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 etal., 2002
, United Nations Office on Drugs and Crime 2015
) affecting an estimated 12 to 30 million people globally and is part of a $32 billion illicit business enterprise (, United Nations Office on Drugs and Crime. Human trafficking. (2015), Available from: http://www.unodc.org/unodc/en/human-trafficking/what-is-human-trafficking.html.
U.S. Department of State 2014
). 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 2000
) (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 2014,
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 2014).
However, human trafficking is often defined very broadly, with documented reports of 25 different types of human trafficking (
Anthony etal., 2017
). There are no positive health outcomes from human trafficking (U.S. Department of State 2016
, Anda etal., 2009
, - Anda R.F.
- et al.
The relationship of adverse childhood experiences to a history of premature death of family members.
BMC Public Health. 2009; 9https://doi.org/10.1186/1471-2458-9-106
Gillies etal., 2016
, Kiss etal., 2015
, Anda etal., 2006
, Zimmerman etal., 2011
), 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 etal., 2009
, - Anda R.F.
- et al.
The relationship of adverse childhood experiences to a history of premature death of family members.
BMC Public Health. 2009; 9https://doi.org/10.1186/1471-2458-9-106
Argentieri etal., 2017
, McEwen, 1998
, Oram etal., 2012
).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 and Dutch, 2008
, Dovydaitis, 2010
, Edmonson etal., 2017
, U.S. Department of Health and Human Services 2017
). All states have legislation protecting children from trafficking (National Conference of State Legislatures 2016
), however not all states provide protection for sex-trafficked adolescents arrested for prostitution (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.
Adelson, 2008
). 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 2017
).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, 2008
, Price, 2017
). 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 and Wetzel, 2014
).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 2017
), 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.
Polaris 2017
).Polaris. Current federal laws. (2017). Available from: https://polarisproject.org/current-federal-laws.
The Fight Online Sex Trafficking Act (
Fight Online Sex Trafficking Act 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, 2018
).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, 2017
).Global Organizations and Regulations
Nations around the globe report the impact of human trafficking (
U.S. Department of State 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 (King, 2008
); a toolkit designed to assist those fighting transnational organized crime of firearms and human trafficking (United Nations 2000
); 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 2017
).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 2014
, United Nations Office on Drugs and Crime 2016
). 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
- •In 2008, 2010, and again in 2016, the American Nurses Association highlighted human trafficking as a public health and human rights crisis (American Nurses Association 2008,American Nurses Association 2010,ANA Center for Ethics and Human Rights 2016), aiming to ensure nurses have skill sets properly identifying and referring victims of human trafficking, and to advocate and support protection and prosecution legislation.
- •In 2014, Vera Institute of Justice completed research and published Trafficking Victim Identification Tool (Simich etal., 2014) and Toolkit to Combat Trafficking in Persons: Global Programme against Trafficking in Human Beings (
Simich, L., etal. (2014). Improving human trafficking victim identification—validation and dissemination of a screening tool. p. 455. Available from: https://www.ncjrs.gov/pdffiles1/nij/grants/246712.pdf.
United Nations Office on Drugs and Crime 2006,United Nations Office on Drugs and Crime 2018). Although these toolkits address the complexity of a comprehensive and coordinated community response to combating human trafficking, still lacking are examples of the implementation of well-developed health care responses (Barrows and Finger, 2008,Dovydaitis, 2010,Isaac etal., 2011). - •In 2015, the American Public Health Association published Expanding and Coordinating Human Trafficking-Related Public Health Research, Evaluation, Education, and Prevention (American Public Health Association 2015). This policy statement advocates for the promotion of quality curricula, provision of guidance supporting survivor-centered and trauma informed care, and recommends specific actions to disseminate knowledge through societies, funding, and certification bodies.
American Public Health Association. Expanding and coordinating human trafficking-related public health research, evaluation, education, and prevention. (2015), Policy Statements and Advocacy]. Available from: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2016/01/26/14/28/expanding-and-coordinating-human-trafficking-related-public-health-activities.
- •In 2016, the Association of Women's Health, Obstetric, and Neonatal Nursing adopted policy (Association of Women's Health Obstetric and Neontal Nurses 2016), and published Human Trafficking to promote and enhance nurses’ engagement in screening, familiarity with mandatory reporting, and efforts supporting human trafficking victims (Association of Women's Health Obstetric and Neontal Nurses 2016).
- •In 2017, the National Association of Pediatric Nurse Practitioners provided support with a human trafficking web page (National Association of Pediatric Nurse Practitioners 2017) and annual meeting promotion of awareness.
National Association of Pediatric Nurse Practitioners. Human trafficking prevention. (2017); Available from: https://www.napnap.org/human-trafficking-prevention.
- •In 2017, the Nurse Practitioners in Women's Health adopted policy recommending safety planning with community partnerships and developing evidence-based interventions (Nurse Practitioners in Women's Health 2017).
Nurse Practitioners in Women's Health. Human sex trafficking. (2017) Available from: https://www.npwh.org/lms/filebrowser/file?fileName=NPWH%20Position%20Statement%20on%20Human%20Sex%20Trafficking%20for %20public%20comment.pdf.
- •In 2017, the Emergency Nurses Association (ENA) published a resource web page (Emergency Nurses Association 2017), including ENA Connection and Human Trafficking: What Emergency Nurses Need to Know.
Emergency Nurses Association. Human trafficking. (2017); Available from: https://www.ena.org/practice-resources/human-trafficking.
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 et al., 2013
). The Academy also supports interventions that promote healthy growth and development, particularly of children exposed to the toxic stress (Gross etal., 2016
) 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 2009
, Edmonson etal., 2017
, Speck and Peters, 1999
).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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Article info
Publication history
Published online: July 02, 2018
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© 2018 Elsevier Inc. All rights reserved.
