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Journal of Human Trafficking
ISSN: 2332-2705 (Print) 2332-2713 (Online) Journal homepage:
Health-care provider challenges to the
identification of human trafficking in health-care
settings: A qualitative study
Frances H. Recknor, Gretchen Gemeinhardt & Beatrice J. Selwyn
To cite this article: Frances H. Recknor, Gretchen Gemeinhardt & Beatrice J. Selwyn (2017):
Health-care provider challenges to the identification of human trafficking in health-care settings: A
qualitative study, Journal of Human Trafficking, DOI: 10.1080/23322705.2017.1348740
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Published online: 14 Sep 2017.
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Date: 28 October 2017, At: 01:17
Health-care provider challenges to the identification of human
trafficking in health-care settings: A qualitative study
Frances H. Recknor, Gretchen Gemeinhardt, and Beatrice J. Selwyn
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University of Texas Health Science Center, School of Public Health, Houston, Texas, USA
This study explored health-care providers’ perspectives on practitioner-related
factors that can challenge their ability to identify adult victims of labor and sex
trafficking seeking medical attention in the U.S. health-care system. Forty-four
interviews were conducted with health-care professionals in Houston, Texas,
between June 2015 and February 2016. Thematic content analysis was conducted to identify emerging themes. Overall, the number of victims identified
by providers was low as was providers’ awareness and knowledge of human
trafficking, particularly forced labor. Clinician-related factors inhibiting identification included the following: inadequate community resources for which to
refer victims and clinician lack of knowledge of extant resources; the absence
of institutional guidance in caring for victims; and clinician-held stereotypes of
stigmatized populations. Findings of this study provide support for existing
scholarship. They also suggest that health-care settings need to implement
protocols for care with mechanisms of referral to vetted community resources
for victims who decide to leave their traffickers. Findings also suggest the need
for evidenced-based education for health-care providers, which address
stereotypes that can impede provider/patient relations. Trainings might draw
on established best practices for working with other stigmatized populations
such as those with HIV and mental illness.
health-care provider; human
trafficking; identification
Human trafficking1 is a crime with health repercussions for both its victims and the public. Often
violent, and coupled with living and working conditions that are unsafe, unsanitary, and overcrowded, human trafficking can give rise to a host of mental and physical effects (Baldwin,
Eisenman, Sayles, Ryan, & Chuang, 2011; Chisolm-Straker et al., 2016; Family Violence
Prevention Fund, 2005; Lederer & Wetzel, 2014; Miller, Duke, & Northam, 2016; Ottisova,
Hemmings, Howard, Zimmerman, & Oram, 2016; Zimmerman, Hossain, & Watts, 2011). In turn,
CONTACT Frances H. Recknor, DrPH, LCSW
[email protected]
University of Texas Health Science Center, School of
Public Health, 1200 Pressler St., Houston, TX 77030, USA.
Frances H. Recknor, DrPH, LCSW is a recent graduate of the University of Texas Health Science Center School of Public Health. Her
major area of study was Community Health Practice. Minors included Health Promotion/Health Education and Health and Human
Rights, with a concentration in Global Health. She is a Licensed Clinical Social Worker.
Gretchen Gemeinhardt, PhD, MBA, FACHE is an Associate Professor at University of Texas Health Science Center School of Public
Health in the Department of Management, Policy and Community Health Practice.
Beatrice J. Selwyn, ScD, is an epidemiologist and associate professor specializing in international maternal and child health, and
rapid epidemiologic assessment methods, at the University of Texas Health Science Center School of Public Health, Houston, TX.
Human trafficking in the United States is defined in the Trafficking Victims Protection Act of 2000 (TVPA, 2000). It is an
overarching term used to describe the act of recruiting, harboring, transporting, providing, or obtaining a person for pressed
labor or commercial sex. It is a federal crime when it reaches the level of a “severe” form, meaning that force, fraud, or coercion
are used to compel the person into labor or commercial sex. With minors, the elements of force, fraud, and coercion do not have
to be present for sex trafficking to be considered “severe.” Thus, a male or female not yet 18 years old is considered a victim of
sex trafficking if he or she has been induced into a commercial sex act, regardless of the form of inducement. Movement of a
person from site to site is not necessary for an act to be considered trafficking. The essence of trafficking is the exploitation of an
individual through manipulative, coercive, and sometimes violent behaviors (U.S. Department of State, 2016). The current study
focuses on adults only and does not address the trafficking of minors.
© 2017 Taylor & Francis
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these ill effects can impact the public, particularly with regard to the spread of communicable
diseases (Macias-Konstantopoulos, 2016, 2017; Moynihan, 2006). Recent studies also indicate that
victims are often not identified when they present for health care. The majority do not reveal their
circumstances and health-care providers do not recognize trafficking (Ahn et al., 2013; Atkinson,
Curnin, & Hanson, 2016; Beck et al., 2015; Hom & Woods, 2013; Macias-Konstantopoulos et al.,
2013; Miller et al., 2016). Developing a treatment plan for these patients can be problematic
particularly if health-care providers do not know about the exploitative circumstances of the
patient’s life (Macias-Konstantopoulos, 2017; Macy & Graham, 2012). The patient may often not
be able to comply with treatment and may present later with a worsened condition (Baldwin et al.,
2011; Barrows & Finger, 2008; Macias-Konstantopoulos et al., 2013, 2015). Also, when providers do
not recognize a patient as a victim of trafficking, they miss the opportunity to counsel and assist him
or her in leaving their trafficker, if the victim chooses.
Public-health professionals are vested in elevating the health of trafficked populations and in
protecting society from its potentially harmful sequelae. One strategy is to increase identification of
victims presenting for medical care. Research that distinguishes the challenges providers face in
recognizing victims could lead to increased victim identification. Providers who are aware of a patient’s
circumstances can tailor treatment plans and increase likelihood of compliance. This would improve
the health outcomes for victims and reduce communicable disease transmission.
The academic literature suggests that impediments to identification are multifaceted. Some impediments are attributable primarily to the victim, such as his or her fear of the trafficker if he or she identifies as
a victim to the health-care provider (Baldwin et al., 2011; Macias-Konstantopoulos et al., 2013;
Macias-Konstantopoulos & Bar-Halpern, 2016; Rollins, Gribble, Barrett, & Powell, 2017). Other impediments are attributable to health-care providers such as lack of training regarding human trafficking. In this
study, barriers related to victim nondisclosure are referred to as “victim factors” while barriers related to
health-care providers’ ability to identify victims are referred to as “health-care-provider factors”
(Macias-Konstantopoulos & Bar-Halpern, 2016; Rollins et al., 2017).
This study explored health-care providers’ perspectives on what inhibits their ability to recognize
patients as victims of labor and/or sex trafficking. There have been limited in-depth, peer-reviewed
studies that look at the perspectives of health-care providers. This study addressed this gap through
conducting semi-structured interviews with health-care providers in Houston, Texas.
Literature review
Studies have shown that trafficking victims accessing health care often do not disclose their victimization
(Baldwin et al., 2011; Baldwin, Fehrenbacher, & Eisenman, 2015; Macias-Konstantopoulos et al., 2013,
2015). Victim factors for this include fear of trafficker retaliation and arrest and/or deportation and
distrust of authority figures. Authors also cite the victim’s own shame and guilt over one’s circumstances
(Baldwin et al., 2011, 2015; Macias-Konstantopoulos et al., 2013, 2015). Victims may also not disclose
their status or ask for help if someone accompanying them serves as an interpreter, particularly if that
person is one’s trafficker or a representative (Baldwin et al., 2011). Victims whose trafficker remains in
close physical proximity while they are being seen by the health-care provider may choose not to disclose
as well (Baldwin et al., 2011; Lederer & Wetzel, 2014).
Victims who disclose their status when they receive health care are more likely to have improved
health outcomes than those who do not reveal their circumstances (Ahn et al., 2013; Atkinson et al., 2016;
Beck et al., 2015; Hom & Woods, 2013; Macias-Konstantopoulos et al., 2013; Miller et al., 2016). When
the health-care provider is aware of the socially restricted network under which a trafficked person lives,
that the patient may not be able to seek follow-up care or obtain test results and/or prescriptions
(Baldwin et al., 2015), the provider can attempt to complete as much treatment as possible in one visit.
The health outcomes in these cases are better than when a patient is not able to follow through with
discharge instructions (Macias-Konstantopoulos, 2017; Macy & Graham, 2012). The provider who is
aware of victimization can also provide appropriate referrals for counseling and assistance to escape the
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situation, if this is the patient’s choice. Leaving one’s trafficker and the circumstances that can be
contributing to ill health may improve the victim’s health outcomes (Baldwin et al., 2011; ChisolmStraker et al., 2016; Family Violence Prevention Fund [Futures without Violence], 2005; Tracy & MaciasKonstantopoulos, 2012).
Health-care providers must know enough about human trafficking to be able to recognize it
(Barrows & Finger, 2008; Family Violence Prevention Fund [Futures without Violence], 2005; Grace,
Ahn, & Macias-Konstantopoulos, 2014a; Macias-Konstantopoulos et al., 2015; Rajaram & Tidball,
2016; Stoklosa, Grace, & Littenberg, 2015). Many health-care providers, however, lack general
knowledge about human trafficking and specific knowledge about how to discern victims and to
respond to their needs (Chisolm-Straker, Richardson, & Cossio, 2012; Grace et al., 2014b; Titchen
et al., 2015; Yankovich, 2015). In a study of 180 emergency room providers, including physicians,
medical students, physician assistants, nurses, and social workers, few had received formal training
on victim identification, 2% had training on clinical manifestations of trafficking, and 5% on
treatment of victims. Only 6% reported having ever cared for a victim (Chisolm-Straker et al., 2012).
Some individuals, institutions, and agencies have developed human-trafficking-training programs
and materials to assist health-care providers in the identification, treatment, and assistance of victims
(Stoklosa, Dawson, Williams-Oni, & Rothman, 2016; Grace et al., 2014a; Powell, Dickins, & Stoklosa,
2017; Schwarz et al., 2016; Stoklosa, Showalter, Melnick, & Rothman, 2016; Stoklosa et al., 2015).
There is limited evidence, however, as to the effectiveness of these trainings. Some studies have
demonstrated trainings may increase provider knowledge of trafficking (Beck et al., 2015; ChisolmStraker et al., 2012; Grace et al., 2014b; Yankovich, 2015), but few evaluations have been conducted
to assess if training results in increased victim identification and improved health outcomes. Indeed,
a review of educational offerings found wide variation in the training content and delivery methodologies (Powell et al., 2017). Efforts are underway to incorporate training into health professional
school curriculums; however, this type of training is not yet mandatory, standardized, or formally a
part of physician education and training (American Public Health Association (APHA), 2016;
Atkinson et al., 2016; Bespalova, Morgan, & Coverdale, 2016; Macias-Konstantopoulos, 2016).
Lack of provider knowledge of trafficking coupled with additional factors increase the chances that a
victim will not be identified. These factors include constraints on providers’ time, competing priorities,
concerns for patient privacy and confidentiality, and provider reticence to bring up issues such as sexual
violence and commercial sexual exploitation (Baldwin et al., 2011; Macias-Konstantopoulos et al., 2013,
2015; Stoklosa, Showalter, et al., 2016). In addition, victims either experiencing or anticipating provider
indifference, insensitivity, and/or judgmental attitudes may choose not to disclose (Baldwin et al., 2011;
Bespalova et al., 2016; Macias-Konstantopoulos, 2016; Macias-Konstantopoulos et al., 2013, 2015; Miller
et al., 2016; Rajaram & Tidball, 2016).
Additional health-care-provider factors that limit identification are related to health-care organizational issues and community capacity to meet victim needs. First, there is no validated screening tool for
trafficking used in health-care settings (Bespalova et al., 2016; Chisolm-Straker et al., 2016; Greenbaum &
Crawford-Jakubiak, 2015; Macias-Konstantopoulos, 2016; Polaris Project, 2016). Second, although an
increasing number of health-care institutions are establishing protocols to guide health-care providers in
the identification and response to trafficked people, these are still in early stages of development
(Stoklosa, Showalter, et al., 2016). Finally, many communities lack the resources and infrastructure to
adequately provide safety and services for a victim if one decides to leave one’s trafficker (Stoklosa,
Dawson, et al., 2016; Atkinson et al., 2016; Macias-Konstantopoulos, 2016; Macias-Konstantopoulos
et al., 2015).
Qualitative studies focused primarily on sex trafficking have documented several examples of provider
factors that impede victim identification in health-care settings. Macias-Konstantopoulos and colleagues
(2013) enumerated victim and provider impediments to victim recognition but reported the findings in
aggregate making it impossible to determine what findings were specific for health-care providers. Their
study focused on victims of sex trafficking only and did not include victims of forced labor. Miller et al.
(2016) conducted a Delphi study with survivors and health-care and non-health-care professionals to
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inform elements important to the development of health-care-provider education in working with
children trafficked for sex. Although all participants provided input on impediments to victim identification, findings from the providers were again reported in the aggregate. The study also focused only on
children and sex trafficking. Baldwin and colleagues (2011) interviewed six key informants and 12 female
survivors of both sex and labor trafficking. Barriers and facilitators of victim identification in health-care
settings were identified; however, it was not clear if health-care professionals were amongst the key
informants included. Although labor trafficking in addition to sex trafficking was studied, the sample was
limited to 12 and only female survivors.
The current study seeks to improve understanding of provider factors that prevent victim identification utilizing the qualitative lens of semi-structured interviews. Specifically, the researchers captured
health-care professionals’ perspectives on factors that impede recognition of trafficked victims seeking
health care. Interviewees reported on their perspectives and experiences with adult male and female
victims of labor and sex trafficking, which goes beyond what previous studies have examined. Of note,
providers’ experiences with minor victims of trafficking are not addressed in this study.
Study design and case selection
This study was part of a larger project wherein the objective was to examine how the public-health and
health-care sectors respond to human trafficking. One of the aims of this overarching scheme, and the
subject of this article, was to describe how health-care professionals attempt to address human
trafficking and the health needs of victims, and the barriers they encounter in doing so. The study
utilized a qualitative descriptive approach, an analytical method often used in health-care research to
capture health-care professionals’ experiences and perceptions of patient/provider interactions and
issues related to the health-care delivery system (Neergaard, Olesen, Andersen, & Sondergaard, 2009).
Researchers frequently use this method when “straight descriptions of a phenomenon” are sought
(Sandelowski, 2000). As health-care practitioners were asked to provide a description of their perspectives, a qualitative descriptive approach was most appropriate (Bodkin, Delahunty-Pike, & O’Shea,
2015; Sandelowski, 2000).
The study was conducted in Houston, Texas. Houston is home to the Texas Medical Center, which
is the world’s largest medical complex, so it offered numerous possibilities for accessing health-care
professionals (Texas Medical Center, 2015). Houston’s reputation as a “hub” for human trafficking
also made it an appealing site (Huls, 2015; Texas Department of Public Safety, 2014; Ursin, 2015).
Given the significant local press attention to trafficking cases and the numerous anti-trafficking
community-awareness campaigns conducted over the last several years in Houston, it was thought
Houston health-care professionals might have unique insights.
Study subjects
Targeted purposive sampling followed by snowball sampling yielded 44 health-care participants. These
included the following: 10 (23%) nurses, 9 (20%) social workers, 5 (11%) physicians, 5 (11%) psychiatrists, 4 (9%) medical and 2 (5%) psychiatry residents, 4 (9%) psychologists/psychotherapists, 2 (5%)
health-care-eligibility workers, 1 (2%) unclassified, and 2 (5%) nursing professors. Sixteen (36%),
inclusive of the latter, also held academic appointments. Of the 44 participants, 18 (41%) spent some
or all of their time on administrative tasks while 24 (55%) participants were direct-care providers. The 2
(5%) academics provided minimal patient care. Respondents worked in clinics, hospitals, trauma centers,
emergency rooms, and academic settings. The study was approved by the Committee for the Protection
of Human Subjects of the University of Texas Health Science Center at Houston.
Data collection
Interviews were held between June 2015 and February 2016. All were conducted by the first author and
followed a semi-structured interview protocol. An interview guide was developed that contained questions such as “What kinds of physical- and mental-health problems do the victims you work with have?,”
“How do you try to help them with these?” and “What barriers stand in the way of their getting the care
they need?” All questions were open-ended and iterative that enabled participants to respond according
to what they, rather than the interviewer, thought was pertinent. On average, sessions lasted 1 hour.
Respondents provided informed consent and all but 3 permitted their interview to be audio-recorded.
These 3 did allow for notes to be taken. The first few recorded interviews were transcribed by the first
author and the remainder by a professional transcription company. Following transcription, interviews
were deleted from the audio-recorder. Data were kept on a password-protected computer.
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Data analysis
Thematic content analysis was employed to build a conceptual framework from the interview data
(Green & Thorogood, 2009). Initial categories were deductively derived from the literature. An iterative
process was used to review interview transcripts and field notes, to refine codes, and to organize
categories into emerging themes. The first author examined thematic data within and between interviews
as well as with information from field observations to enhance validity. In some instances, follow up was
conducted with interviewees for clarification and further questions. All interviews were analyzed by the
first author. The coauthors and two additional research advisors reviewed, discussed and critiqued the
analysis of the primary investigator with her to ensure rigor and to reduce the potential for confirmation
bias. This feedback was integrated into data analysis. ATLAS.ti qualitative data analysis software, Version
7.5.10, was utilized to organize the data (Muhr, 2015).
Several themes emerged from the analysis and are addressed in this article. Pertinent was the fact
that, although some providers were experienced in working with trafficked victims, most were not
and the overall rate of victim identification was low. Providers attributed this to many factors
including the following: low awareness and knowledge of human trafficking on the part of providers;
the projection of provider stereotypes of stigmatized populations onto those trafficked that can elicit
shame and preclude victim disclosure; the lack of community resources to adequately and safely
assist victims; and the lack of health-setting protocols to guide providers as to care provision. These
factors are discussed in greater detail in subsequent sections.
Prevalence of victims identified in health care
It was not possible to ascertain the extent to which providers identified trafficked victims in Houston
health-care settings. Several providers stated that either they had not seen any victims or they may
have seen patients who they did not recognize as victims at that time. Some reported they had been
suspicious trafficking was happening, but the patient would not admit it. For instance, one healthcare provider stated:
I think we’ve had a couple patients that we can be pretty sure about who had been trafficked. There may be
more. One or two patients, otherwise, were very vague about that possibility. We’ve suspected it in some other
individuals, but we haven’t been able to confirm it. (Interview 68, December 11, 2015)
Some health-care providers attempted to estimate how many victims had been seen at their facility.
One provider estimated that 10 or more victims might be seen in his or her emergency center per
month, however, later upon attempting to clarify, was nonspecific (Interview 44, September 29, 2015).
Another stated that he or she could not estimate because the facility did not track human trafficking
and any information would be anecdotal (Interview 43, September 28, 2015). Most health-care
providers simply reported the numbers to be “small” without giving an estimate. One health-care
administrator stated:
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Out of [tens of thousands of visits], I can only identify seven patients so that means the volume is low.…I think the
only explanation I have in my mind is that most of them are afraid, which is rightfully so, and they don’t seek
treatment. [If they do come in for treatment,] they may not be able or willing to come back again. I think it is the
provider or whoever they are living with who may or may not want them to have that kind of treatment. (Interview
69, November 23, 2015)
Those who identified seeing victims saw them in federally qualified health centers focusing on the
following: homeless and LGBTQ (lesbian, gay, bisexual, transgender, and questioning) populations;
programs and clinics serving refugees and immigrants; clinics within and outside of the local safety net
health-care system; and hospital emergency rooms. Victims were seen by a variety of health-care
disciplines. Those providers who consistently reported having seen victims were an infectious disease
physician and sexual assault nurses. The sexual assault nurses saw victims in hospital emergency rooms.
Other health-care providers who had potentially seen victims of trafficking were community health
workers working in a clinic situated in a predominantly immigrant community with a substantial
number of undocumented residents. These workers relayed stories of extreme violence and extenuating
circumstances surrounding border crossings, which may have been trafficking but it was difficult to
determine if the situation was trafficking, wage exploitation, human smuggling, or other crimes
(Interview 67, November 11, 2015). The provider who had seen the largest number of victims and was
the only provider who had knowingly worked with victims of labor trafficking, was a physician well
embedded, living and working for many years, in an immigrant community (Interview 54, October 7,
Other health-care providers thought that either they or colleagues may have seen victims of sex
trafficking but were uncertain due to difficulties in distinguishing between who is a “prostitute” and
who is a “trafficking victim” (Interviews 37, September 16, 2015; and 62, October 19, 2015).
According to one provider:
We’ve never had an actual identified, yes, this person was. … We had one girl… my worker was going out to
meet her, but he’d always meet her at a truck stop. That’s where she wanted to be met, but she was working at
the truck stop. That’s the kind of thing where we’re like, “Okay, this girl is willing”, and I say in quotes, “She’s
willingly doing this, but is she really willingly doing that?“ Then it goes back to, okay, who in their right mind
would want this type of lifestyle? Then you’re like, okay, she’s 23 years old. What has she learned for the last
23 years? It tells you this is what you were made for, and this is all you can do. That you’re lucky somebody
wants you to do whatever for $10 at the truck stop. (Interview 62, October 19, 2015)
Another provider, experienced with working with victims of sex trafficking in emergency centers,
reported that victims are often misidentified as “prostitutes” at triage. The critical piece missed at
triage is the coercive element or the “back story” to the patient’s behavior and presenting symptoms.
This provider reported that it is not at all uncommon for one to be called to see a patient who is
described as a “prostitute”. However, as one interviews the patient, this health-care provider
frequently hears of force, fraud, or coercion, the elements legally distinguishing prostitution from
sex trafficking (Interview 37, September 16, 2015).
Health-care providers cited additional reasons as to why they thought so few victims were recognized
in health-care settings. Providers cited reluctance of victims to self-identify primarily due to fear. These
included fears of (a) retaliation by the trafficker or those working for the trafficker, (b) deportation and/
or arrest, and (c) police and/or authority figures. Providers thought victims might distrust anyone to
whom they disclose for fear that individual would take advantage of and revictimize him or her
(Interviews 5–7, July 21, 2015; 8, July 31, 2015; 30, September 4, 2015; 37, September 16, 2015; 47,
October 1, 2015; 49, October 5, 2015; 61, October 16, 2015; and 70, December 8, 2015).
A few health-care providers speculated that victims may not be identified because they never access
health-care facilities (Interviews 40, September 22, 2015; 57, October 9, 2015; and 58, October 10,
2015). According to one provider, “If you’re my human-trafficking person, if you’re my property and
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you get sick, do you think I care? Do I take you to the hospital? I don’t think so.” This provider went on
to suggest that victims “may not be making it to the health care door. Maybe they end up in the
morgue” (Interview 40, September 22, 2015). Another provider suggested that rather than using a
health-care facility, victims might use over-the-counter medications, illicitly obtained prescription
drugs, or alternative medicine or healers (Interview 58, October 10, 2015). Another speculated that
victims might see health-care providers who work with the traffickers so that they are never registered
as a patient in a health-care facility, or the health-care provider covers up evidence of the crime (Field
Notes June 9, 2016).
Providers suggested that the health-care delivery process itself may preclude victim identification. A
few health-care providers felt language barriers impeded recognition. These providers thought some
victims may not reveal their status when there was no staff member who spoke their language (Interviews
7, July 21, 2015; 27, September 2, 2015; and 32, September 9, 2015). Another provider described a case of
suspected trafficking where he or she and staff members tried unsuccessfully on several occasions to
separate the patient from the person accompanying her who spoke on her behalf. Although this provider
stressed the need for privacy in working with suspected victims, he or she reported that it is not always
possible to achieve (Interviews 47, October 1, 2015; and 57, October 19, 2015). Concerns about violating
patient confidentiality were also reported as factors that might prevent victim identification (Interview
85, October 2, 2015; Field Notes October 29, 2015; April 21, 2016; July 7, 2016). Other providers spoke to
constraints on health-care providers’ time and competing priorities as potential barriers to their ability to
recognize victimization indicators (Interviews 33, September 11, 2015; 35, September 14, 2015; 41,
September 25, 2015; 44, September 29, 2015; 49, October 5, 2015; 57, October 9, 2015; and 66,
November 11, 2015). One emergency room physician stated that trafficked victims may go unidentified
due to the difficulty in making a differential diagnosis given time constraints and competing priorities:
It’s often difficult on the front line to differentiate between human trafficking, domestic violence, drug
dependency related behaviors in terms of sexual assault, STDs [sexually transmitted diseases], assault and
battery. There’s a complex milieu that, I don’t know, is often difficult for us to tease out internally. (Interview
35, September 14, 2015)
In sum, most participants had not identified victims amongst their patients and had not encountered
victims who self-disclosed. Numerous reasons were cited for the low-identification rate. Reasons
ranged from victims’ fear of retaliation by the trafficker if they self-disclosed to the provider; factors
such as lack of clarity between trafficking, sex work, labor exploitation, and/or smuggling; also,
constraints on providers’ time and the competing priorities they face.
Human-trafficking awareness and knowledge
A key determinant for the low identification rate of victims, and cited by many clinicians, was
provider lack of awareness and knowledge about human trafficking (Interviews 17, August 21, 2015;
18, August 24, 2015; 30, September 4, 2015; 37, September 16, 2015; 47, October 1, 2015; 53, October
7, 2015; 57, October 9, 2015; 73, January 6, 2016; and 77; January 25, 2016). Health-care providers
who have worked with victims said the following:
Not too many health care providers are aware of it. If they identify a victim it’s probably because that person
told them so. They are hard to identify because the trafficker is controlling them and threatening them and
their family.…Most people are not properly trained on what are the indicators and they [the victims] usually
only seek medical attention as a last resort. (Interview 41, September 25, 2015)
With human trafficking victims that present to the ER, a lot of times they’re missed by nurses and doctors.
Because there are certain red flags that just aren’t being seen. The whole concept and idea of human trafficking
is relatively new. So, a lot of doctors don’t know about it, a lot of nurses don’t know about it. (Interview 37,
September 16, 2015)
To increase recognition and identification of victims, many health-care providers recommended
training on human trafficking (Interviews 17, August 21, 2015; 30, September 4, 2015; 33, September
9, 2015; 66, September 4, 2015; and 68, November 12, 2015). One participant said, “If you don’t
know about something, how can you look for it? And if you’re not looking for it, you’re definitely
not going to see it” (Interview 66, November 4, 2015). Content on human trafficking, however, was
described as not yet widespread in curriculums within Houston health professional schools
(Interviews 28, August 21, 2015; 30, September 4, 2015; 33, September 11, 2015; & 68, November
12, 2015). One medical school professor said:
There is little in the way of education that goes on of health care professionals… or the medical students, or any
medical group. (Interview 68, November 12, 2015)
Underscoring this, one physician just finishing his or her residency said:
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When I was a medical student here 3 years ago, it wasn’t incorporated into our curriculum but, I think in the past year
or so, it’s part of their curriculum now, so they do get a lecture… But it definitely is a recent thing. (Interview 33,
September 11, 2015)
For health-care providers practicing in Houston, specialized training is available at no cost from two
local nonprofits, United Against Human Trafficking (UAHT) and Doctors for Change. One of UAHT
health educators stated that there are indications of rising awareness and interest by health-care
institutions. UAHT has received increased requests for information beyond awareness and identification such as how to address more nuanced questions of “Okay, once I call a hotline what do I do with
the traffickers in the waiting room?” “What does HIPPA (Health Insurance Portability and
Accountability Act) say about that [patient confidentiality]?” (Interviews 15, August 18, 2015; 83,
February 9, 2016; 85, February 10, 2016; and 87, February 22, 2016). Doctors for Change, a group of
volunteer medical residents, physicians, and health-care professionals, also provides specialized training
for health-care providers. In 2015, its initial year of operation, they trained 84 first-year residents of
different specialties. Since then, they have trained 120 more residents and practicing physicians. After
their inaugural year of trainings, participants reported that eight potential victims were identified and
received resource information. Additionally, Doctors for Change has developed a specialized curriculum for psychiatry residents (Interviews 47, October 1, 2015; 48, October 2, 2015; 68, November 12,
2015; and 77, January 25, 2016).
Several practicing health-care professionals talked about the training they had received on human
trafficking. For some, the only training they had received had been through continuing education.
Additional participants had received training through UAHT, Doctors for Change, or through their
own institutions. In the latter case, the training was sometimes a hybrid between UAHT’s curriculum
and one designed by their institution. Frequency of training, audience, teaching methods, and
instructor knowledge regarding human trafficking, all varied (Interviews 5, September 21, 2015; 6,
September 21, 2015; 33, September 9, 2015; 41, September 25, 2015; 45, September 9, 2015; 46,
September 30, 2015; 52-53, October 7, 2015; 63, October 22, 2015; and 64, October 23, 2015,). Three
participants reported that their institutions did not offer any training on human trafficking
(Interviews 57, October 9, 2015; 62, October 19, 2015; and 73, January 1, 2016).
Two health-care administrators spoke to the challenge of training staff about human trafficking.
One administrator reported it is difficult to justify resources to train staff as he or she was not aware
of any victims being identified in his or her emergency center. At the same time, he or she
recognized not knowing enough about the subject him/herself to distinguish potential victims
(Interviews 73, January 6, 2016; and 74, January 8, 2016). This administrator said:
The way I see it, is do I perceive it as a problem here in the emergency room? Well, not overtly. It’s a problem
that I don’t see so it doesn’t exist. Do I need to spend resources on it? That’s what I’m thinking. It’s sort of like a
doubled edged sword. Do I really know what it takes to recognize even the subtle hint of human trafficking
through the EC [emergency center]? Probably not enough to recognize it. It very well may be a problem that
I’m just ignorant of. (Interview 73, January 6, 2016)
The second administrator, familiar with some cases of trafficking, either preidentified by law
enforcement or emergency-center staff, spoke to the challenges of training all employees in large
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institutions. Recognizing that all staff cannot be trained to the same degree, his or her institution has
staff consult a forensic nurse if a potential victim is identified. By integrating forensic nurses into
their victim-response protocol, the institution ensures that someone on the team treating the victim
has the requisite skills and knowledge to appropriately handle the situation (Interview 74, January 8,
In sum, health-care professionals recognized provider lack of awareness and knowledge about
human trafficking as a main reason for the dearth in victim identification. Although some were aware
of the educational offerings through local nonprofits, others were not and they noted the need for
increased training opportunities. Implementation of widespread training is confounded by the need to
justify training expenses for a problem of unknown magnitude and rarely being identified in their
patient populations, and the logistical challenges in deciding who and how to train employees in large
Labor-trafficking awareness
Specifically related to labor trafficking, although most providers were aware of it, they had little more
than general knowledge or knew how to screen for it. The exceptions were the community health
workers and the physician working in immigrant neighborhoods. Most health-care providers
reported not having identified victims of labor trafficking. Although most had some familiarity
with sex trafficking and its potential adverse health consequences, few could say the same about
labor trafficking. A small number brought up the subject of labor trafficking and no one referenced
the cases of domestic servitude covered in the local press. Although some providers articulated that
cases might present in emergency rooms with severe workplace injuries, they were not familiar with
cases identified in emergency centers (Interviews 35, September 14, 2015; 41, September 25, 2015; 44,
September 29, 2015; 73, January 6, 2016; and 74, January 8, 2016). One participant said that on-thejob injuries “can look like an everyday kind of injury on the job” (Interview 41, September 25, 2015);
therefore, it may not raise red flags amongst health-care providers. Another participant said, “We
just haven’t captured it [in the emergency rooms] because we’re not asking the right questions…I’m
not sure what the right questions are” (Interview 44, September 29, 2015). This participant went on
to say that emergency rooms are so busy with what they already do for patients that adding more
tasks would necessitate more staff. Finally, one interviewee suggested lack of identification of labortrafficking victims could be partly due to victims’ lack of knowledge of the existence of labor
protections in the United States. As a result, victims may not say anything about their circumstances:
I could be speaking way out of turn here, I might have no idea what I’m talking about, but I think, possibly
what makes that so hard is that sometimes, those people don’t know the difference. Maybe their intention was
to come here to work, they wanted to be in the U.S. and then they were trafficked for labor, and those people
don’t know the difference. They don’t know that the situation they’re in is so bad and so illegal. They just think
that’s the way it is here, and they just want to work. I don’t even know that they know to say anything.
(Interview 57, October 9, 2015)
In sum, the level of labor-trafficking awareness and knowledge amongst participants was limited. Few
health-care providers knew how it might manifest itself clinically or how to screen for it. One provider
recognized that with the volume of job-related injuries seen in emergency centers there could
potentially be labor-trafficked individuals amongst those seen, but he or she could not envision
screening all for trafficking without hiring additional staff.
Stereotypes, stigma, and shame
Health-care providers reported stereotypes, stigma, and shame can also pose significant impediments to
victim disclosure and health-care provider identification. Although virtually all health-care providers
spoke about stereotypes within the context of sex trafficking, one participant referred to the impact of
stereotypes in precluding identification of labor trafficking. This participant expressed that most people
only think about sex trafficking so they may not recognize someone in front of them who is trafficked for
labor. He or she said, “If you’re looking for sex trafficking you’re going to miss labor trafficking, right,
you’re just going to do it, that’s just how I see it” (Interview 66, November 4, 2015). The provider will only
see what he or she is looking for (Interviews 45, September 30, 2015; and 66, November 4, 2015).
One nurse identified two stereotypes about sex trafficking that he or she has observed amongst
health-care providers. One, some believe that human trafficking affects only people from other
countries. Two, there is a stereotype that looking like a “prostitute” means that individual is a
“prostitute” (Interview 45, September 30, 2015). The nurse said:
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If I’m a layperson, I say she’s a prostitute, because human trafficking does not affect suburban white girls…
That’s a problem that happens in another country, not the United States. We don’t have those problems. But I
know that young, white women are…a prime target for sex trafficking. They’re the product. …But do most of
the people in the ER know that? No. The young lady with fake boobs, the nice set of veneers, extensions — she’s
a stripper. Clearly, she’s only stripping because she wants to. Right? Perhaps she has someone behind her
saying, “If you don’t get out there and make me X, Y and Z, I’ll kill you — or kill your children.” If you’re not
made aware of those such occasions, it’s easy to put people in boxes. (Interview 45, September 30, 2015)
Another stereotype referenced was that of the “frequent flyer” (Interview 30, September 4, 2015).
Whether it is related to problems with addiction, homelessness, prostitution, or other social issues
and results in frequent visits to health-care facilities attributed to treatment nonadherence, one nurse
reported that these individuals may receive insufficient attention from some health-care providers.
The nurse stated:
What happens a lot of times with people is that they tend to stereotype. I tend to stereotype. I have to be very
aware of that. I think that what happens is there’s this attitude of, “You’re just going to go back out and do it
again. You’re not worth my time. Why are we wasting all of our resources on somebody like you?“ That’s the
attitude. (Interview 30, September 4, 2015)
Victims perceiving discriminatory attitudes, in conjunction with the shame and guilt they might
already feel about their life, may decide not to disclose (Interviews 14, August 17, 2015; 16, August
21, 2015; 17, August 21, 2015; 23, August 27, 2015; 30, September 4, 2015). The same nurse
commented, “That kind of discriminatory attitude increases shame, which increases hiding”
(Interview 30, September 4, 2015). He or she went on to describe how this type of attitude impacted
one patient’s decision to not disclose to a health-care provider that she was being forced into sex
I asked her if she had ever gone to a doctor while she was being trafficked and what would it have taken for her to
reveal she needed help. She said, “Just being treated as if I was a real human would go really far,” but she never
really experienced anybody asking her any of the questions like, “Are you safe?” It was more get in and out.…
One day she went to the hospital to have her baby.… “The baby had to stay a couple of extra days. They didn’t
make me leave. They treated me like I was a real mom. It gave me the courage to ask for help.” (Interview 30,
September 4, 2015)
Another health-care provider expressed concern about the stigmatization victims can experience in
health-care settings. The victims can readily detect attitudes in health-care providers:
They feel safe coming to our clinic because, from what I’ve heard, they say, “You don’t look at me as a victim or
a prostitute. You look at me as just I’m a person who needs some help”. Patients, they can quickly tell … very
quickly … very much so. (Interview 23, August 27, 2015)
One physician spoke about the issue of stigma and stereotypes amongst fellow physicians:
There was one article that came out in the last couple months. They kind of surveyed doctors talking about
what are the barriers and one of them was just stigma. Some people still I guess identify these victims as
prostitutes instead of really a victim who is not in control of their life…So I think there’s still that old
traditional thinking. I think we’re still working on changing that just because with human trafficking it is
still new. (Interview 33, September 11, 2015 )
Several other health-care providers spoke to the difficulties in making the paradigm shift from
viewing people as “prostitutes” to “victims.” Combined with the defensive attitude and demeanor of
some victims, providers may have a hard time seeing victims as needing assistance. Providers often
fall back on their stereotypes of prostitutes when victims do not want to make a police report or walk
away from their circumstances (Interviews 17, August 27, 2015; 33, September 11, 2015; 37,
September 16, 2015; 45, September 30, 2015; and 61, October 16, 2015). One health-care provider
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A lot of times they won’t report. They don’t want help because they can’t leave. They just want the medical
treatment. You have to be okay with that. [Health-care providers] aren’t okay with that. They want to help, they
want to get you free. Then they get frustrated. They’re like, then you’re just a prostitute. They get that whole
mentality of, if you don’t want help you’re doing it for fun, you’re a prostitute. (Interview 37, September 16,
2015 )
In sum, health-care professionals reported that stereotypes, stigma, and shame can inhibit both
victim disclosure and victim identification. Provider beliefs about individuals opting to work as
“prostitutes”, for instance, can preclude recognition of trafficking indicators. In addition, stereotypes
can elicit discriminatory attitudes on the part of the provider, which in turn can provoke the stigma
and shame a patient already feels about his or her situation. Consequently, a patient may decide not
to disclose their trafficked circumstances.
Lack of adequate community resources and health-setting protocols
Some health-care participants identified the lack of adequate and well-coordinated community resources
as barriers to both victim disclosure and health-care provider identification (Interviews 27, September 2,
2015; 35, September 14, 2015; 41, September 25, 2015; 54, October 7, 2015; 61,October 16, 2015; 62,
October 19, 2015; 69, November 12, 2015; and 73, January 6, 2016). Victims may not disclose their
circumstances to health-care professionals if they think there is little hope of being helped or, at the very
least, have a safe place to go. At the same time, providers perceiving a dearth in community resources
and/or safe facilities for victims may hesitate to attempt identification. An emergency room social
worker’s comment highlights victim reluctance to disclose in the absence of safe accommodations:
I think the first step for an individual to disclose is knowing that there is a safe backup plan for them.…Without
that, the person is not going to disclose. Why would you want to tell me that you’re a victim, knowing that I
have nowhere to send you, knowing that Option B is being killed by your trafficker.…[If] I can’t go to a victim
and say, “Hey, I have a feeling there is more going on than you’re willing to tell me, and if there is, I have a
place that you can go.” …Now if you say those words to …a woman that comes in for domestic violence, “I
have a shelter for you to go to,” they’re going to tell me that they’re getting beaten by their husband, because I
have a safe plan for them. Unfortunately, sometimes victims of trafficking do not qualify for women’s shelters
because it’s not actually considered a domestic violence relationship. (Interview 41, September 25, 2015)
The following quote by a nurse suggests the dilemma a lack of community resources can pose for the
health-care professional who screens for victims of trafficking. The nurse also alludes to difficulties
that can arise in the health-care facility if protocols are not in place to guide providers as to how to
handle identified victims:
We need to know that there are resources to support them [when we have identified a victim]. We know that those
don’t exist. They are not there. The next question becomes, you have health care… working hard to identify it.
Then, what happens? We could go down to the ER today and we can identify five. There’s not five down there, but
I’m just saying. Let’s go down and we’ll see they have five and let’s see what happens. (Interview 61, October 16,
An emergency-room physician suggested that, in the absence of knowing what to do with victims
once recognized, some providers choose not to screen:
The biggest challenge for me is people sometimes don’t want to look for something they don’t know what to do
with. A robust place, where you knew that if you called someone, someone would be plugged in and taken care
of and rescued would be a big start, and if you’re going to make it work at an emergency center, it cannot be
something that requires a lot of juggling, because the barrier, then, to find people goes higher and higher and
higher. (Interview 35, September 14, 2015)
The theme of health-care provider avoidance due to a lack of knowing what to do is underscored by
a mental-health professional. This provider compared avoidance of assessing for trafficking to
avoidance of evaluating for suicide risk:
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Yeah, I mean honestly. It’s a vicious cycle of, well, we kind of want to help, but we have nothing. We don’t
know what to say, so we’re not … It’s just like with suicide. It’s the same thing, that whole I don’t … If they say
yes, what do I do? So, I’m just not going to ask the question. I’m going to be avoidant. People may avoid your
subject because they don’t know what to do. (Interview 62, October 19, 2015)
One physician suggested an alternative reason as to why some providers might make the decision not to
screen for trafficking. This physician felt that identification without the offer to assist to the patient is
unethical. “To identify victims but then not to offer them what they need is increasing their misery,
because you’re telling them there is hope and then you’re not giving them anything” (Interview 69,
November 23, 2015).
In brief, health-care providers identified the lack of community resources to which to refer
victims and the lack of institutional protocols to assist victims as potential barriers to both victim
disclosure and provider identification. The health-care provider without an awareness of what
community resources exist to help the patient, particularly safe accommodations, may decide not
to screen for trafficking. Some view screening without a referral network as unethical. The difficulty
for the health-care provider is compounded if there is little or no guidance from their institutions as
to how to handle the situation.
This study reflects health-care providers’ growing awareness of their role in distinguishing trafficking
victims and the need to establish promising practices to support victims in their care. Health-care
professionals typically are concerned with the myriad of physical- and mental-health issues victims
may sustain, as well as providing them with counseling and resources to exit trafficking, if this is
their choice. To maximize opportunities for improved health-care outcomes, health-care providers
need to recognize victims and to understand the exploitative and restricted circumstances under
which they live. Providers can than provide treatment plans with a greater likelihood of adherence.
This benefits the public if trafficked persons can follow through with treatment for infectious and
communicable diseases.
The current study contributes to the body of scholarship regarding provider factors that prevent
victim identification in health-care settings. Although there are academic articles that speak to
identification issues in medical facilities, there is still much to learn. Quantitative studies have
suggested that health-care providers’ lack of knowledge about human trafficking may be a significant
factor in the low numbers of victims being recognized in health-care settings (Chisolm-Straker et al.,
2012; Grace et al., 2014b; Titchen et al., 2015; Yankovich, 2015). The qualitative nature of the present
research, through its use of open-ended questions and semi-structured interviews, enabled the
pursuit of topics important to participants, thereby elucidating greater detail than has been found
in previous studies. New factors potentially impeding victim discernment came to light in this
manner. For example, interviews identified the presence of provider stereotypes. Recognition of this
factor helps inform content needed in future provider training that ultimately can pave the way for
increased identification of victims. The current study expands on studies looking at provider
impediments to victim discernment in additional ways. With its large number of interviews, its
focus on both adult sex and labor trafficking, and its focus on the views of health-care providers
only, it overcomes some of the limitations of those studies that were either based on small samples,
relate primarily to sex trafficking or trafficking of minors and/or do not always distinguish between
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the viewpoints of health-care and non-health-care providers (Baldwin et al., 2011; MaciasKonstantopoulos et al., 2013; Miller et al., 2016). In sum, the current study expands the extant
knowledge base by increasing an understanding of the barriers that make identification challenging
to health-care providers that in futurity enables development of strategies to increase recognition of
trafficked victims.
This study found that, with a few exceptions, most health-care providers had neither encountered
victims who had self-disclosed, nor had they distinguished victims amongst their patients. Many
attributed the lack of recognition to a combination of victim and provider factors such as victim
reluctance to self-identify due to a variety of fears and health-care providers’ low awareness and
knowledge of human trafficking. These findings are consistent with previous scholarship indicating
that victims accessing health care often do not disclose their victimization, contributing to difficulty
in identifying them (Baldwin et al., 2011, 2015; Macias-Konstantopoulos et al., 2013, 2015), and
health-care providers lack general knowledge about human trafficking and specific knowledge about
how to recognize and respond to it (Chisolm-Straker et al., 2012; Grace et al., 2014b; Titchen et al.,
2015; Yankovich, 2015). In this study, aside from the sexual-assault nurse examiners and a few other
providers, the overall awareness and knowledge of trafficking was limited.
Health-care providers reported limited human-trafficking curricular offerings as part of training
and continuing education for health-care providers. Much of the training health-care providers
received, if any, varied in content, teaching methodology, and instructor knowledge regarding
trafficking. This finding underscores other studies that call for strategies to improve provider
training on human trafficking that will enhance both service delivery and health outcomes for
victims (Atkinson et al., 2016; Powell et al., 2017). Powell and colleagues (2017) recommended
standardization of curricula to ensure consistency and fidelity of content across varied health-careprovider educational venues, development of evaluative tools to assess for provider-behavior change
after training resulting in enhanced victim outcomes, continued movement towards the development
of evidence-based curriculums, and the establishment of a national body to oversee recommendation
implementation. Atkinson and colleagues (2016) called for states to develop training for health-care
providers that consider best practices from the 17 states that have passed legislation and established
oversight positions regarding health-care-provider education. For now, in the absence of evidencebased curriculums, health-care institutions looking to train their providers might look to curricular
recommendations made by leading scholars in the field like Miller et al. (2016). In addition, the U.S.
Department of Health and Human Services Office of Trafficking in Persons (2016) has developed an
online curriculum entitled, “Stop. Observe. Ask. Respond to Human Trafficking (SOAR) to Health
and Wellness Training” that might be utilized (U.S. Department of Health & Human Services
[USDHHS], 2016).
This study found health-care providers’ awareness and knowledge of labor trafficking to be
particularly low. Although most providers were aware that it exists, few had seen or identified it,
and few had insight as to how associated health issues could be distinguished from injuries that can
occur in everyday work situations. The only participant with in-depth knowledge of and experience
with victims of forced labor had lived and worked in the same immigrant neighborhood as his or her
patients for many years. Additional participants who thought they might have encountered victims
of labor trafficking were community-health workers living and working in neighborhoods with many
undocumented immigrants. They, however, were uncertain how to distinguish between wage
exploitation, poor working conditions, and the exploitative and often violent conditions surrounding
illegal immigration. The study finding of low awareness and knowledge of labor trafficking was not
unexpected given the dearth in scholarly studies regarding the health needs of those trafficked for
labor. Indeed, the present study is one of a limited number that considers impediments to the
identification of labor trafficking in health-care settings. Illuminated in the current study was the
unique knowledge providers well embedded in the communities in which victims of forced labor
reside may have about the nature of labor trafficking and its effects on victims. This insight might
serve as a foundation upon which additional research in other health-care settings can be built. The
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nexus of labor trafficking and health is an area in need of attention. Almost 20 years after the passage
of legislation criminalizing human trafficking, most of the academic literature still focuses on sex
trafficking though evidence points to forced labor being the predominant form of trafficking
(Littenberg & Baldwin, 2017; National Institute of Justice, 2013; Todres, 2011; Wulfhorst, 2016).
This study also supports extant literature suggesting health-care-provider stereotypes may impede
victim disclosure and identification (Baldwin et al., 2011; Geynisman-Tan, Taylor, Edersheim, &
Taubel, 2016; Macias-Konstantopoulos, 2016; Macias-Konstantopoulos et al., 2013, 2015; Miller
et al., 2016; Rajaram & Tidball, 2016). Previous scholarship suggests that provider beliefs about
those opting to work as “prostitutes” coupled with a lack of knowledge about sex trafficking may
engender discriminatory attitudes towards possible victims, which can in turn elicit shame in and
nondisclosure by victims (Rajaram & Tidball, 2016). The latter dynamic was found in the current
study as well. The presence of this factor suggests that educational initiatives for health-care
providers need to address myths and stereotypes about sex trafficking (Miller et al., 2016) and to
consider best teaching practices utilized in sensitizing health-care providers in working with other
stigmatized populations, such as people with HIV/AIDS, sex workers, substance abusers, immigrants, and those with mental illness (Beaulieu et al., 2017; Knaak, Modgill, & Patten, 2014; Lazarus
et al., 2012; Patten et al., 2012). Although reference to stereotypes of people forced into labor were
minimal in this study, stigma-reduction teaching modalities might also increase identification of
labor-trafficking victims as well.
Finally, the current research supports existing scholarship suggesting that some health-care
providers may hesitate to assess patients for trafficking if there are inadequate referral resources
for referring victims to appropriate services and/or inadequate internal infrastructure and guidance
as to what to do for victims (Atkinson et al., 2016; Macias-Konstantopoulos, 2016; MaciasKonstantopoulos et al., 2015). Participants in the current study indicated reluctance to screen for
trafficking because they perceived inadequate community resources to meet the needs of victims who
decide to leave their trafficker. Participants also intimated hesitation to screen in the absence of
advisement in dealing with victims. Researchers have suggested that in the absence of community
resources and management guidelines, providers subscribing to the bioethical principle of nonmaleficence, or “do no harm,” may equivocate about identification (Atkinson et al., 2016; MaciasKonstantopoulos, 2016; Macias-Konstantopoulos et al., 2015; National Research Council, 1999;
Stoklosa, Showalter, et al., 2016). Based on findings, health-care practitioners and scholars have
recommended the development of hospital protocols to guide identification, treatment, and referral
of victims to local vetted resources. Such protocols should be developed in close collaboration with
the community stakeholders who can provide for those needs (Macias-Konstantopoulos, 2016;
Macias-Konstantopoulos et al., 2015; Schwarz et al., 2016; Stoklosa, Showalter, et al., 2016). A few
descriptive studies exist examining the development and implementation of policies and protocols
and the establishment of networks to community referrals (Schwarz et al., 2016; Stoklosa, Showalter,
et al., 2016). Additional case studies examining this process in various systems of care could be
One other area for further study became apparent during this research. To date, minimal
literature has addressed identification of victims of trafficking who present to health care with
psychiatric symptoms. Although the current study did not specifically address the subject of
trafficked persons and psychiatric illness, psychiatrists interviewed pointed to unique difficulties in
recognizing this subpopulation. This is another area in need of empirical study.
This study has several limitations. Participants recruited through a purposeful and snowballedsampling strategy are not necessarily representative of the target population, thereby limiting
generalizability of the study findings. However, what is learned from this study might be transferrable and beneficial to health-care providers and similar settings elsewhere (Bloomberg & Volpe,
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2012; Shenton, 2004). Purposeful and snowball sampling adds selection bias (Daniel, 2012). It is
possible that health-care providers interviewed had a greater interest in the study subject matter than
those not participating, thereby leading to a false notion that there is growing interest in human
trafficking on the part of the health-care sector.
Another limitation inherent to qualitative studies is the potential for researcher bias. As data
analysis depends on the researcher’s thoughts and choices, efforts must be made to reduce the
potential for subjectivity (Bloomberg & Volpe, 2012; Patton, 1999; Shenton, 2004). In this study, the
coauthors and two additional research advisors scrutinized the results and findings to challenge
potential bias and researcher assumptions. Their critique was incorporated back into the data
analysis. The researcher examined for consistencies and discrepancies both within and between
interviews to enhance study validity (Creswell, 2013; Patton, 1999). Consistency between sources
suggested validity and discrepancies were addressed through clarification with participants and/or
further data collection.
Health-care providers continue to have limited awareness and training regarding human trafficking
as other authors have suggested. This study found awareness and training about labor trafficking to
be particularly limited. Results support previous scholarship suggesting that provider stereotypes and
a lack of knowledge of human trafficking inhibits victim identification. Trainings aimed at improving victim recognition need to be included in the curriculum of health professionals’ schools as does
an awareness of how stereotyping can impact effective provider/victim interactions. Trainings might
draw on established best practices for working with other stigmatized populations, such as the
mentally ill, undocumented immigrants, victims of other types of violence, sex workers, substance
abusers, and/or those who have HIV (Beaulieu et al., 2017; Knaak et al., 2014; Lazarus et al., 2012;
Patten et al., 2012).
The first author wishes to thank her dissertation committee: Sheryl McCurdy, PhD, Gretchen Gemeinhardt, PhD,
MBA, FACHE, Beatrice Selwyn, ScD, and Kerry Ward, PhD. All were vital contributors to this article. I would also like
to thank the many members of the Houston health care, public health, and anti-human-trafficking community who
participated in my study. Thank you also to members of the HEAL Trafficking Network, with special thanks to
Dr. Makini Chisolm-Straker and Dr. Cathy Miller.
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