Keywords

1 Introduction and Background

Although there are 24.9 million victims of trafficking worldwide, trafficking is understudied [1, 2]. Zimmerman and Kiss [3] note that globally 25 million people are being trafficked, 16 million (64%) for labor, 4.8 million (19%) for sex work, and 4.1 million (17%) for forced labor in the construction, manufacturing, mining, or in the domestic and hospitality industries [4]. The Asia-pacific region accounts for the largest number of forced laborers: 15.4 million (62%). Africa reported 5.7 million (23%), followed by Europe and Central Asia with 2.2 million (9%). The Americas account for 1.2 million (5%) and the Arab States account for 1% of all victims. Human trafficking is not restricted to one or two continents. Human trafficking may involve travel: 2.2 million (14%) of forced labor victims move internally and internationally, while 3.5 million (74%) of the victims of sexual exploitation no longer live in their own countries [5]. Trafficking generates 32 billion dollars in tax-free revenue each year [6].

2 Profile of the Person Who Is Trafficked

The global profile of the person who is trafficked differs. Traffickers attract their victims without consideration of race, ethnicity, gender, education, or socio-economic status. The American victim is usually a young woman between 18 and 24 [7]. She is recruited for sex work, childcare, domestic work, or for the hospitality industry by a boyfriend or a person whom she knows. Roommates, friends, employers, drug dealers, and strangers are also identified as recruiters. Young boys are commonly recruited into sex trafficking by family members [8, 9]. This may explain why male sex trafficking victims tend to be younger than their female counterparts [9]. Young men are recruited for farm work and the fishing industry. Children, especially young boys between ages 11 and 14, are primarily recruited for pornography. Some victims lead an apparently “normal lives,” living at home and going to school.

The International Labor Organization estimates that 15.4 (40%) of young women are forced into early marriages by their parents. The reasons are bridal price, debt cancelations, or the settling of disputes. Adolescents may be forced into early marriages where there is a significant difference in age been the young bride and her husband [10]. In parts of Asia and South and Central America, a young girl may be sold to a trafficker by parents who need money to support other members of the family. Sometimes parents or the young woman herself are lured by the offer of a job or education and a better life in a big city. However, jobs and school are false promises which young women painfully learn when they reach their final destination.

In the United States and abroad, usually persons who are trafficked are not free to come and go as they wish. They become distrustful and cool in their interactions with others. They avoid eye contact and do not initiate conversations. Their physical appearance is disheveled; they may appear malnourished and show signs of physical abuse. Often, they have a tattoo and/or a number that marks them as belonging to someone. They have few clothes and limited possessions. It is not uncommon for traffickers to take passports, licenses, cell phones, and other identifying information. Possession of valued identification and other documents by their traffickers is another form of entrapment.

Victims of trafficking live in crowded and cluttered spaces. Sometimes these living spaces are also their workplaces. They have no money although they work long hours in dangerous situations. If they leave their living or workplaces, they are accompanied by someone who controls where they go and what they say. If the trafficked victim does not speak English, the trafficker serves as a translator [11]. In the United States, the proportion of persons recruited for sexual versus labor trafficking has changed significantly. In 2004, 60% of victims were trafficked for labor, and 40% for sex; in 2019, 84% of victims were recruited for sex work and 16% for labor [9]. Over 40% of trafficked women and men have secondary (technical or college/post-graduate) degrees. Researchers [12] who studied over 11,000 individuals who were trafficked reported that a high percentage of women and men were married; 50% were single. Most trafficked individuals come from low-income families and the majority had parents and siblings [12]. Ironically men who were abused as children were likely to become sexual perpetrators, supportive of the notion of a victim-to-victimizer cycle. Females victimized as children do not exhibit this pattern [13].

Females were twice as likely to experience physical and sexual violence than males, especially between the ages of 18 and 29. Incidences of violence toward females decreased with age. Sexual violence is most prevalent among women who work in domestic or hospitality jobs. Young males below 18 are more likely to experience sexual violence. Individuals who were from high socio-economic families were also twice as likely to experience violence than person from lower socio-economic status. Trafficked men and women, who either crossed one border or were using forged documents, reported fewer violent experiences. Overall, although only half of trafficked victims experienced physical or sexual violence, they did receive threats of violence.

3 Trafficking of Young People

In the United States and Canada, rural youth are more often trafficked by family members than urban youth. Youth living in group homes, the intellectually challenged, people who live in homeless shelters, or runaways are identified and recruited into trafficking. There are also “hot spots” where trafficking commonly occurs; hotels/motels with easy access to the parking lot door, truck stops, cities with large, popular sporting events, and major highways. Some European, Asian and South American countries, Germany, Spain, the Netherlands, Thailand, Malaysia, the Philippines, Kenya, the Dominican Republic, and South America are well known centers of sex tourism. Amsterdam and some major cities in Spain have well-known red light districts where women sit at windows and advertise sex [14, 15].

Young people are lured into trafficking on social media platforms and multiplayer video games. Places of employment, malls, homeless shelters, juvenile detention centers, and poor neighborhoods are also recruitment sites. Traffickers commonly use “Romeo pimping” to entrap their victims. These “Romeos” or “boyfriends” often groom their victims by showering them with “love,” attention, expensive gifts, money, and/or drugs, promising them a fairy-tale life. Eventually the trafficker’s behavior shifts to manipulating the victim by asking them to have sex with their friend “this one time” to make money. Then they blackmail or coerce the victim to continue selling sex. Other traffickers shift from being “Romeo” to suddenly using abusive force to force their partner to sell sex [8].

Another common entrapment is through new friends (other girls who are trafficked). They describe themselves as “in the life,” and they become role models who normalize selling sex. Family members use family or parental authority to either groom their children (through sexual abuse) or force their children into the sex trade. Some traffickers take a more forceful approach from the start, abducting, raping, blackmailing, torturing, or threatening young women and men and forcing them to have sex [8]. Migrants are lured into the trade by perceived job opportunities. They soon discover that they have been trapped in prostitution or forced labor [16].

4 Behavior of Traffickers

All traffickers use common controlling techniques, psychological abuse, and threats. Other common means of control, in addition to sexual and physical abuse, is restricting movement, and/or making victims dependent on drugs [8, 9]. Drugs are a powerful motivator. Persons with addictions will do anything to gain access to drugs, especially as their need for higher and/or more frequent doses increases [15].

As noted, psychological abuse often leads to a “trauma bond” between the trafficker and the victim; some victims believe that their traffickers care for them. They, in turn, care about the well-being of their traffickers. Traffickers also use guilt, shame, blackmail, and social isolation to control their victims. As mentioned earlier in this chapter, traffickers withhold money, identification cards, and phones from their victims as a form of control. They also re-locate their victims, moving to different motels and/or different states [8]. Frequent re-location keeps victims disoriented, vulnerable, and socially isolated. Further, traffickers entrap their victims through pregnancy. These women are told that because they cannot work, they must rely on the trafficker to provide for them and their child’s basic needs (food, clothes, shelter). Sometimes victims think that staying in their trafficked situation is the only way to survive because they have no money to pay off their debt, or care for their baby, or no family members that can assist them. Some young victims have difficulty leaving the sex trade because they feel loved by their traffickers and have a deep need for love.

Finally, victims of trafficking work in agriculture, forestry, fishing, construction, domestic work, the hospitality and manufacturing industries, food service, beauty services, traveling sales, housekeeping, and commercial sex work [12, 17]. In these industries, trafficking victims are frequently injured. They are bruised, burned, experience fractures, or are infected with sexually transmitted diseases [18].

5 Health Status of People Who Are Trafficked

During the pandemic, trafficked victims contracted COVID-19. There are no data about the COVID-19 infection rate among persons who are trafficked [18]. Their limited access to health care and their invisibility in the community put them at high risk for contracting COVID-19. Persons who were trafficked faced unusual barriers in accessing tests, vaccines, treatment, and healthcare. Globally, victims of trafficking were stigmatized as carriers or spreaders of the virus.

The pandemic offered a unique opportunity to look at deeply entrenched inequalities in our economic and health systems that feed marginalization, gender-based violence, exploitation, homelessness, poor health, and human trafficking. Persons who had been trafficked were also at risk of violence from their traffickers because their infections made them too sick to fish, work in the fields, care for children, engage in sex work or participate in the hospitality or domestic services. Further, masking and social distancing made it is easier for traffickers to hide their operations, making victims less visible.

The pandemic had a significant economic impact on the trafficked community. This was most evident in the hospitality, farming and fishing industries. During the pandemic, there were very few large social events or banquets in hotels. Hotels laid off staff and some hotels closed. Beauty parlors and nail salons were closed. There were no crowds at sporting events. Migrant farm workers were unable to enter the country or follow the crops. Meat packing companies were closed as more workers became ill with COVID-19. Empty grocery shelves reflected problems in the supply chain. Fishing companies found it difficult to sell their fish because of closed hotels, restaurants, supermarkets, and grocery stores.

Another way to understand COVID-19’s impact on the trafficked community is to examine three groups of trafficked persons: persons who escaped trafficking, persons currently being trafficked and those at risk. During the epidemic, many persons who had escaped trafficking lost their lost their jobs, their housing, and their social mobility. Survivors of trafficking sold cars, cell phones, and other valued possessions to purchase food and avoid homelessness. Battered spouses, runaways, and adolescents found that poverty, harassment, illness and abuse, factors that contributed to their being recruited into trafficking in the first place, made them more susceptible to pressure by former traffickers to return to them [19].

Even in ordinary times, victims of trafficking do not receive routine and preventative care. They suffer from poor mental and physical health, depression, occupational injuries, homelessness, and sexually transmitted diseases. They do not visit health care providers unless they become very ill because of mistrust of health care providers, exhaustion, fear of deportation, fear of judgment from health care providers, or uncertainty about where to get help [20]. They do not receive adequate treatment for infections or illnesses that affect their current and future states of health. The COVID-19 pandemic exacerbated their health issues because clinics were closed and low-acuity medical care shifted to a virtual environment. These changes in health care delivery were especially problematic during the pandemic because victims of sex trafficking no longer had the opportunity to speak privately to a health care provider. Virtual visits are not private.

Trafficking is a lucrative worldwide business. Vulnerable people provide free labor that supports traffickers, organizations, and cartels. Anyone who attempts to interfere or close down the business faces opposition and possible death. Because trafficking is hidden, most people are surprised that trafficking occurs not just in second rate hotels and motels, but in their neighborhoods. Their first clue that trafficking exists comes when the police raid the house next door.

Nurses in Emergency Rooms (ERs) and mobile clinics see persons who are trafficked. However, in these busy settings, patients’ identities may be missed. More in-service education is needed to remind nurses and all health professionals that clues about their patient’s forced occupation are subtle. Their presenting history may not match their injuries or symptoms; the person accompanying the patient may speak for the patient and refuse to leave the patient’s side, the patient may seem in a hurry to leave the health care setting and will refuse to be admitted. The need for public and professional education about trafficking is particularly important for hotel and motel workers and guests, for residents in communities near major freeways, and in cities that are centers for major sport or recreational events. In Pittsburgh, a group of Catholic nuns taught hotel/motel maids how to recognize signs of trafficking in their workplaces and how to report it to management.

Most labor trafficking occurs in the fishing and agriculture industries. The fishing industry employs young men who work at sea. Their only way of escape is to jump overboard, which is not a good option. When the ships are unloaded and the fish is packed in refrigerator trucks, they may find that the truck drivers do not speak their language or do not want to be involved. If the trafficked fisherman manages to escape, he faces a new set of obstacles in a port city he does not know.

Families, men, women, and children are often trafficked to harvest crops. These migrant farm workers work in fields and orchards and in plants that process the food. The farm workers who pick vegetables and fruit work in the sun and rain. Their work requires stamina and physical strength as they travel from field to field harvesting the crops. Traffickers, not the farm workers, get paid. Because the workers are families with young children, escape is difficult. Domestic workers and women who work in the hospitality industry engage in childcare, food preparation/service, or work as maids. They may also be forced into sexual alliances with men in their households or with men who frequent the hotels/motels, or the coffee shops or restaurants where they work. Their traffickers make it difficult for them to run away.

As was noted earlier, fear, the thought that they are “loved,” risk of deportation, concern for the safety of their families, addiction, shame, and knowledge that they have no money and nowhere to go keeps many victims in their situations. They also fear that persons who offer help may also be traffickers.

SOAR is a continuing education program, specifically designed for health care and social service workers. This trauma-informed culturally sensitive approach to human trafficking stands for Stop, Observe, Ask, and Respond [21]. Obviously, the response to the SOAR approach depends on the form of trafficking in which the person has been engaged, and the willingness of the person who is being trafficked to leave his/her line of work, and to trust a person or more typically an organization. The methods of stopping trafficking are complex and differ by the types of trafficking and where it occurs. Addressing sex work, labor, and trafficking in the domestic and hospitality industries need to be approached differently. The appropriate responses are framed by the choices of the trafficked person, the resources of the person/organization, and the part of the world where the trafficked person lives.

Lack of money draws many persons into trafficking. They seek a better life and are willing to travel and work for it. The Social Determinants of Health is another framework that is holistic and considers that trafficking affects all aspects of the person and the community where it occurs [22]. If you look at their situation through the lens of the Social Determinates of Health, you realize that most people who are drawn into trafficking do not possess the factors that enhance health and well-being: education, housing, a safe environment, social support, employment, adequate nutrition, and access to health care. While data indicate that 40% of those who are trafficked have completed high school and some have gone to college, their work often takes them to areas where they do not speak the language or understand the culture. Young people who run away from home usually find themselves homeless, living on the streets, or sleeping in shelters or temporary housing. Usually persons who are trafficked lack positive social support. Young women believe that their traffickers are the only ones who truly care for them.

6 Summary

For traffickers, these factors partially explain why trafficking has persisted in many parts of the world for centuries. It is easy, lucrative, hidden, and tax free. Solving the trafficking problem, even in one country, requires the co-operation of the government, private sector organizations, churches, foundations, health care professionals, and law enforcement [2]. It is easier to prevent than to uproot trafficking. It takes courage, commitment, and compassion. Is nursing as a profession and are nurses ready to assist those who are at risk of or actually being trafficked?

Discussion Questions

  • Describe the different forms in which trafficking occurs.

  • Who is at greatest risk for trafficking?

  • What clues should you look for in assessing a person who may be being trafficked or is at risk?

  • Whom do you tell? What do you do?

  • What do you know about the prevalence of trafficking in the United States?