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American Academy of Nursing on Policy, Council for the Advancement of Nursing Sciences| Volume 66, ISSUE 4, P407-411, July 2018

Policy brief on the nursing response to human trafficking

      Executive Summary

      Human trafficking is a public health emergency affecting an estimated 12 to 30 million people globally. Given that 85% of trafficked victims have contact with health care providers in any year, nurses are critical to: the identification of trafficked persons; effective promotion of their physical, mental, and cognitive health; development and implementation of practice guidelines; implementation of research to inform bestpractices globally; and championing public policy initiatives at local, state, and national levels.

      Background

      Human trafficking is a public health emergency (
      • Krug E.G
      • et al.
      The world report on violence and health.
      , ) affecting an estimated 12 to 30 million people globally and is part of a $32 billion illicit business enterprise (
      • Meinert D.
      Modern-day slavery.
      ,

      U.S. Department of State, Trafficking in persons report, Office of the Under Secretary for Civilian Security and Human Rights, (2014), Washington, DC. p. 422.

      ). The United Nations defines human trafficking as “the recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception…” (
      United Nations
      Protocol to prevent, suppress and punish trafficking in persons, especially women and children, supplementing the United Nations convention against transnational organized crime.
      ) (Article 3) with the primary purpose of exploitation for labor or sex.
      The expanded definition adopted by the National Institute of Justice (NIJ), consists of the following four elements:
      • (1)
        adult or child participates in commercialized sex, labor, organ procurement, or war, where induction for the adult (not necessary for child) is by force, fraud, or coercion;
      • (2)
        recruitment processes involve obtaining persons through lure, ploy, harboring, capture, smuggling, and/or kidnap for recruitment;
      • (3)
        procurement of services through force, coercion and/or fraud, involuntary servitude, peonage, debt bondage, identity theft, slavery; and
      • (4)
        transport locally, regionally, nationally, and/or trans-nationally (

        National Human Trafficking Resource Center. Comprehensive human trafficking assessment. (2014), Available from: http://mspny.org/wp-content/uploads/2013/06/Trafficking-Assessment.pdf.

        ,
        • National Institute of Justice
        Expert working group on trafficking in persons research meeting.
        ).
      However, human trafficking is often defined very broadly, with documented reports of 25 different types of human trafficking (
      • Anthony B.
      • et al.
      The typology of modern slavery: Defining sex and labo trafficking in the United States.
      ). There are no positive health outcomes from human trafficking (

      U.S. Department of State, Trafficking in persons report, 2016 (2016).

      ,
      • Anda R.F.
      • et al.
      The relationship of adverse childhood experiences to a history of premature death of family members.
      ,
      • Gillies D.
      • et al.
      Psychological therapies for children and adolescents exposed to trauma.
      ,
      • Kiss L.
      • et al.
      Exploitation, violence, and suicide risk among child and adolescent survivors of human trafficking in the greater Mekong subregion.
      ,
      • Anda R.F.
      • et al.
      The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology.
      ,
      • Zimmerman C.
      • Hossain M.
      • Watts C.H.
      Human trafficking and health: A conceptual model to inform policy, intervention and research.
      ), particularly for the children trafficked. The individual outcomes are costly to society-at-large, mainly within the health care and justice systems, with trafficking experiences resulting in poor immediate, intermediate, and long-term health outcomes (
      • Anda R.F.
      • et al.
      The relationship of adverse childhood experiences to a history of premature death of family members.
      ,
      • Argentieri M.A.
      • et al.
      Epigenetic pathways in human disease: The impact of DNA methylation on stress-related pathogenesis and current challenges in biomarker development.
      ,
      • McEwen Bruce
      Stress, adaptation, and disease: Allostasis and allostatic load.
      ,
      • Oram S.
      • et al.
      Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: Systematic review.
      ).
      Despite difficulties in measuring the prevalence and incidence of human trafficking, it is clear that human trafficking is recognized as a public health emergency (
      • Clawson H.J.
      • Dutch N.
      Identifying victims of human trafficking: Inherent challenges and promising strategies from the field.
      ,
      • Dovydaitis T.
      Human trafficking: The role of the health care provider.
      ,
      • Edmonson C.
      • et al.
      Emerging global health issues: A nurse's role.
      ,
      • U.S. Department of Health and Human Services
      The role of healthcare providers in combatting human trafficking during disasters. Public Health Emergency.
      ). All states have legislation protecting children from trafficking (

      National Conference of State Legislatures. Human trafficking state laws. (2016), Available from: http://www.ncsl.org/research/civil-and-criminal-justice/human-trafficking-laws.aspx.

      ), however not all states provide protection for sex-trafficked adolescents arrested for prostitution (
      • Adelson W.J.
      Child prostitute or victim of trafficking?.
      ). Coupled with the lack of recognition of the trafficked person, health care systems for adolescents seeking sexual health care have no mandate to report child sexual abuse because traffickers are not a parent, guardian, or caretaker (

      New York Civil Liberties Union. Child abuse reporting and teen sexual activity: Clarifying some common misunderstandings (FAQ). (2017). Available from: https://www.nyclu.org/en/publications/child-abuse-reporting-and-teen-sexual-activity-clarifying-some-common-misunderstandings.

      ).
      Given the inconsistencies between and across federal and state legislation and regulations, health care professionals often are unaware of, or question, which protections apply in their practice areas: state legislation (i.e., child abuse reporting), federal regulations regarding Title X reproductive rights (i.e., confidentiality, emancipation, HIPAA) or federal human trafficking statutes (i.e., sex slavery) (
      • Adelson W.J.
      Child prostitute or victim of trafficking?.
      ,
      • Price B.
      Does child protective services respond to human trafficking in your state?.
      ). The inconsistency in health care policy, procedure, practice, and state and federal regulation results in 87% of trafficked persons having contact with health care providers without recognition or rescue while being trafficked (
      • Lederer L.J.
      • Wetzel C.A.
      The health consequences of sex trafficking and their implications for identifying victims in health care facilities.
      ).

      National and Global Policy Responses and Options

      National Legislative Action

      Examples of national legislative initiatives include the Trafficking Victims Protection Reauthorization Act[s] (2013) (

      Polaris. Current federal laws. (2017). Available from: https://polarisproject.org/current-federal-laws.

      ), which involved passage of an amendment in 2013 to the Violence Against Women Act (1994) regarding susceptible people at risk for human trafficking in disasters and emergencies, and prevention of child marriage. This legislation also created structure in the National Defense Authorization Act (2013) to prevent the use of business contracts when engaging in human trafficking practices (

      Polaris. Current federal laws. (2017). Available from: https://polarisproject.org/current-federal-laws.

      ).
      The Fight Online Sex Trafficking Act (

      Fight Online Sex Trafficking Act (FOSTA), H.R. 1865, 115th Cong. (2017-18).

      ) was signed into law April 11, 2018, allowing investigation and prosecution of websites facilitating sex-trafficking;providing civil remedies for the children sex-traffickedon websites; and removing legislative protections for internet sites (
      • Fonrouge G.
      Trump signs law against online sex trafficking.
      ).
      Other recent legislative initiatives include H.R.767 (115th Congress, 2017-2018) that introduced Stop, Observe, Ask, and Respond (SOAR) and Health and Wellness Act of 2017, establishing programs, training, and best practice processes. As of April 2018, the current bill is under consideration by the Senate Committee on Health, Education, Labor, and Pensions (

      Cohen, S. (2017) Stop, Observe, Ask, and Respond (SOAR) to Health and Wellness Act of 2018, U.S. House of Representative, (Ed.)., Congress.gov.

      ).

      Global Organizations and Regulations

      Nations around the globe report the impact of human trafficking (

      U.S. Department of State, Trafficking in persons report, 2016 (2016).

      ) and are engaged in activities to combat this complex issue that respects no borders. The United Nations General Assembly resolution on Transnational Organized Crime resulted in one toolkit and one protocol (); a toolkit designed to assist those fighting transnational organized crime of firearms and human trafficking (
      United Nations
      Protocol to prevent, suppress and punish trafficking in persons, especially women and children, supplementing the United Nations convention against transnational organized crime.
      ); and a protocol to penalize traffickers while preventing and suppressing trafficking of women and children, and granting temporary or permanent residence to victims in destination countries (
      • Polaris
      The typology of modern slavery defining sex and labor trafficking in the United States.
      ).
      The number and types of transnational organizations that recognize, identify, rescue or facilitate elopement, and provide wrap-around services for traffickedpersons are increasing (
      U.S. Department of Justice Office for Victims of Crime
      Coordination, collaboration, capacity: Federal strategic action plan on services for victims of human trafficking in the United States 2013-2017.
      ,

      United Nations Office on Drugs and Crime, Global report on trafficking in persons 2016. (2016), United Nations.

      ). Some examples include: Polaris, Heal Trafficking, Prajwila, Stop the Traffik, Children's Organization of Southeast Asia, Urban Light, Empower Foundation, Catholic Relief Services, Red Carpet Project, Not For Sale, GoodWeave, and A21.

      Responses from Professional Organizations

      The Academy's Position

      The American Academy of Nursing (Academy) supports the promotion of health and safety in persons affected by human trafficking through closure of gaps in macro and micro systems of nursing education, reflective ethics, practice improvement, systems leadership, and ongoing research related to improvement of cognitive, physical, mental, social and spiritual health outcomes.
      The Academy advocates for the inclusion of Forensic Nurse experts with advanced nursing practice preparation for leadership appointments in federal and state government workgroups and national, state, and local organizations; for service on interprofessional teams; as leaders and team members in coordinated community responses to human trafficking victims; as advisors to government officials of practice area gaps; as subject matter experts serving on interprofessional community organization boards; as champions for raising awareness for screening in all nurse practice settings; as advancd nurse expert clinicians designing and implementing best practices; and as contributors to planning interventions with community partners that encompass immediate and long-term needs and health of the person trafficked.
      The Academy supports routine screenings for violence against persons in all nurse practice settings, particularly for child maltreatment, including persons victimized through human trafficking by intimates and family members (
      • Amar A.
      • et al.
      Screening and counseling for violence against women in primary care settings.
      ). The Academy also supports interventions that promote healthy growth and development, particularly of children exposed to the toxic stress (
      • Gross D.
      • et al.
      Toxic stress: Urgent action needed to reduce exposure to toxic stress in pregnant women and young children.
      ) of human trafficking.
      The Academy advocates for the integration of forensic nursing content into all nursing practice guidelines by educational and practice organizations and institutions, such as emergency and primary health care settings (specifically to provide skilled forensic nursing care in response to the particular needs of human trafficking victims), and where advanced forensic nursing experts influence policy for populations at primary, secondary, and tertiary care levels, in institutions and organizations globally, and where nursing care of patients intersects with legal systems (
      American Nurses Association
      In: Forensic nursing: Scope and standards of practice.
      ,
      • Edmonson C.
      • et al.
      Emerging global health issues: A nurse's role.
      ,
      • Speck P.M.
      • Peters S.
      Forensic nursing: Where law and nursing intersect.
      ).

      Recommendations

      • Promote:
        • The inclusion of advanced forensic nurses with expertise in human trafficking as members of private business boards; commercial bank boards; not-for-profit service organizations; and, government and other organization task forces, advisory boards, and technical working groups, specifically to influence health care policy, advocacy activities, and legislation related to human trafficking and to promote justice for victims of human trafficking.
        • Faculty-led scholarship indexed in the Sigma Theta Tau International Virginia Henderson Repository to chronicle the intersection of nursing with human trafficking victims through qualitative, quantitative, and mixed methods research.
        • Awareness and education of human trafficking through collaboration with specialty nursing organizations, whose members are likely to encounter victims of human trafficking, on promoting awareness and education, particularly the organizations serving nurse practitioners and RNs intersecting with human trafficking patients.
        • Existing legislation, awareness, and continued appropriations, including passage of SOAR Training on Human Trafficking 2017, among nursing educators and education organizations to integrate ahuman trafficking curriculum to promote strengths-based workforce to advance the health of persons affected by human trafficking through recognition, identification, and management.
        • Advocate to place forensic nurses, acute care nurses, and community nurses on each state's and territory's Human Trafficking Task Force, joining attorneys, law enforcement, community programs responding to human trafficking, and organizations supporting the work of the interprofessional team committed to elimination of human trafficking.
      • Advocate:
        • Promote nurse workforce development of human trafficking expertise with policy for foundation and commercial enterprises (National Institute of Nursing Research [NINR], Robert Wood Johnson Foundation, Johnson & Johnson, Dove and others) to fund development of expertise through scholarship and leadership voices condemning human trafficking.
        • For closure of legislative and regulation gaps, wherever found, including the gap in Title X practice guidelines, to formally include sex-trafficking of adolescents as child sex abuse, reportable under all state and territory statutes.
        • To federal and state legislators to enact funded legislation that protects and facilitates rescue or elopement of children and other persons ensnared in human trafficking and to support federal and state agencies mandated in the response.
        • For legislation, in collaboration with the Academy of Forensic Nursing, American Association of Nurse Practitioners, Nurse Practitioners in Women's Health, American Academy of Emergency Nurse Practitioners, Emergency Nursing Association, and others to require every emergency department to have a competent registered nurse 24/7/365 who has advanced nursing education in general forensic nursing principles, concepts, content, and practice to facilitate identification and rescue of persons affected by human trafficking across all developmental stages and in all presentations.
      • Encourage nurses to participate in review panels and technical working groups at the Health and Human Services/National Institutes of Health, NINR, Substance Abuse and Mental Health Services Administration, Department of Justice/NIJ/Office of Justice Programs to include programs that build strengths-based nursing workforce as collaborative members of response teams in the recognition, identification, and intervention strategies necessary to mitigate the biopsychosocial and spiritual impact on health following trafficking trauma.
      • Identify advanced forensic nurse educators for, and consultants to, local, state, tribal, and military law enforcement and criminal justice communities.
      • Urge Congress to support recommended appropriations with adequate funding and distribution in legislative initiatives for the Violence Against Women Act, Victims of Trafficking and Violence Prevention Act, and The Child Abuse Prevention and Treatment Act among others.

      Acknowledgments

      The authors express appreciation for guidance and assistance provided by Inge Corless, PhD, RN, FAAN and Catherine Catrambone, PhD, RN, FAAN, Co-Chairs; Azita Emami, PhD, MSN, RNT, RN, FAAN, Co-Chair; Paula Milone-Nuzzo, PhD, RN, FHHC, FAAN, Board Liaison to the Global Health Expert Panel and Matthew J. Williams, JD, MA, Policy Manager and Academy Staff Liaison to the Global Health Expert Panel; and Previous Chairs: DeAnne Messias (2016–2017), Kathleen Capitulo (2015–2016), Lynn Callister (2009), Marianne Hattar (2009), Marlene M. Rosenkoetter (2003), Joan Uhl Pierce (1999–2001) and for the review and support by the members of the expert panels: Global Nursing and Health; Violence; Women's Health; Psychiatric, Mental Health & Substance Abuse; Cultural Competence & Health Equity; and Expert Panel members interested in promoting liberty and health in vulnerable populations.

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