Human Trafficking: Signs that You Should Know

By Patricia O’Malley, PhD, RN, CNS 

On February 17, nearly 100 nurses gathered at the Sharonville Convention Center in Cincinnati to learn about human trafficking. The all-day conference was sponsored by southwest Ohio chapters of Sigma Theta Tau International-The Honor Society of Nursing including Zeta Phi Chapter at Wright State University and Premier Health Learning Institute. The keynote speaker was Teresa Flores LSW, MS, a national human trafficking expert, author and advocate. Theresa’s story and life’s work to stop human trafficking has been reported on CNN, “Dateline,” “Nightline,” and “America’s Most Wanted,” as well as many national radio shows.   

Theresa shared her story of how she was trafficked at age 15, beginning with rape after being drugged without her knowledge by an older classmate she had trusted.  She was forced into sex slavery when the traffickers threatened to send pictures taken during the sexual assault to her family, church community and the corporation for whom her father worked. For two years, she was sex trafficked across homes and hotels all over Detroit. She remained silent to protect her family until her father was transferred out of state. Ms. Flores was appointed to the Ohio Attorney General’s Human Trafficking Commission in 2009. Her e-books are on the Wall Street Journal and USA Today best seller lists. This report explores the evidence presented at this seminar as well as information from current literature.  

What is human trafficking? 

Human trafficking is defined as modern slavery and occurs worldwide.2 Dayton is a center of human trafficking in Ohio. Easy interstate access to the central and eastern United States and drug activity help to explain why such trafficking has flourished here. Local news agencies have reported on the issue.     

Do you believe you have not cared for a trafficked person? Think again!  Most nurses fail to recognize victims of trafficking and, as a result, precious opportunities for intervention are lost.1, 2

Human trafficking is defined as actions resulting obtaining or holding another person in compelled service and includes sex and labor trafficking. Actions include debt bondage, forced labor and indentured servitude as well as child trafficking.2 Adults and children are made to work under brutal conditions and constant threat.   

Sex trafficking is defined as the recruitment, harboring, transportation or obtaining a person for a commercial sex act through force, fraud or coercion of adults or minors. These victims are found working in truck stops, private homes, strip clubs, escort services, brothels, nail salons or the streets. Sex trafficking of children for adult sex tourism is particularly dreadful; most commonly found in the Far East and Dominican Republic and carries a penalty of up to 30 years in prison for any US citizen convicted of engaging in this practice.1, 2

Persons that are labor trafficked can be found in various roles, including nannies, housekeepers, farm workers, cooks, waitresses, factory and construction workers.2  All are forced to work long hours, with little pay or food to pay “debt” with the daily threat of death to self or family and bodily harm if they resist or escape.2, 3

Worldwide, 600,000 to 800,000 people are trafficked across international borders each year with 18,000 to more than 20,000 trafficked in the US.3 Labor trafficking is prevalent among foreign nationals in the United States. After Germany, the United States is the second largest market for women and children to be trafficked into sex work.2 At least 100,000 children are involved in commercial sexual exploitation with as many as 300,000 minors victimized.2, 3, 4, 5  While many victims are kidnapped or coerced into trafficking, there is no socioeconomic strata that is safe. Most women involved in the commercial sex trade entered via trafficking between the ages of 11 and 14. Many were tempted by promises of a better life, belonging, a way to support one’s family or self. Wherever there is poverty, unemployment, civil unrest, or natural disaster, persons are vulnerable to trafficking.2, 3

Particularly at risk in the past for trafficking were runaways. However, the new at-risk population is young girls and boys enjoying the shopping malls and school events who are extremely vulnerable to attention and promises of new friendship. In a supposedly safe place, the new friend (trafficker) offers conversation, acceptance and positive feedback. As the new relationship blooms, affection, expensive gifts, travel and protection are obtained over a short period, becoming a debt repaid only through sex or labor trafficking with an average of seven years of service. Teresa shared the men and women involved in recruiting victims for these horrific industries easily identify the most vulnerable boy or girl at the mall or school event to begin the relationship that initially seems so exciting and ends in slavery. Teresa warned the audience that young adolescent girls or boys in intense new relationships with older adults (20-something) is a warning sign of possible trafficking.1    

In 2000, the Victims of Trafficking and Violence Protection Act (TVPA) was signed into law.  The TVPA provides resources for victims regardless of immigration status as well as prosecution of traffickers, which is very difficult. Victims of severe trafficking are eligible for the Federal Witness Protection Program which provides health care, shelter, and job training. Fight Slavery Now is a resource to learn more about the issue and ways to make a difference. 2   

How does one recognize a trafficked person? Table 1 describes the physical, behavioral and social observations that can be identified in a nursing assessment.  

Table 1. Recognizing Trafficked Victims1, 2, 3, 4

Physical Observations Behavioral & Social Observations
Black eye, bald spots on scalp Depression, anxiety, suicide ideation
Branding (skin) & bruises that do not match history  Children that do not attend school 
Scars, burns, bite marks Men coming & going all hours at a residence 
Sexually transmitted diseases PTSD
Urinary tract infections  Addiction from traffickers supplying drugs to maintain control 
Vaginal & rectal trauma Overwhelming feelings terror
Physical trauma while pregnant Deep shame-lack of eye contact
Chronic back pain  Unable to ask for help from anyone
Dehydration, malnutrition Fear from threats of sexual or physical violence if they do not comply with trafficker
Exhaustion Someone speaks for the patient. Patient is quiet even when the patient speaks English
Loose and missing teeth Patient without identification
Jaw and neck pain  Patient appears to be under control of the person with them 

When evaluating the patient with these signs, do not ask the patient if they are being trafficked since the term is usually unfamiliar to victims. These patients are deeply fearful of authority figures, and will often decline assistance or provide any information to protect themselves or family from violence. It is important to speak with the patient alone where no one can overhear the conversation. Never use a translator with connections to the person with the patient, who also may be the trafficker.1, 2, 4 Refrain from a judgmental attitude, which can stop communication. Use empathy to understand the patient’s circumstances.3 Health care facilities can be a place of refuge for victims. Limited evidence from a European study suggests that nearly 30 percent of trafficked victims come in contact with the health care system at least one time during captivity.3   

Remember, nurses and physicians are not required to prove that trafficking is occurring. However, if you suspect someone is being trafficked and needs information, call the National Human Trafficking Resource Center (NHTRC) at 1-888-373-7888 or visit You can also provide this number and/or web address to the patient. If the patient is under age 18, trafficking must be reported as suspected child abuse. In any case, contact Social Services for further direction and intervention.2

Want to learn more about trafficking and find resources? Check out these websites:   

24-hour hotline 1-800-THE-LOST 

Selected References 

  1. Flores T. Ending the Silence: Shining the Light on Human Trafficking.  SONK Consortium 2017 Annual Conference. Sharonville Convention Center, Cincinnati. February 17, 2017.  
  2. Sabella, D. The Role of the Nurse in Combating Human Trafficking. AJN.  2011; 111(2): 28-37. 
  3. Conrad C, Downing R. Understanding Human Trafficking in the Nursing Sector. CE4Nurses. Ohio Nurses Association. Accessed March 6, 2017. 
  4. Cole H. Human Trafficking: Implications for the Role of the Advanced Practice Forensic Nurse.  Jour Amer Psychiatr Nurs Assoc. 2009; 14(6): 462-470. 
  5. National Center for Missing & Exploited Children.  Accessed March 6, 2017

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