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proof of human trafficking. However, recognizing the “red flags,” or indicators, can help alert school administrators and staff to a human trafficking situation or another harmful situation. Have unexplained absences from school, or has the student demonstrated an inability to attend school on a regular basis? Suddenly changed his or her usual attire, behavior, or relationships? Suddenly have more expensive material possessions? Chronically run away from home? Act fearful, anxious, depressed, submissive, tense, or nervous and paranoid? Defer to another person to speak for him or her, especially during interactions with school authority figures (this may include an adult described by the student as a relative, but may also be a friend or boyfriend/girlfriend)? Show signs of physical and/or sexual abuse, physical restraint, confinement, or other serious pain or suffering? Seem to be deprived of food, water, sleep, medical care, or other life necessities? Have new branding/tattoos? Have a “boyfriend” or “girlfriend” who is noticeably older? Make references to sexual situations or terminology that are beyond age-specific norms or engaging in uncharacteristically promiscuous behavior? The U.S. government supports a victim-centered approach. It funds a national public awareness campaign and a number of nongovernmental organizations that assist victims. The U.S. government vigorously pursues human trafficking cases and prosecutes the traffickers. For a complete assessment of U.S. government efforts to combat trafficking in persons, please visit the Unites States Office for Victims of Crime http://ovc.ncjrs.gov/humantrafficking/.Issue: The United States is one of the largest markets and destinations for human trafficking victims in the world.1 If staff at your health care organization have not yet encountered a human trafficking victim, very likely they will. Knowing how to identify victims of human trafficking, when to involve law enforcement, and what community resources are available to help the individual is important information for all health care professionals. Over a 10-year period (2007-2017), the National Human Trafficking Resource Center (NHTRC) received 40,200 reports of human trafficking cases in the U.S., with the greatest number of reports coming from California (1,305), Texas (792), Florida (604), Ohio (365) and New York (333).2 Human trafficking is the fastest growing criminal industry in the world and is the second-largest source of income for organized crime.1 Identifying and helping victims of human trafficking can be difficult and can further endanger the victim. Most human trafficking victims or their families have been threatened with harm if the victim reveals their exploitation. In some cases, victims from different countries or cultures don’t realize that their exploitation is unusual or criminal. Also, some human trafficking victims have bonded with their exploiter, a condition called trauma bonding that is similar to Stockholm syndrome. Victims may keep silent about their exploitation from shame or fear of being humiliated. Since medical care is occasionally necessary for trafficking victims, health care professionals are in a unique position to help these unfortunate victims.1 What is human trafficking and who is victimized? Human trafficking is modern-day slavery.3 The United Nations Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Article 3, defines human trafficking as: The recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs. 4 The U.S. Victims of Trafficking and Violence Prevention Act of 2000 (TVPA) defines and classifies human trafficking into two categories: sex trafficking and labor trafficking.5 According to the Office on Trafficking in Persons, human trafficking is a public health issue that impacts individuals, families and communities. Traffickers disproportionately target at-risk individuals, including those who have experienced or been exposed to other forms of violence, and individuals disconnected from stable support networks.6 See the sidebar for vulnerable populations. Recognizing signs of human trafficking The NHTRC and other sources provide the following signs of human trafficking that can be used to recognize potential victims:2 Poor mental health or abnormal behavior: • Appears fearful, anxious, depressed, submissive, tense, nervous or paranoid Quick Safety Issue 42, June 2018 Page | 2 Legal disclaimer: This material is meant as an information piece only; it is not a standard or a Sentinel Event Alert. The intent of Quick Safety is to raise awareness and to be helpful to Joint Commission-accredited organizations. The information in this publication is derived from actual events that occur in health care. ©2018 The Joint Commission, Division of Healthcare Improvement Health problems that may alert health care providers to human trafficking • Burns • Fractures • Bruises/contusions • Respiratory and other infections • Tuberculosis • Sexually transmitted diseases • HIV infection • Pregnancy • Abortion-related complications • Abnormal vaginal discharge • Chronic vaginal and cervical infection • Pelvic inflammatory disease Source: Journal of Applied Research on Children: Informing Policy for Children at Risk, Human Trafficking, 2011; Vol. 2: Issue 1, Article 8. Sample screening questions for human trafficking victims • Where do you sleep and eat? • Do you live there with other people? • Is your family there, or nearby? • Are the doors and windows locked so you cannot get out? • Has your ID or documentation been taken from you? • Have you been denied food, water, sleep or medical care? • Have you been threatened if you try to leave? • Has anyone threatened your family? • Have you been physically harmed in any way? • Are you being forced to do anything you do not want to do? • Avoids eye contact • Refuses to change into a gown and/or to cooperate with physical exam • Behavior or demeanor does not align with injury or complaint (i.e., acts like it is “no big deal,” even with concerning injuries) • Refuses treatment that does not take place during that visit (i.e., refuses to go to specialist) Poor physical health: • Appears malnourished • Signs of repeated exposure to harmful chemicals • Signs of physical and/or sexual abuse, physical restraint, confinement or torture Other: • Is not in control of identification (ID or passport) • Is not allowed or able to speak for themselves (a third party may insist on being present and/or interpreting) • Claims of just visiting • Unable to clarify address or where he/she is staying • Unsure of whereabouts and/or of what city he/she is in • Loss of sense of time • Inconsistencies in his/her story • Tattoo(s), brand(s) or other marking(s)1 When human trafficking is suspected Every situation of human trafficking is unique; it is important to use a victim-centered response. Not all victims of trafficking will be ready to seek assistance, and health care professionals cannot force an adult victim to report the crime of human trafficking. However, if the victim is a minor (under 18 years of age), the provider is legally obligated to contact Child Protective Services.1 Medical providers can provide trafficking victims with information and options, while supporting them through the process of connecting with service providers if they are ready to report their situation.7 If human trafficking is suspected: • Remain nonjudgmental • Observe the body language and communication style of the patient and those who accompany him/her3 • Use plain language; try to use words the patient uses. • Try to interview and/or examine the patient privately at some point during the visit. 3 Ensure the patient is alone when you discuss sensitive issues. • If you are able to interview the patient alone, use simple screening questions (see sidebar box for sample questions to screen a patient who may be a victim of human trafficking). 1 • Find an interpreter if necessary1 • Build a trusting rapport with the patient1 • Document your concern in your notes to ensure it is not overlooked if the victim returns for care or assistance Safety actions to consider: If a patient has disclosed that they have been trafficked, the health care professional should take the