims include adults and children of all genders. Labor trafficking is often achieved through the control mechanism of debt bondage. Traffickers offer persons outside the United States promises of legitimate jobs in exchange for a legal visa and travel expenses to this country. Once they have arrived, the victims of this scheme may be charged exorbitant fees for food, rent, and material needs and are unable to repay the debt, remaining under the control of the trafficker.

The Action-Means-Purpose (AMP) model is one tool that can be used to assess whether a situation meets the federal definition of human trafficking. It asks whether a perpetrator has implemented any of the actions and used any of the means for the purposes of making the victim perform commercial sex acts, services, or labor. The presence of at least one item from each category determines possible human trafficking.

AMP MODEL TO ASSESS FOR TRAFFICKING

Action	Means	Purpose
(Polaris, 2020c)
Induces Recruits Harbors Transports Provides or obtains	Force Fraud Coercion	Commercial sex Services Labor

SMUGGLING

The crime of human smuggling is different from human trafficking, but it is frequently confused with human trafficking, and the two crimes are sometimes related. Unlike trafficking, the definition of smuggling includes transportation across international borders. Smuggling usually involves the consent of a person who is being transported. People who are smuggled generally pay to be transported across a border, but once they have arrived at their destination, they may become victims of trafficking (Polaris, 2021).

Smuggling is addressed in the Immigration and Nationality Act, Title 8, Section 1324 (a)(1), which provides criminal penalties for acts or attempts to bring unauthorized aliens to or into the United States, transport them within the United States, harbor unlawful aliens, encourage entry of illegal aliens, or conspire to commit these violations, knowingly or in reckless disregard of alien’s legal status (U.S. CIS, n.d.).

A tragedy that occurred in San Antonio, Texas, illustrates why criminal penalties for smugglers are in place: In July 2017, the bodies of eight deceased persons were found in a tractor trailer that was parked behind a Walmart store. There were 30 additional people in the trailer who suffered from lack of air conditioning and water in heat over 100 °F (Forsyth, 2017).

Human Trafficking Venues

Labor trafficking occurs most often in the agriculture and hospitality industries, landscaping, and traveling sales. The exploiters frequently target immigrants and economically marginalized persons. Some examples of labor trafficking include coercing farmworkers through violence to harvest crops, holding factory workers in inhumane conditions and with little or no pay, and forcing people to work as domestic servants (NHTH, 2023a).

Sex trafficking venues are often related to commercial sex, which may occur in:

• Brothels
• On the street
• Truck stops
• Hotels or casinos
• Escort services
• Massage parlors

Sex trafficking may also occur in venues related to pornography, sex tourism, exotic dancing, stripping, and “mail-order” brides (U.S. DHHS, 2018).

TOP VENUES FOR LABOR TRAFFICKING, TEXAS, 2021

Venue/Industry	Reported Cases
(NHTH, 2023b)
Domestic work	31
Construction	14
Illicit activities	14
Agriculture/farms	9
Traveling sales crews	7
Restaurants/food service	7

TOP VENUES FOR SEX TRAFFICKING, TEXAS, 2021

Venue/Industry	Reported Cases
(NHTH, 2023b)
Illicit massage/spa business	69
Hotel-/motel-based	66
Residence-based commercial sex	59
Pornography	44
Online ad/venue unknown	34

Dynamics of Human Trafficking

Once a trafficking victim becomes entrapped by the exploiter, leaving may be difficult because the victim may fear physical abuse or be subjected to false promises. They may be manipulated into thinking that they are indebted to or protected by the exploiter. Victims may become isolated from family and friends, feel ashamed, be controlled by drugs, or develop a type of traumatic bond with the exploiter (CDC, 2022).

The dynamics of the relationship between an exploiter and a trafficking victim share similarities with the dynamics of the relationships associated with domestic violence. In both cases, the victim may have difficulty leaving the relationship emotionally, physically, and financially, or may fear the repercussions of leaving.

It has long been thought that trafficking victims and domestic violence victims exhibit feelings of trust or affection toward their abuser or captor (sometimes referred to as Stockholm syndrome) and experience shame, self-blame, and posttraumatic stress, but a better explanation for the behavior is what’s referred to as appeasement. Appeasement may be explained through a psychobiological model to describe an adaptive survival behavior in which the victim’s behavior appears to be affectionate to calm the perpetrator and diminish the victim’s sense of being in a life-threatening situation (Bailey et al., 2023). Appeasement is consistent with “fawning,” which is one of the four acute stress responses (fight, flight, freeze, and fawn) (Guy-Evans, 2023).

Exploiters can operate as individuals, small businesses, or in large, organized criminal networks. Traffickers and victims frequently share similar backgrounds and ethnicities, which gives exploiters an advantage to manipulate victims whom they somewhat understand. Some exploiters are the same age as the victims and work as peer recruiters.

Traffickers may be owners of brothels or massage businesses or own businesses that employ domestic servants or agricultural workers. Traffickers may be family members, intimate partners, or friends of the victim. They may own factories or corporations, and trafficking may exist within a legitimate business.

Traffickers frequently exploit industries such as advertising or airlines. They may also exploit buses and other forms of travel. Trafficking may be associated with landlords, passport service businesses, labor brokers, and the hotel industry. Although these businesses can be used for criminal trafficking activity, legitimate business owners should be aware of exploiters and report trafficking situations (NHTH, n.d.-a.).

Vulnerability Factors

Factors that are associated with increased risk for victimization may be viewed using a public health approach according to the socioecological model. This model describes individual, relationship, community, and societal factors that may result in vulnerability to human trafficking (Greenbaum, 2020).

Individual vulnerability factors include:

• History of exposure to homelessness
• Running away from home
• Physical, sexual, or other types of abuse
• Involvement with Child Protective Services, the juvenile justice system, or foster care
• Identification as lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+)
• Being marginalized
• Immigration status as an unaccompanied minor

Relationship vulnerability factors include but are not limited to:

• Poverty
• Unemployment
• Family violence
• Loss or abandonment
• Peer or family exploitation

Community vulnerability factors are seen in areas where residents are involved in mass migration, corruption prevails, and exploitation is tolerated. Persons who live in a community that is exposed to violence and natural disasters are also vulnerable to human trafficking.

Societal vulnerability factors are seen in groups that subscribe to cultural beliefs that support marginalization and inequality in matters of race, gender, and the rights of children. Individuals in societies that are without human trafficking laws or do not hold exploiters accountable are also at risk (Greenbaum, 2020).

IMPACTS OF HUMAN TRAFFICKING

Statistics

The true prevalence of human trafficking in the United States is unknown because of the concealed nature of the crime. The unofficial estimate is hundreds of thousands when cases among adults, minors, sex, and labor trafficking are combined.

It is believed that more women and children are victims of sex trafficking and domestic servitude and that more boys and men are trafficked for other forms of labor, but it is not possible to present dependable statistics. Some researchers use reports of missing children to estimate statistics of trafficked children.

REPORTED CASES

Nationally, in fiscal year 2021, there was a 49% increase in the number of persons who were referred to U.S. attorneys for human trafficking. The number of referrals increased from 1,360 in 2011 to 2,027 in 2021, and the number of prosecutions more than doubled, rising from 729 to 1,672 over the same time period.

The National Human Trafficking Hotline gathers data from calls made to their hotline. Recent statistics for the state of Texas are described in the tables below.

REPORTED TRAFFICKING CASES IN TEXAS BY TYPE, 2021

Type	Number
(NHTH, 2023b)
Sex	661
Labor	131
Sex and labor	51
Not specified	74
Total cases	917

REPORTED TRAFFICKING CASES IN TEXAS BY GENDER, 2021

Gender	Number
(NHTH, 2023b)
Female	758
Male	137
Gender minorities	11

REPORTED TRAFFICKING CASES IN TEXAS BY AGE, 2021

Age	Number
(NHTH, 2023b)
Adult	616
Minor	240

BUYERS OF COMMERCIAL SEX

Buyers of commercial sex are what drive the crime of human sex trafficking, because if there were no demand from buyers, there would be no financial benefit for sex traffickers. Researchers have found that 21% of men in the United States reported paying for sex during their lifetimes, and 6% reported paying for sex over the past year.

Although buyers may belong to any socioeconomic group, men who buy sex frequently are more likely to have an annual income of $100,000 or more. Among men who had not bought sex for at least 6 years, 34.5% reported having first paid for sex while serving in the military. The group of active, high-frequency buyers reported that their first transaction was set up by someone that they knew, and 20% were minors at the time (Raphael & Feifer, 2020).

In 2021, Texas became the first state to pass a law to charge buyers of commercial sex as a felony crime. Lawmakers believe that HB 1540 will discourage buyers and, without the demand for commercial sex, will deter traffickers from exploiting vulnerable victims (Texas Legislature, 2021).

MINORS

It is difficult to quantify the number of minors who fall victim to human trafficking, and many youth who are victims of sex trafficking have been misidentified as criminals rather than victims, possibly contributing to inaccurately low statistical data. There is evidence that minors (defined as under 18 years of age) are frequently recruited when they have run away from home. In 2021, it is likely that an estimated 1 in 6 of the 25,000 U.S. children who were reported to the National Center for Missing and Exploited Children as having run away from home were victims of sex trafficking (NCMEC, 2022).

Health Impacts

Human trafficking impacts the health of its victims. Most epidemiological studies on human trafficking have focused on women and children who have been sexually exploited. These studies have historically concentrated on HIV, sexually transmitted infections (STIs), chronic health problems, and mental health issues. It is known that victims of trafficking are abused physically, psychologically, and sexually.

In healthcare settings, individuals may present with chronic health conditions such as diabetes, chronic pain, chemical dependency, HIV, or depression that have gone untreated because they have been unable to access healthcare. Adolescents may not be up to date on their immunizations or experience from vitamin deficiency, developmental issues, or other malnutrition and toxic stress.

Physical symptoms that are commonly reported include:

• Fatigue
• Memory problems
• Dizziness
• Headaches
• Stomach problems
• Cardiovascular issues
• Hearing problems
• Respiratory issues
• Infectious disease (tuberculosis, HIV)
• Undetected chronic disease (cancer or diabetes)
• Infections or mutilations
• Significant weight loss
• Back pain
• Chronic pain
• Chemical dependency
• Dental problems

Reproductive and sexual health concerns include:

• Sexually transmitted infections
• Abnormal PAP, cervical dysplasia
• Pregnancy
• Pelvic pain

Mental health issues have also been identified and found to persist longer than physical symptoms. These include:

• Depression
• Loss of self-esteem
• Shame
• Anxiety
• Addiction (especially opioid)
• Complex trauma resulting in psychosis
• Self-harm
• Suicide attempts
• Posttraumatic stress disorder (PTSD)
  (Stop Violence Against Women, 2020)

IDENTIFICATION AND ASSESSMENT OF HUMAN TRAFFICKING IN CLINICAL SETTINGS

The goals of healthcare providers who wish to intervene and assist victims of human trafficking are in direct conflict with those of exploiters. Exploiters hope for the continued vulnerability of their victims and see their victims as merchandise. Exploiters use concealment and misdirection to confuse anyone who they view as a threat to their profits and manipulation, power, and control to discourage victims from disclosing their circumstances.

In order to develop a capacity to listen to patients who have a history of violence, healthcare workers must be willing to extend themselves into areas of malfeasance and human fallibility. Healthcare professionals’ best resource is knowledge. Being aware of warning signs and indicators of human trafficking can alert the clinician to possible victims.

Setting and Presentation

The media often portrays trafficking victims as women who are in chains or have a sign written on their hands that says, “Help Me.” However, this is not what most trafficking victims look like. When victims of human trafficking present in healthcare settings, it is uncommon for them to self-disclose that they are victims. They have significant trust issues, and even when asked directly, they are not likely to disclose that they are victims. The exploiter may also accompany victims, and as with victims of domestic violence, that presence will discourage victims from making any disclosures to a clinician.

A healthcare professional may encounter victims of sex trafficking in a clinic or emergency department setting who are requesting treatment or testing for pregnancy, abortion, sexually transmitted infections, and contraception. They may request a sexual assault forensic exam or treatment for substance abuse. Victims may experience broken bones or nonaccidental injury at the hands of exploiters or buyers.

Victims of labor trafficking may have physical injuries, pesticide poisoning, or salmonella from unclean water sources. If their illness or injury is severe, these patients may present in outpatient clinics or in the emergency department.

Behavioral health providers may encounter victims of trafficking who are depressed, cannot sleep, have anxiety, or are suicidal. Dentists may see these victims when dental problems become severe.

“Red Flags”

Human trafficking may be indicated by numerous possible signs. Clinicians may note one or more of the following “red flags” in a healthcare setting.

PHYSICAL SIGNS

• Signs or a history of deprivation of food, water, sleep, or medical care
• Physical injuries typical of abuse, such as bruises, burns, cuts, scars, prolonged lack of health or dental care, or other signs of physical abuse
• Brands, scars, clothing, jewelry, or tattoos indicating someone else’s “ownership”
• Presence of sexually transmitted infections
• Pregnancy
• Possession of cell phones, jewelry, large amounts of cash, or other expensive items that appear inconsistent with the patient’s stated situation
• Substance abuse or dependence signs and symptoms
• Clothing that is inappropriate for the weather or emblematic of commercial sex

PSYCHOLOGICAL/EMOTIONAL SIGNS

• Fear, anxiety, depression, nervousness, hostility, flashbacks, avoidance of eye contact
• Restricted or controlled communication, or use of a third party to translate, with no indicator of inability to understand English
• Inconsistencies in the history of the illness or injury
• Denial of victimization
• Attempted suicide, submissiveness, fearfulness, self-harm, or other signs of psychological abuse
• Appearing to be controlled by a third party (e.g., looking for permission to speak, not being left alone)
• Isolation from family or former friends
• Fear of employer
• Described or implied threats to self or family/friends
• History of running away

ENVIRONMENTAL/SITUATIONAL SIGNS

• Working and living in the same place
• Lacking the freedom to leave their working or living conditions
• Being escorted or kept under surveillance when they are taken somewhere
• Not being in control of their own money
• Having no, or few, personal possessions
• Frequently lacking identifying documents, such as a driver’s license or passport
• Indicators of being a minor in a relationship with a significantly older adult
• Not knowing their own address
• Being in possession of hotel keys

RED FLAGS AMONG MINORS

Minor victims may present with the same physical findings as adult victims, but it is important to also take note of a youth’s belongings. Trafficked youth generally have a cell phone and may also have in their possession items that seem too costly for their age and occupation, such as expensive jewelry, purses, and large amounts of cash.

A careful social history may elicit that the child is “couch surfing” or “staying with a friend” and not attending school. Trafficked youth may have a chronic illness such as asthma or diabetes that is neglected. They may be accompanied by an older person whom they call “Daddy” or “Uncle” or refer to as their “boyfriend.”

It is important to note that 1 in 6 runaways is likely to be trafficked within 48 hours of leaving home and may become sexually exploited in exchange for food, a place to stay, or cash. This is sometimes referred to as “survival sex” and is another form of commercial sexual exploitation. The youth may also disclose a history of involvement in the foster care or juvenile justice system.

Although children who have run away and are on the street are particularly vulnerable to traffickers, youth who live at home with parents or who are in foster care homes or group homes are also vulnerable to exploiters and may become victims of trafficking or CSEC when approached at malls, schools, parks, youth groups, and online.

Screening

Screening should take place in a quiet environment free from interruptions. Food, drink, and tissues should be available during the interview, and the interviewer should be prepared to offer clothing and referrals to medical care and other services as indicated. The screener should be sensitive to the fact that formal dress, suits, and uniforms may be emblematic of immigration or enforcement agencies and are not conducive to open communication.

(See also “Trauma-Informed Care” below.)

STRATEGIES TO INTERVIEW THE PATIENT ALONE

In order to provide an opportunity for the patient to communicate freely, the healthcare professional may need to implement a strategy to create privacy when the patient is accompanied by someone else. Strategies include: requesting that the patient leave the room with a clinician and without any accompanying person to undergo a procedure such as an X-ray, requesting that any accompanying person step out of the room due to hospital privacy policies, or asking an accompanying party to leave the room in order to provide assistance with registering the patient.

If the person who is accompanying the patient refuses to leave or to allow the patient to be separated, it may not be in the patient’s best interest for the healthcare professional to insist. If the trafficker feels threatened, there is a risk that the patient will not be allowed to receive treatment or be harmed after leaving the facility. The same is true for involving law enforcement or security. If the trafficker becomes suspicious, it may jeopardize the ability of the patient to return for needed treatment (HEALTrafficking.org, 2020).

SAFETY MEASURES

When working with human trafficking survivors, safety is a primary concern. Although many emergency departments have metal detectors to screen for weapons, it is important that all healthcare institutions have a response protocol in the event of violence. It is equally important that healthcare professionals are aware of how to keep their patients and themselves safe at work.

When working with crime victims and suspects in particular, the healthcare professional should pay attention to the environment and be prepared to act quickly. Because of the criminal nature of human trafficking, security should be alerted when a patient is suspected of being a human trafficking victim. Personnel should also be cognizant of prevention measures such as registering a high-risk patient under an alias, flagging their chart not to give information to the public, or placing the unit under lockdown if a direct threat occurs (Titler & Reynolds, 2020).

OVERCOMING SURVIVOR BARRIERS TO DISCLOSURE

The goal of the healthcare professional should not be to elicit a disclosure but to create a safe space where patients feel that they can be treated, learn more about their options, and receive support to make informed decisions (NHTTACenter, 2021). There are many barriers to disclosure by human trafficking survivors to healthcare workers:

• Patients who are trafficked are frequently in the presence of their trafficker or another person who is watching what they say and are not free to discuss their situation.
• They may be unable to communicate due to linguistic issues, illness, or trauma.
• Patients do not have any reason to trust healthcare professionals, are fearful of their trafficker, and are concerned that they will not be believed or might be arrested.

Survivors who have experienced human trafficking are experts on this topic and understand what healthcare providers need to know in order to create a safe space for disclosure. According to survivors, it is important that healthcare workers have a working knowledge or skills in these areas:

• Resources for human trafficking survivors
• Mandatory and nonmandatory reporting of human trafficking
• Trust-building
• Means of separation from the trafficker
• Survivor empowerment, follow up, and monitoring
• “Red flags” for human trafficking
• Skilled collaboration and assessment
• Compassion
• Advocacy
• Respect
• Trust
• Patience
• Gentleness
• Sensitivity
• Safety
• Nonjudgmental attitude

Survivors also recommend that healthcare professionals:

• Obtain informed consent for all treatments
• Share accurate timeframes
• Avoid touching the patient and, when clinically necessary, only do so after asking permission
• Provide opportunities for the patient to be in control when possible
• Listen and respond to the needs that patients verbalize
• Include other survivors in the care team to reduce the possibility of shame
  (Chisolm-Straker et al., 2020)

Assessment Tools

Several assessment tools have been developed to assist professionals in identifying victims of trafficking. These tools require training and are available online at no cost.

In Texas, youth are screened using the Commercial Sexual Exploitation Identification Tool (CSE-IT). The CSE-IT was developed by West Coast Children’s Clinic for social workers to screen at-risk youth who are 10 years of age and up for commercial sexual exploitation. The evidence-based and validated CSE-IT tool uses a weighted scoring system to evaluate observations made by the professional rather than answers given on a questionnaire to the youth. A free, 3-hour training on how to use the tool is offered monthly by Texas Network of Youth Services and aims to ensure that all youth services providers have the tools they need to identify, prevent, and respond to commercial sexual exploitation of youth (TNOYS, 2021).

The Vera Institute of Justice’s (2014) Trafficking Victim Identification Tool (TVIT) is validated and continues to be used by health professionals, law enforcement officers, and other service providers to screen adult victims of trafficking. This tool consists of a 30-topic questionnaire and was developed over two years with a grant from the National Institute of Justice. The tool is available in both English and Spanish and comes in a full or abbreviated version. This tool requires about an hour to administer, and the results are evaluated by a human trafficking expert. The topics that are covered include background and demographics, migration into the United States, and working and living conditions. The total responses are evaluated, and needs such as safety, housing, social service, and employment are assessed. This tool works best with reliable referral networks so that victims can receive the services that they need from community partners (TX DHHS, 2023).

New York State’s Covenant House developed the Human Trafficking Interview and Assessment Measure (HTIAM-14) to assess youth for trafficking. It is similar to the other screening tools, with the child welfare professional scoring responses to quantify risk; it is brief to administer; and it does not require expertise in trafficking (TNOYS, 2023).

TRAUMA-INFORMED CARE

Trauma is an intense response to a stressful situation that can result in lasting negative effects on an individual that are averse to their health and well-being. Trauma impacts an individual’s worldview, identity, and relationships. These beliefs impact how the individual will respond to available services and the criminal justice system.

Therefore, whenever a clinician is interacting with a potential victim of human trafficking, trauma-informed care and interviewing techniques are important so that the individual is not inadvertently retraumatized. Providers should incorporate the “Four Rs” into their trauma-informed practice:

1. Realize the prevalence of trauma
2. Recognize that trauma affects how an individual responds to interactions with the organization or system
3. Respond by putting knowledge into practice
4. Resist retraumatization of individuals

Any service provider who interfaces with an individual who has a history of trauma—from the receptionist to the physician—should be educated about trauma-informed care and strive to create an environment in which the patient feels safe, believed, and empowered. Nobody should be made to feel like a witness to a crime for which they are the victim (OVC, 2023).

Principles of a Trauma-Informed Approach

Promising practices for a trauma-informed approach to screening rely on caring for each individual as if they have experienced a trauma and being mindful to avoid retraumatizing the patient. There is a focus on physical, psychological, and emotional safety and an emphasis on helping the patient achieve a sense of control, empowerment, and agency.

The six principles of a trauma-informed approach include:

1. Safety. The provider ensures safety for the patient, both physical and emotional, and maximizes the patient’s control. The provider aims to meet the basic needs of the patient, including necessary medications.
2. Trustworthiness and transparency. The provider spells out the limits of confidentiality and ensures that the patient is heard and understood.
3. Peer support. The provider encourages the patient who has survived trauma to implement self-help.
4. Collaboration and mutuality. The provider acknowledges the individual roles of the patient and staff and attempts to even out power discrepancies.
5. Empowerment, voice, and choice. The provider supports the individual’s sense of agency and helps the survivor become empowered.
6. Cultural, historical, and gender issues: The provider recognizes that there may be sources of trauma from cultural, racial, ethnicity, gender, and historical issues, including adverse childhood experiences (ACEs).
   (Human Trafficking Collaborative, UOM, n.d.)

Asking Difficult Questions

Sometimes it is difficult to frame questions in a way that will feel nonjudgmental to a victim. The ability to ask questions in a way that does not cast blame will provide the health professional with better information and is unlikely to cause harm to the patient.

• An opening statement such as “I would like you to tell me everything that you are comfortable sharing” can be very helpful.
• If immigration status might be an issue, it is best to not ask about this initially.
• Asking, “What were you wearing?” could be interpreted by the patient as blaming them for the occurrence based on their dress. Instead, one might ask, “What are you able to remember about what you were wearing?”
• It is important to avoid asking victims of human trafficking “why” questions about any of their actions or responses. Asking “why” may cause the victim to feel or believe that they did something wrong and is likely to negatively impact the interview.

Forensic Experiential Trauma Interview

Principles from the Forensic Experiential Trauma Interview (FETI), developed by Russell Strand, can be utilized by healthcare professionals who work with victims of trauma. The FETI is based on the neurobiology of trauma that entails a shutting down of the prefrontal cortex during the traumatic or stressful event. The prefrontal cortex, when operating efficiently, is the cognitive part of the brain that normally records the memory of an event (who, what, why, where, when, and how). During a traumatic event, less-advanced portions of the brain record the event. Stress and trauma interrupt how memories are stored and may lead to the victim expressing inconsistent or incorrect statements.

• Interviewers make a sincere effort to establish safety, trust, and comfort for the victim. They acknowledge the victim’s trauma and ask nonleading questions such as, “What are you able to tell me about your experience?” or “I would like you to share with me everything that you are comfortable sharing.” Statements such as “Help me understand about the car ride” replace the use of “Why did you get in the car with him?”
• Interviewers do not interrupt, and they pause to allow victims time to think through the question. They may ask, “What were you feeling?” or “What was your thought process during this experience?” instead of “Why did you do that?”
• Interviewers express empathy and understanding and allow the victim to say they “don’t remember” rather than asking the victim to guess.
• Interviewers acknowledge that the victim may remember more after some time has passed.
  (Lonsway & Archambault, 2021)

Forensic interviews of children and adolescents utilize a multidisciplinary team approach and generally take place in a child advocacy center. A certified interviewer conducts the interview while law enforcement, social services, behavioral health, and medical representatives observe from another room. These interviews are generally recorded using an audio-visual system, and observers document their observations according to each discipline’s requirements (Childsafe, 2020).

RESPONSE AND FOLLOW UP

Healthcare Professionals’ Role in Intervention and Response

Healthcare professionals are on the frontlines of providing direct patient care to human trafficking survivors and are uniquely positioned to recognize and respond. It is incumbent upon the provider to be aware of indicators of human trafficking, implement trauma-informed care for all patients, and refer individuals to other resources as needed. According to one study, 67% of survivors who were actively being exploited encountered healthcare professionals but their situation was not recognized (U.S. DHHS, 2023).

Survivor-Centered, Multidisciplinary Referrals

Every institution should develop a survivor-centered approach to victims of human trafficking. Providers should be prepared to make an immediate referral of patients to multidisciplinary community partners using a “warm hand-off”(transfer of care between providers in the presence of the patient) and a personal approach when a patient requests assistance. The patient may need an immediate referral for housing, legal assistance, a T visa application, advocacy, or a report to law enforcement. It is essential that the facility provide education and training to providers so that they are well-acquainted with local and state resources.

If the patient does not request immediate help, the treatment plan should still include referrals to comprehensive care services that are unique to the patient’s needs and sensitive to the patient’s circumstances. The goal of the provider is to treat the patient and offer information and support (HEALTrafficking.org, 2018).

Removing victims from exploitation is only the first step, and recidivism among trafficked individuals is common without multifaceted treatment for recovery and reintegration. Reintegration and recovery require economic and social inclusion, safe housing, a reasonable standard of living, and physical and mental well-being. Survivors also require opportunities to grow personally, socially, and economically and access to justice, education, and training. To succeed, survivors must have an environment that provides access to strong emotional and social support. Unfortunately, many survivors are not identified and, as a result, do not receive assistance. Others may be criminalized, and some decline assistance. The recovery trajectories for survivors are often complex and nonlinear (Surtees, 2021).

Reporting Trafficking in Texas

TRAFFICKING IN MINORS AND VULNERABLE ADULTS

Trafficking in minors (under the age of 18), including child sex or labor trafficking, is a form of child abuse and maltreatment. Suspicion of such crimes must be reported within 48 hours to the Department of Family and Protective Services (DFPS). In Texas, any citizen who suspects child abuse must make a report. Reporters who feel that a child is in imminent danger should call emergency services (911) first.

The same is true with suspicion of trafficking among vulnerable adults, such as those who are unable to provide for their own care or protection due to disability or aging. Texas law states that suspected abuse, neglect, or exploitation of a person who is 65 years or older or an adult with disabilities must be reported immediately to DFPS.

• Texas Abuse Hotline: 800-252-5400
• Website: txabusehotline.org
• Texas Relay Service: 7-1-1 or 800-735-2989 (voice or TTY)

Professionals must make a verbal report or online report of suspected abuse but do not need to follow with a written report. The reporter does not need to be certain of abuse and should report if they have a reasonable suspicion (TX DFPS, 2020).

Professional Mandated Reporters

Professional mandated reporters in Texas are defined as persons who are licensed or certified by the state, work for an agency or facility licensed or certified by the state, and have contact with children within the scope of their normal work. The law states that such professionals are required to make a report of abuse or neglect involving a child or a vulnerable adult themselves and may not delegate the duty to another person such as a coworker or family member.

Professional reporters include, but are not limited to:

• Teachers
• Nurses
• Doctors
• Daycare employees
• Employees of a clinic or healthcare facility that provides reproductive services
• Juvenile probation, detention, or correctional officers

Making a Report

It is recommended that the reporting party gather the following information before making the report:

• Names of the involved persons
• Dates of birth
• Social Security numbers
• Home address
• School or daycare
• Employer
• Primary language
• Disability or special needs

Confidentiality and Liability

DFPS is required to keep the reporter’s identity confidential. A person who knowingly files a false report may be subject to civil or criminal liability. If the DFPS determines that there is no abuse or neglect and the report was filed in good faith, the reporting party is protected from liability. In addition, an employer may not suspend, terminate, or discriminate against a professional who makes a suspected child abuse report in good faith (TX DFPS, 2020).

TRAFFICKING IN COMPETENT ADULTS

There are no specific reporting statutes for trafficking that might be applied to competent adult victims due to the assumption that competent adults have the right to privacy and agency. Therefore, the professional must obtain permission from the victim before making a report.

Professional reporters of child and vulnerable adult abuse in Texas are not obligated to report competent adult trafficking victims to law enforcement unless they are treating them for a gunshot wound or an overdose of a controlled substance, per the state’s health and safety codes 161.041 and 161.042 (Texas Statutes, 2020a, 2020b).

Instead, healthcare providers should use a trauma-informed approach to provide adult victims with information, resources, and options. Victim referrals should include direct service providers such as legal assistance, housing, advocacy, law enforcement, and the local or state hotline for human trafficking victims. Professional reporters may also make a confidential report to the National Human Trafficking Hotline (see below).

WHEN TO REPORT SUSPECTED HUMAN TRAFFICKING IN TEXAS

If patient is …	Then …
Minor (under age 18)	Report within 48 hours to law enforcement or the Dept. of Family and Protective Services
Competent adult	Report only with patient consent (but anonymous report to national hotline allowed)
Age 65 or over	Report immediately to law enforcement or the Dept. of Family and Protective Services
Vulnerable/disabled/dependent adult	Report immediately to law enforcement or the Dept. of Family and Protective Services
Being treated for a gunshot wound	Report immediately to law enforcement
Being treated for overdose of controlled substance	Report immediately to the Department of State Health Services (DSHS)

Implications of Law Enforcement Involvement

Involving law enforcement is mandatory in Texas if the human trafficking survivor is a minor or a vulnerable adult, but the arrest and criminalization of trafficked youth for commercial sexual activity typically compounds their trauma. Placement in the juvenile justice system also exposes trafficking victims to other youth detained for criminal acts.

In 2000, the federal Victims of Violence and Trafficking Prevention Act redefined the commercial sexual activity of minors as victimization as opposed to criminal behavior regardless of whether the child’s activity appeared to be voluntary. This law does not protect all minors from arrest under the age of 18 in Texas, however, because the age of consent is 17 according to the state law, and there are other laws that allow for children who are as young as 14 to consent to sexual activity as long as the other party is no more than 3 years older (Human Trafficking Search, 2020).

If the survivor is a competent adult, the healthcare professional must abide by the wishes of the survivor and also consider HIPAA privacy restrictions. Once police are involved, they are limited in their actions by the protections that are available to the survivor. Programs through Trafficking Victims Protection Act, Violence Against Women Act, and Deferred Action for Childhood Arrivals may apply, as may local safe harbor provisions (HEALTrafficking.org, 2018).

Immigrants may be assisted by the U visa or T visa program, but they also run the risk of being deported by Immigration and Customs Enforcement (ICE). If the patient has been charged with a previous crime, the law enforcement officer may be required to arrest the patient based on state or local law (HEALTrafficking.org, 2020).

If law enforcement is called to the clinical setting because of violence or suspicious activity, there is a risk that the patient’s trafficker will not allow the patient to return for care or that the patient may be harmed after leaving. It is important that the care provider and/or institution think carefully before involving law enforcement or security (HEALTrafficking.org, 2020).

Community, Local, and State Resources in Texas

The state of Texas is actively addressing the issue of human trafficking. Several organizations offer a variety of services.

• The Texas Human Trafficking Resource Center is an excellent resource for healthcare providers, Health and Human Services staff, community partners, and victims of human trafficking. The website provides links to local, state, and national resources that assist with human trafficking. It includes the 52-minute video Be the One, which focuses on prevention, recognition, and reporting of human trafficking.
• Polaris, the National Human Trafficking Hotline, provides a link to content specific to Texas and downloadable materials in several languages to print and distribute. Texas information includes statistics, events, and resources for the state.
• The Coalition to Combat Human Trafficking (CCHT) is a nonprofit organization whose focus is to educate, bring awareness, and provide direct assistance to victims of sex and labor trafficking. The organization partners with law enforcement, refugee services, faith-based programs, shelters, and advocacy groups (CCHT, 2022).
• Traffick911 is an organization in Northern Texas that provides direct services including crisis response, advocacy, case management, and mentorship to commercially sexually exploited children. They partner with first responders and are available to offer crisis services to children 24 hours a day.

(See “Resources” at the end of this course for website links/contact information.)

Organizational Protocols

Healthcare institutions are well-situated to address the public health issue of human trafficking. A task force of the Hospitals Against Violence (HAV) urged the Centers for Disease Control and Prevention to create an ICD-10-CM code that classifies human trafficking as a form of abuse, which was implemented in 2019.

Hospitals can establish identification and response protocols within their institutional settings and provide staff education to ensure that victims will be identified. Nurses and other healthcare professionals can work locally with law enforcement to insure a multidisciplinary collaborative response. At the state and national level, nurses can bring public awareness to the issue and lobby legislators to improve programs that assist victims. It is essential that healthcare professionals develop relationships with community partners and local resources as well (Zangerle, 2018).

In order to serve patients who are being exploited or vulnerable, a comprehensive, multidisciplinary approach is necessary. The goal of such a protocol is not to identify victims of labor or sex trafficking and elicit a disclosure. Instead, the purpose of the protocol is to promote the creation of procedures and an environment where victims may be safely treated as well as be supported to seek assistance and become educated about their options.

The protocol toolkit from HEAL Trafficking promotes a trauma-informed approach and defines human trafficking as a public health issue. Protocol aims include:

• Clarifying roles and procedures regarding identification and reporting
• Providing staff education to ensure a survivor-centered approach
• Improving staff ability to refer patients to housing, support, and other needs
• Maximizing safety by utilizing safety planning proactively
• Collaborating with other community partners such as social services, the district attorney, direct service providers, and law enforcement
• Collecting de-identified data for analysis with community partners and state authorities
  (HEALTrafficking.org, 2018).

National Human Trafficking Hotline

• Hotline number: 888-373-7888

This organization is not an investigative agency or affiliated with law enforcement. When a report is made to the National Human Trafficking Hotline, consent and safety are the most important elements that are considered. When a call is received, the following actions will occur:

• A skilled advocate will assess the circumstances for potential labor or sex trafficking of a person of any age, nationality, race, or gender. Whenever possible, the hotline personnel will speak directly with victims in order to discuss reporting and referral options and receive consent to act on that person’s behalf.
• If the victim is a child, the hotline advocate will immediately inform the appropriate authorities.
• When the hotline advocate determines that the call concerns a potential case of human trafficking, a supervisor is immediately alerted to begin coordinating a response. Action steps frequently include:
• A follow-up call to the caller (with their consent) for additional information
• A report to the designated law enforcement agency
• Coordination with service providers for emergency assistance or transfer to a service provider

Tips of suspected human trafficking may also be provided anonymously (NHTH, n.d.-b).

(See also “Resources” at the end of this course.)

CONCLUSION

The crime of human trafficking creates a ripple effect when the trauma of victims expands steadily in circles that encompass families, communities, and professionals who assist them. It is a crime associated with serious adverse mental and physical consequences and increased mortality in a cohort of individuals who may not define themselves as victims.

Change can only occur with a coordinated, multidisciplinary response and must include the efforts of professionals to learn to recognize the signs of human trafficking, take action in a trauma-informed manner when working with victims, and comply with mandated reporting laws.

In order to eradicate this form of human exploitation, legislators must continue to redefine our laws to protect the vulnerable; peace officers must enforce these laws; other members of society, such as healthcare practitioners, other mandated reporters, and citizens, must empathize with survivors; and prosecutors must hold offenders accountable.