Practice Tip of the Week | Human Trafficking Intervention in Nursing

By Jason Spees, MSN, MaOM, APRN, L.Ac., FNP-C, Dipl. Ac. & C.H.

Human trafficking (HT) is a form of human exploitation of one person by another using some type of force, fraud, or coercion to compel them to perform a labor or sex act for something of value. ¹ The American Academy of Nursing on Policy and the American Nurses Association recommends nurses to have increased education and the development of advocacy and expertise in human trafficking. ^2,3 Below are practice tips for a nurse to remember when a suspected or confirmed patient experiencing HT arrives in the clinical environment.

Identification

The exploitation of humans is clouded by social myths and sensationalism. ^4-6 Sensationalism takes an extreme form of a phenomenon and presents it as typical. It can dull the lens a nurse uses to identify less obvious forms of trafficking, such as the production and sale of child sexual abuse material, familial trafficking, or the labor trafficking of an adult housekeeper. The nurse must have a calm and dispassionate approach to evaluating a potential trafficking situation.

After a review of the medical record for red flags and risk factors of labor or sex trafficking, the nurse should assess their basic and medical needs first, starting with what is most important to the patient. ^7-9 Then, the nurse may develop an index of suspicion for HT by asking general questions about how the patient makes money, what their relationships are like, and what their living conditions are. ^10-12 Responses may lead to further questions and prompt the use of a validated screening tool such as the Trafficking Victim Identification Tool, Rapid Appraisal for Trafficking, or the Six-Item Screening Questionnaire. ^13-15

Sometimes, a trafficker may accompany the patient. ¹⁶ If the trafficker is a family member, the nurse’s detection may be impaired by the presumed healthy relationship between them. ⁸ There are not clear guidelines for identifying minors affected by familial trafficking but there are risk factors such as parental substance use, poverty, or other adverse child experiences that may help to determine likelihood. ¹⁷ It is essential to try to separate the person from their trafficker, citing policy or asking the patient to leave the room “for a urine sample,” to create privacy. ^8,16

Trauma Informed Care

When seeking to help a person who is experiencing trafficking, the nurse must create medical trust with the patient. ¹⁸ Designing a space where the patient feels comfortable is key. ⁹ Support them by fulfilling their basic needs, offering resources, making appropriate referrals and restoring their agency as much as possible. ¹⁹ Ways to bridge trust include providing privacy and offering them choices such as leaving the door open or closed, asking them where they would like to sit, or asking them an open-ended question about what you may do to help them feel more comfortable. ^9,16 Make eye contact, using reflective listening. ^8,9

The nurse must also self-reflect to dismantle any biases or “rescue mentality” they may have of trying to save a patient from trafficking. ^20,21 A rescue attempt is an intervention that the patient may or may not want and might serve to break medical trust or be perceived as a threat to their survival. ^22,23 Be aware the patient may have complex reasons for not disclosing their situation and adjust your approach accordingly. ^11,16 Do not ask for unnecessary details of trauma so as not to re-traumatize the patient. ^9,24

Response

Use the same language that the patient uses such as their stated name and pronouns. ⁸ If they refer to the trafficker as their boss, pimp, or boyfriend, then reflect back those same words. ⁷ If possible, have a provider of the same gender and race. ²⁵ Use interpreters for second language English speakers. ^7,11 Follow mandatory reporting laws. Do not try to get the patient to disclose their trafficking status or accept help or resources if they are not ready. ^7,10 Reaffirm that your clinical space is safe and that you care about them. ²⁰  Offer the Human Trafficking Hotline and text number. ¹² Your note is a legal document and should be unbiased and written carefully. ²⁶ Be careful to not use legal language i.e., “allegedly,” “perpetrator,” and do not jump to conclusions. Place what the patient says in quotation marks and note their mood. ¹²

Safety

Let the doctor, advanced practice registered nurse, or physician assistant you are working with know about your suspicion for HT and work together with them. Nurses should follow policies and protocols within their institution. If there are none, approach management and stakeholders about creating one. ^7,27 All policies should be informed by survivors. ^9,20,28 Use ICD-10 codes with caution as the trafficker may have online access to the portal or discharge paperwork. ^29,30 Inform the patient of what you are documenting, its potential impact, and give them a choice in degree of detail recorded when possible. ²⁹

The nurse’s role, while potent, is limited. The clinical encounter is a single point in time along the road in the patient’s recovery, which involves multiple disciplines. People who are recovering from HT may leave the life and then return to it several times before fully exiting or sell sex on their own after. ²⁵ Many survivors have to learn basic life skills and need support in terms of appointment flexibility, extra help with access to medications or resources for food and housing. ^7,25 These tips are supplementary material for a full course on human trafficking.

REFERENCES

1.            Office of Trafficking in Persons. What is human trafficking? 2023. https://www.acf.hhs.gov/otip/about/what-human-trafficking

2.            Speck PM, Mitchell SA, Ekroos RA, Sanchez RV, Messias DKH. Policy brief on the nursing response to human trafficking. Nursing Outlook. 2018;66(4):407-411. doi:10.1016/j.outlook.2018.06.004

3.            American Nurses Association. American Nurses Association takes action on critical public health issues. 2019.

4.            Community Psychology. Rethinking Human Trafficking Representation. 2024. https://www.communitypsychology.com/rethinking-human-trafficking-representation/

5.            Polaris. Myths, facts, and statistics. 2023

6.            Wallinger C. Media Representation and Human Trafficking: How Anti-Trafficking Discourse Affects Trafficked Persons. 2010. https://www.google.com/url?sa=t&source=web&rct=j&opi=89978449&url=https://digitalcommons.unl.edu/cgi/viewcontent.cgi%3Freferer%3D%26httpsredir%3D1%26article%3D1003%26context%3Dhumtrafconf2&ved=2ahUKEwjKnorepK6GAxWB4skDHUSBBuQQFnoECC0QAQ&usg=AOvVaw3r7bNwMxxS_mhhFJUnLlW_

7.            Cutuli L. Core competencies for human trafficking response in health care and behavioral health systems. 2021

8.            Greenbaum J, Kaplan D, Young J. Exploitation, labor and sex trafficking of children and adolescents: health care needs of patients. Pediatrics. 2023;151(1):e2022060416.

9.            National Human Trafficking Training and Technical Assistance Center. Adult Human Trafficking Screening Tool and Guide. 2018. https://nhttac.acf.hhs.gov/resources/toolkit-adult-human-trafficking-screening-tool-and-guide

10.         Sabella D. The Role of the Nurse in Combating Human Trafficking. AJN American Journal of Nursing. 2011;111(2):28-39. doi:10.1097/01.NAJ.0000394289.55577.b6

11.         Hodge DR. Assisting Victims of Human Trafficking: Strategies to Facilitate Identification, Exit from Trafficking, and the Restoration of Wellness. Social Work. 2014;59(2):111-118. doi:sw/swu002

12.         Byrne M, Parsh S, Parsh B. Human trafficking: Impact, identification, and intervention. Nursing Management. 2019;50(8)

13.         Greenbaum VJ, Dodd M, McCracken C. A short screening tool to identify victims of child sex trafficking in the health care setting. Pediatric emergency care. 2018;34(1):33-37.

14.         Chisolm‐Straker M, Singer E, Strong D, et al. Validation of a screening tool for labor and sex trafficking among emergency department patients. Journal of the American College of Emergency Physicians Open. 2021;2(5):e12558.

15.         Simich L, Goyen L, Powell A, Mallozzi K. Improving human trafficking victim identification: Validation and dissemination of a screening tool. Vera Institute of Justice New York, NY; 2014.

16.         Peck JL, Meadows-Oliver M, Hays SM, Maaks DG. White paper: Recognizing child trafficking as a critical emerging health threat. Journal of Pediatric Healthcare. 2021;35(3):260-269. doi:10.1016/j.pedhc.2020.01.005

17.         White CN, Robichaux K, Huang A, Luo C. When families become perpetrators: A case series on familial trafficking. Journal of Family Violence. 2024;39(3):435-447.

18.         Pearce JJ. Working with trafficked children and young people: Complexities in practice. British journal of social work. 2011;41(8):1424-1441.

19.         Busch-Armendariz N, Nsonwu MB, Cook Heffron L. Human trafficking victims and their children: Assessing needs, vulnerabilities, strengths, and survivorship. IDVSA Journal Articles. 2011;

20.         Richie-Zavaleta AC, Villanueva AM, Homicile LM, Urada LA. Compassionate care—going the extra mile: sex trafficking survivors’ recommendations for healthcare best practices. Sexes. 2021;2(1):26-49.

21.         Polaris. Language Matters: 5 Ways Your Words Impact Trafficking Survivors. 2024. https://polarisproject.org/blog/2023/01/language-matters-5-ways-your-words-impact-trafficking-survivors/

22.         Balgamwalla S. Trafficking Rescue Initiatives as State Violence. Penn St L Rev. 2017;122:171.

23.         Balgamwalla S. Trafficking in Narratives: Conceptualizing and recasting victims, offenders, and rescuers in the war on human trafficking. Denv L Rev. 2016;94:1.

24.         Office of Trafficking in Persons. ASK: Screen and identify individuals who may have experienced trafficking using a trauma-informed, person-centered approach. Administration for Children & Families. 2024. 

25.         Nichols A, Edmond, T., Heil, E. Social Work Practice with Survivors of Sex Trafficking and Commercial Sexual Exploitation. Columbia University Press; 2018.

26.         Isaac NE, Enos VP. Documenting domestic violence: How health care providers can help victims. US Department of Justice, Office of Justice Programs; 2001.

27.         Scannell M, MacDonald AE, Berger A, Boyer N. Human Trafficking: How Nurses Can Make a Difference. Journal of Forensic Nursing. 2018;14(2):117-121. doi:10.1097/JFN.0000000000000203

28.         Cutbush S, Desselle LM, Larson M, D’Arcangelo B. Standards of Care for Anti-Human Trafficking Service Providers: Literature Review. 2023.

29.         Greenbaum J, McClure R, Stare S, Barnes W, Castles C, Culliton E. Documenting ICD codes and other sensitive information in electronic health records: guidelines for healthcare professionals who encounter patients with a history of human trafficking or other forms of violence. HEAL Trafficking, International Centre for Missing and Exploited Children. 2021.

30.         Greenbaum J, Garrett A, Chon K, Bishop M, Luke J, Stoklosa H. Principles for safe implementation of ICD codes for human trafficking. Journal of Law, Medicine & Ethics. 2021;49(2):285-289.