Policy Paper (Facial Recognition)

An official position statement of the Association of Women’s Health, Obstetric and Neonatal Nurses

Approved by the AWHONN Board of Directors, March 2016.

AWHONN 1800 M Street, NW, Suite 740 South, Washington, DC 20036, (800) 673-8499

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A W H O N N P O S I T I O N S T A T E M E N T

Human Trafficking

Position urses are ideally positioned to screen,

N identify, care for, provide referral services for, and support victims of human trafficking.

Therefore, the Association of Women’s Health,

Obstetric and Neonatal Nurses (AWHONN) sup-

ports improved education and awareness for

nurses regarding human trafficking. Patients

should be screened for human trafficking in pri-

vate, safe, health care settings. If there is a lan-

guage barrier, professional interpreter services

are imperative.

To protect the safety of women who have been

trafficked, AWHONN opposes laws and other

policies that require nurses to report the results of

screening to law enforcement or other regulatory

agencies without the consent of the woman who

experiences the human trafficking. However,

nurses and other health care professionals

should be familiar with laws for mandatory

reporting in their states, especially for minors,

and comply as applicable.

Background Human trafficking, a modern form of slavery, is

generally divided into several categories: forced

sexual exploitation, forced labor, and domestic

servitude. Victims of forced sexual exploitation

may have to work in a variety of settings,

including but not limited to prostitution, exotic

dancing, pornography, and/or as mail order

brides (Richards, 2014). Victims of forced labor

work for little or no money, often for long hours,

and without appropriate safety measures or

compensation. Female victims of forced labor are

also often sexually exploited (U.S. Department of

State, 2005).

Human trafficking is a global problem present in

all countries, including the United States. Within

the United States, sex trafficking of U. S. citizens

is more common than labor trafficking; labor

trafficking is more prevalent among foreign na-

tionals (Sabella, 2011). Trafficking victims in the

United States come from all over the world, but

not all of these victims originate from other

countries; many are U.S. citizens.

ª 2016 AWHONN, the Association of Women’s Health, Obstetri Nurses. Published by Elsevier Inc. All rights reserved.

While there is no single profile for those who have

been trafficked, certain individuals may be more

vulnerable to being victimized: runaways; home-

less and orphaned adolescents; foreign na-

tionals; individuals with histories of trauma or

violence; females; and lesbian, gay, bisexual, and

transgender individuals (Greenbaum, 2014;

Institute of Medicine, 2013; National Human

Trafficking Resource Center, n.d.).

While the exact number of trafficking victims is

unknown, it is estimated that 80% of the victims

are women and girls (U.S. Department of State,

2005). As such, they are at increased risk for

gynecologic and obstetric problems, including

persistent or untreated sexually transmitted

infections, unintended pregnancies, repetitive

abortions or miscarriages, trauma to the rectum or

vagina, and infertility. Further, basic primary

health care services are rarely provided to this

population. As a result, they often have untreated

medical problems, including but not limited to

physical injuries associated with abuse and

torture (e.g., burns, lacerations, missing or broken

teeth), malnutrition, dehydration, substance use

disorders, depression, anxiety, and posttraumatic

stress disorder (Deshpande & Nour, 2013; Grace,

Ahn, & Macias Konstantopoulos, 2014; Richards,

2014).

The Role of the Nurse One of the most challenging issues associated

with human trafficking for nurses and other clini-

cians is the identification of victims (American

College of Obstetricians and Gynecologists,

2011). In a survey of trafficking survivors,

28% came into contact with health care workers

during the trafficking situation but were not

recognized as victims (Family Violence

Prevention Fund, 2005). Victims may not have

the language or maturity to disclose their traf-

ficking status and/or may fear what will happen if

they do disclose.

Nurses are some of the few professionals who

may interact with trafficked women and girls while

they are still in captivity (Dovydaitis, 2011); thus,

they should be aware of the warning signs

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A W H O N N P O S I T I O N S T A T E M E N T

(physical and emotional) associated with traf-

ficking in women and girls. The National Human

Trafficking Resources Center (2012) identified a

number of these warning signs:

� Presence of cotton or debris in vagina and/ or rectum,

� Problems with jaw or neck, � Inability to keep appointments, � No identification, � Tattoos or branding, � Accompanied by a person who does not

allow her to speak or does not want to leave

her alone during interview and/or care,

� Inconsistent stories (conflicting stories or misinformation),

� May not speak English, and � Lack of documentation of age appropriate

immunizations and health care encounters.

Interviewing a woman who has been trafficked

poses safety concerns for the woman, others

close to her, and the interviewer. For this reason,

the interview technique must be specific to the

situation in order to avoid the potential for

causing harm (World Health Organization,

2003). Nurses should be specifically trained

about the safety needs of this vulnerable popu-

lation, including how to phrase conversations,

the availability of appropriate resources for

immediate and follow-up care, and the various

cultural aspects and norms of care. Education

should also extend to the implications for ano-

nymity, confidentiality, and informed consent as

appropriate, such as in the case of specific

traumas.

As part of the educational process, nurses

should examine their own perceptions of human

trafficking so they do not inadvertently impose

those perceptions and leave the individual

feeling more victimized and/or criticized.

Respect and nonjudgment are key components

of the interview and care encounter (International

Organization for Migration, 2007). Nurses must

also be aware of the range of risks involved

for the victim, including immigration violations,

labor laws, and other legal implications. Victims

may also experience physical harm or death for

revealing the situation, and their families may

punish or banish them as well (World Health

Organization, 2003).

Nurses also support and participate in safety

planning for victims and are encouraged to

be aware of follow-up resources. Delays or

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inappropriate referrals can result in harm and/or

increased risk for the victim. These resources

may include local organizations specializing in

working with trafficked women; free health ser-

vices (general practice, reproductive health,

hospital, and mental health); sources of advice on

housing and other social services; legal aid/

immigration advice services; local churches/

community support organizations; language

training centers; and nongovernmental organiza-

tions in the women’s home country (World Health

Organization, 2003).

Nurses should be aware of the need to establish

boundaries as appropriate to maintain their per-

sonal safety. It is not unusual for care providers

of victims of abuse (in this case human traf-

ficking) to experience emotional distress them-

selves; therefore, nurses should be aware of

professional resources for debriefing and coun-

seling (International Organization for Migration,

2007). Nurses are uniquely situated as trusted

professionals that provide support and empa-

thetic care. The perception of the victim that the

nurse can be trusted can facilitate honest

communication and a willingness to share the

situation.

Recommendations AWHONN supports research and policy initia-

tives to improve care and support for victims of

human trafficking. Such initiatives may include

the following:

� Development of a validated, brief, screening tool to better identify victims of human traf-

ficking in clinical settings.

� Mechanisms to support continuity of care, especially when warning signs of human

trafficking are present.

� Advancement of research focused on the long-term health implications for victims of

human trafficking.

� Development of educational opportunities in relation to interdisciplinary and multidisci-

plinary interviews and ongoing care.

� Development of validated lists for legal, health care, mental health, safe housing,

and culturally appropriate resources. One

such resource is the National Human Traf-

ficking Resource Center, which maintains a

crisis hotline.

� Enhancement of multi-sector collaboration and coordination in order to support infor-

mation sharing.

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460

� Public health campaigns to raise awareness of human trafficking particularly targeted to

at-risk populations.

� Support for legislative efforts that seek to penalize traffickers and fund support ser-

vices for victims.

Nurses should take leadership roles in these

initiatives. Improvements in screening, identifica-

tion, and treatment will ultimately lead to safer,

healthier women.

REFERENCES American College of Obstetricians and Gynecologists. (2011).

Human trafficking; Committee opinion no. 507. Obstetrics &

Gynecology, 118(3), 767–770. http://dx.doi.org/10.1097/AOG.

0b013e3182310d06

Deshpande, N. A., & Nour, N. M. (2013). Sex trafficking of women and

girls. Reviews in Obstetrics & Gynecology, 6(1), e22–e27. http://

dx.doi.org/10.3909/riog0214/

Dovydaitis, T. (2011). Human trafficking: The role of the health care

provider. Journal of Midwifery & Women’s Health, 55(5), 462–

467. http://dx.doi.org/10.1016/j.jmwh.2009.12.017

Family Violence Prevention Fund. (2005). Turning pain into power: Traf-

ficking survivors’ perspectives on early intervention strategies.

Retrieved from https://www.futureswithoutviolence.org/userfiles/

file/ImmigrantWomen/Turning%20Pain%20intoPower.pdf

Grace, A. M., Ahn, R., & Macias Konstantopoulos, W. (2014). Inte-

grating curricula on human trafficking into medical education

and residency training. JAMA Pediatrics, 168(9), 793–794.

http://dx.doi.org/10.1001/jamapediatrics.2014.999

JOGNN, 45, 458–460; 2016. http://dx.doi.org/10.1016/j.jogn.201

Greenbaum, V. J. (2014). Commercial sexual exploitation and sex

trafficking of children in the United States. Current Problems in

Pediatric and Adolescent Health Care, 44, 245–269. http://dx.

doi.org/10.1016/j.cppeds.2014.07.001

International Organization for Migration. (2007). The IOM handbook on

direct assistance for victims of human trafficking. Retrieved

from https://healtrafficking.files.wordpress.com/2015/03/iom_

handbook_assistance.pdf

Institute of Medicine. (2013). Confronting commercial sexual exploi-

tation and sex trafficking of minors in the United States: A guide

for the health care sector. Retrieved from http://iom.

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g/guideforhealthcaresector.pdf

National Human Trafficking Resource Center. (2012). Modern day

slavery in America: Recognizing and responding to human

trafficking in a healthcare context. Retrieved from https://

traffickingresourcecenter.org/resources/recognizing-and-respo

nding-human-trafficking-healthcare-context

National Human Trafficking Resource Center. (n.d.). The victims.

Retrieved from https://traffickingresourcecenter.org/what-

human-trafficking/human-trafficking/victims

Richards, T. A. (2014). Health implications of human trafficking.

Nursing for Women’s Health, 18(2), 155–162. http://dx.doi.org/

10.1111/1751-486X.12112

Sabella, D. (2011). The role of the nurse in combating human traf-

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U.S. Department of State. (2005).Trafficking in persons report. Retrieved

from http://www.state.gov/j/tip/rls/tiprpt/2005/46606.htm

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ty-GWH.pdf

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