Human trafficking is an abusive and exploitative form of interpersonal violence. It is a global public health problem associated with a multitude of health problems. The United States (US) recognizes both labor trafficking and sex trafficking as “severe forms of trafficking in persons” punishable under federal and state laws. Under the US Trafficking Victims Protection Act (TVPA) of 2000 and its subsequent reauthorization acts, as amended (22 USC § 7102):

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  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,” and

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  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.” ^,

Federal law assumes that persons under the age of 18 years performing commercial sex acts have been induced to engage in commercial sex and does not require that force, fraud, or coercion be proven for minors to be considered victims of sex trafficking. (Pursuant to Pub. L. 106-386, 114 Stat 1469 (2000), a commercial sex act refers to “any sex act on account of which anything of value is given to or received by any person.”) Antitrafficking legislation since the TVPA of 2000 has focused further attention on prosecution, protection, and prevention of child trafficking. The Justice for Victims of Trafficking Act of 2015 authorized a range of provisions for combating trafficking and assisting victims, including an amendment to the Child Abuse Prevention and Treatment Act of 1988 by which the legal definition of child abuse and neglect was expanded to incorporate “sex trafficking” and “severe forms of trafficking in persons” involving minors. Although mandated reporting statutes vary across jurisdictions, all states, the District of Columbia, and US territories mandate the report of suspected child abuse and neglect to the proper authorities.

Finally, it is important for providers to understand that the law differentiates between human trafficking and human smuggling. Whereas human trafficking involves the exploitation of a victim for compelled labor or commercial sex, human smuggling involves a person contracting a smuggler to facilitate their voluntary and illegal entry into a country. Although human smuggling is a crime of migration committed against the state (not against a person), persons smuggled across international borders may be subjected to labor or sex trafficking during transit or upon arrival at their destination. Under these circumstances, their voluntary consent to smuggling does not render legal their subsequent entrapment in forced labor or commercial sex and such individuals are considered victims of the crime of human trafficking under federal law. Understanding this distinction is important to educating victims about their legal rights and linking them to services where they can access the legal protections and redress to which they are entitled.

The US Department of State has determined that human trafficking is an umbrella term that comprises a number of different forms of compelled service including forced labor, bonded labor (debt bondage), domestic servitude, sex trafficking, child sex trafficking, forced child labor, and child soldiering. Exploitation of adults and children in the United States has been reported in typically formal labor markets (e.g., restaurant and hospitality, construction, agriculture, farming), informal labor sectors (e.g., domestic work, landscaping, traveling sales crew, peddling rings), and commercial sex industries. In the United States, the illegal commercial sex economy may involve street-based commercial sex, brothels and cantinas, technology-facilitated rendezvousing, escort services, adult entertainment venues, child sex tourism abroad, live-streaming of child sexual abuse, and child and adult pornography. ^{, ,} Additionally, nail salons, massage parlors, health spas, and other unregulated bodywork businesses can serve as storefronts for both labor and sex trafficking. ^,

Prevalence estimates of human trafficking are historically wide-ranging and influenced by multiple factors. Data integrity and reliability are challenged by the clandestine nature of human trafficking, the failure to use a standardized definition of trafficking across organizations and countries, the focus of the data collecting agency (i.e., law enforcement versus social service agency, labor versus sex trafficking, adults versus minors), and the lack of centralization or even compatibility across databases. In 2016, the United Nation’s International Labor Organization in collaboration with the Walk Free Foundation and International Organization for Migration (IOM) estimated that 24.9 million persons around the globe are trapped in forced labor, including sexual exploitation. According to this study, women and girls account for 71% and children account for 25% of victims, and nonsexual forced labor comprises the majority of cases. Centralized, reliable, high-quality data are needed to enhance our understanding of the scope of the problem globally and within individual countries.

Polaris, a US nongovernmental organization (NGO), has been monitoring human trafficking and operating the National Human Trafficking Hotline (NHTH) in the United States since 2000. Although reporting hotlines fail to capture all cases of trafficking, statistics from the national trafficking hotline offer relevant proxy data regarding the extent of the problem. According to published hotline statistics, nearly 52,000 situations of human trafficking involving one or more victims were identified across the US and US territories between December 2007 and December 2018. In 2018 alone, the NHTH identified over 23,000 individual survivors of human trafficking, 64% of whom were survivors of sex trafficking, 24% labor trafficking, and 6% both forms of trafficking.

Within the subset of tip calls received by the national hotline for which survivor demographic data are available, the majority of survivors are adults (≥18 years), female, and Latinx. Extrapolation from the limited data suggests that the average age (mode age range) at the onset of trafficking was 25 (15–17) years old for labor trafficking and 18 (15–17) years old for sex trafficking. ^, Given the challenges in collecting comprehensive and accurate information, demographic data from identified and reported cases in any local or national database may not accurately reflect the overall demographics of US trafficked persons.

Although human trafficking can affect persons of any age, gender identity, sexual orientation, ethnicity, race, citizenship, socioeconomic standing, religion, and physical or intellectual ability, certain populations are at greater risk for trafficking. Circumstances that place individuals at risk for trafficking are those that increase their dependence on others to meet their basic needs or obtain something of value. Box 187.1 lists factors associated with increased vulnerability to human trafficking. ^,

Traffickers entrap and maintain control over victims of human trafficking in multiple ways. Figure 187.1 summarizes the constellation of methods used, which often extends to financial disempowerment, debt bondage, coerced involvement in illegal activities, blackmail, and a host of other criminal tactics. ^{, ,}

Polaris Human Trafficking Power and Control Wheel.

Adapted from Polaris and available for download at https://humantraffickinghotline.org/resources/human-trafficking-power-and-control-wheel .

According to 2018 NHTH data, the top labor trafficking recruitment methods used, in order of reported frequency, included false job offers or advertisements, false promises/fraud, smuggling-related initiation, coercion, and familial inducement.

In nearly 12,000 cases of child trafficking , data from the Counter-Trafficking Data Collaborative suggest that children are most commonly trafficked by family members (41%), intimate partners (14%), and friends (11%) by means of psychological abuse (24%), physical force (16%), sexual violence (10%), and substance-related coercion (9%).

Research has established a correlation between substance use and human trafficking. A retrospective chart review of 12- to 18-year-old victims of sexual violence found that drug use rates were significantly higher among commercially sexually exploited and trafficked youth compared to sexually abused and assaulted youth.

The complex relationship between substance use and human trafficking has been increasingly recognized and understood. Substances can play a key role throughout the various stages of trafficking, including in the recruitment, entrapment, and exploitation of victims. Highly addictive substances (e.g., opioids, stimulants) provide a relatively easy opportunity for traffickers to entrap experimenting adolescents and young adults by exploiting newly evolving addictions. In cases where the trafficker is someone close or known to the individual being targeted for recruitment, the trafficker may be the person who introduces the addictive substance and encourages its use with the intent of creating a vulnerability to exploit. Similarly, previously formed addictions offer traffickers a mechanism through which they can entrap individuals with addiction for the purpose of exploiting them.

In addition to facilitating recruitment and entrapment, victim accounts suggest substances may play a central role in maintaining control over trafficked persons. In some cases, traffickers force drug-naïve victims, particularly adolescents, to use substances as a means of weakening their defenses and creating an addiction that can be leveraged to exert control over them during their exploitation. In other cases, the trafficker may simply ensure substances are available and trafficked persons may initiate use on their own as a way to cope with the physical and emotional trauma of their trafficking situation. Victims’ reliance on substances to numb their pain and cope with the anxiety, depression, and PTSD related to their everyday experiences while trafficked creates high levels of dependence on the trafficker for access to the drug. Traffickers are thus able to exert and maintain control over trafficked individuals by regulating the type (drug class), manner (route of administration), and extent (dosage and frequency) to which the substance is available to them.

In addition to mental health disorders potentially heightening risk for trafficking, the traumatic experiences endured by victims while being trafficked may induce or unmask mental health disorders. Trafficking may exacerbate preexisting mental health disorders and lead to increased frequency or severity of psychiatric manifestations. In a historical cohort study of trafficking survivors receiving mental health services in the United Kingdom, the most commonly encountered diagnoses in the adult sample included 34% affective disorders; 28% PTSD, severe stress, or adjustment disorder; 15% schizophrenia and related disorders; and 22% intentional self-injurious behaviors. Similarly, 27% of the youth in the study were diagnosed with affective disorders and another 27% with PTSD, severe stress, or adjustment disorder. Among youth, 27% exhibited intentional self-harm while in care. In a US study among court-involved commercially sexually exploited female youth, 88% endorsed substance use, 76% identified with having a mental health problem, 43% reported previous psychiatric admissions, and 14% reported suicidal ideation.

Anecdotally, traffickers can use a victim’s mental illness to remain undetected. A trafficked person who presents to an ED providing accounts of seemingly unrealistic events may be erroneously assumed to be suffering from acute paranoid delusions, persecutory delusions, or hallucinations. Any inconsistencies in their accounts might even raise suspicion among providers of malingering for secondary gain rather than memory gaps related to trauma. Subsequent attempts to obtain assistance in the ED may be misdiagnosed as episodes of acutely decompensated psychiatric illness rather than real life events related to being trafficked. In this manner, traffickers can continue their abuse and control with less concern that the veracity of a victim’s report will be investigated.

Trafficked adolescent and adult women often experience decreased ability to negotiate condom use during transactional sexual encounters, ^, as well as decreased access to family planning services and prenatal care. ^, Decreased reproductive control and diminished access to family planning services theoretically increases the likelihood that trafficked women may present to an ED for such services (e.g., counseling about alternative discrete forms of contraception, STI screening and treatment, HIV counseling and testing, and emergency contraception). Moreover, lack of access to prenatal care is associated with adverse pregnancy outcomes, including insufficient gestational weight gain, premature rupture of membranes, and precipitous labor, and these outcomes may be at play among trafficked women who present to the ED in the later stages of pregnancy seeking to either initiate prenatal care or deliver.

For trafficked adolescent and adult women, desires to carry or terminate a pregnancy are influenced by the circumstances of their trafficking situation, but such decisions may be unduly influenced by traffickers. As in intimate partner violence, pregnancy also carries an increased risk of trafficker-perpetrated abuse and violence, which in turn is related to increased risk of preterm labor, small-for-gestational-age infants, postpartum depression, and decreased likelihood of breast-feeding. ^, Pregnant and postpartum women who present to an ED for violence-related injuries should be queried about other potentially exposed children. Limited evidence suggests that traffickers may use pregnancy and children (e.g., threats of forced abortion, threats to take away children, threats to cut off financial support) to exert and maintain control over their mothers. ^{, , ,}

Little is known about the experiences of trafficked women’s children in the United States. An exploratory study in 2016 found that children of sex workers or trafficked mothers experience significant health risks and outcomes, including behavioral and mental health problems, physical and sexual abuse, the use of cough medicine, alcohol, and other sedating substances to induce sleep, death from a wide range of causes including neglect (e.g., exposure after being left in a car, house fire after being left home), untreated HIV, poisoning, overdose, lethal physical abuse (e.g., abusive head trauma, previously shaken baby syndrome ), and gang-related murder.

The ED care of a trafficked person involves providing appropriate emergency medical care for the chief complaint, while respecting the patient’s goals for the encounter. ED evaluation may include addressing acute medical issues, evaluation of possible untreated chronic medical problems, documentation of acute and remote injuries, STI testing and treatment, and consideration of a sexual assault medical forensic examination and evidence collection. For both labor and sex trafficking, empirical STI treatment and emergency contraception may be indicated.

When a case of suspected human trafficking has been identified, a sexual assault medical forensic examination may be clinically appropriate. Research shows that the use of sexual assault or forensic nurse examiners results in better patient outcomes in legal and emotional support. To the extent that the resource is available, EDs may preferentially offer this service or consider transfer to a crisis center.

Trauma-Informed Approach to Care

Studies of trafficked persons have demonstrated the critical importance of using trauma-informed approaches to care. ^, The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma as “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” Trauma results in neurobiologic changes such that commonly occurring smells, sounds, sights, and procedures of the ED environment may be perceived as threats by those with trauma histories, including trafficked persons. For example, a patient who appears to be uncooperative, avoidant, jumpy, or agitated, may instead be manifesting a natural “fight,” “flight,” or “freeze” stress reaction.

Sincere, empathetic, nonjudgmental communication is the foundation of trauma-informed care. This includes clinician awareness and mitigation of conscious and unconscious biases, including their manifestation in body language and word choice, in order to prevent retraumatization of trafficked persons. ^{, ,} Loss of control is a major part of the trafficking experience and the medical environment can exacerbate those feelings. Therefore, emergency clinicians should look for and offer choices when possible, helping the patient regain a sense of autonomy. Clear communication about the clinical team composition, the care plan, events to expect, and possible timeline, allows a trafficked patient to feel a sense of control. ^{, ,}

Helping a traumatized patient to feel safe and calm includes a mindfulness of a patient’s stress reactions, including demeanor, speech, and even pulse rate. When these reactions are observed, clinicians may respond using psychological first-aid techniques of connectedness, calmness, safety, structure, self-efficacy, and hope ( Fig. 187.2 ). Potentially triggering environmental factors could include the visibility of security guards who may remind the patient of prior traumatizing law enforcement experiences. Trauma-informed approaches are especially important for the agitated patient with an experience of trauma. Beginning with de-escalation and psychological first-aid techniques can mitigate retraumatization and should be balanced with staff safety concerns. If restraints are necessary for the safety of the patient and staff, use of the least restrictive measures possible is recommended.

Statement or action examples grounded in psychological first-aid principles.

Adapted from: Fischer KR, Bakes KM, Corbin TJ, Fein JA, Harris EJ, James TL, Melzer-Lange MD. Trauma-informed care for violently injured patients in the emergency department. Annals Emerg Med . 2019 Feb 1;73(2):193-202.

The Privacy, Educate, Ask, Respect, and Respond (PEARR) tool provides a trauma-informed framework for the clinician assessing any form of interpersonal violence, including human trafficking. The first step of the PEARR tool is to find a place to speak to a patient alone, explaining any limits to confidentiality with the patient before beginning this sensitive discussion. The clinician attempts to educate the patient regarding abuse, neglect, or violence in a nonjudgmental and normalized manner, and then asks about the patient’s personal experience. The patient may or may not disclose their exploitation experience at this point in time. The final step involves ongoing respect of the patient’s wishes and responding according to their goals. It is common for patients experiencing interpersonal violence, including trafficking, to choose to return to their exploiter. If a patient denies victimization or declines assistance, and there are persistent concerns about abuse, neglect, or violence, then the clinician may offer the patient information about resources that can assist in the event of an emergency (e.g., local service providers, crisis hotlines).

Multidisciplinary Response

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