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Human Trafficking: Identifying and Assisting Potential Victims

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Duval County Medical Society CME Portal

Human Trafficking: Identifying and Assisting Potential Victims

Linda Edwards, MD1,
and Francys C. Martin, Esq., LHRM2

1University of Florida College of Medicine, Jacksonville, FL, 2University of Florida Self Insurance Programs, Gainesville, FL

Address Correspondence to:

Francys C. Martin, Esq., LHRM

P.O. Box 112735

Gainesville, Florida 32611
Phone: (352) 273-7006
Email: martinfc@ufl.edu

Date of Release: December 1, 2019
Date Credit Expires: January 1, 2022
Estimated Completion Time: 1 hour
Background:

The Duval County Medical Society (DCMS) is proud to provide its members with free continuing medical education (CME) opportunities in subject areas mandated and suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME). This month, the DCMS CME Portal includes an article, “Human Trafficking: Identifying and Assisting Potential Victims” authored by Linda Edwards, MD, and Francys C. Martin, Esq., LHRM, which has been approved for 1 AMA PRA Category 1 credit.TM For a full description of CME requirements for Florida physicians, please visit www.dcmsonline.org.

Faculty/Credentials:

Linda Edwards, MD is the Senior Associate Dean for Educational Affairs and Associate Professor for the Department of Medicine, University of Florida College of Medicine, Jacksonville, FL. Francys Calle Martin, Esq., LHRM is the Senior Loss Prevention Attorney and Vice President of Florida Academic Healthcare Patient Safety Organization.

Needs Assessment:

Human trafficking is believed to be one of the fastest growing illicit industries in the world. Yet, most data regarding human trafficking is only an estimation because of the underground nature of the crime. Physicians have a responsibility to be on the lookout for potential victims and respond appropriately with treatment and resources. To do so, they need to be able to identify potential victims and have knowledge of legal and social services.

Objectives:

1. Becoming familiar with the broad categories of human trafficking.
2. Demonstrate an understanding of the dynamics of human trafficking.
3. Learn how to identify potential victims of sex and labor trafficking.
4. Prepare yourself to assist potential victims and provide resources to them.

CME Credit Eligibility:

A minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted. If you take your test online, a certificate of credit/completion will be automatically downloaded to your DCMS member profile. If you submit your test by mail, a certificate of credit/completion will be emailed within 4 weeks of submission. If you have any questions, please contact the DCMS at 904-355-6561 or dcms@dcmsonline.org. 

Faculty Disclosure:

Linda Edwards, MD and Francys Calle Martin, Esq., LHRM report no significant relations to disclose, financial or otherwise with any commercial supporter or product manufacturer associated with this activity.

Disclosure of Conflicts of Interest:

St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee and other individuals who are in a position to control the content of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.

Joint Sponsorship Accreditation Statement:

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. The St. Vincent’s HealthCare (SVHC) is accredited by the Florida Medical Association to provide continuing medical education for physicians. St. Vincent’s Healthcare designates this educational activity for a maximum of 1 AMA PRA Category 1 credit.TM Physicians should only claim credit commensurate with the extent of their participation in the activity.

Under Florida Statutes, human trafficking is defined as the act of transporting, soliciting, recruiting, harboring, providing, enticing, maintaining, or obtaining another person for the purpose of exploitation of that person.1 Simply put, it is a form of modern-day slavery, as codified by the Florida Legislature.1 Physicians have a responsibility to be on the lookout for potential victims and respond appropriately with treatment and resources. To do so, they need to be able to identify potential victims and have knowledge of legal and social services.  

Human trafficking is believed to be one of the fastest growing illicit industries in the world. Yet, most data regarding human trafficking is only an estimation because of the underground nature of the crime. Traffickers range from opportunistic individuals to sophisticated criminal organizations, with activity around the globe. The resulting victimization is extreme and involves diverse populations with a host of needs. Under Florida Statutes, human trafficking is defined as the act of transporting, soliciting, recruiting, harboring, providing, enticing, maintaining, or obtaining another person for the purpose of exploitation of that person.1 Simply put, it is a form of modern-day slavery, as codified by the Florida Legislature.1

The Trafficking Victims Protection Act of 2000, also known as the TVPA, was the first comprehensive federal law to address trafficking in persons.2 The TVPA defines the federal government’s response to human trafficking, provides new immigration relief and benefits for eligible victims, and specifies crimes under which traffickers can be prosecuted. Since 2000, it has been expanded several times through the Trafficking Victims Protection Reauthorization Act to allow victims to sue their traffickers, create programs to shelter minors, implement prevention strategies including information about workers’ rights and systems of reporting, as well as creating programs to ensure U.S. citizens do not purchase products made by victims, and prevention of child marriage.3


Human Trafficking in Florida

In Florida, the primary method of capturing data on human trafficking of minors is through reports to and investigations by the Department of Children and Families. Over 2,000 reports of trafficking were received for the fiscal year of 2017-2018. 92 percent of these were classified as commercial sexual exploitation of children, and over 7 percent classified as labor trafficking.4 There is no comprehensive report that captures the trafficking of adults in Florida. According to a 2016 report on forced labor by the International Labour Organization, 40.3 million people across the globe are trapped in this form of slavery.5

 

The Dynamics of Human Trafficking

Human trafficking is classified into two general categories: sex trafficking and labor trafficking. These broad categories can be broken down into distinct forms of trafficking, each with their own specific way of operating. The Polaris Project, named for the North Star used by slaves to guide their way to freedom, is a nonprofit organization that provides information and resources regarding human trafficking. It has gathered information on over 32,000 cases since 2007, further classifying 25 different types of human trafficking, and publishing a report identifying the characteristics of each as well as the myths associated with human trafficking.6 Of these classifications, each has varying business models, trafficking profiles, recruitment strategies, victim profiles, and methods of controlling the victim. The 25 classifications of human trafficking compiled by Polaris are:


-  Escort Services

-  Illicit Massage, Health, and Beauty

-  Outdoor Solicitation

-  Residential Brothels

-  Domestic Work 

-  Bars, Strip Clubs and Cantinas

-  Pornography

-  Traveling Sales Crews

-  Restaurants and Food Service

-  Peddling and Begging

-  Agriculture and Animal Husbandry

-  Personal Sexual Servitude

-  Health and Beauty Services

-  Construction

-  Hotels and Hospitality

-  Landscaping

-  Illicit Activities

-  Arts and Entertainment

-  Commercial Cleaning Services

-  Factories and Manufacturing

-  Remote Interactive Sexual Acts

-  Carnivals

-  Forestry and Logging

-  Health Care

-  Recreational Activities


Healthcare Professionals: Assessing & Responding

Healthcare professionals are in a unique position to identify and assist victims of human trafficking. As frontline providers, you will likely encounter victims of sex trafficking and labor trafficking, and victims who may experience both, in your daily practice. Healthcare providers have earned a trusted status in our communities. For this reason, victims may be more likely to disclose their situation to healthcare providers because they believe their disclosure will be kept in confidence.

Conducting a full evaluation and asking a potential victim about their personal and work life can be crucial when there is suspicion of a trafficking situation. Traffickers significantly limit the contact their victims may have with others, so a healthcare provider may be the only contact the victim is permitted to have away from their captor. Victims of trafficking are also likely to be placed in dangerous situations, making it more likely that they will have contact with healthcare providers for injuries or care of diseases. In fact, a study published in the Annals of Health Law found that nearly 88 percent of trafficking victims were seen by healthcare providers while being trafficked, and of these, 68 percent were seen in the emergency department.7 Being able to identify some of the indicators of trafficking in both adults and minors will provide healthcare providers an early opportunity to assist victims and provide resources, for which protocols are available.8  

 

Sex Trafficking

Sex trafficking is identified as 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. A commercial sex act is any sex act for which anything of value (including but not limited to money, drugs, shelter, food, or clothes) is given to or received by any person.9 Florida has consistently been the third highest state for sex trafficking, behind California and Texas, with 261 cases reported in 2018.10 Sex trafficking can take place in a number of different venues and industries. In Florida, the top venues and industries for sex trafficking have been hotels/motels, residence-based commercial sex, illicit massage or spa businesses, escort services, and online advertising.11

Personal sexual servitude can take various forms, making the distinction between ongoing sexual abuse and personal sexual servitude complex, and different survivors may define their experiences differently. It can occur when an individual is permanently sold, often by their family to settle a debt, or to an individual buyer for the explicit purpose of engaging in sex acts. Traffickers are often members of an organized crime organization, smugglers, intimate partners, family members, or landlords. To control the victim, a trafficker may impose ongoing sexual assault, abuse, confinement, use of illicit drugs and/or alcohol, and withholding food or shelter.  Victims are frequently trapped due to insurmountable debts, and can be exploited for labor as well. Traffickers may also seek to earn a profit from distributing pornographic material featuring the victim, which may also include the production and distribution of child pornography. While most victims of sex trafficking are female, the rate of male victimization in personal sexual servitude is four times the rate of other sex trafficking types. In general, the rate of sex trafficking of men and boys is widely believed to be vastly underreported.12

Sex trafficking may also occur within organized residential brothels or private homes used more informally for commercial sex, and where a family member or intimate partner is trafficking the victim. In formal brothels, victims tend to be women and girls, typically from Latin America, Mexico, and Asia. In residences informally used as brothels the victim is typically a child, with boys making up a growing percentage. Victims are often recruited through fake romantic interests, false job offers, or promises of immigration.

Outdoor solicitation occurs when traffickers force victims to solicit sex in a public setting. In cities, this generally occurs on a particular block or area known for commercial sex. In rural areas, it frequently takes place at rest stops along major highways. This is one reason why truck drivers have been encouraged to receive education on human trafficking, which led to the creation of a national organization and state initiatives.13 Physical violence, as a means of controlling the victim, is used more in outdoor solicitation than any other type of trafficking.

Illicit massage, health, and beauty businesses may also function as legitimate businesses providing spa services, but also concealing the sex and labor trafficking of women trapped by these businesses. Although they appear to be single storefronts, the majority are controlled by a larger network, with a few people owning several businesses that provide the same services. Research suggests there are at least 7,000 trafficking storefronts in the United States, and possibly far more.6 The traffickers tend to be women of the same ethnicity, often having been trafficked themselves, and making it difficult to distinguish the victim from the trafficker.

 

What to Look For:

Sex trafficking victims may feel shame or fear and hesitate sharing their experience. Healthcare providers may notice multiple or recurrent sexually transmitted infections (STIs), vaginal or rectal trauma, multiple sexual partners, chronic headaches or abdominal pain related to stress, and tattoos that indicate some sort of ownership or property status. Behaviorally, victims may be depressed or demonstrate a flat affect. They may also have anxiety or panic attacks, irritability and aggression. In addition, there may also be a history of multiple emergency department visits and the patient is unable to explain injuries.14

 

Labor Trafficking

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. Since 2007, the National Human Trafficking Hotline has received reports of more than 7,000 labor trafficking cases in the United States. Florida had 58 cases of labor trafficking reported in 2018, primarily in the areas of agriculture, domestic work, hospitality, and construction.15

Because it is so labor intensive to harvest crops, victims become more susceptible to forced agricultural labor or exploitation. The exploitation often occurs via a contract that promises an hourly pay rate, but then pays the victim by the amount harvested. They are often charged exorbitant fees for their travel or boarding, leaving them unable to pay back their trafficker that further entraps them. The trafficker may be a contractor, subcontractor, grower, or buyer.  Victims are disproportionately male Latino migrant workers in the U.S. on a seasonal visa.  Traffickers control their victims by exploiting their visa status, stealing their wages through improper deductions, or refusing to pay hourly rates, and isolating them in rural areas.  Medical care is often inaccessible or not offered at all by the trafficker, making this victim population more difficult to find and identify.6

Domestic workers often live within their traffickers’ households and serve as cooks, maids, nannies, and caretakers for the elderly or infirm. This type of labor trafficking may also occur in the context of intimate partner violence or forced marriages as a means of maintaining control over the victim. The traffickers are generally wealthy diplomats, royalty, or staff of international organizations, making the victim even more vulnerable to their influence. Victims are predominantly middle-aged women from the Philippines recruited through a temporary work visa. They are often forced to work 12-18 hours per day for little or no pay. They are isolated and very often have their wages stolen or travel documents taken from them. Domestic trafficking victims are often trapped in servitude for years, even decades.16

Hospitality businesses such as hotels, resorts, or casinos also have a significant number of labor trafficking victims working most frequently in housekeeping. Most are women and men from Jamaica, the Philippines, and India. About 46 percent of cases are male and 69 percent are female. These statistics are non-cumulative and include both human trafficking and labor exploitation cases. These cases also reference multiple victim populations. Very often, they have been promised lucrative wages they plan to use to support family back home. Traffickers are often subcontractors that provide labor to the hotel, meaning the hotel is not aware of the abuse and the victim is left with little support to assist with any grievances.17

Labor trafficking in the construction industry usually occurs within small contracting businesses working on both large construction sites and private homes. Employers will often classify the victim as an independent contractor, or pay them under the table, thereby limiting their access to protections and benefits, as well as any assistance from labor organizations. The majority of victims are men from Mexico, El Salvador, Honduras, and Guatemala, who have visas or are undocumented. They are very often controlled through fraud regarding the amounts they will be charged for visas, recruitment fees, or illegal migration. Payment is often withheld and they are threatened with deportation.18

 

What to Look For:

Patients who are victims of labor trafficking may present with musculoskeletal and ergonomic injuries, as well as malnutrition and dehydration because they are not permitted time to eat or drink.


Injuries including poor dental hygiene, skin infections, and chemical or pesticide exposure are left untreated and often advanced. They may also have visual difficulties from straining their vision in dark, unlit factories. Behaviorally, they may appear anxious or exhibit paranoid behavior, and give conflicting stories about their injuries.14

 

Child Trafficking

Child trafficking is distinct and separate from the other categories of human trafficking. When trafficking involves a child under the age of 18 who has been subjected to a commercial sex act, they are considered a victim regardless of the use of force, fraud, or coercion. Children are more susceptible than other demographics. In fact, most cases of sex or labor trafficking began when the victim was between the ages of 15 and 17.15 Thus, the “means” in child trafficking may be easily defined as taking advantage of the vulnerability of a minor. Common risk factors for child trafficking include children who frequently run away, and those who have experienced sexual abuse, sexual assault, or rape. Those who identify as LGBTQ are particularly susceptible, making up 40 percent of homeless youth nationally, and are over seven times more likely than peers to experience sexual violence, and are three to seven times more likely to engage in sex to meet basic needs.16

 

What to Look For:

Common behavioral indicators include avoiding answering questions, appearing frightened, resistant, or belligerent toward authority, seeming coached, and preoccupied with money. Behavioral indicators are infinite, as each child will react differently to trauma. Physical indicators of child trafficking may be more easily ascertainable and may include: possessing large amounts of cash, multiple cell phones, or hotel keys; presence of a controlling or abusive adult or unrelated children; a symbol tattooed, burned, or branded; references to traveling to other cities or states; appearance not fitting their current situation, for example a homeless child who has money, electronics, new clothes or shoes; or a child who presents alone or with an unrelated adult. If a child exhibits a combination of risk factors, behavioral indicators, and physical indicators, the healthcare professional should make diligent efforts to ensure the child is kept in a safe place until authorities can properly intervene and confirm the suspicions of trafficking.

 

Helping Patients

If a patient presents to your facility with indicators for human trafficking, first make sure their immediate safety is secured and their primary health concern is addressed. Many facilities already have processes in place for addressing trafficking concerns, or may have personnel trained in addressing trauma who may also be helpful. When performing your initial assessment, remember that the purpose of this is to create a safe environment and begin to build a relationship of trust, not to rescue the patient. They may not feel they can be safely rescued, as the trafficker has often accompanied them, or may fear for the safety of others. Remain conscious of the language you use, understanding that they may not identify as victims or as trafficked, and simply remain open to providing them the care and resources they request at that time. If the patient will be returning, every effort should be made to coordinate those services and visits with other healthcare providers, social workers, and behavioral health professionals given the patient’s likely inability to remove themselves from their captor with any regularity. A directory of Florida agencies and services has been compiled by the U.S. Department of Health and Human Services with all necessary contacts and links.17

Reporting to state regulatory bodies or law enforcement may be mandated given the patient’s age or presentation. If so, the event should also be reported to the National Human Trafficking Hotline. If reporting is not mandated, and the patient does not wish for you to report, provide them the contact information for the National Human Trafficking Hotline. Calls to the National Human Trafficking Hotline are confidential unless there is imminent danger to the patient or others, or there is a life threatening emergency. 

Polaris operates the National Human Trafficking Hotline that can be reached by calling 1-888-373-7888 and the BeFree textline that can be reached by texting 233733 to report a tip or to obtain services in the victim’s area.18 The Department of Homeland Security also maintains the Blue Campaign to end human trafficking and suspected human trafficking can be reported to Federal law enforcement at 1-866-347-2423.19

Pursuant to Florida’s 2019 Human Trafficking Bill,20 healthcare professionals licensed by the Boards of Medicine, Osteopathic Medicine, and several other boards are required to complete one hour of continuing education and post a sign about human trafficking in their office by January 1, 2021.21 A download of the sign and additional resources, education, and training on human trafficking for healthcare providers are available from the Florida Department of Health.22 Any of the organizations referenced herein can direct healthcare providers to state and local resources available to potential victims.  

1. Human Trafficking, Florida Statute 787.06. (2019)

 

2. Trafficking Victims Protection Act of 2000, 22 USC § 7102. (2000)

 

3. Trafficking Victims Protection Reauthorization Act of 2003, 22 USC § 7101, Trafficking Victims Protection Reauthorization Act of 2005, 22 USC § 7101, Trafficking Victims Protection Reauthorization Act of 2008, 22 USC § 7101.

 

4. Statewide council on human trafficking 2018 annual report 2018: Florida: an all hands on deck approach to combat trafficking. Statewide Council on Human Trafficking; 2019 Jan. 40 p.

 

5.  Global estimates of modern slavery: forced labour and forced marriage. Geneva (CH): International Labour Organization and Walk Free Foundation; 2017. 68 p.

 

6. Anthony B, Penros JK, Jakiel S, et al. The Typology of Modern Slavery: Defining Sex and Labor Trafficking in the United States. Polaris; 2017 Mar. 80 p.

 

7. Lederer L, Wetzel, C. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law. 2014 Jan;23(1):61–91.

 

8. Framework for a human trafficking protocol in healthcare settings [Internet]. National Human Trafficking Resource Center. [cited 2019 Aug]. 1 p. Available from:

https://traffickingresourcecenter.org/sites/default/files/Framework%20for%20a%20Human%20Trafficking%20Protocol%20in%20Healthcare%20Settings.pdf.

 

9. Trafficking Victims Protection Act of 2000, as amended by the Justice for Victims of Trafficking Act of 2015, 22 USC § 7102.

 

10. National Human Trafficking Hotline. Sex trafficking [Internet]. 2019 [cited 2019 Aug]. https://humantraffickinghotline.org/type-trafficking/sex-trafficking.

 

11. National Human Trafficking Hotline. Florida statistics [Internet]. 2018 [cited 2019 Aug]. Available from: https://humantraffickinghotline.org/state/florida.

 

12. Willis B, Robert N, Friedman S. ECPAT-USA and Boys Too. Brooklyn (NY): ECPAT-USA; 2013. 20 p.

 

13. Truckers against Trafficking [Internet]. 2019 [cited 2019 Aug]. Available from: https://truckersagainsttrafficking.org.

 

14. Alpert EJ, Ahn R, Albright E, et al. Human Trafficking: Guidebook on Identification, Assessment, and Response in the Health Care Setting. Boston (MA) and Waltham (MA): MGH Human Trafficking Initiative, Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts Hospital and Committee on Violence Intervention and Prevention, Massachusetts Medical Society; 2014 Sep. 56 p.

 

15. 2017 statistics from the National Human Trafficking Hotline and BeFree textline. Polaris; 2018. 4 p.

 

16. Sex trafficking and LGBTQ youth. Polaris; 2019. 3 p.

 

17. Florida: efforts to combat human trafficking. Administration for Children & Families; 2017 Jul 31. 2 p.

 

18. Polaris Project. National human trafficking hotline [Internet]. 2019 [cited 2019 Aug]. Available from: https://polarisproject.org/get-assistance/national-human-trafficking-hotline.

 

19. Department of Homeland Security. Blue campaign [Internet]. 2019 [cited 2019 Aug]. Available from: https://www.dhs.gov/blue-campaign.

 

20. Chapter 2019-152, Florida Law. (2019)

 

21. Florida Department of Health. Human trafficking [Internet]. 2019 [cited 2019 Aug]. Available from: http://www.flhealthsource.gov/humantrafficking/#home.

22. Florida Department of Health. Resources and training [Internet]. 2019 [cited 2019 Aug]. Available from: http://www.floridahealth.gov/programs-and-services/prevention/human-trafficking/resources.html.

To take the test and earn CME credit, click here.

1. Physical indicators of child trafficking include:

a.       Possessing large amounts of money

b.      Symbols that are tattooed, burned, or branded

c.       Presenting to the visit alone or with an unrelated adult

d.      All of the above

 

2. The first federal law to address the trafficking of persons in the United States was passed in 2000 and was called:

a.       The Children and Families Act

b.      The Trafficking Victims Protection Act

c.       The Victims Act

d.      The Prevention of Modern Day Slavery Act

 

3. According to the 2016 report by the International Labour Organization, how many people are trafficked across the world:

a.       30 million

b.      5 million

c.       40 million

d.      15 million

 

4. The Polaris Project provides information and resources on human trafficking and has identified how many different types of human trafficking?

a.       55

b.      2

c.       15

d.      25

 

5. In one study, 88% of trafficking victims were seen by a healthcare provider while being trafficked. 68% of these were seen in the:

a.       Operating Room

b.      OB/GYN Clinic

c.       Emergency Department

d.      Ophthalmology Clinic

 

 

6. Florida has consistently been the third highest state for sex trafficking, behind these two states:

a.       California and Texas

b.      California and New York

c.       Texas and Georgia

d.      Texas and Virginia

 

7. In order to control the victim, traffickers may utilize the following tactics:

a.       Abuse and violence

b.      Illicit drugs and alcohol

c.       Withholding immigration documents and money

d.      All of the above

 

8. Cases of labor trafficking in Florida are found primarily in the areas of agriculture, domestic work, hospitality, and construction.

a.       True

b.      False

 

9. Most cases of sex or labor trafficking began when the victim was between the ages of:

a.       1 and 3

b.      15 and 17

c.       5 and 6

d.      10 and 12

 

10. Calls to the National Human Trafficking Hotline are confidential unless:

a.       There is imminent danger to the patient

b.      There is imminent danger to others

c.       There is a life threatening emergency

d.      All of the above