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The Health Care Providers Role in Management and Prevention of Human Sex Trafficking Kristen Dela Cruz Vanguard University of Southern California


The goal of this research paper is to explore what human sex trafficking is, what has been done so far to terminate it, and what role health care providers can play in that fight. This paper will define sex trafficking and identify who is affected by it and where it happens. Signs and symptoms of sex trafficking victimization will be explained, along with what actions health care providers can take once victims have been identified. The importance of counseling, treatment, and rehabilitation will be explored, as well as the significance of policy and protocol change in handling sex trafficking victims. This paper implies that future research into effective training procedures for health care providers on the subject of sex trafficking victim identification and rescue is needed.

HEALTH CARE PROVIDERS AND SEX TRAFFICKING The Health Care Providers Role in Management and Prevention of Human Trafficking Seventeen-year-old Sarah is approached at the mall by a charming young man, offering her a job as a waitress in his local restaurant. Sarah is intrigued. She is sick of witnessing her parents endless fighting and wants to save enough money to move out after graduation. A few days later, persuaded by the prospect of making some extra money this summer, Sarah calls the man back and he confirms that they are still looking for waitresses to start immediately. He tells her to meet him at his restaurant, which is a fancy place on one of the upper floors of a nearby hotel. The man ushers Sarah out of the elevator and along a hallway, speaking on his cell phone as she looks ahead for signs of a restaurant entrance. It all happens so fast: a door suddenly opens to her right and she is shoved in and held at gunpoint. The restaurant owner is nowhere to be seen, and these new men force her at gunpoint to drink bottles of vodka and take blue pills that make her groggy and disoriented. She was not brought here to work as a waitress, but as a prostitute. Human trafficking is fundamentally a form of modern slavery, and according to the United Nations it is the fastest-growing international crime industry (Moynihan, 2013, para. 3). While drugs can essentially be sold just once, a human trafficking victim can be sold repeatedly. An estimated 27 to 29 million people are currently being trafficked from 127 to 137 different countries, and in 2008 this international trade is estimated to have generated $32 billion in profit for traffickers (Eccleston, 2013, p. 40); it is likely that $7 to $10 billion is earned annually from sex trafficking in the U.S. alone (McClain & Garrity, 2011, p. 244). It is also estimated that 28% of trafficking victims come into contact with the health care system at least once during their captivity. Although the magnitude of this violation of human rights is mind-boggling, nurses and health care providers around the world are still comparatively uneducated on the topic and

HEALTH CARE PROVIDERS AND SEX TRAFFICKING untrained in handling this issue and assisting victims who come into their care (Moynihan, 2013, para. 3). This demonstrates that there is a significant opportunity for health care providers to manage and prevent sex trafficking. Resources should be assembled and utilized to train health care providers in identifying victims, familiarizing themselves with services for counseling and recovery, and working for policy changes within their workplaces and communities. Human trafficking is the process of obtaining people and transporting them with the intention of selling them for involuntary and unpaid labor (McClain & Garrity, 2011, p. 243). It is considered a form of slavery because the victims are detained and made to work by dishonest means, often under threats of violence or through psychological manipulation (Moynihan, 2006, p. 100). Human sex trafficking, therefore, is the acquisition, coercion, and selling of people for sex, whether it be prostitution, pornography, escort servicing, or exotic dancing (McClain & Garrity, 2011, p. 243). Many still believe that this is a crime committed in other parts of the world. It has, however, been recently recognized in the United States as a serious issue (Moynihan, 2013, para. 8), especially since the Internet has made it possible to sell adult services as easily and anonymously as household goods (McClain & Garrity, 2011, p. 244). Factors such as poverty, lack of resources, and potential victims unawareness of danger (Moynihan, 2013, para. 6) contribute to this criminal issue, no matter the location. Victims are often enticed by hopes of a well-paying job that will provide them with improved living conditions and quality of life. Some parents believe their childs only chance for a better life is to leave home and find opportunities elsewhere, and may naively send them into dangerous trafficking traps. There are even parents who, out of desperation, willingly sell their own children (Moynihan, 2013, para. 6).

HEALTH CARE PROVIDERS AND SEX TRAFFICKING According to McClain and Garrity (2011), traffickers frequently recruit victims from areas that are considered vulnerable due to greater rates of homelessness, poverty, lower literacy rates, and drug use. These areas often have quick access to highways or waterways, making it easier for traffickers to transport victims to cities with high demand. The cities that are considered high demand are usually near military bases, conventions, large sporting events, truck stops, and tourist destinations (p. 244). The human price of sex trafficking is still unknown. This lucrative multi-billion dollar criminal industry sentences its victims to disease, substance abuse, abortion, suicide, depression, and the psychological effects of sexual assault, interpersonal violence, and forced violence (Moynihan, 2006, p. 100). Ninety-five percent of sex trafficking victims withstand sexual or physical abuse at the hands of their traffickers (Moynihan, 2013, para. 7). They are often stripped of their freedom and live in substandard conditions. Those who might have occasional contact with the outside world may be too frightened to seek help or escape, due to psychological intimidation and manipulation. Isolation, lack of support from family and friends, and the resulting increase in vulnerability decreases victims chances of escape. Exposure to diseases transmitted sexually and by close contact (such as tuberculosis, HIV/AIDS, etc.) creates public health implications for both the victims and their customers (Moynihan, 2013, para. 7-9). Thus far, the domestic and international approach to fighting sex trafficking has been focused on costly and dramatic raids (Soderlund, 2005). The well-publicized abolitionist raids focus [more] on the moment of the raid (p. 65) and less on what happens to victims after the raid. More resources are used to rescue rather than rehabilitate victims. It is not generally advertised that rescue escapes are common. When faced with fear of punishment, lack of support, no autonomy or guidance, poverty, and the prospect of low-income work opportunities,

HEALTH CARE PROVIDERS AND SEX TRAFFICKING the likelihood of that victim to return to some type of prostitution is high (p. 66, 81). While recognizing that rescue is obviously a priority, Soderlund suggests that more efforts should be made to empower survivors to participate in their own liberation (p. 83). Health care providers may not be raid participants, but they are still very much in a position to rescue victims and guide them toward rehabilitation. Professor Barbara Moynihan, BSN, MSN, PhD has had a long nursing career dedicated to helping victims of violence and sexual assault. She insists that health care providers can help this cause by learning how to identify signs and symptoms of victimization. If a victim is allowed to seek health care by their trafficker, nurses and other health care providers that are alert for clues can help this victims ordeal come to an end. If they miss these clues, the victim will return to their sexual slavery with no certain opportunity for escape in the future. Health care providers should be watchful for signs that vary among the physical, nonverbal, hidden, and vague: An unclear chief complaint and unwillingness to communicate or comply with treatment Injuries and trauma not consistent with patient history Bruises, fractures, scars, cigarette burns, malnutrition, poor dental health, tattoos (may be the mark of a pimp) Infections and poorly treated wounds, communicable diseases (e.g. tuberculosis), uncontrolled chronic conditions (e.g. diabetes), panic attacks, and stress-related disorders Students who frequently visit the nursing office claiming to feel ill and wanting to leave school History of recurrent absences and academic failures

HEALTH CARE PROVIDERS AND SEX TRAFFICKING Adolescents seeking contraception or STD treatment, women and adolescents with a history of multiple pregnancies and abortions Abnormal vaginal discharge, chronic cervical and vaginal infection, recurrent urinary tract infections, pelvic inflammatory disease, pain during intercourse, and STDs Women and adolescents accompanied by an older boyfriend, a large age gap in an intimate relationship, a youth traveling with an older companion who is not their legal guardian Adolescents and children with a history of sexual abuse, substance abuse, family violence, homelessness, and chronic running away Adolescents and children with access to material goods that a youth could not afford (McClain & Garrity, 2011, p. 246) When asked what the most challenging part of this battle is, Professor Moynihan responded that it is often difficult for health care providers to remain unbiased when dealing with victims of sex trafficking. Most providers do not recognize that this person has been subjected to the most egregious treatment [and] may not trust the provider (B. A. Moynihan, personal communication, June 15, 2013). It is important to hone and use assessment skills for recognizing signs and symptoms of victimization because the victim, out of fear, may withhold information or be reluctant to comply. Once a patient is suspected of being a victim of sex trafficking, a basic screening can be done by asking questions regarding living situation, where meals are obtained, freedom to come and go, ability to socialize, presence of threats, and being forced to do anything unwillingly (McClain & Garrity, 2011, p. 247). Forensic nurses can use their expertise to present analysis of medical evidence in court when prosecuting traffickers, and by collaborating with law

HEALTH CARE PROVIDERS AND SEX TRAFFICKING enforcement officials to help determine how best to build programs and policies for protecting victims (Moynihan, 2006, p. 101). Health care providers must also familiarize themselves with resources available for counseling, treatment, and recovery to which they can refer victims once they have been correctly identified. There are several hotlines and organizations that are dedicated to assisting victims of sex trafficking and abuse, offering long-term counseling and treatment. It may need to be emphasized that most are not affiliated with law-enforcement, as some victims may fear that they will be charged and punished for prostitution if they seek help (McClain & Garrity, 2011, p. 248). These resources cover basic victims needs including shelter, nourishment, medical care, safety, language interpretation, legal assistance, counseling, and income support (Isaac, Solak, & Giardino, 2011, p. 11). From October 2002 to January 2003, the National Institute of Justice initiated the National Assessment of Service Providers and Trafficking Victims. This assessment revealed that several barriers stand in the way of victims receiving proper services. Nurses and other health care providers should be aware of these barriers in order to better overcome them: Inadequate resources, funding, training, and knowledge of victims rights No formal rules or regulations, no in-house protocols for dealing with victims Unproductive collaboration with Federal and local agencies Language and safety concerns Victims legal status Isolation and lack of support (p. 12-16) Some service providers with ulterior agendas have even made deals with pimps: in exchange for being allowed to distribute condoms and safe-sex education (the

HEALTH CARE PROVIDERS AND SEX TRAFFICKING accomplishment of which makes their cause look good), they agreed to ignore victims and neglect giving them information about resources for escape (Hodge, 2008, p. 148) The last and most overlooked action that health care providers can take in the fight against sex trafficking is working for policy change within their own hospitals and clinics. Health care teams can work together to create standard operating procedures for handling sex trafficking victims, so that facilities can develop a culture of proactive assistance. Maintaining these protocols and sharing them with other facilities can make it easier for future victims to be rescued and receive the care and assistance they need (Moynihan, 2013, para. 21-22). Isaac, Solak, and Giardino (2011) suggest that the Houston Rescue and Restore Coalitions H.E.A.R training program would benefit health professionals worldwide, and facilitate increased awareness of human sex trafficking and competence in assisting victims. The H.E.A.R acronym stands for: Human trafficking and health professionals; Examine history, examine body, examine emotion; Ask specific questions; and Review options, refer, report. This program consists of a one-day training session with case studies and multimedia tools, and a newsletter that is sent out to various healthcare facilities that will address the topic and evaluate short-term and long-term outcomes of the program (p. 24-27). Evidently, solid efforts are being made to manage and prevent sex trafficking, but it will take a lot of time and energy for this global crime industry to be brought to an end. Health care providers can do their part to rescue each victim that comes into their care. If this action is taken globally, then progress can be made towards a world free from sex-slavery. But for every victim rescued several remain enslaved. What, if anything, can be done for these victims? Rekart (2005) takes the stance that although sex-work is not to be condoned, it is a reality and it is

HEALTH CARE PROVIDERS AND SEX TRAFFICKING dangerous. He argues that assistance can and should be given outside of the health care or law enforcement realm. He puts forward that the physiological and psychological harms that sex workers are exposed to can be mitigated through education, prevention, care, empowerment, occupational health and safety, decriminalization, and human-rights activism (p. 2123). Rekart (2005) suggests that it is imperative to teach both sex workers and sex work customers about the importance of safe sex, in order to alleviate the spread of infectious disease. Anonymous telephone hotlines can be a source of information for potential and actual victims, as well as their loved ones. Areas with a high demand for trafficking can benefit from friendly walk-in clinics or shelters with available counseling and basic health care. The presence of these types of facilities may encourage victims to get help, and may often be the only opportunity for victims to be rescued. In communities where it is common for children and adolescents to be sold into prostitution out of desperation for money and food, resources are needed to provide them with condoms, health care, and sex education. These, Rekart maintains, are all ways that health care providers can give their services to sex trafficking victims outside of the hospital or clinic setting (p. 2130). Human sex trafficking remains prevalent and far-reaching. The sheer magnitude of the situation can be overwhelming to someone just beginning to open their eyes to it. Professor Moynihans advice for nurses who would like to become involved in the fight against human sex trafficking is to take the first step of learning about it. Then, she recommends looking into the Polaris Project, which is a non-governmental organization that works to provide assistance to sex trafficking victims and spread awareness about their cause. Moynihan also lists the International Association of Forensic nurses (IAFN), the Department of Health and Human Services in Washington, D.C., and the Half the Sky Initiative as reliable resources. For those who wish to


HEALTH CARE PROVIDERS AND SEX TRAFFICKING obtain more facts about this issues prevalence in the United States, the Trafficking in Persons (TIP) Report is an annual update on the state of human trafficking in the U.S., and can be found at this website: (B. A. Moynihan, personal communication, June 15, 2013). In one of her articles, Moynihan (2013) quotes a popular story that may have been heard before in different contexts. But she believes it can be applied well to the human tragedy of sex trafficking: A man is walking on the beach and notes that the beach is covered with starfish that have washed up in the tide. He observes a little boy picking them up and tossing them back into the water. Why are you doing that, he asks the little boy. There are so many that you cannot make a difference. The boy looked at him and threw another starfish into the ocean. It made a difference to that one, he said. (para. 26) Human sex trafficking seems an overwhelmingly large issue to tackle, as it is an issue that spreads internationally, it often operates under clandestine conditions that are difficult to penetrate, and the world has not yet come to a unified or effective front against it. It is also an uncomfortable subject that people generally dont like to discuss, which perpetuates the lack of awareness and action. But great strides can and will be made if the worlds health care providers take the initiative to stay informed and act on behalf of the victims who may not be able to act for themselves.


HEALTH CARE PROVIDERS AND SEX TRAFFICKING References Eccleston, D. (2013). Identifying victims of human trafficking. Community Practitioner, 86(5), 40-42. Retrieved from Hodge, D. R. (2008). Sexual trafficking in the United States: A domestic problem with transnational dimensions. Social Work, 53(2), 143-52. Retrieved from Isaac, R., Solak, J., & Giardino, A. P. (2011). Health care providers training needs related to human trafficking: Maximizing the opportunity to effectively screen and intervene. Journal of Applied Research on Children: Informing Policy for Children at Risk, 2(1). Retrieved from McClain, N. M., & Garrity, S. E. (2011). Sex trafficking and the exploitation of adolescents. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 40(2), 243-252. Retrieved from Moynihan, B. A., (2006). The high cost of human trafficking. Journal of Forensic Nursing, 2(2), 100-101. Retrieved from Moynihan, B. A., & Amenta, E. (2013, January 12). Stolen lives: What nurses can do to stop sex trafficking. Reflections on Nursing Leadership, 38(3). Retrieved from rafficking.aspx Rekart, M. L. (2006). Sex-work harm reduction. The Lancet, 366, 2123-2134. doi:10.1016/S0140-6736(05)67732-X


HEALTH CARE PROVIDERS AND SEX TRAFFICKING Soderlund, G. (2005). Running from the rescuers: New U.S. crusades against sex trafficking and the rhetoric of abolition. NWSA Journal, 17(3), 64-87. Retrieved from