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BY: SR. ROSEMARY DONLEY, SC, PhD, APRN, FAAN and CARMEN KIRALY, PhD, APRN

Illustration by: Napal Naps

Human trafficking is not a 21st-century phenomenon. For centuries, people of every nation have exploited others to show dominance or gain profit. Youth, including those who are poor or from abusive or neglectful homes, are among the most vulnerable. Human trafficking is the recruitment, transportation, transfer, harboring or receipt of persons by threat or use of force or other forms of coercion, such as abduction, fraud, deception and payments/benefits to family members or guardians who exploit vulnerable persons under their care. Exploitation includes prostitution or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude or the removal and sale of organs.¹

People entrapped by trafficking may be desperate, naive, impoverished citizens of developing or developed countries, lured into an underground $150-billion-dollar economy to work in the sex, agriculture or fishing industries, domestic or nanny services, or forced to work off a debt, known as debt bondage.² People also are trafficked to harvest their organs, to serve in their countries' armies, including child soldiers, or to enter into early marriages.³ Although it is difficult to get an exact count on human trafficking, it's estimated there are 21 million victims worldwide.⁴ Of those trafficked globally, 49% are women, 23% are girls, 21% are men and 7% are boys.⁵

SEX TRAFFICKING OF WOMEN AND GIRLS
Human trafficking often exists in plain sight, but it can be so hard to see. Traffickers do not respect age, gender, race or country of origin. Contrary to popular belief, human trafficking happens in every country, including in the United States, in our communities. Young American women are recruited into the sex trade in malls, bus and train stations, and on high school and college campuses. Others meet traffickers on social media, dating sites or the dark web.⁶ Recruiters use
different strategies: gifts, access to drugs and alcohol, romance or coercion. They offer friendship, admiration and the promise of more exciting lives. Preying on loneliness, online traffickers, usually older men or women, learn about the lives and aspirations of young people. After gaining their trust, they arrange meetings and lure them into sex work.⁷

Young women brought to the United States for sex work often come from Asia. They can be deceived with promises of jobs, good
salaries and career pathways. Poor families may sell their daughters to traffickers. Unfortunately, what happens when these young women arrive in the United States is far from what they or their families expected.⁸ Young Asian women may not speak English or be familiar with America's culture or norms. When their traffickers take their identifying papers, they are trapped.

Victims of trafficking suffer physical and psychological abuse. Many victims of trafficking were abused before they got "in the life." The homes that young people have escaped from may be worse than their present situations. They lack trust. Some victims fear their traffickers and will not speak in their presence. Others who are trafficked are sure that they are with someone who will protect them and give them love and support.

Beatings give victims of trafficking reasons to fear serious harm to themselves or their families. Sex workers are threatened if they do not follow their traffickers' orders. If victims lack proper documentation, they are warned that they will be reported to the Immigration and Customs Enforcement Agency, or ICE.⁹

Persons in the sex trade suffer from sexual infections and other injuries. Because genital infections negatively affect "business," girls or women with sexually transmitted diseases are taken to emergency departments or walk-in clinics. The history and information given to the health team are inaccurate and follow-up appointments usually are not kept. It is easy not to recognize victims of trafficking during brief encounters.

Sex trafficking diminishes personal as well as public health. While risks to traffickers are few, the costs to persons who are trafficked are complex and persist after the trafficking has ended.¹⁰ (See sidebar for links to information about trafficking awareness and interventions in health care settings.)

Some working to end trafficking believe that the only way to stop human sexual trafficking is to control demand by fining and arresting men who pay for sex, closing motels, hotels and massage parlors with a pattern of prostitution on site, and fining owners.¹¹ Other remedies include the monitoring and blocking of online dating sites and websites like Backpage.com where men arrange for sex.¹² (Backpage.com was seized by federal agencies in 2018 as part of an enforcement action.)

TRAFFICKED DOMESTIC WORKERS
Although the majority of trafficked women find themselves immersed in sex work, women also are trafficked for domestic work or care of children. Trafficked domestics and nannies work long hours in homes around the world for low wages. Recruited internationally, they may be college students seeking summer work in the United States or poor women from developing countries looking for work. When they sign up with staffing agencies, their terms of employment are not clearly stated. Because they live with families, they are hidden from public view; the trafficking of domestic workers is largely invisible. Trafficked domestic workers work more hours than the standard work week and receive less than the minimum wage.¹³ While not all domestic workers and nannies suffer from low salaries, crowded living conditions and long working hours, many trafficked domestic workers and nannies are abused.^{14, 15}

EXPLOITATIVE NURSING CONTRACTS
Those working in health care should be aware that some workers from foreign lands, notably nurses in hospitals and long-term care facilities, are lured into working in the United States through unfair labor practices. Working in the United States is appealing to foreign-born nurses who are seeking higher salaries and better professional opportunities. For example, nurses from India and the Philippines often are approached by staffing agencies because they have been educated in English. The Philippines, especially, has a surplus of nurses because nursing schools there train more nurses than are needed in their country.

Some staffing agencies require that nurses sign complex legal contracts as a condition of migration. Some foreign-born nurses overlook the fine print in the contract. The contract describes how staffing agencies will assist nurses in navigating work visas, travel arrangements, living accommodations near their worksite and other services. The foreign-born nurse agrees to a salary that is less than newly hired registered nurses with similar experience. The hospital pays the staffing agencies' recruitment and placement costs. In signing the contract, which usually covers three years, nurses agree to its terms.

Economic abuse of foreign-born nurses who enter the United States on work visas is a concern of governments, nursing associations and interest groups working to prevent and combat human trafficking. Working at the policy level, the CGFNS, also known as the Commission on Graduates of Foreign Nursing Schools, and its Alliance for Ethical Recruiting have developed a Code for Ethical International Recruiting. The alliance certifies staffing agencies that have policies and practices that meet the code's standards. Its staff offers education about ethical recruitment practices to international nursing associations, schools of nursing and foreign-born nurses. Consultation and pre-departure orientations for nurses also are provided.^{16, 17}

Not all staffing agencies take advantage of foreign-born nurses. Based on survey findings, the alliance reported that 69% of nurses who had completed visa screens prior to entering the United States reported positive experiences, while 14% of the sample reported negative experiences. Foreign-born nurses found it difficult to live in communities without people from their countries of origin. Others were overwhelmed by professional expectations and the culture of American health care. When foreign-born nurses failed to fulfill their contracts, they were required to assume the debt for the cost of their coming to the United States.¹⁸

FORCED LABOR IN AGRICULTURE, FISHING, THE MILITARY
Forced labor occurs when persons work because of coercion or intimidation. Victims of trafficking in the agriculture industry come from America's guest worker, migrant and seasonal worker communities: men, women, families and children, some as young as 5 years of age. It is estimated that such farm workers number about 2 million to 3 million people. They experience wage theft, dangerous working conditions and exposure to pesticides.¹⁹

In its 2018 Trafficking in Persons Report, the U.S. State Department highlighted countries where human trafficking is evident in the fishing industry.²⁰ There are reports of young children forced to work on fishing boats. In one example, a mother from Ghana, no longer able to feed her children, sold her two young sons to a fisherman. The children were rescued when inspectors visited the ship.

Each year, the State Department publishes a list on its website that includes countries divided into tiers; Tier Three countries are those that are not meeting minimum standards to prevent human trafficking.²¹ The International Labor Organization and Walk Free reported that 152 million children, between 5-17 years of age, were laborers in 2017.²² Forced work is dangerous, exposing workers to injury, harmful materials and toxic wastes as well as physical and verbal abuse.

Another form of trafficking is the recruitment of children to serve in their country's army. The U.S.' Child Soldiers Prevention Act of 2008 defines a child soldier as any person under 18 years of age who is compelled to serve in his or her country's armed forces; is recruited to serve in another country's army, or is a child under 15 who is voluntarily recruited into the government's armed forces.²³ Children are increasingly being recruited as fighters, domestic workers, sex slaves, spies and messengers in conflicted areas of the Middle East and Africa, with numbers more than doubling from 2012 to 2017.²⁴

TRAFFICKING TO HARVEST ORGANS
Organ transplantation is an amazing medical procedure that has extended the lives of many. However, organs are scarce resources. Trafficking persons for organ donation is called illegal organ trade, transplant tourism or organ purchase. The story is simple. The rich seek out the poor and pay them for their organs. People with money can buy organs from poor individuals anywhere in the world. Organ trafficking is a hidden, underground and underreported activity. It provides another example of how poverty forces people to sell their bodies or parts of their bodies in order to live. Organ trafficking makes up a miniscule percentage of trafficking; however, there's been little to indicate there are aggressive efforts to combat it.

WHAT DRIVES HUMAN TRAFFICKING?
What causes individuals, corporations and countries to engage in or ignore human trafficking? Poverty within countries and among families, personal and corporate greed, and the desire to participate in the supply chain and compete on price in the world's markets are what drive the use of forced labor, including the labor of children. The Bureau of International Labor Affairs maintains a list of products believed to be produced by children and the countries where these child workers are exploited. The most recent list, published by the Department of Labor in March, reveals that 35 products were made with the forced labor of children in 25 countries.²⁵ These data call attention to companies that use forced labor to bring their products to market around the world. The range of products varies widely from sugarcane to coffee, garments to gold, and much more. ²⁶

ENDING TRAFFICKING
Within the last decade, efforts to end human trafficking within the United States have progressed from a social movement to improved federal prosecution and policies to fight the crime. Verbal accounts of trafficking from survivors helped garner the interest of government officials,²⁷ and approaching human trafficking as a moral crusade made its horrors real.

Clinicians, health care providers, public health workers and educators acknowledge that more education is needed to identify persons who are being trafficked for sex work as well as those at risk of being trafficked. Victims of trafficking are not found in back alleys; they are present in health care settings, in neighborhoods and in schools. Even in those settings, victims are elusive and have reasons not to trust people and agencies that could help them. Providing emotional and legal support to human trafficking victims is imperative and part of the solution in eradicating trafficking.

Recently, there has been a change in focus from prosecuting the victims of human trafficking to prosecuting others, for example, those who recruit and profit from the victims of trafficking. There is increased awareness that the internet enables human trafficking. Recent literature reflects interest in decreasing the demand for paid and exploitative sex. This lens causes professionals and ordinary citizens to report men who pay for sex. Others want massage parlors, hotels and motels that indirectly profit from the trafficking industry to be raided, and their owners to be publicly embarrassed and fined.

Public and professional awareness about the scope of human trafficking and its impact on local and global communities needs to be strengthened. Human trafficking demands the attention of the public and private sectors,²⁸ and its victims deserve our compassion and proactive support. Children and young teens are especially vulnerable to trafficking in its many forms. Trafficked young people are vulnerable to injuries, HIV and other sexually transmitted diseases, overdoses of drugs or alcohol, and suicide. Prevention of trafficking saves young lives.

SR. ROSEMARY DONLEY, SC, is a professor of nursing and holds the Jacques Laval Chair for Justice for Vulnerable Populations in the School of Nursing at Duquesne University in Pittsburgh.

CARMEN KIRALY is a professor in the School of Nursing at Suffolk County Community College in Brentwood, NY.

NOTES

1. United Nations Office of Drugs and Crimes, Global Report on Trafficking (United Nations publication, No. E.19.IV.2), www.unodc.org/documents/data-and-analysis/glotip/2018/GLOTiP_2018_BOOK_web_small.pdf.
2. United Nations Office of Drugs and Crimes, Global Report on Trafficking.
3. Child Soldiers International, Annual Report 2016-2017, https://www.child-soldiers.org/news/annual-report-2016-17.
4. World's Children, 21 Million People Worldwide are Victims of Human Trafficking, www.worldschildren.org/trafficking-guide?gclid=EAIaIQobChMIhYaCq-u24Q VgoWzCh1PEQRREAAYASAAEgI-kPD_BwE.
5. United Nations Office of Drugs and Crimes, Global Report on Trafficking.
6. U.S. Department of Homeland Security, What Does Human Trafficking Look Like?, www.dhs.gov/blue-campaign/what-does-ht-look-like.
7. Matthew Johnson and Meredith Dank, The Hustle: Economics of the Underground Commercial Sex Industry, Urban Institute (2014), http://apps.urban.org/features/theHustle/index.html.
8. Eleanor Goldberg, "Super Bowl Is Single Largest Human Trafficking Incident in U.S.: Attorney General," Huffington Post, Feb. 3, 2013, https://www.huffpost.com/entry/super-bowl-sex-trafficking_n_2607871.
9. U.S. Immigration and Customs Enforcement, "Human Trafficking and Smuggling," (2013, revised 2017), www.ice.gov/es/factsheets/human-trafficking.
10. Marcelo Suarez-Orozco, Carola Suarez-Orozco and Winmar Way, "The Empire of Suffering: Tracking of Children in the Global Millennium," Paper from Workshop 2-3, Pontifical Academies of Sciences, Pontifical Academies of Social Sciences and World Federation of the Catholic Medical Associations (Nov. 2013), http://www.endslavery.va/content/endslavery/en/publications/scripta_varia_122/suarez_orozco.html.
11. Sarah Godoy, "We Cannot End Sex Trafficking without Addressing Demand," Forbes, Jan. 11, 2018, https://www.forbes.com/sites/rebeccasadwick/2018/01/11/human-trafficking-demand/#22be60d84b7c; Kevin Malone, "Sex Trafficking Is a Pandemic in the U.S., and It's Time to End Demand," The Daily Signal, Dec. 4, 2018, https://www.dailysignal.com/2018/12/04/sex-trafficking-is-a-pandemic-in-the-us-and-its-time-to-end-demand/. Charlotte Alter and Diane Tsai (video), "Catching Johns: Inside the National Push to Arrest Men Who Buy Sex," Time, Special Report 2015, http://time.com/sex-buyers-why-cops-across-the-u-s-target-men-who-buy-prostitutes/.
12. "Human Trafficking and the Dark Web," Medium, Feb. 6, 2017, medium.com/homeland-security/human-trafficking-and-the-dark-web-bfb9bbae62dc.
13. John Cavanaugh and Ai-jen Poo, "Human Trafficking of Domestic Workers in the United States," Findings from the Beyond Survival Campaign–National Domestic Workers Alliance and Institute for Policy Studies (2017) 1-42, https://ips-dc.org/wp-content/uploads/2017/03/Beyond-Survival-2017-Report_FINAL_PROOF-1-1.pdf.
14. Suzanne H. Jackson, "Marriages of Convenience: International Marriage Brokers, 'Mail-Order Brides,' and Domestic Servitude," University of Toledo Law Review 38, no. 895, 2006-2007, heinonline.org/HOL/LandingPage?handle=hein.journals/utol38&div=61&id=&page=.
15. Kimberly A. Chang, Julian McAllister Groves, "Neither 'Saints' nor 'Prostitutes': Sexual Discourse in the Filipina Domestic Worker Community in Hong Kong," Women's Studies International Forum 23, Issue 1, (Jan.-Feb. 2000), 73-87.
16. Franklin A. Shaffer et al., "Code for Ethical International Recruitment Practices: The CGFNS Alliance Case Study," Human Resources for Health 14, (Suppl 1), 31.
17. See the website of the Alliance for Ethical International Recruitment Practices, www.cgfnsalliance.org/.
18. Ron Hurtibise, "Sunrise Firm Settles Suit with Nurse Who Claimed She Was Threatened with Immigration Fraud Charges," South Florida Sun-Sentinel, Aug. 10, 2018, https://www.sun-sentinel.com/business/fl-bz-medpro-recruitment-firm-agrees-to-modify-policies-20180809-story.html.
19. Monica Ramirez, "Human Trafficking in the Agricultural Industry: Prevalence and Risk Factors," slide presentation, www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwiNntjTm9LhAhVNqlkKHXkoA-cQFjAAegQIBhAC&url=https%3A%2F%2Fwww.nationallatinonetwork.org%2Fimages%2FHuman_Trafficking_in_the_Agricultural_Industry_Monica_Ramirez.pdf&usg=AOvVaw03sHlk60uSJ8TSpe5TubMQ.
20. U.S. State Department,"Trafficking in Persons Report 2018," https://www.state.gov/j/tip/rls/tiprpt/2018/.
21. U.S. State Department, "Tier Placements and Regional Maps," https://www.state.gov/j/tip/rls/tiprpt/2018/282584.htm.
22. Beate Andress, International Labour Organization, "Forced Labour–Why Definitions Matter," Feb. 3, 2014, https://www.ilo.org/global/about-the-ilo/newsroom/news/WCMS_234854/lang—en/index.htm.
23. U.S. State Department, "Trafficking in Persons Report 2018."
24. Child Soldiers International, Annual Report 2016-2017. Radhika Coomaraswamy, "Girls in War: Sex Slave, Mother, Domestic Aide, Combatant," U.N. Chronicle XLVI, no. 1-2 (Jan. 2009), unchronicle.un.org/article/girls-war-sex-slave-mother-domestic-aide-combatant.
25. U.S. Department of Labor, Bureau of International Labor Affairs, "Child Labor, Forced Labor and Human Trafficking," 2018, www.dol.gov/agencies/ilab/our-work/child-forced-labor-trafficking.
26. U.S. Department of Labor, Bureau of International labor Affairs, List of Goods Produced by Child Labor or Forced Labor, www.dol.gov/agencies/ilab/reports/child-labor/list-of-goods.
27. Ronald Weitzer, "The Social Construction of Sex Trafficking: Ideology and Institutionalization of a Moral Crusade," Politics & Society 35, no. 3 (Sept. 1, 2007): 447-75, https://journals.sagepub.com/doi/abs/10.1177/0032329207304319.
28. David Barney, "Trafficking Technology: A Look at Different Approaches to Ending Technology-Facilitated Human Trafficking," Pepperdine Law Review 45, no. 4 (2018), 747-84, https://digitalcommons.pepperdine.edu/plr/vol45/iss4/3/.