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Rural Health Information Hub

Jul 29, 2020

“It's on Us”: Healthcare's Unique Position in the Response to Human Trafficking

by Jenn Lukens

Part one of a two-part series on human trafficking in rural America. Read part two — Human Trafficking in Native Populations: Q&A with Commissioner Jeannie Hovland.

Before joining the board of Transitions of Pennsylvania, a local women's resource center, Kendra Aucker said human trafficking wasn't exactly on her radar.

a pair of hands raised with broken chains“I live in an idyllic part of the state, but I've learned that it happens right here. I mean, there are people right here who traffic their own children,” said Aucker, who also serves as CEO of Evangelical Community Hospital in Lewisburg. The hospital sits on U.S. Route 15 and Interstate 80, two of the most traveled roadways by which human traffickers pass through.

“What really opened my eyes was learning that up to 88% of survivors indicated that they sought healthcare during the time they were trafficked,” recalled Aucker.

Designed by the Nebraska Hospital Association, this chart represents the data from the source referenced in the previous paragraph.

The Reality of Human Trafficking

Human trafficking, as defined by the U.S. Department of Homeland Security, “involves force, fraud, or coercion to obtain some type of labor or commercial sex act.” Referred to as a form of “modern-day slavery,” human trafficking occurs in every state and is not limited by the size of a community. While there is debate about the exact dollar amount, the industry generates profits into the billions, making it one of the most profitable crimes in the world. It has been identified as a public health concern by researchers, federal agents, and healthcare professionals alike.

“This is a social issue in our communities and, as human beings, we have the responsibility to treat human trafficking as the crisis it is and to do our part to tell the story and make a difference,” emphasized Aucker.

Polaris is a federally funded nonprofit that maintains one of the most extensive data sets on the issue of human trafficking in the United States. Informing the data are thousands of calls, texts, and messages that are fielded by its National Human Trafficking Hotline. Polaris's latest statistics indicate that human trafficking has continued to rise, from 7,748 confirmed cases reported to the hotline in 2016 to 10,949 in 2018. Polaris's demographic breakdown shows that nearly half of survivors are minors, there are five times more females trafficked than males, and minorities are more likely to be trafficked.

Types of Human Trafficking

The two most common forms of human trafficking, as defined by the Trafficking Victims Protection Act of 2000:

Sex trafficking: 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.

Labor trafficking: 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.

The federal Trafficking Victims Protection Act (TVPA) of 2000 differentiates between sex and labor trafficking, but pegs the former as the most common by nearly 8:1. Both have been identified as problems in rural America, but definitive statistics are lacking. What is known is that the characteristics of many rural locations make them attractive to traffickers passing through or looking to set up shop. A secluded location, away from heavy legal forces and home to vulnerable populations, can be the perfect haven for traffickers.

Lisa Davis.

Lisa Davis is the director for the Pennsylvania Office of Rural Health (PORH) and is a driving force in the effort to educate rural healthcare facilities on the reality of human trafficking.

“The stories I've heard are gut-wrenching, but they are all over the map,” said Davis, who went on to describe desperate situations that become advantageous for human traffickers: a young girl who has run away from home, a migrant worker with a dream of a better life, someone with a substance use disorder looking for relief, or a desperate mother who can't pay rent.

The PORH human trafficking outreach campaign logo.

The Pennsylvania Office's efforts have served as a model for other State Offices of Rural Health (SORHs), with a statewide education and outreach campaign and hosting the first Pennsylvania Rural Human Trafficking Summit in 2019 in partnership with federal, state, and local agencies to raise awareness and train healthcare providers.

Preying on the Vulnerable

While cinematic portrayals of human trafficking may resemble reality in some parts of the world, research has found that what is true in rural America can look much different. Those trafficked commonly have vulnerabilities, such as recent migration or relocation, single motherhood, recent contact with the child welfare system, a substance dependency, homelessness, or mental health conditions. Often, the victim already has a relationship with the perpetrator who has taken advantage of their trust and targeted their vulnerabilities to create dependency.

Anne Boatright.

The Nebraska Hospital Association (NHA) created a Human Trafficking Toolkit to be a practical guide for healthcare systems to help identify human trafficking and develop a standard policy to address it. At the start, NHA sought out professionals with varying expertise to give input, including Anne Boatright, a practicing Sexual Assault Nurse Examiner (SANE) and member of the Nebraska Attorney General's Human Trafficking Task Force.

Debunking Myths

Polaris's 12 Myths of Human Trafficking confront additional misconceptions, including:

  1. It's always or usually a violent crime.
  2. All human trafficking involves commercial sex.
  3. Traffickers target victims they don't know.

Boatright has trained over 3,000 Nebraska medical providers, the majority of whom practice in rural areas, on human trafficking identification. She commends the Toolkit, which has helped her disseminate the information in a way that, she said, would have taken a decade. In the Toolkit, common misconceptions about human trafficking are addressed, such as, “It just doesn't happen in rural settings.”

“Many think of it happening only in urban areas to people who are abducted and held against their will,” Boatright explained. “But we aren't seeing that a lot. We see those with a vulnerability and someone exploiting the vulnerable because they have the ability to do so.”

Map of trafficking risk in Nebraska

Lisa Lohnes has lived and worked among vulnerable populations in rural Minnesota. She is currently one of eight Safe Harbor Regional Navigators, part of a program funded by the state of Minnesota. As such, Lohnes serves as the main point of contact for connecting sexually exploited youth and adults to human services. An employee of Support Within Reach, she said that the majority of the organization's clients are low-income and therefore attractive targets to traffickers.

Commissioner Jeannie Hovland
Q&A with Commissioner Jeannie Hovland

Part two of this series features a conversation with the Commissioner of the Administration for Native Americans about the nuances of human trafficking among Native populations and what is being done to address them.

Lohnes grew up in Minnesota's Cass Lake, home of Leech Lake Indian Reservation, and is a member of the Spirit Lake, Mni Wakan Oyate tribe. She has seen sexual exploitation firsthand: “They're desperate, so they trade sex for drugs, products, and even food that they need. And sex traffickers are master manipulators, so they tend to target the vulnerable.”

Support Within Reach logoShe went on to explain what researchers and public health professionals agree is often at the root of exploitation: “Historical trauma and intergenerational trauma create a loss of hope. They don't see a way out. That's where survival sex comes in – something that happens a lot with these communities. Not everybody is provided opportunities, so we try to make a way out for them.” Homelessness is a big factor that contributes to sexual exploitation in northwest Minnesota, so Lohnes and her team coordinate with transportation services, homeless shelters, transitional housing, and mental health providers.

Historical trauma and intergenerational trauma create a loss of hope. They don't see a way out. That's where survival sex comes in – something that happens a lot with these communities. Not everybody is provided opportunities, so we try to make a way out for them.

Like many human service organizations, Support Within Reach offers trainings to communities and professionals such as law enforcement and healthcare providers. Right now, the pandemic has moved their trainings online, allowing them to reach more groups of people at a faster rate.

Rural Providers Uniquely Positioned

Healthcare providers have a valuable role to play in the identification of human trafficking victims and the provision of their physical and psychological care. Survivor records from 2018 indicate that health services were one of the most common points of access to a lifeline for those actively being trafficked, along with family/friends, and law enforcement.

Healthcare facilities are one of few places they may be allowed to visit. Sexually transmitted diseases, urinary tract infections, pregnancy, and physical injuries are just a few reasons for appointments or emergency room admissions. But the signs aren't always recognized. “One former trafficked person was in a hospital 17 times before someone noticed there was something else wrong,” reported Davis.

The National Human Trafficking Hotline Framework includes other considerations for red flags and a systemized approach on healthcare protocol when suspecting human trafficking.

Boatright said some of the indications are more obvious than others ― like an unusual tattoo, malnourishment, and evidence of injury. Others may be related to the guardian ― like a large age gap, insistence on being present during an exam, or controlling the patient's identification card. A hotel key or large amounts of cash may also warrant suspicion.

“It's ultimately about power and control for these traffickers,” explained Boatright. “But it's not unusual for nurses or physicians to miss these signs. When I was regularly identifying trafficked persons, there would be times where I knew something was wrong, but I didn't know quite what it was or how to name it. It's common for medical personnel to have similar feelings. I try to teach people to follow their gut and know where to go with it.”

An Intentional Approach

These trauma-informed steps, outlined in the Nebraska Hospital Association's Human Trafficking Toolkit, can be the first steps to help a victim out of a harmful situation.

  • Provide a quiet, safe place for the patient
  • Separate any companions from the patient
  • Attend to the physical needs
  • Adopt an open, non-threatening body position
  • Engage the patient

One challenge is that trafficked persons may not recognize that their situation qualifies as trafficking. For instance, they may say that they can't afford to leave their boyfriend or that an uncle is making them sleep with a drug dealer for cheaper drugs. Providers can help their patients self-identify by asking the right questions. At the same time, Boatright reminds healthcare providers that their job is not to act as investigators but to provide trauma-informed healthcare to build trust so that the victim feels comfortable opening up about their reality.

Medical providers are going to get these disclosures above other professionals, law enforcement and others, so it's on us.

“Medical providers are going to get these disclosures above other professionals, law enforcement and others, so it's on us,” she explained.

Leading a System-Wide Response

Back in Pennsylvania, after learning about the reality of human trafficking in her state, Aucker immediately started implementing system-wide changes throughout Evangelical Community Hospital in 2018. She started with a mandatory training for her staff, followed by voluntary trainings from a third-party expert that made quite the impact.

Kendra Aucker.

“It was probably one of the most profound trainings that we have ever done. People were texting their family members calling for family meetings. People got emotional. I think when you talk about what human trafficking is, people think about their wives, their daughters, and their neighbors because it's modern slavery – force, fraud, or coercion – people were appalled by it. And so, it lit my workforce.”

Aucker and her team recruited champions within the facility to lead the charge. An on-call system with SANE nurses and a screening assessment were created to help clinic and hospital staff accurately identify a trafficked person.

As knowledge grew and systems were refined, Aucker's team developed a unique training curriculum, which won the 2019 Optimal Operations Award from the Hospital and Healthsystem Association of Pennsylvania. Now, they're working with larger healthcare systems to adopt the training throughout those systems. Aucker's employees serve as everyday advocates in their communities for human trafficking prevention.

“What Kendra has done can be replicated in any hospital, regardless of geography,” commended Davis, who learned of Aucker's commitment to addressing human trafficking and invited her to speak at the 2019 Pennsylvania Rural Human Trafficking Summit.

Coding for Human Trafficking

ICD-10 codes
specific to human trafficking were introduced in 2018. The codes are intended to help providers adequately diagnose and plan the resources necessary to provide appropriate treatment as well as track data on human trafficking.

Since launching the plan, Evangelical Community Hospital has successfully identified ten trafficked persons, contributing to the 621 victims identified in Pennsylvania. Aucker gives the credit to her staff: “It's one of the benefits of being a community hospital. I now have nearly 2,000 individuals who have this on their radar and who are speaking out about this.”

Where Do We Go from Here?

One of the first steps to address human trafficking on the local level, Aucker suggested, is for people in leadership positions to get educated: “An administrator of a hospital is a leader who can give a voice to this. That's your responsibility. The rest is already out there to aid you in developing a program for your organization.”

If we fail to get them the help they need, they may end up back in this situation.

Once identified, trafficked persons will need a line of support services if they are to successfully break away from their perpetrators. “If we fail to get them the help they need, they may end up back in this situation,” warned Boatright. Psychological trauma such as post-traumatic stress disorder commonly follows survivors of human trafficking. If in-house therapy is not offered, immediate referrals to a tertiary care center is important for healing.

Connecting to community groups that can provide multidisciplinary efforts to address human trafficking can also pay off. Child protective services, human services organizations like Support Within Reach, law enforcement, and state patrol all have a vital role to play.

On the state level, Davis advocates that SORHs and other rural health organizations have a responsibility to train up their healthcare facilities and staff. “I think State Offices of Rural Health are in a unique position because they know their rural communities and their rural healthcare leaders and are a respected source of information. They also have forums in which they can speak collectively and stress that human trafficking is a rural concern and it is a responsibility of a healthcare delivery system to raise awareness and serve as a point of intervention,” said Davis.

Interviews for this article were conducted prior to the COVID-19 outbreak. Follow-up calls with each participant indicate that human trafficking has not stopped, but it will take time to get definitive answers about the pandemic's effect. Polaris's article The Effect of COVID-19 on Human Trafficking explains more.