Human Trafficking. Part 1: An Update on the Crisis

Human trafficking, also known as modern-day slavery, is ‘a crime that involves compelling or coercing a person to provide labor or services, or to engage in commercial sex acts.’1The United States Department of Justice. Human trafficking. https://www.justice.gov/humantrafficking.

Labor trafficking 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.’2Victims of Trafficking and Violence Protection Act of 2000. https://www.govinfo.gov/content/pkg/PLAW-106publ386/pdf/PLAW-106publ386.pdf. Sex trafficking is further defined as ‘a commercial sex act induced by force, fraud or coercion, or in which the person induced to perform such an act has not attained 18 years of age’.2Victims of Trafficking and Violence Protection Act of 2000. https://www.govinfo.gov/content/pkg/PLAW-106publ386/pdf/PLAW-106publ386.pdf. A ‘commercial sex act’ is one in which a person receives or gives anything of value for a sex act, which therefore makes it illegal for a trafficker to offer or for a ‘buyer’ to obtain a minor for this purpose.3The United States Department of Justice. Citizen’s Guide To U.S. Federal Law On Child Sex Trafficking. https://www.justice.gov/criminal-ceos/citizens-guide-us-federal-law-child-sex-trafficking. Sex trafficking is considered a global public health crisis.4Marcinkowski B, Caggiula A, Tran BN et al. Sex trafficking screening and intervention in the emergency department: A scoping review. J Am Coll Emerg Physicians Open 2022;3(1):e12638. doi: 10.1002/emp2.12638. Compelling someone could take the form of force or fraud, while coercion can be subtle/overt and physical and/or psychological.5Human Trafficking Statistics by State 2022. https://worldpopulationreview.com/state-rankings/human-trafficking-statistics-by-state.,6US Immigration and Customs Enforcement. Human Trafficking and Smuggling. https://www.ice.gov/factsheets/human-trafficking. Traffickers use violence, manipulation, deception (promising lucrative jobs or faking romance to exploit victims), or may prey on individuals by offering protection or adventure.7FBI. Human Trafficking News. https://www.fbi.gov/investigate/violent-crime/human-trafficking.,8Office of the Attorney General for the District of Columbia. Human Trafficking Fact Sheet. https://oag.dc.gov/public-safety/human-trafficking-initiatives/human-trafficking-fact-sheet. It is not necessary to prove force, fraud, or coercion when minors are involved.7FBI. Human Trafficking News. https://www.fbi.gov/investigate/violent-crime/human-trafficking.

Human trafficking is ‘a crime that involves compelling or coercing a person to provide labor or services, or to engage in commercial sex acts.’

Figure 1. Victims of human trafficking globally

Figure 2. Highest rates for individuals trafficked (#/100,000)5Human Trafficking Statistics by State 2022. https://worldpopulationreview.com/state-rankings/human-trafficking-statistics-by-state.

Human Trafficking Globally and in the US
Globally, almost twenty-five million individuals were estimated to be in forced labor in 2016, of which 4.8 million involved forced sexual exploitation.9International Labor Organization. Forced labour, modern slavery and human trafficking. http://www.ilo.org/global/topics/forced-labour/lang–en/index.htm. An additional fifteen million individuals are subjected to forced marriages. (Figure 1) Men, women, and children experience human trafficking, which affects all races, age groups, classes, education levels and environments. In some regions, more than 60% of trafficking victims are minors.1The United States Department of Justice. Human trafficking. https://www.justice.gov/humantrafficking.,10UNICEF. Children account for nearly one-third of identified trafficking victims globally. Press Release, July 29, 2018. https://www.unicef.org/press-releases/children-account-nearly-one-third-identified-trafficking-victims-globally.

The US is considered a ‘destination country’ for trafficking and a top destination for trafficking of minors.6US Immigration and Customs Enforcement. Human Trafficking and Smuggling. https://www.ice.gov/factsheets/human-trafficking.,11UNICEF USA. Child Trafficking. https://www.unicefusa.org/mission/protect/trafficking It is also a source and transit country.11UNICEF USA. Child Trafficking. https://www.unicefusa.org/mission/protect/trafficking In 2019, the US National Human Trafficking Hotline identified 22,326 victims and survivors of human trafficking.4Marcinkowski B, Caggiula A, Tran BN et al. Sex trafficking screening and intervention in the emergency department: A scoping review. J Am Coll Emerg Physicians Open 2022;3(1):e12638. doi: 10.1002/emp2.12638. However, according to another source, there were 11,500 cases of human trafficking reported in the US in 2019, 72% of which involved sex trafficking.5Human Trafficking Statistics by State 2022. https://worldpopulationreview.com/state-rankings/human-trafficking-statistics-by-state. The highest incidences were found in Nevada, Mississippi and Florida. (Figure 2) An estimated 20% of human trafficking involves children.5Human Trafficking Statistics by State 2022. https://worldpopulationreview.com/state-rankings/human-trafficking-statistics-by-state.

Nonetheless, these numbers only account for reported cases. In one report based on extrapolation from three sites, the FBI’s national Uniform Crime Reporting (UCR) Program was estimated to report only between 14% and 18% of the potential number of victims of human trafficking.12National Institute of Justice. Gaps in Reporting Human Trafficking Incidents Result in Significant Undercounting. August 4, 2020. https://nij.ojp.gov/topics/articles/gaps-reporting-human-trafficking-incidents-result-significant-undercounting. ‘Polaris’ estimates the actual number of victims in the US is in the hundreds of thousands.

Risk Factors
Risk factors for becoming a target of human trafficking include homelessness, runaway youth, substance addiction, foster care, disabilities, low income/poverty, illegal immigration, lack of education, early childhood trauma or abuse, and a history of prostitution.1The United States Department of Justice. Human trafficking. https://www.justice.gov/humantrafficking.,13Armstrong S, Greenbaum VJ. Using Survivors’ Voices to Guide Identification and Care of Trafficked Persons by U.S. Health Care Professionals: A Systematic Review. Advanced Emerg Nurs J 2019;41(3):244-60.,14Sutherland ME. Breaking the Chains: Human Trafficking and Health Care Providers. Mo Med 2019;116(6):454-6. In addition, political unrest, disasters and war are risk factors, creating need and migration crises that result in exploitation.15U.S. Department of Health & Human Services. Public Health Emergency. Human Trafficking & Health Professionals: Questions and Answers. https://www.phe.gov/Preparedness/planning/abc/Pages/human-trafficking-faqs.aspx. ,16Obertová Z, Cattaneo C. Child trafficking and the European migration crisis: The role of forensic practitioners. Forensic Sci Int 2018;282:46-59. doi: 10.1016/j.forsciint.2017.10.036. (Table 1) It is also believed that the global COVID-19 pandemic elevated the risk for factors such as isolation, economic difficulties, illicit use of the internet, and reduced access to healthcare.17Greenbaum J, Stoklosa H, Murphy L. The Public Health Impact of Coronavirus Disease on Human Trafficking. Front Public Health 2020;8:561184. doi: 10.3389/fpubh.2020.561184. Young individuals are often approached at school, social venues, in malls, train stations, and via the internet and social media.8Office of the Attorney General for the District of Columbia. Human Trafficking Fact Sheet. https://oag.dc.gov/public-safety/human-trafficking-initiatives/human-trafficking-fact-sheet.

Table 1. Risk Factors for Human Trafficking
Homelessness / runaway youth
Substance addiction
Foster care
Disabilities
Low income / poverty
Lack of education
Illegal immigration
Early childhood trauma / abuse
History of prostitution
Political unrest, disasters, and war

Venues for Human Trafficking
Victims of human trafficking work in legal and illicit industries and venues. These include massage parlors, salons (nail/hair/beauty), strip clubs, brothels, bars, cantinas, escort services, carnivals, domestic work, child care, elder care, landscaping services, forestry and logging, farms, factories, sweat shops, construction, traveling sales crews, fisheries, restaurants, outdoor locations for solicitation, ‘home-based’ commercial sex, forced removal of organs and child pornography.6US Immigration and Customs Enforcement. Human Trafficking and Smuggling. https://www.ice.gov/factsheets/human-trafficking.,7FBI. Human Trafficking News. https://www.fbi.gov/investigate/violent-crime/human-trafficking.,18Pascalev A, Van Assche K, Sándor J et al. Protection of Human Beings Trafficked for the Purpose of Organ Removal: Recommendations. Transplant Direct 2016;2(2):e59. doi: 10.1097/TXD.0000000000000565.,19Unert KM, Walsh CG, Clayton EW. Combatting human trafficking in the United States: how can medical informatics help? J Am Med Inform Assoc 2021;28(2):384-8. doi: 10.1093/jamia/ocaa142.,20Polaris. The Typology of Modern Slavery. https://polarisproject.org/the-typology-of-modern-slavery/. ,21National Conference of State Legislatures. Human Trafficking State Laws. https://www.ncsl.org/research/civil-and-criminal-justice/human-trafficking-laws.aspx. Individuals are also trafficked from their homes.14Sutherland ME. Breaking the Chains: Human Trafficking and Health Care Providers. Mo Med 2019;116(6):454-6.

The organization ‘Polaris’ estimates that the actual number of victims in the US is in the hundreds of thousands.

General Indicators of Human Trafficking
General indicators/ ‘red flags’ are identifiable signs and symptoms of human trafficking.5Human Trafficking Statistics by State 2022. https://worldpopulationreview.com/state-rankings/human-trafficking-statistics-by-state.,6US Immigration and Customs Enforcement. Human Trafficking and Smuggling. https://www.ice.gov/factsheets/human-trafficking.,8Office of the Attorney General for the District of Columbia. Human Trafficking Fact Sheet. https://oag.dc.gov/public-safety/human-trafficking-initiatives/human-trafficking-fact-sheet. ,22Department of Health and Human Services. Adult Human Trafficking Screening Tool and Guide. https://www.acf.hhs.gov/sites/default/files/documents/otip/adult_human_trafficking_screening_tool_and_guide.pdf. ,23International Labor Organization and the European Commission. Operational indicators of trafficking in human beings. March 2009. http://www.ilo.org/wcmsp5/groups/public/@ed_norm/@declaration/documents/publication/wcms_105023.pdf. Red flags can be behavioral, physical, work-related, or involve loss of control and abnormal living conditions. (Figure 3) It is important to remember that there may be a different reason for a sign or symptom, and that combinations/multiple red flags are an additional alert that should increase suspicion of human trafficking.

Figure 3. General indicators/red flags
Behavior/Appearance Denied Control, Monitored
  • Unsure of location/moves frequently/ does not know where they live
  • Unsure of the day or date
  • Avoids eye contact, social interaction, and law enforcement
  • Not allowed to speak to others
  • Fearful of answering questions
  • Responds in a rehearsed or scripted way
  • Fears family harm if they do not do as they are told
  • Looks malnourished, neglected, and/or injured
  • Lacks possession of their identification and travel documents
  • Accompanied by an individual who speaks and acts for the (parent/ guardian, ‘partner’, ‘aunt’, sponsor)
  • Monitored by another person when talking or interacting with others
  • Movement is controlled, cannot come and go at will
  • Living in dangerous, overcrowded, or inhumane conditions provided by employer
  • Living where they work, and/or isolated
Work-related Extra red flags of sex trafficking
  • Working excessive/unusual hours
  • No free time or vacations
  • Working in dangerous conditions; without proper safety gear, training, adequate breaks, other protections
  • Transported by guards
  • Guards at work/harboring site or video cameras; barbed wire
  • Owes debt to employer; wages withheld
  • Owes a debt that they cannot pay off
  • Hired for a different job (false promise)
  • Cannot freely leave
  • Pressured to stay or threatened with deportation or other harm
  • Working in an industry where it may be common to be pressured into sex acts for money (e.g., illicit massage parlors)
  • Employed in the commercial sex industry or in venues where sex may be sold
  • Signs of gang affiliation
  • Cell phones or expensive items not purchased by the potential victim
  • Truancy
  • Living with someone who is abusive
  • Living with someone with a substance abuse problem

Suffering by victims
Victims of human trafficking suffer greatly. In a systematic review based on 31 studies, with just over half conducted in SE Asia, the most common physical complaints were back pain, stomach pain, dental pain, and dizziness.24Ottisova L, Hemmings S, Howard LM et al. Prevalence and risk of violence and the mental, physical and sexual health problems associated with human trafficking: an updated systematic review. Epidemiol Psychiatr Sci 2016;25(4):317-41. doi: 10.1017/S2045796016000135. Such is the personal devastation experienced by victims, that more than 40% of those in sex trafficking are reported to have attempted suicide.25Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law 2014;23(1):61-91. https://www.icmec.org/wp-content/uploads/2015/10/Health-Consequences-of-Sex-Trafficking-and-Implications-for-Identifying-Victims-Lederer.pdf. Prevalent mental health complaints include depression, anxiety, PTSD, severe stress, and adjustment disorders. 24Ottisova L, Hemmings S, Howard LM et al. Prevalence and risk of violence and the mental, physical and sexual health problems associated with human trafficking: an updated systematic review. Epidemiol Psychiatr Sci 2016;25(4):317-41. doi: 10.1017/S2045796016000135.,25Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law 2014;23(1):61-91. https://www.icmec.org/wp-content/uploads/2015/10/Health-Consequences-of-Sex-Trafficking-and-Implications-for-Identifying-Victims-Lederer.pdf.

More than 40% of those in sex trafficking are reported to have attempted suicide.25Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law 2014;23(1):61-91. https://www.icmec.org/wp-content/uploads/2015/10/Health-Consequences-of-Sex-Trafficking-and-Implications-for-Identifying-Victims-Lederer.pdf.

Legal Framework and Anti-Trafficking Efforts
The first comprehensive federal law was the 2000 Trafficking Victims Protection Act (TVPA).7FBI. Human Trafficking News. https://www.fbi.gov/investigate/violent-crime/human-trafficking.,26https://www.congress.gov/106/plaws/publ386/PLAW-106publ386.pdf. This incorporates ‘3P’ strategies: 1) Prevention through public awareness programs; 2) Protection – immigration relief for victims in the US from overseas through ‘Continued Presence’ or a ‘T visa’; and 3) Prosecution, with the FBI granted the authority for investigation.7FBI. Human Trafficking News. https://www.fbi.gov/investigate/violent-crime/human-trafficking.,27US Department of State. The 3Ps: Prosecution, Protection, and Prevention: Fact Sheet. https://www.state.gov/the-3ps-prosecution-protection-and-prevention-2/. Under the TVPA, law enforcement can request temporary legal status in the US when a victim’s presence is required in support of the success of the investigation. A ‘T visa’ gives victims temporary US residency, and they can apply three years later for permanent residency. Under TVPA, victims also receive restitution mandated from defendants.

Under the Mann Act (1910) and its amendments, it is a felony to ‘knowingly persuade, induce, entice, or coerce an individual to travel across state lines to engage in prostitution or attempts to do so.’28Homeland Security. Human Trafficking Laws & Regulations. Updated: 05/26/2022. https://www.dhs.gov/human-trafficking-laws-regulations. Additionally, the PROTECT Act is designed to protect minors from abuse and sexual exploitation. Section 7202 of the Intelligence Reform and Terrorism Prevention Act resulted in the establishment of a Human Smuggling and Trafficking Center to work nationally and with foreign governments. The Customs and Facilitations and Trade Enforcement Reauthorization Act of 2009 bans the importation of goods made by victims of human trafficking. The Child Abuse Prevention and Treatment Act (CAPTA) emerged in 1988, providing financial assistance for pilot programs for the prevention, identification, and treatment of child abuse and neglect.29Wikipedia. Child Abuse Prevention and Treatment Act. https://en.wikipedia.org/wiki/Child_Abuse_Prevention_and_Treatment_Act. This has undergone several amendments, including one whereby individual states may choose to regard individuals up to 24 years-of-age as victims of child abuse and neglect or sexual abuse.30English A. Mandatory Reporting of Human Trafficking: Potential Benefits and Risks of Harm. AMA J Ethics 201719(1):54-62. doi: 10.1001/journalofethics.2017.19.1.pfor1-1701. This amendment became effective in 2017.

A further amendment in 2019, the ‘Victims of Child Abuse Act Reauthorization Act’ protects individuals making reports in good faith concerning child abuse and neglect, as well as those providing information or help, from civil and criminal liability.

Individual states may choose to regard individuals up to 24 years-of-age as victims of child abuse and neglect or sexual abuse.

Federal laws also dictate sentencing of perpetrators. A mandatory minimum of 10 years and up to life in federal prison is handed down for transportation of a minor for involvement in criminal sexual activity and for sex trafficking of a minor 14 to 17 years-of-age.3The United States Department of Justice. Citizen’s Guide To U.S. Federal Law On Child Sex Trafficking. https://www.justice.gov/criminal-ceos/citizens-guide-us-federal-law-child-sex-trafficking. For under 14 years-of-age or if force, fraud, or coercion were involved the minimum is 15 years. For adults, and online promotion of sex trafficking, sentences are up to 10 years or more.3The United States Department of Justice. Citizen’s Guide To U.S. Federal Law On Child Sex Trafficking. https://www.justice.gov/criminal-ceos/citizens-guide-us-federal-law-child-sex-trafficking. Enticing an individual into slavery or involuntary servitude carries a sentence of up to 30 years.31Truckers Against Trafficking. Human Trafficking Laws. https://truckersagainsttrafficking.org/human-trafficking-laws/. Forced labor, trafficking for peonage (the status or condition of involuntary servitude based on real or alleged indebtedness), slavery or involuntary servitude and holding a person in peonage carry up to 20-year sentences. The length of sentences increases further if the victim dies. Sentencing is also applicable for other aspects of human trafficking as noted in statutes.3The United States Department of Justice. Citizen’s Guide To U.S. Federal Law On Child Sex Trafficking. https://www.justice.gov/criminal-ceos/citizens-guide-us-federal-law-child-sex-trafficking.

Forced labor, trafficking for peonage, slavery or involuntary servitude and holding a person in peonage carry up to 20-year sentences.

State definitions and laws vary. Perpetrator activities typically defined to fall under trafficking, and therefore subject to criminal prosecution, include recruitment, transportation, transfer, harboring or receipt of individuals for the purpose of exploitation and may also include other activities such as enticing, isolating, deprivation of liberty, purchasing, benefitting or profitting.21National Conference of State Legislatures. Human Trafficking State Laws. https://www.ncsl.org/research/civil-and-criminal-justice/human-trafficking-laws.aspx. In addition to laws criminalizing trafficking for perpetrators, a majority of states has trafficking laws that apply to ‘buyers’ of commercial sex acts including prohibition of ‘mistaken age’ as a defense, and a requirement that convicted sex traffickers register as sex offenders.1The United States Department of Justice. Human trafficking. https://www.justice.gov/humantrafficking.,21National Conference of State Legislatures. Human Trafficking State Laws. https://www.ncsl.org/research/civil-and-criminal-justice/human-trafficking-laws.aspx.

Barriers/difficulties in reporting and in processing reported cases
Barriers to reporting and investigation of human trafficking include lack of knowledge of red flags and other factors, and an inability to identify potential victims. Among law enforcement officers, for example, barriers include lack of training, delayed identification until later in criminal proceedings, and the difficulty in differentiating human trafficking from other crimes such as prostitution which resulted in misclassification.12National Institute of Justice. Gaps in Reporting Human Trafficking Incidents Result in Significant Undercounting. August 4, 2020. https://nij.ojp.gov/topics/articles/gaps-reporting-human-trafficking-incidents-result-significant-undercounting. In addition, victims may be unable or unwilling to share information that shows that force, fraud or coercion were involved, and are scared to do so due to fear of both their trafficker and perceived legal repercussions for themselves.8Office of the Attorney General for the District of Columbia. Human Trafficking Fact Sheet. https://oag.dc.gov/public-safety/human-trafficking-initiatives/human-trafficking-fact-sheet. ,12National Institute of Justice. Gaps in Reporting Human Trafficking Incidents Result in Significant Undercounting. August 4, 2020. https://nij.ojp.gov/topics/articles/gaps-reporting-human-trafficking-incidents-result-significant-undercounting. They may fear harm to their family or have nowhere else to go. Individuals may also not realize that they are being trafficked.

Promoting Information on Human Trafficking
Notices promoting the national human trafficking hotline, which contains information on human trafficking, is either legally required or encouraged in most states.21National Conference of State Legislatures. Human Trafficking State Laws. https://www.ncsl.org/research/civil-and-criminal-justice/human-trafficking-laws.aspx. (Figure 4) Such notices must be posted in clear view of individuals working in the facility. Locations that may fall under this, depending on the state, can include the following:21National Conference of State Legislatures. Human Trafficking State Laws. https://www.ncsl.org/research/civil-and-criminal-justice/human-trafficking-laws.aspx. ,32California Legislative Information. CIVIL CODE – CIV. DIVISION 1. PERSONS [38 – 86] PART 2. PERSONAL RIGHTS [43 – 53.7]. https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?division=1.&part=2.&lawCode=CIV. ,33Illinois General Assembly. Public Act 100-0671. 1/1/2019. https://www.ilga.gov/legislation/publicacts/fulltext.asp?Name=100-0671&GA=100.

  • Agricultural (farm) labor contractors.
  • Lodging facilities.
  • Adult entertainment services
  • Primary airports, intercity passenger rail or light rail stations, and bus stations.
  • Urgent care centers and emergency rooms within general acute care hospitals.
  • Truck stops and roadside rest areas
  • Restaurants, bars, night clubs and other facilities with a retail license to serve alcohol.
  • Privately operated job recruitment centers
  • Certain massage establishments
  • Tattoo and ear-piercing registered locations
  • Public gatherings/special events on public property and requiring a permit
  • Public or private elementary and secondary schools

Figure 4. Two state notices (CA and IL)

Training on Human Trafficking
At the time of writing, 32 states mandate training on human trafficking for public employees in certain professions.21National Conference of State Legislatures. Human Trafficking State Laws. https://www.ncsl.org/research/civil-and-criminal-justice/human-trafficking-laws.aspx. Training typically includes definitions, general information, what to look for and how to identify potential victims, guidance, and protocols for reporting. Professions requiring such training include law enforcement officers, other first responders, prosecutors, healthcare professionals, social services, flight attendants, ticket counter agents, gate agents, and school employees. In addition, seven states encourage training for public and private employees in certain professions.21National Conference of State Legislatures. Human Trafficking State Laws. https://www.ncsl.org/research/civil-and-criminal-justice/human-trafficking-laws.aspx. Professional licensing may also be subject to training in human trafficking. For example, State Dental Boards can mandate training for licensing and license renewal.

Conclusions

Human trafficking is a tragedy and a crisis, and victims suffer greatly. Recently enacted laws have strengthened the ability to prosecute perpetrators and to protect victims. However, numerous barriers to identification and prosecution of HT remain, including lack of training, inability to seek help and reluctance on the part of victims. Given the wide range of health issues victims of trafficking suffer, a healthcare professional may be the first contact victims have outside of their trafficked environment. Part 2 on this topic will explore the role of healthcare professionals, in particular dental professionals, in identifying victims and enabling interventions.

Resources

  • Department of Homeland Security Blue Campaign to End Human Trafficking – https://www.dhs.gov/blue-campaign
  • Federal law enforcement: 1-866-347-2423
  • National Center for Missing & Exploited Children’s CyberTipline or call 1-800-THE-LOST.
  • National Human Trafficking Hotline. HOTLINE: at 1-888-373-7888. SMS text to 233-733. https://humantraffickinghotline.org/
  • Polaris Project Website – https://polarisproject.org/ Hotline (1-888-373-7888). Text INFO or HELP to 233733.
  • Police – 911; local contact number
  • State Child Abuse and Neglect Reporting Numbers – contact your local child protective services office or law enforcement agency
  • U.S. Immigration and Customs Enforcement (ICE) & Homeland Security Investigations (HSI) – 866-347-2423 – https://www.ice.gov/features/human-trafficking

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