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).