Human Trafficking, a recent webinar series put on by the Missouri Nurses Association, highlighted the delicate and necessary role health care providers play in eradicating human trafficking. The series spanned four sessions covering an introduction to human trafficking for health care providers, case studies, screening examples and trauma responses, and investigations. Intervening human trafficking cases requires an understanding of what trafficking is, the effects of trauma, and the role providers play in providing support. Too often, failing to provide a safe environment or ask the right questions leads to delayed or missed intervention opportunities.

The series began with an introduction by Alison Phillips, director of the Missouri Attorney General’s Office Anti-Human Trafficking Task Force. Citing multiple studies, Phillips uncovered the alarming percentage of human trafficking cases undetected by health care providers. 88% of trafficking victims have had contact with a healthcare provider while being trafficked. 97% of victims who were seen by health care workers were never offered any help or resources.

“You as a health care worker are in a unique key position to identify and intervene on behalf of victims,” Phillips said. According to Phillips, Children’s Mercy Hospital in Kansas City identified 62 victims in 2019 and 58 in 2020. “That’s about one child a week for a year in one hospital in one city. I think if all hospitals had the same type of training and education, we could be helping a lot more people.”

The human trafficking training models presented in the webinar and used by Children’s Mercy KC and St. Luke’s Health System focus on trauma-informed, patient-centered approaches to care. Human trafficking can lead to chronic trauma, impacting a victim’s physical, mental, emotional, and behavioral health. Victims may not self-identify as a victim or realize they’ve been exploited, may not remember what happened to them, and/or may not trust health care providers. For these reasons, it’s necessary to approach potential trauma or trafficking with sensitivity and allow the patient to guide their care.

Looking at the Big Picture

Victims of human trafficking usually are not seeking help explicitly for their situation; often, victims come in for other unrelated emergencies. However, knowing warning signs of trafficking and how to ask appropriate questions can help connect missing pieces. Exploitation can be difficult to pinpoint if a victim does not offer that information, so understanding how trafficking works and what to look for can be instrumental in gathering necessary details.

By law, human trafficking is defined as: the recruitment, transportation, transfer, harboring or receipt of persons, by means of 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 the giving or receiving of payments or benefits to achieve the consent of another person having control over another person, for the purpose of exploitation. Exploitation shall include, at the minimum, the exploitation of prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude, or the removal of organs.

Essentially, there must be an act (recruitment/transport/harbor of victim), means (force, fraud, threat), and a purpose (forced labor, sexual acts, removal of organs) to be considered trafficking. The key element differentiating trafficking from sexual assault or other forms of abuse/neglect, which is how many cases are misidentified, is the exchange for something of value. It’s important to note that if the victim is a minor, force through coercion or other means does not need to be present as minors are not able to consent to sexual acts.

Presenter Heidi Olson, MSN, RN, CPN, SANE-P, is the Sexual Assault Nurse Examiner (SANE) program manager at Children’s Mercy KC. Her experiences working with both sexual assault and trafficking victims underscores the need to look at the bigger picture. In one example she provided, a teenage girl seeking care for sexual assault and suicidal ideations was brought into the emergency department by her mother. The attending nurse saw her prior history of sexual assault and decided to do a screening for potential trafficking. The screening, used in modified versions by the series’ presenters, features a range of questions pertaining to possible signs of abuse or exploitation. Examples of questions include asking about prior histories of running away, physical harm in relationships, forced sexual activities, or if they’ve ever been in a position where they traded a sexual favor in exchange for something they needed or wanted.

Though the girl appeared to need treatment for sexual assault, her screening results showed a high likelihood of exploitation. Per the hospital’s protocol, social workers and several other agencies were notified, and it was later discovered the mother may have played a role in her daughter’s trafficking. This discovery may not have been made if the nurse hadn’t recognized possible warning signs and had the forethought to do a screening.

In another example, a female teen at “flight risk” was brought in for a motor vehicle accident. During her intake process and initial interviews, many red flags and inconsistencies were documented, but none were immediately acted on. The patient’s story did not make sense, she had a history of trouble with law enforcement, the owner of the car involved in the accident was undetermined, among other strange details. “Someone should have stepped back and said, this is bizarre,” said Olson. “There’s a ton of things going on that say something’s not right.”

Throughout the process, multiple people and departments within the hospital and law enforcement worked with the teen but did not communicate with each other or connect the dots of what could potentially be going on. After discovering signs of sexual assault and getting in touch with the teen’s mother, Olson and the rest of the care team discovered more red flags that provided a clearer narrative.

Once Olson had a better understanding of the teen’s situation, and was able to ask the appropriate questions safely, the patient admitted to an exchange of sex for goods. “That is all I needed to know. Her saying yes to exchanging a sex act for value is trafficking,” said Olson. “And with a minor, you don’t have to have forced coercion. If they disclose yes to sexual trafficking, they cannot consent to that.”

Human Trafficking Red Flags

As demonstrated in these cases, individual instances of emergencies like sexual assault, suicidal ideations, motor accidents, etc. may seem like a one-off occurrence. It’s necessary to treat the whole person and look at the whole case to make connections that provide guidance, especially if the victim is struggling to engage. While human trafficking cases are sometimes difficult to identify at first, knowing what to look for and communicating with others working with the victim can help create a clearer picture. Treating patients individually within each department and procedure allows opportunities for crucial details to get lost or miscommunicated.

What red flags should providers look for?

  • Patterns in the patient’s history: prior abuse, sexual assaults, history of self-harm, running away, substance use, family involvement in harmful or unsafe living arrangements
  • Physical signs of harm or abuse, especially injuries that don’t match the victim’s story or are in different stages of healing
  • Behavioral concerns: inappropriately or sexually dressed, overly tired, withdrawn, bragging about having a lot of money or flashy gifts/clothing, hungry, using substances, carrying hotel room keys or excess cash, limited or scripted communication, attachment to cell phone
  • Emotional concerns: anxious, fearful, suicidal, mistrusting, angry, irritable, prone to outbursts or trauma reactions
  • Lifestyle concerns: new tattoo or brand, older boyfriend or friends with dangerous lifestyles, gang involvement, homeless or runaway, references to traveling to other cities, couch surfing, little or no access to health care
  • Inconsistencies in story, inability to remember details or events of recent days, clearly not from area or speaking the language, someone speaks for them, or resisting an interpreter

While these individual concerns may not indicate trafficking, a victim exhibiting a combination of these red flags may indicate a larger problem. In some case studies, signs of abuse combined with specific tattoos raised alarm that led to identifying trafficking. Tattoos often used by traffickers and pimps to dehumanize, label, or otherwise show ownership of their victims include barcodes, dollar signs, “daddy”, “pimping” or pimp/boyfriend names, “loyalty”, “property”, “whore life”, and five-pointed crowns. “I would want to see more [than just a tattoo] to know if this person is actually a victim, but a five-pointed crown in my mind has no other purpose,” Phillips said.

human trafficking body tags

Unfortunately, identifying trafficking isn’t as simple as asking a patient if they are a victim. In an example provided during the webinar, a patient was asked this and lied out of fear, causing human trafficking and assault to immediately be ruled out for the remainder of their assessment. However, in a similar example, a nurse trained in trauma-informed care was able to establish a sense of trust with a patient who had also lied. The patient eventually admitted that the “boyfriend” she told providers about was really her pimp, allowing them to begin appropriate interventions. “Listen to your gut,” said Olson. “If something seems off, pay attention to that. Being patient and kind goes such a long way with patients who have experienced a lot of trauma and unfortunately a lot of unkindness from health care professionals.”

Trauma-Informed Care

Trauma-informed care is an appreciation for the high prevalence of traumatic experiences lived by those seeking care. “We need to presume the clients we serve have a history of traumatic stress and exercise universal precautions,” said Jennifer Green, MSN-FN, BSN, BA, RN, SANE-A. Green is the Clinical Forensic Care Program Manager at Saint Luke’s Health System. According to Green, trauma is remembered by the body and providers can unintentionally trigger overwhelming feelings and reactions if not careful.

Many trafficking victims, and victims of trauma in general, are impacted by the trauma they’ve experienced. They may be hesitant to seek help or trust health care providers. For practitioners to ensure the cycle of harm isn’t continued within their walls, they need to be educated on trauma and equipped to navigate it. Victims often have urgent needs, especially if they are currently facing exploitation, and the first priority should be ensuring their safety, comfort, and confidentiality. Victims are more likely to engage and display trust if these needs are met. Identifying immediate needs can be guided by Maslow’s hierarchy:

  • Physiological: Does the patient have low blood sugar? Are they dehydrated? Are they exhausted?
  • Safety-related: Do they feel safe? Are they triggered? Are they angry?
  • Relational: Are they in need of connection? Do they need to feel validated/seen/loved?

Olson recommends pausing and considering what the patient has just experienced prior to coming in and [how] they will be engaged. “When they do not feel seen or heard, that’s when the lid is flipped,” she said. “When a doctor or nurse doesn’t listen to them, that’s what prompts that anger and sends them into fight or flight.”

Trauma takes a physical, mental, and emotional toll. It can affect memory and behavior, slow thought processes, cause difficulty making decisions or solving problems, and lead to withdrawal and silence, or extremely talkative behavior. Emotions can be irritable, anxious, depressed, helpless, hopeless, overwhelmed, guilty, confused. According to a study on childhood trauma, the number of children in the U.S. exposed to trauma within one year exceeds four million. Those that experience or witness trauma or grooming through sexual abuse are at greater risk for profound emotional, behavioral, physiological, cognitive, and social problems.

Those who don’t understand trauma may ask why a person who was being exploited or abused didn’t leave, but victims often form a trauma bond with their trafficker. According to Green, brains develop schema over time and if a child is traumatized repeatedly, the belief that this is the norm is established. For example, if a child is sexually abused by a parent for years, consistently forced or motivated into keeping quiet or being told it’s because they’re “too attractive”, a trafficker exhibiting the same behavior will feel familiar.

Attachment bonds are formed extremely young and establish schemas surrounding relationships. When victims experience a form of “love” or attachment similar to the abusive relationship they had with a parent figure, they may develop a similar attachment to their trafficker. “If something happens once, it may be a fluke, but if it happens over and over and over again, it builds a pathway and an outcome we come to expect over time,” Green said. “So when we have these children, where a dad or partner has done it and now a trafficker has done it, it reinforces the schema with themes of “other people will hurt me” and feelings of helplessness.”

Over time, the chronic trauma exhausts the neural pathways by constantly triggering fear and panic sensors, causing slowed development. Trauma and related dissociative disorders are often misdiagnosed as attention deficit disorders or anger issues because some symptoms may be present while trauma may be unrecognized or unacknowledged. Misdiagnosis can worsen existing issues, especially if medication is involved. Rushing a diagnosis without understanding the bigger picture counters a whole-person or trauma-informed approach.

Assessing Trauma

To prepare to assess trauma in a potential trafficking victim, the webinar demonstrated that providers must first apply the pillars of trauma-informed care:

  • Safety: Meet immediate patient needs to ensure they feel safe, stable, comfortable, and are aware of confidentiality. Repeat short statements such as “You are safe” and “I am here to help” – patients experiencing severe trauma may not be able to process complex sentences. Repetitive, calming validation can help de-escalate. Provide food, drinks, breaks, tissues, a place to regain composure, and the reassurance that they can ask for what they want or need. Never conduct interviews with the trafficker nearby.
  • Trustworthiness/transparency: Explain all procedures in terms they can understand and inform them how long procedures will take and what to expect. Describe their rights, the interview process, and roles of everyone involved in their care. Employ interpreters if their first language is not English. Ask consent before touching them every time.
  • Peer support: Enlist help of victim specialists when possible and connect survivors with social services. Be mindful they may have had negative prior experiences with health care professionals and may be afraid or distrustful.
  • Choice: Frequently remind the patient they are in the driver’s seat. They have the option to choose what kind of care they receive and to speak up if they need anything.
  • Collaboration: Encourage the person to ask questions and make decisions about their treatment.
  • Empowerment/voice: Trauma-informed care seeks to answer “what happened to you” versus “what’s wrong with you”. Consider body language and nonverbal cues. Ask if there is anything you should know prior to a procedure or if they have any preferences or difficulties with certain procedures.

Once a safe environment and trust has been established, a screening can be conducted to spot signs of trauma and exploitation. Screenings for children, like the one mentioned in the previous example, focus on identifying potential signs of abuse, exploitation, and patterns in their history that could be red flags.

At Children’s Mercy KC, Olson and other SANE providers will assess screenings for exploitation for all acute sexual assault victims and on a case-by-case basis. Social work services are immediately involved, and the following agencies are notified for child trafficking, exploitation, or pornography suspicions:

Adult screenings ask similar questions, usually including a more balanced emphasis between sex and labor trafficking. Screening questions for adults, other than those related to sexual acts, include inquiring about being tricked into jobs that don’t exist or situations they never wanted, being forced to commit acts to pay off a debt they can’t afford, or not being allowed to keep legal or identification documents, or talk to friends and family, among other things.

If adult patients answer yes to any screening questions, it’s a potential red flag for trafficking, especially if other signs are present. If they seem to be at-risk, Olson and Green recommend discussing referral options to specialists trained on human trafficking. Mandatory reports of abuse must be completed for minors and eligible adults.

Unfortunately, some patients may not disclose any information, especially if they don’t identify as a victim. It’s critical to continuously remind all patients, “I am a safe person for you and this is a safe place to receive care.”

Trafficking in Missouri

According to Phillips, the most present forms of trafficking in Missouri are labor trafficking (domestic services, agriculture, factory and farm work) and exploitation of migrant populations. Sexual exploitation in Missouri falls mostly under prostitution and escorting. 9000 illicit massage businesses were identified around Kansas City, St. Louis, and resort areas. Massage businesses highlight an intersection of sexual exploitation, forced labor, and taking advantage of someone’s migrant status. “A lot of these types of trafficking overlap,” said Phillips. “Where you see labor trafficking, you will likely see sex trafficking, and vice versa.”

Missouri has a landscape prone to trafficking – unfrequented rest stops, gas stations, and hotels along desolate truck routes are hot spots for traffickers to transport victims. According to Phillips, the opioid crisis in rural communities throughout Missouri also plays a role in familial trafficking. Familial trafficking occurs when a parent sells their child in exchange for having needs met, including receiving drugs or money. In areas with high rates of poverty and homelessness, instances of familial trafficking and running away are often higher.

To combat human trafficking in Missouri, Phillips recommends turning to grassroots activists in your community before turning to government representatives. “Representatives come up with their own solutions. The people with boots on the ground doing the work every day – they know what kind of legislation we need and are very rarely asked.”

The Attorney General’s Office is also working on a training program in partnership with Missouri Hospital Association with hopes of rolling it out this summer. A toolkit will be available with screening tools, hospital policies, resource guides, among other information. Complement to the toolkit will be a video training module series of 15-minute videos discussing what trafficking is, screenings for minors and adults, survivor experiences and their interactions with hospitals, working with law enforcement, and more.

Anyone can be a victim of human trafficking. For anyone with questions or concerns regarding trafficking, the National Human Trafficking Hotline (1.888.373.7888) is available 24/7 and offers additional resources and information in 200 languages. The Missouri Coalition Against Trafficking and Exploitation (MOCATE) offers a statewide resource guide organized by county and can assist with finding resources including housing, advocacy opportunities, and substance rehabilitation programs.

Learn more about the webinar series and access recorded presentations of each session here.