Human trafficking is a crime in which force, fraud, or coercion is used to compel a person to perform a commercial sex act or forced labor. Sex trafficking is the recruitment, harboring, transportation, provision, obtaining, patronizing, advertising, or soliciting of a person for the purpose of a commercial sex act, in which the commercial sex act is induced by force, fraud, or coercion. If a person younger than 18 is induced to perform a commercial sex act, it is a crime regardless of whether there is any force, fraud, or coercion. Labor trafficking (also known as forced labor) 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 purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.

There is new evidence that trafficking victims seek care for acute and chronic health problems including injuries, illnesses, and impairments at hospitals, clinics, and other healthcare providers. For example, in recent surveys, interviews, and focus groups, survivors of human trafficking said they had visited clinics for contraception of all kinds, mainly condoms, birth control pill, and IUD; for pregnancy diagnosis; for STD testing, treatment, and referral; and sometimes for basic or health primary care. Survivors said that they also sought breast and cervical cancer screening and infertility testing and services, sometimes when they were still trapped in trafficking, more often when they were no longer being trafficked but had not disclosed what had happened to them. Healthcare providers are “first responders” and have unique opportunities to intervene and to offer assistance and resources to trafficking victims. For this reason, healthcare providers and staff should be trained to recognize the signs of human trafficking and how to respond appropriately.

Spotting the indicators of human trafficking should begin with the first contact with the client. Each person in the clinic has a role and responsibility to identify signs and indicators, beginning with the scheduler. Some signs the scheduler, receptionist, and in-take staff might note would be:

• No Identification: Driver’s License, passport, social security card, other papers
• Escorted or guarded by someone
• Someone else speaks for the client
• No identifiable address or home
• Disoriented, unable to identify whereabouts, unable to identify family and friends
• Wearing inappropriate clothing for the season or place
• Age inappropriate partner or significant other
• Signs of physical abuse: bruises, cuts, burns, broken bones
• Signs of self-harm: e.g., scars from repeated cutting

Sometimes indicators of trafficking may emerge when the client describes the chief complaint. These could include:

• Clear Demonstration or Articulation of Fear, Anger or other Hyper-emotion
• Serious Injury or Illness from Hazardous Conditions at Workplace
• Complications from Surgical or Chemical Abortion
• Multiple Visits for STDs in Short Period of Time
• Vaginal or Anal Injury

As the clinician takes the medical history – or looks at the medical records of the client if they have been to the clinic before, some key indicators may emerge. These include (for sex trafficking):

• Multiple sex partners
• Multiple unintended pregnancies
• Multiple miscarriages
• Multiple past abortions
• Multiple Sexually Transmitted Infections
• Multiple types of contraception used simultaneously or serially
• Multiple use of Plan B or other emergency contraception
• Multiple use of RU 486 or other chemical abortifacient
• Multiple UTIs
• History of substance abuse
• History of drug overdose
• History of homelessness

In addition to the indicators noted during scheduling, check-in, taking of the medical history some indicators of human trafficking may emerge during the medical exam itself. These include:

• Signs of physical abuse: bruises, cuts, burns, broken bones, wounds or scars from a weapon
• Injuries from violence or hazardous work conditions
• Gynecological complications: cysts, fistula, vaginal fissures
• Pelvic inflammatory disease, pelvic pain
• Vaginal injuries, bleeding, or tissue damage
• Foreign objects in vagina (sponges, etc.)
• Anal injuries, bleeding, or tissue damage
• Serious communicable diseases such as hepatitis or tuberculosis
• Dermatological issues such as scabies or lice
• Signs of self-harm: e.g., scars from repeated cutting
• Suicidal ideation or suicide attempt

• Serious communicable diseases such as hepatitis, tuberculosis, and malaria
• Inflicted and/or work-related injuries
• Substance use disorders
• Untreated chronic medical conditions,
• Malnutrition,
• Toxic exposures (e.g., pesticides, lead, chemicals, dust, silica, mercury)
• Malnutrition, weight loss or stunted growth
• Dehydration
• Exposure (to heat or cold)
• Over-use injuries, loss of function
• Chronic pain
• Untreated or late-presenting acute or chronic conditions

Yes. Federal law states that in any case of a child being sold by trafficker to a buyer or any case of commercial sex between a buyer and a child, the child is a victim of human trafficking under the Trafficking Victims Protection Act of 2000. Force, fraud, or coercion is not required. Enforcing this law has been a huge challenge in cities across the United States. Unfortunately, some jurisdictions still place minors in detention for the crime of prostitution, even though the child is the victim. Under federal law, the trafficker and the buyer are criminals, and the child is a victim when a child is being purchased for sex.

The Trafficking Victim Protection Act notes that victims of trafficking are often forced through physical violence to engage in sex acts or to perform slavery-like labor. Force includes rape, and other forms of sexual abuse, torture, starvation, imprisonment, threats, psychological abuse and coercion. A victim-centered approach seeks to minimize re-traumatization of the trafficking by providing the support of victim advocates and service providers. In a victim-centered approach, the victim's concerns, safety, and well-being take priority in all matters and procedures. The Department of Justice Office of Victims of Crime describes a victim-centered approach as the systematic focus on the needs and concerns of a victim to ensure the compassionate and sensitive delivery of services in a nonjudgmental manner.

Healthcare providers are mandated reporters for child abuse and, in some states, other kinds of abuse. As such, they are required to report suspected abuse, including some forms of human trafficking. Know your federal and state mandated reporter laws. There are new federal laws related to child abuse and human trafficking. For example, the Justice for Victims of Trafficking Act (JVTA) of 2015 amended the Child Abuse Prevention and Treatment Act of 1974 (CAPTA) to include child sex trafficking as a form of child abuse under federal law. Follow the guidelines that are already in place for reporting child trafficking as child abuse. Remember: It is a misdemeanor criminal offense to fail to report suspicions of child abuse or neglect. Especially in the case of child sex trafficking it is important to report even if someone says it has already been reported.

No single organization or entity can respond comprehensively to a trafficking victim’s needs. Communities need to deliberately create systems that make connections if they do not already exist. Ideally, these connections are established before there are identified victims. Healthcare providers need to be a part of any community coalitions that are already in place to help trafficking victims. One of the first steps to assisting trafficking victims is connecting them with organizations and government agencies with the training and resources to respond to their needs. In many DHA facilities, partnerships with community organizations, including Memos of Understanding, are already in place and can be utilities to connect trafficking victims and survivors with additional needed services.

Victims of labor trafficking very rarely come forward on their own, but further, the population most DHA clinics serve would rarely encounter labor trafficking victims. However, in situations where they might, it is important to note that many victims do not know that they are a trafficking victim, either because they are unfamiliar with U.S. law or because they believe they consented to the situation by initially accepting a job offer from the trafficker. In addition, traffickers exert a level of control that prevents most labor trafficking victims from revealing what is happening to them even when they encounter law enforcement or service providers, out of fear of retaliation. The fact that victims rarely report this crime makes it especially important for Clinic providers to recognize the signs of labor trafficking and know how to respond. When a foreign-born victim of trafficking comes to the clinic, if possible, provide the healthcare services sought. Then, connect your client to an NGO that works with foreign born labor trafficking victims. Under the Trafficking Victims Protection Act, foreign born victims of trafficking are entitled to benefits if they are applying for or have received continued presence or a T visa. They need to obtain a certification letter from the U.S. Department of Health and Human Services (HHS). This letter grants them a Social Security number, work authorization, case management, and access to benefits equivalent to those of a refugee.

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule permits certain disclosures to report injury or abuse. For examples, HIPAA permits disclosure in the following circumstances:

• Reports of child abuse or neglect
• Disclosures required by law
• Disclosures agreed to by the individual
• Disclosures necessary to prevent harm
• Reports of crime in emergencies

Human trafficking can also be reported without violating HIPAA regulations if no identifiable health information is divulged. In addition, if mandatory reporting requirements dictate, a mandated reporter must report.

To connect with local anti-trafficking community organizations, find out if the community your DHA facility is in has a coalition or task force to combat trafficking in persons. If there is one, attend the next Coalition meeting. This is the one of the best ways to identify many of the organizations providing services to trafficking victims. Another way to locate human trafficking resources in the community is to do some basic research and outreach to NGOs in your local community and neighborhood.

Healthcare providers play a vital role in identifying, treating and assisting victims of trafficking. By creating a welcoming and trusting atmosphere and adopting a victim-centered approach, healthcare providers can assist in preventing, reducing, and ultimately putting an end to human trafficking. As one survivor said, “The clinic was the first place that seemed to actually see me as a person. The nurse saw that I was frightened and listened to me. It was the first time I thought about telling someone what was actually happening.”