At the conclusion of this activity, participants will be able to achieve the following:
- Define human trafficking.
- Describe common forms and venues of human trafficking.
- Identify, during a medical examination, potential warning signs of human trafficking.
- Understand the steps to take when encountering a victim of human trafficking.
In order to obtain AMA PRA Category 1 Credit™, participants are required to adhere to the following:
- Review the learning objectives at the beginning of the CME article. If these objectives match your individual learning needs, read the article carefully. The estimated time to complete the educational activity is one hour.
- After reflecting on the contents of the article, demonstrate your understanding by answering the post-test questions in the online form at www.mdadvantageonline.com/cme/fall-2021. These questions have been designed to provide a useful link between the CME article and your everyday practice. The entire online form must be completed, including the evaluation section. The post-test cannot be processed if any sections are incomplete. If you are unable to complete the online form, please contact Alysiana Bagwell at 888-355-5551 or ABagwell@mdanj.com.
- If a passing score of 80% or more is achieved, a CME certificate awarding AMA PRA Category 1 Credit™ will be immediately available to download. Individuals who fail to attain a passing score will be offered the opportunity to reread the article and submit a new post-test.
- All post-tests must be submitted between November 30, 2021, and December 1, 2022. Submissions received after December 1, 2022, will not be processed.
Author: Angelo J. Onofri, Mercer County (NJ) Prosecutor and Vice Chairman of the New Jersey State Commission on Human Trafficking.
Article Content Last Updated: This content was updated as of November 22, 2021.
Accreditation Statement: HRET is accredited by the Medical Society of New Jersey to provide continuing medical education for physicians. This enduring article has been planned and implemented in accordance with the accreditation requirements and policies of the Medical Society of New Jersey (MSNJ) and Health Research Education and Trust of New Jersey (HRET) in joint providership with MDAdvantage Insurance Company. HRET is accredited by the Medical Society of New Jersey to provide continuing medical education for physicians.
AMA Credit Designation Statement: HRET designates this enduring activity for 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Disclosure: The content of this activity does not relate to any product of a commercial interest as defined by the ACCME; therefore, there are no relevant financial relationships to disclose. No commercial funding has been accepted for the activity. This article was peer reviewed in accordance with the MDAdvisor Guidelines for Peer Review.
“It ought to concern every person, because it is a debasement of our common humanity. It ought to concern every community, because it tears at our social fabric. It ought to concern every business, because it distorts markets. It ought to concern every nation, because it endangers public health and fuels violence and organized crime. I’m talking about the injustice, the outrage, of human trafficking, which must be called by its true name—modern slavery.”1 – President Barack Obama, 2012
As former President Obama stated, human trafficking is a form of modern-day slavery.2 It is a violation of federal and state law and a violation of human rights. Additionally, it is not the case that human trafficking happens only in Liam Neeson movies.
The parties involved in human trafficking typically include the trafficker, who is the person in control, and the enforcer, who is usually the second in charge. Traffickers can be men and/or women of any age, socioeconomic level, race or ethnicity. The traffickers control their slaves by force, ranging from beatings to sexual assault, starvation, drug dependence and fraud. They are not always organized criminals. In New Jersey, a number of the street gangs that were participating in illegal narcotics sales have now turned to human trafficking because there is so much money to be made.
The victims of human trafficking can be anyone. The people most vulnerable to being recruited or forced into human trafficking are undocumented individuals, those living in poverty, runaway or homeless youth and those suffering from mental health issues. However, it is important to note that anyone can be a victim. Trafficking does not happen only to inner-city people or folks from foreign countries. Children and adolescents from affluent neighborhoods can also be victims of trafficking. The traffickers are often known by the victim. For example, a young suburban girl may be introduced into trafficking by her boyfriend.
“The traffickers play on victims’ insecurities. They initially provide a sense of family and belonging.”
The means for human trafficking are physical restraint and threats of serious bodily harm against the victim or any other person, such as family members. The traffickers play on victims’ insecurities. They initially provide a sense of family and belonging. They control individuals by taking their passports, visas and driver’s licenses and by facilitating access to illegal drugs. They prey on victims of domestic violence or spousal abuse or persons or families in debt bondage. Promises are made about work and being paid. A victim trying to come into the country may be told, “We’ll get you to the United States, and you will owe us this amount of money. We know you don’t have it, but to work off that debt, we’re going to put you to work in one of the places that we own.” Rarely do the victims ever receive any money out of these situations.
The frequent forms of trafficking fall into three distinct categories.3 The first includes victims working in factories, hotels, migrant jobs, cleaning services, construction and landscaping, peddling rings, restaurant work, hair salons and nail salons. The second category targets individuals in domestic servitude, housekeeping and nanny work. And the third encompasses the commercial sex business including prostitution, stripping, pornography, escort services, and particularly work in brothels and massage parlors.
In the end, the consumer controls the human trafficking industry. If people stopped using the services of trafficked individuals, the economy for that industry would dry up.
Human Trafficking in New Jersey
Human trafficking occurs across the nation. In particular, New Jersey’s dense population and its location on the I-95 corridor between New York and Philadelphia are prime factors that make human trafficking enticing. There are roadways, airports, seaports and terminals that make it very easy for victims to be transported into the state. Atlantic City, in particular, is a major hub of human trafficking.
In New Jersey, each type of human trafficking has been identified. There are those who have been working in the illegal sex industry and also as laborers in places like nail or hair salons. There have been migrant workers who were being trafficked as day laborers on the various farms throughout the state. There are cases happening right now in New Jersey; some that are known and being investigated, and others that aren’t yet known.
As an example, there was a case in Mercer County (NJ) where an individual was being taken to the Red Roof Inn Motel on Route 1. There was a steady stream of men going in and out of that particular hotel when the police were alerted by a concerned citizen. The police went in and broke up the ring. As a means of control, the traffickers were using threats against the victim’s family in China. The traffickers even had a photo of the individual’s 12-year-old sister and said that if she didn’t do what was asked of her, her sister would be brought in to do the work next.
In another significant case, the U.S. Attorney’s Office in Newark investigated a human trafficking case that involved a hair braiding salon.4 The traffickers used numerous methods of control, such as coercion by withholding documents and debt bondage. The victims were adolescent girls trafficked from a foreign country by a family who was respected both in the Newark community and in West Africa. Traffickers would travel to Chad and Togo and offer the opportunity for young African girls to learn a skill in the United States and get an American education. But once the girls arrived, all of those promises were broken. The traffickers told the girls that if they didn’t do the work, they would be turned into the police as prostitutes. They were forced to work seven days a week braiding hair, and they never received any money. Meanwhile, it is estimated that the traffickers, who are now in jail, brought in approximately four million dollars.
Human Trafficking and The Law
Human trafficking is a federal crime under the Trafficking Victims Protection Act.5 In New Jersey, there have been numerous laws passed in recent years strengthening the definitions and consequences of human trafficking. Human trafficking is a first-degree crime and carries a sentence of between 15 and 30 years in state prison.6 Typically, traffickers are held without bail under the New Jersey Bail Reform Act because they present a danger to the public.
The elements of human trafficking as defined by New Jersey law are that a person knowingly either holds, restrains, recruits, lures, entices, harbors, transports, provides or obtains another person to engage in sexual activity or provide labor or services. In New Jersey, we don’t need to show force, fraud or coercion if the victim is a minor used in sex trafficking. Also, any victims who are 16 and under can testify via closed circuit television so that they don’t have to see their captor and trafficker in the courtroom because there had been several trials where the trafficker was still trying to control the victim through subtle coercion. Also, there is a human-trafficking-related charge for any licensed driver who “recklessly” transports a trafficking victim.
A statute went into effect on July 1, 2013, that created a second-degree crime for providing services, resources or assistance, knowing it is being used for human trafficking.7 Under New Jersey law, the trafficking victim may collect restitution from the trafficker in an amount which is the “greater of the gross income or value to the defendant trafficker of the victim’s labor or services” or “the value of the victim’s labor or services as determined by the New Jersey Prevailing Wage Act.”6
Additionally, a New Jersey law criminalizes the procuring or attempting to procure a person to engage in sexual activity or labor services if it is a known human trafficking victim or if a reasonable person would conclude that the person being procured was a human trafficking victim.8
How to Identify Victims of Human Trafficking
One of the most challenging aspects of identifying victims of human trafficking is that they tend not to self-identify as victims. There is a climate of fear caused by the methods of coercion and control that are being used by the trafficker. Sometimes the individuals may not even know they are victims of human trafficking, which is often seen with undocumented individuals. There also tends to be significant feelings of shame, self-blame and helplessness. The victim may think, “I got into this on my own because of my drug dependency or because of issues that I was having.” Additionally, the individuals who are recruited into trafficking often also have some untreated mental health issues.
There are some general indicators that apply to all victims of human trafficking.9 Typically, a human trafficking victim doesn’t have any type of legal documentation. The trafficker is keeping those documents so that the individual is unable to run. Many times, the victim will claim that they are just visiting an area but is unable to articulate where they are staying or cannot remember the address. This is important because they don’t know where they’re being held.
Human trafficking victims do go to medical appointments. Human traffickers are motivated to keep their slaves healthy because that’s money for them. Often, when a victim is at a doctor’s appointment, there is someone who comes into the exam room to speak for them or acts on their behalf. During the medical appointment, a physician or healthcare provider may notice that an individual exhibits a loss of sense of time or space, often because of forced drug addiction. Victims often avoid eye contact, especially if they are forced into sexual activity, because it helps them to dissociate themselves from traumatic experiences. The victims are also not in control of their own money.
The victims are generally malnourished and in poor health. Many times, they are drug addicted. Signs of physical abuse include bruising, black eyes, burns, cuts, broken bones, broken teeth and multiple scars, including from electric prods. There could also be evidence of a prolonged infection that could easily have been treated through a routine physical or checkup.
“There may be clues in an individual’s behavior or appearance that suggest that they are underage or younger than they are reporting.”
There are some specific indicators for sex trafficking victims that medical professionals should know. There may be clues in an individual’s behavior or appearance that suggest that they are underage or younger than they are reporting. An individual may report an excessively large number of sexual partners, especially when it is not age appropriate (such as a 15-year-old girl reporting dozens of sexual partners). There is often evidence of sexual trauma and multiple or frequent sexually transmitted infections (STIs). There may be multiple or frequent pregnancies. There may be unexplained or unusual scar tissue, potentially from forced abortions. The patient may be using lingo or slang relating to their involvement in prostitution. These indicators, along with addiction to drugs and alcohol, lack of health insurance and paying with cash, may help to identify a human trafficking situation.
An additional indicator that has been noted by law enforcement officials is the presence of tattoos on the neck and/or lower back that the individual is reluctant to explain.10 Many victims have tattoos, such as a person’s name or initials, that may represent the trafficker, meaning that they belong to them. In one particular case in Trenton, all of the victims who were rescued had barcodes on their upper arm, indicating that they were the property of the trafficker.
Look for the following clues to identify victims of human trafficking:
- No passport or other form of identification or documentation
- Non-English speaking and/or not speaking on own behalf
- Evidence of inability to move or leave a job
- Bruises or other signs of physical abuse
- Evidence of being controlled
- Fear or depression
How Can Medical Providers Help?
Healthcare providers are in a unique position to recognize, identify and reach out to victims of human trafficking. Medical professionals should not be looking to rescue the victim but should report any suspicious behaviors or scenarios. (See HUMAN TRAFFICKING REPORTING CONTACTS for contact numbers.) Of course, if you suspect that the victim is in immediate danger, notify the police by calling 911.
Healthcare providers should familiarize themselves with social service providers in their area who are working on the issue of human trafficking and then work with these agencies to create a protocol for responding to victims of trafficking. When you’re conducting an examination, utilize your existing assessment and examination protocols for victims of sexual assault or sexual abuse, including culturally-sensitive protocols and age-appropriate language. If you ask about sexual history, be sure to distinguish between a consensual and nonconsensual encounter. As professionals skilled in talking to people, you may be in the best position to recognize when someone is holding back information or in a situation that doesn’t seem quite right.
In general, be observant and look for any inappropriate responses. An individual may come in wearing inappropriate clothing, such as lingerie, very short skirts or other items that may be associated with the sex trafficking industry. Ask questions. “That’s an interesting tattoo. Why do you have that barcode?” In addition to tattoos, you may see excessive cutting or excessive burns because cigarette burns and electric prods are used as a means of control. A victim who is with their trafficker or a “trusted associate” of the trafficker may claim that they are with their boyfriend or an uncle. Many times, they will use the lingo, stating, “That’s my daddy.” These are all little indicators that can be used by you as a medical professional to help identify victims of human trafficking.
Questions to Ask During a Medical Examination When Trafficking is Suspected
- What type of work do you do?
- Are you being paid?
- Where do you sleep and eat?
- Can you leave your job if you want to?
- Can you come and go as you please?
- Have you or your family been threatened?
- What are your working and living conditions like?
- Are there locks on your door/windows so you cannot get out?
- Has your identification or documentation been taken from you?
- Do you have to ask permission to eat/sleep/go to the bathroom?
If possible, choose a comfortable examination space that is conducive to confidentiality. If appropriate, try to separate the individual from his or her belongings and the escort or interpreter by getting the individual into a gown or putting them in an X-ray room alone. Perhaps they will feel more comfortable and speak more openly with you. Keep in mind also that the victim may be carrying some sort of tracking or communication device, such as a GPS transmitter, a cell phone or other small device.
Try to record as much information about the situation as possible, being careful not to put yourself or the individual in any danger. If it is possible for you or a staff member to get a license plate number, that greatly helps law enforcement. If you suspect someone might be trafficked, report it to the appropriate prosecutor’s office or municipal police department.
Most importantly, remember that every incident of human trafficking is different. Each indicator taken individually may not imply a trafficking situation, and not all victims of human trafficking will exhibit the classic signs. However, recognition of several indicators may point toward the need for further investigation.
As a medical professional, you are required to report human trafficking cases if you become aware of them. When information is reported to a trafficking hotline, the identity of the reporter is kept confidential. You will not even be asked to provide your name. The person answering the call will just take the information and follow up on it. There is no penalty for reporting a suspicious patient or situation, even if nothing further comes of it. You might call to state you are concerned about a patient you saw with a certain tattoo on their arm. If you were to say, as an example, “I just saw a patient who had a barcode tattoo, and they got in a car with NJ license plate ABC123,” that’s really all you would need to say to the hotline. That would get law enforcement involved to build probable cause, which is done through surveillance, in order to help rescue folks who need help.
As former President Obama pointed out, the injustice and outrage surrounding human trafficking cannot be ignored. The problem affects all of us. As medical professionals, you can take your position on the frontlines of this battle and help in the fight against modern-day slavery.
Human Trafficking Reporting Contacts
National Human Trafficking Resource Center Hotline: 888-373-7888
Text “HELP” or “INFO” to BE FREE (233733)
Live Chat at www.humantraffickinghotline.org
New Jersey Contacts
Assistant Prosecutor Heather M. Hadley: (609) 989-6571
Detective Alicia Bergondo: (609) 989-6821
Hotline: 855-363-6548 (855-END-NJ-HT)
Reports of sex trafficking involving children: Careline (800-842-2288); National Hotline
Reports of sex trafficking involving children: ChildLine (800-932-0313); National Hotline