Human Trafficking Definitions and Legal Considerations

Original Editor - Stacy Schuirring

Top Contributors - Stacy Schiurring, Tarina van der Stockt, Jess Bell and Kim Jackson  

Trigger warning. This page contains information about Human Trafficking, including physical abuse, sexual assault and abuse.

Introduction

"Human Trafficking is the recruitment, transportation, transfer, harbouring, or receipt of people through force, fraud or deception, with the aim of exploiting them for profit. Men, women, and children of all ages and from all backgrounds can become victims of this crime, which occurs in every region of the world." -United Nations, Office of Drugs and Crime

The United States Department of State describes "trafficking in persons" "human trafficking" and "modern slavery" as interchangeable terms.

Human trafficking is a global issue. It affects all races, genders, ages, and socio-economic groups. Recently, researchers, policymakers, and survivors of human trafficking are pushing to change the perception of human trafficking from a purely law enforcement issue to a public health issue.

These crimes are widespread and occur in every segment of society. However, human trafficking is often hard to identify and remains hidden from view. Gallo et al have suggested that regular screening and monitoring for trafficked persons at locations they are likely to visit could improve the possibility of identifying and assisting more trafficked people. An estimated 22-88% of trafficked persons will come into contact with a healthcare professional during their exploitation. Due to the nature of rehabilitation medicine assessment, documentation, and surveillance, healthcare professionals are well-suited to identify and assist trafficked persons.

This article will provide an overview of key definitions and concepts, and the different types and dynamics of human trafficking. It will also discuss how healthcare providers can identify, assess, and addict victims of human trafficking.

Concepts and Definitions

United States Federal Law

Trafficking Victims Protection Act of 2000 (TVPA), as amended (22 U.S.C. §7102).

Signed into law on October 28, 2020 by President Clinton, the Trafficking Victims Protection Act of 2000 (TVPA) was created to “ensure just and effective punishment of traffickers, and to protect their victims.” The 2000 Act had three main components, commonly referred to as the three P's.

A summary of the TVPA as quoted by the Alliance to End Slavery and Trafficking:

1. Protection: The TVPA increased the U.S. Government’s efforts to protect trafficked foreign national victims including, but not limited to:

• Providing assistance to victims of trafficking, many of whom were previously ineligible for government assistance
• Establishing non-immigrant status for victims of trafficking if they cooperated in the investigation and prosecution of traffickers

2. Prosecution: The TVPA authorized the U.S. Government to strengthen efforts to prosecute traffickers including, but not limited to:

• Creating a series of new crimes on trafficking, forced labor, and document servitude that supplemented existing limited crimes related to modern slavery and involuntary servitude
• Recognizing that modern slavery takes place in the context of force, fraud, or coercion and is based on new clear definitions for both trafficking into commercial sexual exploitation and labor exploitation

3. Prevention: The TVPA allowed for increased prevention measures including, but not limited to:

• Authorizing the U.S. Government to assist foreign countries with their efforts to combat trafficking, as well as address trafficking within the United States, including through research and awareness-raising
• Providing foreign countries with assistance in drafting laws to prosecute trafficking, creating programs for trafficking victims, and assistance with implementing effective means of investigation
  

In 2009, then Secretary of State Hillary Rodham Clinton identified a fourth P, “Partnership,” to serve as a “pathway to progress in the effort against modern-day slavery.”

Below is a list of definitions and concepts within the context of human trafficking. Please refer to this list as needed throughout the Rehabilitation's Role in Human Trafficking Awareness course.

• Coercion is a means of control. It is the act of persuading another person into action by means of threats or force. According to the TVPA (22 U.S.C. §7102), coercion "may be understood as threats of serious harm to or physical restraint against any person; any scheme, plan, or pattern intended to cause a person to believe that failure to perform an act would result in serious harm to or physical restraint against any person; or the abuse or threatened abuse of the legal process."
• Commercial Sex Act, according to the TVPA (22 U.S.C. §7102) is "any sex act on account of which anything of value is given to or received by any person."
• Debt Bondage (also known as debt slavery, bonded labour, or peonage), according to the TVPA (22 U.S.C. §7102), is "the status or condition of a debtor arising from a pledge by the debtor of his or her personal services or of those of a person under his or her control as a security for a debt, if the value of those services as reasonably assessed is not applied toward the liquidation of the debt or the length and nature of those services are not respectively limited and defined."
• Force, in the context of human trafficking, is a means of control over victims. The use of monitoring and/or confinement is often used during the early stages of victimization to erode the victim's resistance. Physical forms of force used in human trafficking can include physical restraint, and physical and sexual assault. This is related to harbouring of a victim which involves isolation, confinement, and monitoring.
• Fraud, according to the TVPA (22 U.S.C. §7102), "consists of some deceitful practice or willful device, resorted to with intent to deprive another of his right, or in some manner to do him an injury. In the context of human trafficking, fraud often involves false promises of jobs or other opportunities."
• Human Smuggling is the exchange of fees or services to gain transportation or fraudulent documentation to illegally cross a border into a foreign country.
• Involuntary Servitude (also known as involuntary slavery), according to the TVPA (22 U.S.C. §7102), "includes a condition of servitude induced by means of (A) any scheme, plan, or pattern intended to cause a person to believe that, if the person did not enter into or continue in such condition, that person or another person would suffer serious harm or physical restraint; or (B) the abuse or threatened abuse of the legal process."
• Labour trafficking (also known as forced labour), according to the TVPA, is defined as, “the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.”
• Obtaining, in the context of human trafficking, is the forced taking or exchange of something to gain control over another person.
• Patronizing, in the context of sex trafficking, is receiving a sexual act or sexually explicit performance.
• Recruiting is the proactive targeting of vulnerable persons and the grooming of wanted behaviours by means of fraud and coercion by human traffickers.
• Sex trafficking, according to the TVPA, is defined as, “a commercial sex act that 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.”
• Slavery, in the context of human trafficking, is when a controlled person is forced to provide labour and/or services against their will.
• Soliciting, in the context of sex trafficking, involves the offering a sexual act or sexually explicit performance.
• Transporting includes the movement and arrangement of travel for persons being trafficked.

Human Trafficking versus Human Smuggling

	Human Trafficking	Human Smuggling
Consent	Victims are forced, defrauded, or coerced into trafficking If consent was initially offered it is rendered null by exploiting labour, services, or commercial sex	Individuals give consent to being illegally smuggled and involved a transaction of some sort The transaction is mutual and ends at the arrival at the agreed-upon destination
Victim of the crime	committed against an individual	committed against a country
Domestic or Transitional	Victimization can be transnational or domestic Trafficking does not require crossing international or state borders	Smuggling is transnational by definition
Information in the above table is adapted from the Human Trafficking Fact Sheet created by the US Department of Health and Human Services Office on Trafficking in Person.

Human trafficking is involuntary. The victims are trafficked by force, fraud, and/or coercion to provide labour or services against their will. Human trafficking victims do not have to be moved, relocated, or transported in any way. It can occur in the victim's own town or home. In the United States, any person under the age of 18 who is a victim of sex for profit is automatically considered a trafficking victim.

The crime of human trafficking is defined by three core elements: the act, the means, the purpose.. This is also known as the Action-Means-Purpose (AMP) Model. This model illustrates the federal definition of a “victim of severe forms of trafficking in persons,” contained in 22 USC §7102.

According to the Polaris Project: "Human trafficking occurs when a perpetrator, often referred to as a trafficker, takes any one of the enumerated Actions, and then employs the Means of force, fraud or coercion for the Purpose of compelling the victim to provide commercial sex acts or labor or services."

This image is adapted from information provided by the United Nations Office on Drugs and Crime.

Human smuggling is voluntary. It is the exchange of fees or services to gain transportation or fraudulent documentation to illegally cross a border into a foreign country. Human smuggling does not involve coercion, most people seeking out these services are fleeing violence or poverty.

To further your understanding of the differences between human trafficking and human smuggling, please view the following optional 8-minute video.

Consensual Commercial Sex versus Sex Trafficking

"Sex work is consensual. Human trafficking is not. When you conflate the two, and you label all sex workers as victims of human trafficking, it totally takes away from the folks who are being trafficked" -Julia Baumann, founder and coordinator of Safe Space

	Consensual Commercial Sex	Sex Trafficking
Consent	All involved individuals give consent Not a violation of the sex worker's human rights	Trafficked individual does not give consent, but is coerced into the sexual act or performance Sex trafficking is a violation of the victim's human rights
Person involved	Sex workers are consenting adults	Victims of sex trafficking can include men, women, and children
Payment for Services	Sex workers earn and keep income	All income or services go to the trafficker, not the victim

Consensual Commercial Sex (also known as sex work) is when a person willingly takes part in the sale of a consensual sexual act or conduct.

Sex Trafficking (also known as Sexual Exploitation) is the sale of nonconsensual sexual acts or conduct through force or coercion.. Victims of sex trafficking include all races, genders, ages, socioeconomic backgrounds, and nationalities.

Human Trafficking by the Numbers

It is difficult to find reliable statistics regarding human trafficking. Quality data collection is hampered by the hidden nature of trafficking, challenges of victim identification, gaps in data accuracy, and safety and privacy concerns of sharing victim information. Data and statistics on human trafficking may not reflect the full scope of the problem due to these reasons.

The extent of human trafficking is difficult to establish and the tracking of trafficking is challenging for many complex reasons: (1) navigating legal definitions, (2) trafficker movement restrictions and isolation of victims, (3) the fear and stigma of victim self-reporting, and (4) the lack of frontline professionals trained in identification and monitoring of human trafficking.

The International Labour Organization (ILO) and the Walk Free Foundation, in partnership with the International Organization for Migration (IOM) attempted to document the extent of human trafficking worldwide. They released a report on the Global Estimates of Modern Slavery in September 2022. This report estimates that in 2021, approximately 27.6 million people were in forced labour. Of these, “17.3 million are exploited in the private sector, 6.3 million in forced commercial sexual exploitation, and 3.9 million in forced labour imposed by state.” The report also estimates that in 2021 approximately 49.6 million people were in “modern slavery." This figure includes both the estimate for forced labour and forced marriage.

Types of Human Trafficking

The US State Department recognizes two types of human trafficking and classifies them as federal crimes:

1. Labour trafficking (also known as forced labour) involves the use of force, fraud, and/or coercion to obtain labour from the trafficked person. Labour trafficking can occur within any industry or sector: agriculture and meat farming, factory work, hospitality industry such as restaurants, hotels, or massage parlors; retail, mines, private homes, or drug trafficking operations.
   Two widespread forms of labour trafficking include:
   • Domestic servitude involves a victim performing forced labour in a private residence.
   • Forced child labour involves children being forced or coerced to work. Unfortunately, forms of slavery including the sale of children, and debt bondage of children continue to exist across the world. Forced child labour is different from children who are able and choose to legally seek employment and work.
     • Some indicators of forced child labour include (1) when the child appears to be in the custody of a non-family member and their work benefits that person, (2) withholding food, rest, or schooling to a child who is working.
2. Sex trafficking involves the use of force, fraud, and/or coercion to perform a commercial sex act or conduct. The victim can suffer threats of serious physical or psychological harm, threats to friends or family, or debt bondage. Sex trafficking can occur in any location including physical locations and on the internet. Examples of sexual exploitation can include prostitution, escort agencies, phone sex lines, stripping on a webcam or internet chat rooms, and pornography. ,
   • Child sex trafficking involves sex trafficking with a person under the age of 18 years. The use of force, fraud, or coercion is irrelevant, children engaging in commercial sex is illegal in most countries around the world.

The United Nations, private and not-for-profit organisations such as Stop the Traffick acknowledge other types of human trafficking including:

1. Forced marriage occurs when a person is forced into marriage under threats of force, fraud or through coercion. Situations where forced marriage may occur include: as access into a country or access to benefits.
2. Forced criminal activity involves a person carrying out a criminal activity under threats of force, fraud or through coercion. Forced criminality can include drug distribution, cannabis cultivation, begging, pickpocketing or bag snatching, ATM theft, or the selling of counterfeit goods.
3. Child soldiers involves a child serving as a soldier or committing a crime to the benefit of the trafficker under threats of force, fraud or through coercion.
4. Organ harvesting and trafficking involves the removal of an organ or body part to sell on the black market. The victim can be cheated out of an agreeable price for the organ, have an organ removed without their knowledge during treatment for another medical condition, or kidnapped and have an organ removed without their consent.

Dynamics of Human Trafficking

Trafficker

People who deal in human trafficking do so for monetary and financial gain. These crimes go undercounted and unrecognised because they are often difficult to detect.

Trafficker Profiles

Both US and international law state that human traffickers can be classified as corporations or other legal entities, or private persons.. An extensive review of federal human trafficking prosecution in the United States since TVPA was enacted in 2000 found that the vast majority of prosecuted human traffickers were private persons. The review found that in 2020, the average defendant was a 36yo man, with 81% of all human trafficking case defendants being male. When comparing sex and labour trafficking cases from 2020, men made up 82% of defendants in sex trafficking cases and women made 43% of defendants in labour trafficking cases. This data was found to track with global trends, However there is no one human trafficker's profile type and they could come from any segment of the population. Human traffickers can be foreign nationals or local citizens, family members, spouses/partners, friends, acquaintances, or strangers. They can be individual actors or part of a larger organisation. They can be pimps, gang members, diplomats, or business owners.

The review went on to say that traffickers often know and have a trusting relationship with their victims. Data on sex trafficking cases from 2020, approximately 43% of defendants previously knew their victims. Of these cases: 31% were social media contacts, 21% as a spouses or intimate partners, 13% as a human smuggler, and 10% as a friend or classmate. Data on labour trafficking cases found approximately 57% of defendants previously knew their victims.

At what point a person transitions to a trafficker can be difficult to identify. The review points to the fact that the nature of the coercion used by the trafficker is highly personalised.

Trafficker Recruitment Techniques

Human trafficking recruitment is often based on the deception of innocent, unsuspecting victims. Recruitment techniques commonly used by traffickers include:

• Threats or use of violence
• Manipulation
• Seduction and romance
• Forced pregnancy
• False employment promises
• False promises about education or travel
• Sale by family
• Recruitment of formerly enslaved persons
• Abuse of religious beliefs
• Abduction or kidnapping

In some cases, a former victim of human trafficking will become a trafficker themselves. This is most commonly the case of female victims of sex trafficking.This speaks to the grooming and psychological manipulation victims of human trafficking suffer and endure.

The Trafficked Person

Trafficked persons can come from any segment of the population, however, traffickers tend to prey upon people with the following vulnerabilities:

• Poverty/economic hardship
• Limited English proficiency
• Lack of lawful immigration status
• lack of stable safe housing
• Lack of a social safety net
• Following a natural disaster, war or political instability
• Limited economic and educational opportunities
• Psychological or emotional vulnerability

Trafficked persons are often tricked or misled into trafficking by (1) false romantic intentions, (2) promises of good employment or pay, and (3) a stable life.. They can be of any gender or age, and come from any educational, socio-economic, ethnicity or nationality, or religious background. However, women and girls are at a higher risk of being trafficked for sexual exploitation. Refugees are also often victimised due to dire living situations in refugee encampments.

Red Flags and Health Impact of Human Trafficking

"Polyvictimization, also known as complex trauma, describes the experience of multiple victimizations of different types, such as sexual abuse, physical abuse, bullying, exposure to family violence, and more. This definition emphasizes different kinds of victimization, rather than just multiple episodes of the same kind of victimization, because it signals a generalized vulnerability. Research shows that the impact of polyvictimization is much more powerful than even multiple events of a single type of victimization." - National Children’s Advocacy Center

Victims of human trafficking suffer physical, mental, emotional, and psychological injuries. They lose their independence and autonomy. Their quality of life is hugely and devastatingly affected. A study by Hossain et al interviewed more than 200 victims of sex trafficking and assessed for mental health and quality of life. They found 55% had high levels of depression symptoms, 48% had high levels of anxiety symptoms, and 77% were potentially suffering from PTSD.

The following table is a summary of red flags for human trafficking.

Physical Health

Reproductive/Sexual health: frequent treatment of sexually transmitted infections or injuries, multiple unwanted pregnancies, lack of sexual desire or over-sexualised behaviours Signs of physical abuse: fractures or burns, bruising; signs of concussions, traumatic brain injuries or unexplained memory loss Gastrointestinal problems Malnutrition Changes in sleep: sleeplessness, sleep disturbances, nightmares, and/or insomnia Fatigue Skin or respiratory problems caused by exposure to agricultural or other chemicals Communicable and non-communicable diseases Oral health issues, including broken teeth Chronic pain Tattoos or branding of ownership

Emotional/Psychological Health

Unable to concentrate or provide basic information including age, address or time Substance abuse Self-harm and suicidal ideation Depression, anxiety, panic attacks Fear of being alone, distrust, and fear of strangers Guilt, shame, and/or self-blame Post-traumatic stress disorder Eating Disorders Suspicious behaviour: appears nervous or avoids eye contact; seems overly fearful, submissive, tense, or paranoid Has a lack of autonomy or independence. Person will defer to another before giving information, no control over identification documents Cultural, linguistic barriers and isolation Withholds information. The person can be unwilling to answer questions about their health, and gives confusing or contradicting information

Optional in-depth reading:

• Please read here for a list of Red Flags of Labour Trafficking provided by the State of Texas, USA.
• Please read here for a list of Red Flags of Sex Trafficking provided by the State of Texas, USA.

The following table lists population-specific healthcare needs for survivors of human trafficking.

Immediate and short-term needs	Chronic pain Complications from unsafe abortions Oral health problems Headaches Vaginal and anal health concerns Anxiety, depression, suicidal ideation Post-Traumatic Stress Disorder (PTSD) Somatic disorders Substance abuse-related health issues: abscess, HIV+, Chronic Venous Disorders
Long-term needs	Physical abuse counseling Head/neck/spine injuries Fractures Burns Wound care Sleep deprivation Psychosis Dehydration/malnutrition Gastrointestinal problems Ingestion of poisons and drug use Vaginal/anal pain and lacerations Unintended pregnancy Sexually Transmitted Infections (STI’s), HIV exposure Contraception

Interaction and Assessment of a Trafficked Person

Healthcare professionals can affect human trafficking with accurate identification of trafficked persons. Proper identification requires healthcare professionals to be familiar with vulnerabilities and red flags of human trafficking that may be revealed during routine assessments, especially when taking a detailed social history. A small number of human trafficking screening tools are available for use in the clinic. Unfortunately, there are only a handful of validated screening tools available for clinician use. Many of the tools would be of limited practical use in the health care environment because they (1) lack evidence-based support, especially for the health care environment, (2) have long administration times which may be difficult to utilise in the fast-paced medical setting, (3) require the administrator to have expertise in human trafficking, and (4) only available and/or validated in the English language. Please see the resource section at the end of this article for downloadable options.

Once a trafficked person has been identified, the healthcare professional should interact with them in the following ways:

Respect for Autonomy.

• Use the term "trafficked person" or "trafficking survivor" rather than "trafficking victim" to change the misconception that persons who have endured this form of trauma are "helpless victims."
• Treat trafficked persons as moral agents who have retained or can regain capacities for self-determination and decision-making power.
• Trafficked persons deserve dignified respectful healthcare, which includes rights enjoyed by all patients such as: privacy in their care, and use of a professional medical interpreter. This also includes an explanation of the legal limitations of medical confidentiality due to the mandatory reporting requirements of human trafficking to the proper authorities.

Special Topic: Mandatory Reporting Laws to Address Human Trafficking

In the United States, healthcare professionals are legally required to make a report to law enforcement or child protection agencies when they have an interaction with a trafficked person. These laws include (1) mandatory child abuse reporting laws, (2) domestic violence reporting laws, and (3) laws requiring reports of knife or gunshot wounds.

Benefits of these laws: Healthcare professionals are incentivised to report human trafficking under these laws, which should increase the overall awareness of human trafficking and improve education and assessment skills within the healthcare community. Triggering an appropriate investigation can result in protective measures for trafficked persons and prosecution of the traffickers. A growing number of states have created "safe harbor" laws where trafficked persons are not treated as criminals but rather as survivors in need of trauma-informed care and supportive services.

Risks of these laws: While mandatory reporting laws can protect and benefit trafficked persons, they also invoke vulnerability risks of trafficked persons related to their mistrust of authorities and fear of their traffickers. These reporting requirements also override the confidentiality protections that normally apply in healthcare settings. This has the potential for trafficked persons to lose trust in the healthcare system due to their fear of reprisal by their traffickers, prosecution by law enforcement, or deportation.

To ensure the protection and safety of trafficked persons, healthcare and law enforcement professionals must be properly trained in human trafficking and their roles as part of a multidisciplinary team. Trafficked persons must have access to trauma-informed care, and support systems must have the necessary resources to provide meaningful prevention and protection. With measures in place to ensure that the risks of mandatory reporting laws are limited, healthcare professionals can assume the role of mandatory reporters of human trafficking while meeting their ethical obligations.

Nonmaleficence and Beneficence.

• All healthcare professionals have an obligation to first do no harm (nonmaleficence) and to act in the best interests (beneficence) of our patients. Examples of positive interactions between patients and healthcare providers include (1) the removal of harm, (2) the prevention of harm, and (3) the promotion of good.
• The principle of nonmaleficence cautions against pressuring for a disclosure that they are being trafficked, especially in the presence of the trafficker. Aggressive attempts can be psychologically harmful to the trafficked person, and can potentially trigger intense stress, anxiety, fear, and retraumatising the individual,
• A trafficked person's decision over disclosing their situation and whether to accept clinical assistance are based on the individual person's firsthand experience and knowledge of the potential trafficker repercussions. For this reason, the patient's decisions must be respected to the extent possible when mandatory reporting laws do not apply.

Justice.

• The unique circumstances surrounding the care of trafficked persons often challenge the concept of justice (the fair distribution of resources) by limiting trafficked persons’ ability to access appropriate and affordable health care outside of acute injuries and illnesses.
• Many healthcare professionals do not receive appropriate education and training to recognise the signs and symptoms of human trafficking. This is significant as it leaves healthcare professionals unable to comprehensively assess and respond to the complex and challenging healthcare needs of trafficked persons.
• Healthcare professionals must make treatment decisions for trafficked persons while considering the possibility of nonadherence and limited ability to follow through with long-term treatment plans, often for reasons outside of their control. Examples of pressing treatment needs for this population can include communicable diseases, substance use disorders, and mental illnesses. A healthcare professional's decision to not test or initiate interventions due to assumptions about medical adherence must be carefully weighed against potential trafficker repercussions. At times it may be necessary to make referrals to known and trusted organizations or other providers to find alternative options to manage the unique challenges and circumstances of trafficked persons.

The following table lists provider strategies when interacting with a trafficked person.

Physical posturing	Maintain open and accepting body language Maintain relaxed body posture, neutral positions with hands at side, and be mindful to keep legs together Ask permission to make physical contact every time, and explain the procedure before making contact
Attitudes	Don’t stigmatise, victimise, or ask unrelated questions Normalise the experience for the patient Believe and validate the patient, confront any biases, and empathise.
Language	Provide empathetic and empowering statements: “It is normal to feel this way” “Thank you for sharing with me” “You are very brave to tell me” “I am so sorry that this happened to you. No one deserves that” Use non-judgmental language such as “sex without a condom” vs “risky sex” Use the term “survivor” vs “victim” Encourage patient autonomy by saying “Is it okay if I?” instead of “I need to” Ask “What is the most important thing you need right now?

The information in this table is modified from the Healthcare Provider Toolkit by REST.

Optional: to learn more about interacting with suspected victims of human trafficking, please read this manual supported by the US Department of Justice.

Create and Maintain a Safe Healthcare Environment

In addition to building trust and rapport at an individual healthcare provider level, safety can also be enhanced at a facility and/or organisational level for survivors of human trafficking. Strategies can include:

• installation of a systemwide policy to see patients alone for at least a part of every visit. Examples of policy change can include: (1) posting signage that outlines this policy in plan view in common areas, (2) staff education, (3) completing assessments and interventions only when alone with the patient.
• creation of a separation protocol to allow healthcare providers to examine or question the individual they believe is a victim of trafficking in a private, safe environment when there is suspicion that they are with a trafficker. The protocol should include: (1) who will carry out the physical separation process, (2) the steps to follow if the suspected trafficker refuses to comply, and (3) having a plan in place with hospital security and/or local law enforcement incase the trafficker becomes dangerous.
• It is important to document that informed consent was obtained when working with adults and to contact local child protective services when working with a minor.

Intervention and Response

Healthcare providers can impact human trafficking using a multi-level approach, advocating for change from bedside care to society level. The use of an ecological framework will provide the most holistic and wide-reaching response to human trafficking. The levels of responsibility within this framework include: (1) individual-level healthcare provider training, (2) health facility–level screening policies and response protocols, (3) community-level multidisciplinary resources and response teams, and (4) society-level awareness campaigns, funding allocation, and data collection.

Framework level	Examples of Interventions
Individual-level	training related to human trafficking, including case studies with real-life examples trauma-informed care training
Health facility–level	creation and use of screening policies and response protocols have facility-level resources available in the electronic medical record
Community-level	24-hour hotline multidisciplinary response teams to coordinate care across the service continuum beyond the hospital or clinic through established trusted and vetted professional relationships
Society-level	improving awareness within the healthcare and greater community of human trafficking provide funding for training/education opportunities collect data to create and add to the profile of human trafficking
The information in the table is based on data from Munro-Kramer et al 2022.

Healthcare professionals can provide individualised interventions to trafficked persons to address human trafficking vulnerability factors and red flags within the safety of the health care setting. This can include:

• the initiation of established organisational protocols
• referral to trusted and vetted providers or outside organisations
• utilisation of trauma-informed and people-centred screening processes
• education on communicable diseases, substance use disorders, and mental illnesses within your scope of practice

Special Topic: Trauma-Informed Ethics of Care

The trauma-informed approach to care is strongly recommended as a beneficial framework for caring for survivors of physical and psychological trauma, which includes persons who have experienced human trafficking. For these patients, effective care requires a sensitive, compassionate, measured approach with attention to healthcare practices to limit the triggering of fear, stress, shame, and stigmatisation.

Trauma-informed care shares many principles with patient-centered care and is influenced by a healthcare provider's understanding of the impact of interpersonal violence and victimisation on an individual’s life and development.

Examples include mindful sensitive wordage and proper verbal cues when requesting a patient disrobe for examination and assessment, and nonjudgement education on the use of contraception.

According to the US Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration, the trauma-informed approach:

1. Realises the widespread impact of trauma
2. Recognises the signs and symptoms of trauma
3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices
4. Seeks to actively resist re-traumatisation

Optional: to learn more about trauma-informed care, please read this link to The Healthcare Provider's Toolkit created by REST.

Multidisciplinary Team and Referral Network

Each survivor of human trafficking is unique and requires a different mix of services and support during their recovery journey. A strong multidisciplinary approach within the medical system and out to community-based organisations and services will establish a safety net for safe return to the community. Building a comprehensive referral network will better meet the needs of survivors of human trafficking and their family members.

A referral network should include interactions between:

Healthcare	Provides collaboration with various healthcare professionals to identify and respond to human trafficking including: short and long-term medical treatment dental needs sexual assault forensic examination substance use treatment malnutrition and/or dehydration treatment and education
Legal aid	provide information regarding legal options and advocates assistance with visa application assistance with orders of protection provide legal representation against their traffickers assist with the documentation needed for eviction and housing issues obtain proper legal documentation, such as proof of age and name at birth assist expungement relief for victims with a criminal history as a result of their trafficking provide family court services
Community-based organisations	Often are the leaders in the development of a protocol and serve as a primary referral for a variety of services: housing interpretation/translation services childcare vocational training
Social Services	access to benefits for those with incomes to include: cash, food, or energy assistance childcare Head Start programmes child support offices vocational assistance programmes for individuals with disabilities
Public Health Sector	Can assist in preventing and identifying trafficking in a variety of ways, including: health safety inspectors identifying potential indicators of trafficking in businesses or homes community health workers monitoring the spread of disease and infection among at-risk populations researchers identifying methods for preventing trafficking incidence of trafficking and community surveillance
Law Enforcement	function as part of the criminal justice system provide referrals to local service providers creation of a human trafficking task force provide certification to assist in applying for immigration relief
Behavioural Health	Guide survivors to address trauma through: counseling and therapy services treatment for substance use sexual assault trauma services school-based counselors medication management
School-based services	school-based health centres counseling and therapy services Head Start programming literacy programmes mentoring programmes childcare parental support activities such as before/after school childcare, parenting classes, GED prep classes accommodations for those struggling with school free or reduced meal programmes Referrals to community resources
Connection to other survivors of human trafficking	Survivor engagement allows networks to better serve clients by providing mentorship, identifying challenges and opportunities, and achieving agency missions and mandates.

The information provided in this table was adapted from data given by the National Human Trafficking Training and Technical Assistance Center.

Healthcare professionals also have a wider responsibility to their greater community. As specialised educators and advocates healthcare professionals can collaborate with community and society-level stakeholders and lawmakers to help bring about change and support for trafficked persons. This can include:

• increasing awareness of human trafficking through healthcare facilities and community level education programmes
• advocating for local and national policies which promote community health and wellness
• combating social or cultural norms that contribute to human trafficking
• creating and maintaining an evidence-based guide and training programme to prevent future human trafficking

Resources

North American Resources:

• National Human Trafficking Hotline (USA)(English and Spanish)
  • Find local services
  • Downloadable Awareness Materials, available in multiple languages
  • Call: 1-888-373-7888 (TTY: 711)
  • Text: 233733
  • Chat Online: Human Trafficking Hotline Web Chat
• Canadian Human Trafficking Hotline (English and French)
  • Find local services
  • Downloadable Awareness Materials, available in multiple languages
  • Call: 1-833-900-1010
  • Chat Online: Canadian Human Trafficking Hotline Web Chat
• National Human Trafficking Education Centre | The Joy Smith Foundation (Canada)
• Polaris Project (USA)
• HEAL Trafficking (USA)

Texas, USA

• iWatchTexas: Texas Suspicious Activity Reporting Network
• The Heart of Texas Human Trafficking Coalition
• Refugee Services of Texas

Michigan, USA

• Michigan Human Trafficking Task Force
• University of Michigan Law School Human Trafficking Clinic

Ontario, Canada

• Ontario Anti-human Trafficking Services and Supports (Canada)

Clinical Tools and Resources:

• Health, Education, Advocacy, Linkage (HEAL) Trafficking and Hope for Justice: Protocol Toolkit for Developing a Response to Victims of Human Trafficking in Health Care Settings. Please follow link to request the toolkit (free resource).
• Real Escape from the Sex Trade (REST) Healthcare Provider Toolkit & Resources
• Guidelines for Administering the Trafficking Victim Identification Tool (TVIT)
• Commercial Sexual Exploitation-Identification Tool (CSE-IT) Training
• Short Screen for Child Sex Trafficking (CST) for the Healthcare Setting
• Adult Human Trafficking Screening Tool (AHTST), available in both English and Spanish
• Comprehensive Human Trafficking Assessment
• Domestic Minor Sex Trafficking (DMST) Practitioner Guide and Intake Tool