Human trafficking has been a global issue that significantly impacts the healthcare system and communities. Healthcare professionals working in different healthcare settings are in the position to identify, diagnose, treat, and refer potential victims of human trafficking. Guided by ethical principles and legal standards to guide their actions and decision-making to care for victims of human trafficking, this unique opportunity for awareness of every potential victim is essential.
NHTH: National Human Trafficking Hotline
Human Trafficking is considered a crime that affects virtually every country globally . It is a human rights issue that violates the dignity of each victim. It primarily involves the perpetuation of violence against children and women. In the United States and worldwide, it remains a significant public health issue. It is a form of contemporary slavery known as "trafficking in persons" . According to the United Nations , human trafficking consists of three core elements: the act, the means, and the purpose that results in the exploitation of vulnerable victims.
In the United States, human trafficking divides into two categories of sex and labor trafficking . However, there is an emerging global health problem of organ trafficking, which is newly recognized. Sex and labor trafficking victims come from highly diverse backgrounds and can vary significantly in age, gender, race, culture, immigration status, and socioeconomic background .
Health care professionals in different stages of training and levels of care are usually the first responders in the identification, diagnosis, treatment, and referral of the potential victims of human trafficking. Although victims may go unrecognized upon presentation in any health care setting, it is crucial to discern that any individual has the potential to have been a victim of human trafficking. Health care professionals in the healthcare settings such as the emergency department, urgent care, and retail clinics who encounter victims of human trafficking should be guided by ethical principles  and legal standards while at the same time recognizing their obligations under Human Rights Law . These principles and standards and other perspectives are needed to guide health care professionals in their actions and decision-making as they encounter many of society's vulnerable victims of human trafficking.
The profile of a typical victim limits the ability to identify the actual victims; therefore, it limits the support and care they need. Some factors can increase an individual's vulnerability to trafficking. These include youth, a history of childhood abuse, homelessness, sexual minority group, cognitive or physical disability, migrant worker, low socioeconomic status, and racial or ethnic minority.
Given the variety of settings healthcare professionals work, they are on the "front line" to encounter victims of human trafficking. Physicians and other health care providers are poised for indicators and red flags that a patient may be a victim of human trafficking. Approximately 88% of human trafficking victims have interacted with a healthcare professional during their life during their captivity , yet physicians and other healthcare professionals have missed these opportunities for intervention. Thus, being vigilant for indicators, relevant signs, and symptoms are essential.
An outline are some possible tip-offs that the patient might be a victim of trafficking, which include the following :
• Younger than 18 years and is a suspected commercial sex worker.
• A person accompanying the victim exhibits a controlling behavior. This can be a parent, spouse, friend, or employer. This person may insist on staying with the victim and translating for him or her.
• Does not have appropriate identification documentation (such as a passport or a driver's license). Alternatively, if these documents are available, the person accompanying the patient does not allow him or her to handle them.
• Shows signs of neglect or abuse, such as malnourishment, evidence of cigarette burns on the arms, or other forms of physical abuse.
• A discrepancy exists between the medical history provided and the clinical findings.
• Seems unusually fearful or submissive, especially when interacting with the person who accompanied him or her to the dental office.
• Entered the United States recently from Latin America, Eastern Europe, or Asia.
Likewise, although no one indicator or a combination of indicators automatically confirms trafficking, specific indicators may act as warning signs during visits to healthcare facilities which include: sexually transmitted infections, pregnancy testing, abortion procedures, malnutrition, dehydration, drug and alcohol addiction, chronic pain, depression, anxiety, fear, burns, and bruises. Thus, physicians and other health care professionals working on the front line are in positioned to recognize the victims of human trafficking.
Victims of human trafficking will likely be reluctant to give out personal information, has a fear of authority figures, and conducting interviews can be difficult. Another person often accompanies victims, and getting the client alone is considered the initial step to a successful encounter . Build a trusting rapport with the patient and find an interpreter alongside if necessary. Physicians or other health care professionals need to pay attention to subtle and nonverbal cues such as affect, body language, and attitude because the patient is unlikely to identify herself as a trafficking victim. Asking a patient outright if he or she is a victim of human trafficking is not likely to be successful  because many victims do not know or are unaware that human trafficking illegal in the U.S. and other countries. Some victims decline to get help because of consequences and worse outcomes of trying to escape. Similarly, the victim's family may be threatened by some traffickers if they try to escape.
Promoting a safe environment and not further endangering the victim is a minimum standard of care applicable to all physicians and other health care professionals working in the emergency department, urgent care, and retail clinics. The management of victims of human trafficking must involve a multifaceted approach and patient-centered care. It is imperative to provide a safe place for interaction and to talk about the details of their trafficking history. When indicated, a collaborative and integrated care approach facilitates consultation with other medical, surgical, gynecological, and psychiatric disciplines and ensures that human trafficking victims have adequate access to quality health care, including substance abuse treatment options.
Health care professionals must recognize the standards and perspectives to guide decision-making during their encounters with potential victims of human trafficking in the health care settings while simultaneously guided by ethical principles . The principles that are fundamental in governing provider-patient relationships are beneficence (intention to do good), nonmaleficence (do no harm), justice (fairness), and autonomy (freedom to choose). These principles serve as necessary directives for frontline healthcare professionals and provide guidance to form the foundation of effective response when facing a potential victim of human trafficking in a healthcare setting.
Health care professionals should act in the best interests of their patients (beneficence) and not harm (nonmaleficence), either through acts of omission or commission . Patients' needs, goals, wishes, priorities, risks, and vulnerabilities must be understood to carry out these duties and incorporated into the care plan. Beneficence and nonmaleficence call for trauma-informed care  sensitive to the victim's past experiences with the health care system and society. This approach maximizes healing and recovery while minimizing the risk of retraumatization . Thus, increasing the efficiency and effectiveness of interactions with the victims.
On the contrary, victims may become reluctant to disclose that they are in a difficult situation when accessing health care. Therefore, the principle of nonmaleficence should be applied with caution. Aggressive attempts by a healthcare professional to confirm the suspicion and obtain admission or disclosure can be psychologically harmful to the victim and can potentially trigger significant fear, stress, and anxiety. Equally, it can provoke distressphysically and psychologically as past trauma is re-experienced.
Justice is the principle that requires health care professionals to distribute services fairly and treat patients' cases equally. However, the principle of justice can be challenging due to the controlling and imperceivable nature of the crime. Victims of human trafficking who are considered abusive and exploitative situations would instead focus on day-to-day survival over preservation of activities for overall well-being even though they have access to primary care and follow-up care. This may be one reason for the greater utilization of urgent care centers, emergency departments, and retail clinics rather than long-term comprehensive primary care services. Primary care appointments and nonadherence can be problematic. For example, if a suspected victim presents with a sexually transmitted infection, a point of care treatment that is equally effective is preferable to recurring multidose treatment, which carries a risk of nonadherence. Thus, the fair allocation of services and ongoing assessment among the victims and survivors of human trafficking is challenging.
Victims of human trafficking may develop general feelings of shame, self-blame, guilt, humiliation, helplessness, and even the loss of sense of autonomy. Traffickers are usually psychologically manipulative to gain and sustain control of the victims. Health care providers must be cognizant to when and how these victims do need help. An assessment of a person as helpless is harmful  because it undermines victims' perceptions as moral agents in their capacities for self-determination and decision making. A victim can actively gauge the trustworthiness of a health care personnel with whom they interact, thus make decisions about whether disclose or hide their situation, whether to decline or accept assistance, or possibly victims decide to conform with the trafficker in order to gain the trust and consequently opening the door to carry out a successful escape attempt. Victims of human trafficking possess autonomy in varying degrees, and health care professionals should be aware.
In addition to the principles, the rules of confidentiality can also create much-needed space between the victims and their traffickers, increasing the chances that suspected trafficking victims will be forthcoming, adequately identified, diagnosed, and treated. Like any other patient, victims of human trafficking deserve the dignity and respect as individuals we care for.
Victims of human trafficking can be discouraged from seeking help due to mandatory reporting that has the potential to bring victims and survivors to the attention of social service and law enforcement agencies , leading to skepticism about the ability of health care professionals in providing needed care. However, not all states require a mandatory reporting of adult human trafficking instances  to law enforcement or call the hotline unless the victim is under 18. It is under the legal obligation to phone the child protective services. After identification of the victim and careful planning, a health care provider needs to be aware of the following : a) The victim is not forced to report the crime, and b) The victim and or victim's family may jeopardize their safety for reporting the crime.
For adult victims of human trafficking, a healthcare professional can call the hotline anonymously without permission. However, it can be problematic because consent from the victim is needed to make an official report . However, contact information and a safe place to make the call herself will be available.
The National Human Trafficking Hotline (NHTH)  is an anti-trafficking resource center that can assist victims and survivors in finding local resources and developing a suitable safety plan for the client.
In some jurisdictions, filing an anonymous tip concerning an adult patient who is a suspected trafficking victim and who refused rescue assistance might pose a legal risk for the health care professional, whereas in other jurisdictions, filing a report could be mandated by statute. For instance, most states mandate that a health care professional report suspected abuse and neglect when treating a patient with an injury resulting from a firearm or another weapon . Each health care professional or provider must decide on what proper course of action should be considered on a case-by-case basis. Guided by good moral decisions, it is imperative to respect the patient's right to self - determination when reporting suspected trafficked victims. In all aspects, there is no definitive rule that would guide a provider in all situations.
Human rights violations are both a consequence and a cause of trafficking in persons . Human rights violations are varied, occurring at different stages of the cycle. The right to life, liberty, and security; the right not to be subjected to torture and or cruel, inhuman, degrading treatment or punishment; the right to freedom of movement; the right not to be submitted to slavery, servitude, forced labor, or bonded labor; the right to freedom of movement; the right to be free from gendered violence; the right to the highest attainable standard of physical and mental health; and the right of children to special protection are some of the particular human rights violation in cases of trafficking [16,17]. Undoubtedly, it violates customary international law . It is justifiable that a healthcare provider who encounters such vulnerable victims wishes to assist. However, it is troublesome if care is not offered that may worsen the victim's condition. While providers have good intentions, there are challenges and barriers to meeting victims' healthcare needs that are beyond this paper.
Human trafficking remains a global health concern that affects individuals, communities, and society. Thus, from an ethical and legal perspective, addressing the role of a physician and other health care providers includes proper identification of suspected victims, the needs, priorities, wishes, goals, risks, vulnerabilities, resource allocation, and mandatory reporting. Although the readily accessible point of care services such as the emergency department, urgent care centers, and retail clinics become a haven for victims of human trafficking, victims go unrecognized or untreated. Physicians and other health care providers, especially those on the front lines, must maintain constant vigilance and remember that any individual is a potential victim. Given the complexity of the needs faced by trafficked victims, providers may confront the challenges of ethical and legal standards. For this reason, working collaboratively with other health disciplines, social services, and law enforcement is vital to the successful provision of comprehensive services for those victims and, hopefully, a way out of trafficking.