Human sex trafficking can be illustrated in one sentence: "I can sell a kilo of cocaine once and I'm out of product, but I can sell a woman over and over 25 times a night 365 days a year and make a quarter of a million dollars off one girl." That observation a pimp made to Mary de Chesnay, RN, DSN, PMHCNS-BC, FAAN, editor of the book "Sex Trafficking: A Clinical Guide for Nurses," sums up why human sex trafficking has become a growth industry.
"Trafficking is a $32 billion a year business, more than Starbucks, Nike and Google combined," said de Chesnay, a professor in the WellStar School of Nursing at Kennesaw (Ga.) State University. "It's the most lucrative criminal enterprise behind drugs."
Many people think sex trafficking happens only in third-world countries, but it's also pervasive in the U.S. "It's not just an international problem, it's a national problem," said Patricia Crane, RN, MSN, PhD, WHNP-BC, DF-IAFN, associate professor at University of Texas Medical Branch Galveston and a specialist in forensic nursing. Victims include U.S. citizens and people from countries such as Mexico, Eastern Europe, Asia and South America.
The early 1970s is when de Chesnay first met a child who was being trafficked. When she asked the 11-year-old girl with an ectopic pregnancy about the baby's father, the girl replied, "It could be my father, my four brothers, or the men who come to party on the weekend."
That child was the first in a long line of girls and women (and some boys and men) de Chesnay has seen during her career. Accurate numbers are hard to come by, but the Polaris Project, an advocacy group that combats human trafficking, estimates that 100,000 children are involved in the sex trade in the U.S. each year. The average age of a U.S. victim is 12 to 14 years old.
Nurses are in a prime position to identify possible victims of sex trafficking when they seek medical treatment in the ED, free clinics, physician offices and other locations. But too often those opportunities are missed. According to the Family Violence Prevention Fund, a study found that 28% of trafficking survivors had contact with a healthcare provider during the situation, but the abuse wasn't recognized.
How do victims become entangled in sex trafficking? de Chesnay said many victims are "runaways or throwaways, they have bad home lives." Pimps hang out around bus stops and other locations to meet the runaways. The "Romeo" pimp first befriends girls (most victims are female). Soon the girl moves in with him. Selling the girl might start with the pimp simply asking her to date his friend. Soon she is on the street, at hotels or even in the pimp's home being sexually abused. de Chesnay said Romeo pimps are the most common, but a second type is the violent pimp, who isn't interested in establishing a relationship. In rare cases a victim might be kidnapped.
Poverty is another factor. "They get involved because it's an opportunity to make some money," said Donna Sabella, CRNP, PhD, MEd, MSN, PMHNP-BC, director of global studies and the office of human trafficking at the College of Nursing and Health Professions at Drexel University in Philadelphia. "They may also need money for an addiction."
So why don't victims just leave? "If they were functioning well like us, they would find a way," said de Chesnay. "But these girls are broken in spirit. They have no self-worth and are damaged mentally and physically."
Fear is another contributing factor, Sabella said. "The pimps say they'll hurt them, their family or their children," she said.
Victims of sex trafficking have "all kinds of medical and psychological issues," de Chesnay said. Physical signs and symptoms of potential trafficking include burns, dislocated limbs or fractures, missing teeth, vaginal or rectal trauma, persistent or untreated sexually transmitted diseases or urinary tract infections, malnutrition and problems with the jaw or neck. Other signs include not being able to produce identification, having inconsistent stories about their lives and how injuries occurred, hypervigilance, and the presence of tattoos that might be "brands."
A victim might seem submissive, allowing the accompanying person, who might be his or her pimp, to respond to questions. Sabella said it's important to get the patient alone. She suggested saying, "It's hospital policy that we speak to patients alone."
Crane said that another option is to have the person with the victim fill out paperwork or ask him or her to stay in the waiting area while the nurse obtains a specimen. Once alone with the patient, nurses should choose their words carefully. "Don't ask them it they are being trafficked," Sabella said. "They won't understand the term."
Instead, Crane suggested questions such as: Can you come and go as you please? Where do you sleep and eat? Has anyone threatened your family? Is anyone forcing you to do anything you do not want to do?
Crane advises conveying messages such as, "We are here to help you. We can find you a safe place to stay. If you are a victim of trafficking and you cooperate, you won't be deported."
When faced with a trafficking victim, "the immediate problem is the medical condition," said de Chesnay. "Be kind, nonjudgmental and provide access to services." (See resources below story.)
She said nurses shouldn't present themselves as rescuers because victims don't always want to be rescued. Nurses should let victims know what to do when they are ready by providing them with information about resources such as the national hotline.
Sabella added that nurses should be aware that the victim doesn't know them and is in a difficult situation. "Don't be surprised if someone doesn't jump up and say thank you," Sabella said. "Be prepared when people say no."
In some cases, the nurse might be laying the groundwork for helping a victim leave in the future. "One woman went home because her pimp said he would kill her dog," Sabella said. "She came back the next day with the dog." She suggests telling victims they can call the hospital if they change their mind. If possible, the same nurse who saw the patient could do a follow up call in a few days, allowing another opportunity for contact. Crane said if a woman won't admit to being a victim, Crane will set up another visit to provide another chance to talk with her.
Some experts recommend giving the victim a card with the hotline number written on it, but de Chesnay advises not giving victims materials. "If pimps see it, they will beat them up," she said, adding that Georgia recently passed a law requiring the posting of signs with the hotline in places such as hospitals and hotels.
Nurses also should watch for victims in their own backyards. "A lot of this [sex trafficking] takes place in neighborhoods," Sabella said.
Reporting & recovery
If the victim is a child, mandatory reporting laws for abuse apply. In addition, some states require reporting in the cases of victims of domestic violence. Nurses should tell the patient if they are required to file a report. Reporting gives victims access to an advocate who can help with resources. For example, in March 2013, President Obama signed the latest reauthorizaton of the Trafficking Victims Protection Act, linking it to the Violence Against Women Act. "VAWA money can now be used for sex trafficking victims in a domestic violence situation," said Crane. The victim has to agree to cooperate in prosecuting the pimp to receive funds that can help her or him escape from the situation.
Unfortunately, few residential recovery programs exist in the U.S. — Sabella estimates 10 to 15. She was a founding member of Dawn's Place, a residential recovery program for trafficked and prostituted women in Philadelphia. Sabella modeled the one-year program after a program in Phoenix. Such programs often must depend on volunteers because little funding is available for these efforts.
Besides needing treatment for physical problems such as injuries from beatings and gynecological issues, survivors will need care for psychological conditions such as post-traumatic stress disorder, anxiety and depression.
"Slavery didn't end with the Emancipation Proclamation," de Chesnay said. "Nurses can step up and play a role in ending it for good. The crucial first step is awareness, people need to be educated about human trafficking, learn the warning signs and memorize the hotline number."
Nurses can request their facilities hold a seminar on the topic. Sabella and de Chesnay, who both teach a course on human trafficking, said that the subject should be part of nurses' basic education.
The next step is to work with law enforcement to develop policies for the facility where the nurse works. "Many nurses do not act because they do not know what to do once they become aware," de Chesnay said. "The protocol must spell out clearly the steps to take if a human trafficking victim walks through the door."