Introduction

Human trafficking is a growing concern globally. Americans may widely underestimate human trafficking’s current extent in the United States (U.S.) because of stereotypes about traffickers, victims, and sex workers, and also because many Americans lack knowledge about this topic. Despite the general public’s lack of knowledge, trafficking reports are rapidly increasing in the United States today. The SIDEBAR defines terms associated with human trafficking.

SIDEBAR: Human Trafficking Definitions^1,2

• Human Trafficking: Recruiting, transporting, harboring, soliciting, maintaining, patronizing, advertising, providing, and obtaining people through force, manipulation, fraud, or threats to achieve control over a person for exploitation
• Victims: people currently in an exploitative situation
• Sex worker: A person who voluntarily provides sex work regularly or occasionally in commercial exchange for money or goods. Sex work differs from sexual exploitation, or the forcing of a person to commit sexual acts.
• Survivors: people who have escaped their trafficking situations
• Survivor-informed practice: Including meaningful input from a diverse community of survivors at all stages of a program or project, including development, implementation, and evaluation
• Traffickers: people using force, manipulation, threats, or fraud to force victims into exploitative situations
• Trauma-informed care: collaborating with community resources to empower individuals to determine their own futures
• Venue: The place in which trafficking occurs; human trafficking does not necessarily involve crossing state or international borders

In 2010, Faith Robles, a 14-year-old teenager from Mexico, moved in with her boyfriend’s family in Queens, New York.³ The family promised her a job that would “change her life,” but she did not learn this involved sleeping with men against her will—sometimes up to 30 men daily—until after her boyfriend smuggled her into the U.S. At the time, Robles was unaware that her boyfriend and four of his relatives were involved in a human trafficking ring. After she arrived, the family threatened to kill her family and traffic her sister if she sought help from authorities or did not comply with their demands. Robles was a victim of sex trafficking for three and a half years, suffering multiple beatings, sexual assaults, and a broken jaw following an escape attempt. She was finally able to escape at age 17 when she sought help from police officers.³ Hearing from survivors like Faith Robles has helped healthcare providers develop interventions that are survivor-informed. This continuing education activity will cover several aspects of human trafficking as it relates to pharmacy using evidence collected by reliable organizations and researchers.

Unfortunately, many victims in the U.S. today share stories like Robles’. In August 2022, the Federal Bureau of Investigation (FBI) announced that they located and identified 84 minors who were victims of sex trafficking during a nationwide sex trafficking operation. (Most trafficked victims are between 16 and 24 years of age. Even when adult victims are identified, they could have just turned 18 or are still young adults. People in the human trafficking community have a saying: “Trafficked children become trafficked adults when not found.”) FBI agents found an additional 141 adult victims. Human trafficking rates continue to increase in the U.S. Reports of human trafficking to the National Center for Missing and Exploited Children Tipline increased from 21.7 million to 29.3 million reports from 2020 to 2021.⁴ Readers should note that collecting and reporting data on human trafficking has some limitations; many cases of human trafficking are never reported.⁵ Sometimes it’s because the victims are afraid or under a trafficker’s strict control and cannot seek help. Sometimes, it's because people who might be able to help a victim do not recognize the problem or have no idea how to help. Sometimes, it’s because systems have not looked at the issue, determined what (if anything) the system’s responsibilities are, and established policies and procedures to prevent trafficking and provide help.

Readers should also note that to be considered human trafficking, the trafficker need not move a victim across state or international borders; thinking that movement is a necessary component of human trafficking is a common misperception. Current federal laws only require that the trafficker has met the criteria for the 3 elements of “act,” “means,” and “purpose.”⁶

• ACT means that the trafficker has recruited, transported, transferred, harbored, harbored, provided, advertised, maintained, obtained, or received a victim
• MEANS is only required if the victim is over 18 and indicates the trafficker has used threat or use of force, coercion, fraud, deception, abuse of a position of vulnerability, payments or benefits, or abduction. A minor cannot consent to sex with an adult and automatically is considered a victim of trafficking if ACT and PURPOSE are identified.
• PURPOSE is very simple; the trafficker’s sole purpose is to exploit the victim

In short, these requirements indicate that someone who coerces an individual to provide sex or labor against their will in exchange for housing or drugs would be considered a human trafficker, as doing so is exploitation. Someone who moves victims from place to place is also a trafficker, and in some states, people or organizations that knowingly harbor traffickers and their victims would also be complicit in human trafficking.^7,8

In 2024, the National Human Trafficking Hotline reported California, Texas, and Florida as the top states for human trafficking with 1733, 1360, and 832 cases identified, respectively.⁹ Between 2019 and 2023, the picture changes somewhat, with Nevada, Georgia, and Mississippi documenting rates of 58.5, 46.6, and 43.1 cases per 100,000 residents, respectively.¹⁰ Human trafficking often occurs along highways that provide access to easy getaways, quick transportation, or access to large numbers of men; many traffickers move their victims often to avoid detection, but also move their victims to follow the money. In the latter case, they may move their victims closer to a place where men will congregate in large numbers—sorting events, conferences, etc. The busiest interstates in the U.S. include I-5 in the West, I-95 in the East, and I-80 stretching from California to New Jersey. The Polaris Project (see SIDEBAR) asserts that common trafficking venues include illicit massage parlors, informal underground businesses, and hotels and motels along major highways. For this reason, the National Association of Truck Stop Operators and large hotel chains, such as Marriott, offer training to help employees identify and report human trafficking victims.¹¹

SIDEBAR: The Polaris Project¹²

The Polaris Project is a nonprofit social justice organization that fights sex and labor trafficking through the U.S. National Human Trafficking Hotline. Polaris uses survivor-driven trafficking data to improve trafficking identification, provides assistance for victims and survivors, and educates the community. More information on the Polaris Project can be found on its website (https://polarisproject.org/).

Polaris hosts the National Human Trafficking Hotline around the clock. Readers should make note of this resource, as it will often be the first and safest place to seek help when patients indicate or pharmacy staff suspects that an individual is being trafficked.

• Web site: https://humantraffickinghotline.org/en in English
• Web site: https://humantraffickinghotline.org/es in Spanish
• 1-888-373-7888
• TTY: 711
• Text* 233733

Human trafficking is a crime under federal and international law. The International Labor Organization estimates that the human trafficking “industry” generated $32 billion in 2005, making it the third largest source of income for organized crime.^13,14 Current estimates are unavailable but would clearly be much larger. Human trafficking victims can come from any background and may live for years under their trafficker’s control. Trafficking is rarely stranger abduction. Victims may be trafficked by their own family, friends, or acquaintances with or without the victim’s knowledge.^15,16

Human traffickers prey on others in reprehensible ways.¹⁷ Policy makers, public health groups, and researchers have tried to understand the motives behind human trafficking to identify factors that would help develop anti-trafficking interventions. Many publications indicate traffickers become involved primarily for financial gain because the profits associated with human trafficking can be enormous. Many of the interventions currently employed identify traffickers by tracking large quantities of cash and banking patterns. Recent research has found that in some cases, traffickers make considerably less money than expected. These traffickers may be motivated by cultural norms, ideology, or religions that devalue human life. Traffickers may be former victims who go on to recruit and control others. And some traffickers simply have sociopathic tendencies.¹⁷

Traffickers use various tactics to manipulate victims, including¹⁵

• Debt-bondage
• Emotional manipulation
• Lies or deceit
• Subjecting victims to unstable or unpredictable conditions
• Physical, sexual, or psychological violence
• Threats against family members
• Transporting victims to unfamiliar places to create a language barrier
• Withholding documents

Pre-trafficking vulnerabilities for victims include poverty, trauma, domestic violence, learning difficulties, lack of educational or work opportunities, loss of family, community- or gender-based violence, and natural disasters.² Human trafficking survivors with vulnerabilities are at higher risk of re-victimization. The SIDEBAR describes types of human trafficking.

SIDEBAR. Types of Human Trafficking^16,18,19

All forms of human trafficking include exploitation, abuse of vulnerable situations, psychological violence, and deprivation of freedom. Added physical and/or sexual violence is also common. Specific types of trafficking may include one or more of the following:

• Sex trafficking: forcing someone to sell sex; more commonly affects women but often happens to children of both sexes
• Forced labor: involuntary servitude, often in industries with large numbers of workers and little regulation; most common element of modern-day slavery. (Readers should be aware that the use of the word “slavery” is controversial. Many U.S. groups do not use it due to historical context. It’s more often used globally.)
• Domestic servitude: jobs related to domestic help; often hidden in plain sight
• Debt bondage: begins with debt that the victim is unable to pay immediately; employer exploits the victim by adding additional expenses to increase debt
• Other forms: forced marriage, organ removal for sale, and enforced crime

Readers should note that human trafficking differs from human smuggling. In human smuggling, the purported purpose is to transport or hide individuals who lack proper documentation (e.g., passports, driver’s licenses, or other identification) and circumvent officials without regard to immigration laws (a transportation-based crime). The people smuggled across borders often have chosen to be smuggled as a means to reach an otherwise inaccessible destination. Victims of human trafficking are generally held in circumstances against their will. Nevertheless, traffickers may also use victims’ immigration status and threaten to deport victims to coerce victims to do as they are told. In some cases, smuggling may lead to trafficking.

With 30% to 88% of U.S. trafficking victims seeking healthcare at least once while being trafficked, life-saving identification of trafficking victims in healthcare settings is crucial.²⁰ Several researchers have attempted to estimate how many victims seek healthcare, but because of the nature of the topic and the risk associated with disclosure, it’s been difficult. Two studies shed some light on victims’ contact with healthcare providers. In a meta-analysis of 420 victims, 50% to 98% of victims reported seeking healthcare services in diverse medical settings while they were trafficked.²¹A second study found that roughly 63% of victims had visited emergency departments (ED) and identified hospitals and ED as their most frequent source of care.²² Trafficking victims tend to use complaint-based episodic acute care services (e.g., minute clinics, urgent care centers, and EDs) more often than long-term comprehensive primary care services.²³ Each visit represents an opportunity to identify potential behaviors, injuries, or actions that may signal victimization. Several studies have documented that healthcare professionals tend to have limited recognition and knowledge of human trafficking.^24,25

No data is available about victims’ use of pharmacies, but pharmacy employees in community settings are likely to encounter human trafficking victims. Pharmacists and technicians should be prepared to recognize human trafficking signs for quick, appropriate, and life-saving action.

History of Human Trafficking in the United States

Let’s return to Faith Robles. Fortunately, Ms. Robles pressed charges against her boyfriend and his family for the damage and trauma she endured. In 2020, a judge sentenced Robles’ boyfriend and his family to prison terms of between 25 and 40 years under charges of “sex trafficking, sex trafficking conspiracy, sex trafficking of minors, interstate prostitution, alien smuggling, and money laundering conspiracy.”³ However, if Robles had reported her case in the early 1970s, she would not have been able to press charges; the federal government did not incorporate human trafficking crimes into U.S. law until recently.

The first U.S. law for human trafficking was the 1974 Child Abuse Prevention and Treatment Act (CAPTA). CAPTA required states to establish child abuse reporting laws as a condition of receiving federal funds.²⁶ Mandated reporters and agencies to which people who observe or suspect abuse are to report vary by state law but generally states require reporting in some capacity. Healthcare providers should always check their states’ applicable laws periodically so they know exactly what the state requires.

Mandated reporters are personnel who must report suspected or confirmed exploitation, abuse, or neglect of vulnerable populations. As of July 2023, Alabama, Colorado, Connecticut, Hawaii, Oregon, Vermont, and Washington state laws specifically list pharmacists as mandated reporters for child victims. Other states list mandated reporters as “healthcare personnel” or people responsible for the care and/or treatment of child victims. The reporting timeframe for suspected child abuse is highly state-specific. Many states still require a written follow-up within 48 hours, while others have changed to 48 hours (New York, Massachusetts), 24 hours (Virginia, Texas), 12 hours (Connecticut), or require reporting "immediately."^27-31 Pharmacy staff should check their states’ requirements. Most states do not require mandatory reporting by healthcare personnel for victims 18 years old or older unless the adult is elderly or in some way vulnerable. States that do not require healthcare providers to report adult victims may do so because of the victims’ heightened safety risk, vulnerability, mistrust in authorities, and fear of their traffickers.³² Federal law does not currently require states to mandate reporting for adults or provide funding to meet reporting requirements.

The Trafficking Victims Protection Act (TVPA) of 2000 created the first comprehensive federal law to address human trafficking. The TVPA offered immigration relief for human trafficking victims, creation of public educational programs for prevention of future trafficking, and increased prosecution of trafficking.^26,33 Since January 2000, Congress has reauthorized this Act multiple times, with the last reauthorization in 2023. Recent efforts to reauthorize the bill have stalled in Congress.³⁴ The 2023 TVPA reauthorization added some additional coverage³⁵:

• It increased protections for child survivors of human trafficking
• It provided funding for state welfare agencies to identify and assist child victims of human trafficking and work more closely and efficiently with the juvenile justice system
• It eliminated barriers to services for child victims of human trafficking: consent from a parent or guardian is no longer necessary to apply for ID and other forms of identification, making it easier for children to apply for benefits and services
• It expanded support for research concerning social media’s impact on human trafficking

As an aside, proponents of better laws regarding human trafficking point to the Epstein case as affirmation that human trafficking survivors deserve justice.³⁶ The core components are still in effect, but some authorizations for funding, grant and pilot programs, and reporting and coordination mandates need reauthorization.³⁶

In 2013, the U.S. Department of Health and Human Services (HHS) created the Stop, Observe, Act, and Respond (SOAR) program to provide human trafficking training to healthcare and related professionals. The program includes victim identification and implementation of best practices for necessary reporting, referrals, communication, and treatment. In 2018, the HHS required public posting of best practices on the HHS website for entities receiving federal grants.³⁷ SOAR’s program for individuals and groups are available at https://acf.gov/otip/training-technical-assistance/soar-health-and-wellness.

In 2015, the Justice for Victims of Trafficking Act (JVTA) improved U.S. trafficking response. The law strengthened victim resources, including increasing individuals’ criminal liability if they buy commercial sex from victims, creation of the survivor-led U.S. Advisory Council on Human Trafficking, and a national strategy for combating human trafficking.³⁸

Current human trafficking reporting laws are inconsistent due to variations among states; federal law does not clearly define a “mandated reporter” and does not require healthcare providers to report trafficking victims 18 years old or older.²⁶ The American Hospital Association; the law firm of Jones Day; and the Health, Education, Advocacy, Linkage (HEAL) Trafficking network have collated state-specific reporting requirements for healthcare providers on the HEAL Trafficking website (https://healtrafficking.org/wp-content/uploads/2021/01/Human-Trafficking-and-Health-Care-Providers_Legal-Requirements-for-Reporting-and-Education-02_25_21.pdf).²⁶

PAUSE AND PONDER: What policies, if any, does your workplace currently have to identify trafficking victims?

Healthcare Providers & Human Trafficking

Human trafficking victims are often in situations that compromise their health and safety. Most trafficked people seek healthcare from licensed providers at some point during their exploitation. Pharmacists and pharmacy technicians in outpatient settings may interact with victims without realizing their situation. Healthcare providers should be able to recognize possible victims and survivors confidently and take appropriate action to intervene if needed; however, most health professionals report that they are unfamiliar with how to identify or respond to a trafficked person effectively.^2,39

The Pharmacy Team in Action

Pharmacists’ involvement on the healthcare team is increasing and expanding from dispensing drugs to include medication and disease management and more expansive responsibilities. Pharmacy is unique because the available healthcare counseling is highly accessible by the public.

For safety and reporting, pharmacy team members should generally trust their instincts in a suspicious situation, especially when patients^2,39,40

• Act as if under control of another person, i.e., another person accompanies the patient, speaks for them, or there is a lack of rapport between the patient and accompanying individual
• Report a history of frequent address changes, vagueness about where they live and/or medical history
• Have poor or concerning physical appearance suggesting neglect, and/or physical harm, i.e., poor hygiene or inappropriate clothing for current weather conditions or for their age (i.e., clothing is more promiscuous or revealing than normal for a teen)
• Present with illnesses or injuries not easily explained, especially repeated or partially treated concerns
• Exhibit signs and symptoms of self-harm, suicidal ideation, depression, or drug or alcohol misuse

Many state laws require pharmacists to counsel patients on new prescriptions. Prescription filling patterns that may signal trafficking include frequent sexually transmitted infection (STI) treatment, no insurance coverage, cash-only payments, prescriptions routinely lost or stolen, or a medical history of prescriptions from acute care clinics rather than a primary care physician.³³ Victims may be hesitant to access healthcare because of safety concerns and are more likely to self-treat using over the counter (OTC) medications. Table 1 lists frequently used or misused OTC products for self-treatment, and this information may assist pharmacists and pharmacy technicians with screening for potential victims. Upon suspicion of trafficking, pharmacists should try to screen the patient privately.

Table 1. OTC Products Frequently Used or Misused for Self-Treatment of Trafficking-Associated Medical Concerns^41,42

Privacy is essential to obtaining accurate and sensitive information that a victim might otherwise not be comfortable with sharing, especially for victims who fear for their safety and accompanied by an abuser. When pharmacy team members try to speak to the patient alone, they should remain calm and ask for privacy cautiously. The pharmacy team may emphasize the importance of privacy to the accompanying individual, perhaps by saying, “I’m going to step in here and speak to [patient’s name] alone because these are deeply personal health issues.” Note that this approach doesn’t ask a question—which might give the trafficker wiggle room to argue—but instead states a fact in a neutral manner. However, pharmacy staff should not push if they experience push-back from the suspected trafficker. Most pharmacies have a separate space for consultation or vaccinations that they may use when patients need privacy or to review sensitive information.

PAUSE AND PONDER: What are some ways your pharmacy team can work to improve health outcomes for victims and survivors of human trafficking?

Avoiding Bias + Using the Correct Language

Pharmacy team members should be aware of their language when speaking to victims; personal biases may perpetuate stereotypes and influence clinical decision making for therapy or diagnoses.

Well-intentioned but poorly informed organizations or people can perpetuate stereotypes that are not evidence-based or all-encompassing. Understanding bias and perpetuated stereotypes reduces barriers to optimal healthcare. Stereotypes associated with trafficking including victim appearance, location, traffickers, or current situations prevent victims from escaping and/or receiving treatment.¹ Table 2 addresses common stereotypes or myths associated with human trafficking in the U.S.. Pharmacy team members should question, acknowledge, and resolve their personal biases towards trafficking to reduce stigmatizing language and shame.

Table 2. Common Human Trafficking Myths vs Reality^1,43

Healthcare providers should always use strength-based language to avoid victim blaming. For example, providers should refrain from using the term “child pornography,” and instead refer to it as “child sexual abuse materials.”¹ For sex trafficking victims, they should refer to sexual acts as “exploitation” rather than “prostitution.” Table 2 explains the difference between sex trafficking and commercial sex or prostitution.

Victims may experience intense shame or secrecy surrounding their experiences that limits their ability to seek medical attention. Healthcare equity for trafficking victims starts with establishing trust. To gain trust, providers should identify and eliminate unconscious biases to improve service accessibility and health outcomes.

HEALTH CONSEQUENCES FOR VICTIMS

Traffickers often expose victims to numerous health risks before, during, and after exploitation and may restrict victims’ access to care. A key indicator of human trafficking is delayed care. Many patients have reasons to delay care (e.g., lack of insurance, no transportation, or difficult access to care), but delayed care in combination with other flags may indicate a patient is in trouble.^44,35 Victims’ lack of access to proper care and poor environmental conditions may lead to deterioration or exacerbation of conditions.⁴⁵

Mental Health and Addiction

Due to mental exhaustion from trauma, most victims face debilitating mental health issues. Victims may present with signs and symptoms of posttraumatic stress disorder (PTSD), depression, anxiety, dissociation, and substance use disorders. Serious symptoms warranting need for behavioral health therapy may include

• Difficulty sleeping
• Feeling detached or withdrawn
• Guardedness
• Hopelessness
• Recurrent thoughts of trauma
• Sudden emotional reaction when reminded of trauma
• Suicidal ideation
• Tendency to startle easily

Drug or alcohol addiction may exacerbate victim vulnerability, be used as a coping mechanism, or be a part of the trafficker’s tactic to control victims. An anti-trafficking service provider reported that 66% of victims claimed their substance use led to being trafficked, while 4.5% claimed their substance use began after being trafficked.⁴⁶ Substance use throughout victimization occurred in 84.3% of victims, with the most common substances used being alcohol, marijuana, cocaine, and opioids.⁴⁶ Due to high mortality rates from opioid overdoses, patients who are or have been trafficked warrant screening for opioid addictions.

Healthcare providers need to engage in trauma-informed care when helping victims of human trafficking.⁴⁷ The experience of trauma overwhelms the victim’s ability to cope and healthcare providers need to recognize trauma’s impact on victims. They need to employ a trauma-informed approach. A trauma-informed approach has four components⁴⁷:

• Realizing trauma’s pervasive impact and the potential paths victims can follow for recovery
• Recognizing trauma’s signs and symptoms in individuals, families, staff, and others involved in the system
• Responding in a manner that fully integrates knowledge about trauma into policies, procedures, and practices
• Taking care to communicate in ways that actively avoid retraumatization

A trauma-informed approach means collaborating with community resources to empower individuals to determine their own futures.⁴⁷ Using the National Human Trafficking Resource Center (NHTRC) hotline is a good way to initiate contact with community resources, as its staff is trained to help healthcare providers determine and identify the next best steps when trafficking is suspected or reported.

The Substance Abuse and Mental Health Services Administration (SAMHSA) supplies additional information on child trauma-informed care for patient and provider use (https://www.samhsa.gov/childrens-awareness-day/child-traumatic-stress-resources).⁴⁷

Unprotected Sexual Intercourse

Victims of sex trafficking are at elevated risk for STIs and unwanted pregnancies. Pharmacists should attempt to counsel victims of sex trafficking on proper testing or screening, including the common signs and symptoms of various STIs, types of tests, and when and how to test. The CDC lists specific STI treatment guidelines on its website (https://www.cdc.gov/std/treatment-guidelines/default.htm).⁴⁸

Monkeypox (now called Mpox) has been an emerging concern particularly for men who have sex with men. Monkeypox presents as a painful rash accompanied by fever, lethargy, muscle aches, and headaches.⁴⁹

In female patients of childbearing age who have had recent unprotected sexual intercourse, pharmacists may recommend OTC emergency contraceptive pills (ECPs), or an intrauterine device (IUD) or “morning after” pill if allowed by state law.

Copper IUDs are a highly effective emergency contraceptive when inserted up to five days after sexual intercourse. This extended period for use and high efficacy rate may be beneficial for victims of human trafficking who may not have immediate access to emergency contraceptives, but IUD insertion can be expensive, and the trafficker may not allow the victim to see a qualified provider. The most common side effects for IUDs are heavy menstrual bleeding, spotty menstruation, or abdominal discomfort. Because victims of sex trafficking may have increased risk for STIs, victims should generally be tested and/or treated for STIs prior to IUD insertion and monitored after insertion.⁵⁰

ECPs contain either levonorgestrel or ulipristal acetate (UPA) with 1.2% and 1.2-2.1% efficacy, respectively. UPA-containing ECPs are more effective between 72 and 120 hours post-intercourse than levonorgestrel-containing ECPs. Side effects may include nausea, vomiting, fatigue, and irregular vaginal bleeding.⁵⁰

More information on emergency contraception eligibility criteria and safety is located on the World Health Organization’s (WHOs) website.⁵⁰ In any emergency contraceptive, efficacy decreases as the time between intercourse and treatment increases. Pharmacists should inform patients that contraceptives do not induce abortions.

Physical Abuse

Victims may be vulnerable to physical abuse while being trafficked. Common signs of physical abuse are bruises, wounds, fractures, internal injuries, chronic pain, or head, neck and back injuries. Physical abuse may also present as substantial weight loss, dehydration, malnutrition, increased vulnerability to illness, and insomnia. Physical abuse is a medical emergency; if a patient’s safety is in danger, the pharmacy must report the situation to authorities immediately if the patient is a minor. States may require pharmacists to report abuse of an adult under state-specific mandatory reporting laws.

Acting on Human Trafficking

Upon suspicion or confirmation of trafficking, pharmacy technicians should alert the pharmacist and pharmacists should try to see the patient alone when possible. All involved staff must remain vigilant about everyone’s safety and avoid directly challenging the victim and/or accompanying individual. Direct confrontation, or raising the suspicion of an accompanying individual, can put a victim at risk of additional harm. It’s critical to note repeatedly that intervention can be dangerous. Most authorities indicate that the best action is to call the National Human Trafficking Hotline at 1(888) 3737-888 or call 911.⁵¹

In instances that involve language barriers, pharmacists should advise the accompanying individual that professional interpreters may be needed instead of relying on ad hoc interpreters (untrained children [who should only be used in emergencies], friends, family, or untrained staff).^52-58 The reasons for working alongside interpreters (and interpreters prefer healthcare providers use the term “working alongside” rather than “using” to reflect that this is a collaborative endeavor) are evidence-based. Ad hoc interpreters are more likely to make mistakes, violate confidentiality rules, and increase risk of adverse outcomes. Professional interpreters are also fluid speakers and need not stop and think or reformulate language before translating. Untrained interpreters often leave out the niceties of language—niceties that increase trust and cultural understanding between patient and provider. When using an interpreter, the clinician should address the patient directly and seat the interpreter next to or slightly behind the patient.^52-58 Readers who want to learn more about the nuances of professional interpretation may be interested in What’s in a Word? A Guide to Understanding Interpreting and Translation, available online for free at https://www.ncihc.org/assets/documents/publications/Whats_in_a_Word_Guide.pdf.

Pharmacists and technicians should be patient, compassionate, and sensitive to build trust and gather sufficient information. Since 2011, the Institute of Medicine and the U.S. HHS have recommended screening for intimate partner violence and abuse by asking patients, “Do you feel safe at home?” at each visit.⁵⁹ In 2013, the U.S. Preventive Services Task Force also made this recommendation. Although the question was meant to identify intimate partner violence, it has identified other types of abuse. This question surprises many patients, and many healthcare practitioners find it uncomfortable to ask. Pharmacy staff might ask this question, but it probably should not be the first question to the suspected victim. Saving this and similar questions should come after establishing some rapport with the patient and the patient seems comfortable. Regardless, patients may not answer truthfully or at all, but just asking the question let’s victims know that someone cares, and help is available.⁵² When interviewing patients, pharmacists should ask “trauma-informed” questions but consider the harmful effect of reliving traumatic experiences.² Table 3 provides additional appropriate example questions when screening patients for human trafficking.

Table 3. Example Screening Tool for Suspicion of Human Trafficking^2,15,18

• Are you limited as to who you can talk to and when?
• Do you have the freedom to leave your current job?
• Do you have to ask permission for necessities, such as eating or using the bathroom?
• Do you owe your employer money or other debts?
• Has anyone ever physically hit, threatened, or raped you or anyone you work with for any reason?
• Has anyone ever forced you into sexual intercourse for work?
• Has anyone threatened your family?
• Has anyone threatened you with deportation?
• Is someone else controlling your money or finances?
• Is someone else in control of where you are allowed to go?
• Is someone else in control of your identification documents, including your birth certificate or passports?
• Was someone else in control of your travel arrangements to the U.S.?
• What is your working or living condition like?

Healthcare providers may be unable to help patients involved in human trafficking—affected individuals may be too afraid to engage. Individuals need to be able and willing to help themselves. Providers should also offer patients choices; if the patient does not verbalize immediate danger, pharmacists can gently discuss reporting to police, non-government organizations, or helplines. When patients do not want to act, healthcare providers should prioritize care for the patient’s health conditions, gain the victim’s trust, and document clearly. Pharmacy teams should write down any information that may be helpful in an investigation, including time of day, address, and vehicle information, if available.

Providers must always consider security risks. Pharmacy staff should never attempt to confront a potential human trafficker or victim directly. They should try to arrange follow-up with patients and document their contact information. Pharmacists may also ask for consent to call the patient’s primary care provider.

That said, pharmacy teams need to always follow statutory and healthcare organization procedures. Again, the National Human Trafficking Resource Center (NHTRC) hotline is available for pharmacy teams to use and pharmacy personnel can call the hotline for guidance. The NHTRC helps providers identify local resources and coordinate with social service organizations. Its hotline is available 24/7 at 1 (888) 3737-888 or text HELP or INFO to “BeFree” (233733). Pharmacists may choose to submit an anonymous tip online on the NHTRC website (https://humantraffickinghotline.org/report-trafficking).⁶⁰ If the patient is a minor or in imminent danger, a staff member should stay with the patient, remain calm, and contact 911 or the local police department when it is safe to do so.

Providers should do their best to ensure proper self-care after a stressful or intense situation.

Conclusion

Faith Robles is now a spokeswoman, advocate, and aftercare provider for victims of human trafficking which demonstrates that victims, when they can access help, can survive and flourish.⁶¹ Pharmacy teams should remain vigilant when encountering suspicious circumstances. Trafficking victims may have multiple health issues because of their trauma and abuse. Pharmacy team members can easily recognize signs of human trafficking through prescription, disease, or behavioral patterns. Individualized screening and determination of the type of trafficking involved is necessary for treatment recommendations and referrals. Pharmacy teams should address victims’ concerns while considering the patient’s health, safety, and personal hardships. Pharmacies may advocate for federal and/or local legislation focused on trafficking prevention and education to drive large-scale change.

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