Human trafficking is often described as a hidden crime. But the sad reality is that it affects around 27.6 million people worldwide, according to the International Labour Organization. These individuals are often right in front of us.
For nurses, this reality means the difference between potentially saving a life and unknowingly overlooking a cry for help.
In a recent NurseDot podcast episode, host Cara Lunsford, RN, sat down with Francine Bono-Neri, PhD, RN, APRN, PNP, co-founder of Nurses United Against Human Trafficking (NUAHT), to dive deeper into this epidemic and how nurses can help.
Bono-Neri recalled the day she unsuspectingly encountered a victim of trafficking during a clinical rotation at a teaching hospital in New York. A 16-year-old girl was admitted with significant cellulitis. She presented with visible signs of poor hygiene, including dental issues, lice, sexually transmitted infections, self-inflicted mutilation, IV substance marks, a UTI, and other concerns.
“I’m thinking, she’s 16. How does this happen?” she said. “We were in a very affluent area of Long Island, and there was a gentleman who was sitting in the visitor’s chair, and he was the complete opposite of how she presented.”
She described him as well-dressed, clean-cut, and well-spoken. As part of the admission process, she inquired about his relationship to the patient. The man responded, “She’s a very good friend of mine. I’m worried about her. I care about her, and I just want to make sure she’s OK.”
At the time, no one suspected trafficking. It wasn't until a year later, while attending a presentation by her NUAHT co-founder, Tammy Toney-Butler, CEN, TCRN, CPEN-Forensic Examiner, SANE, that she realized the teen had most likely been a victim of human trafficking.
"It was so overwhelming to me. I literally felt like I was hit by a Mack truck during her presentation,” she said. “I was thinking, 'My gosh, I failed as a mandated reporter. Every single one of us did.'"
Why nurses miss the signs
Bono-Neri learned that she wasn’t the only nurse who had encountered a human trafficking victim without realizing it. She discovered that it’s a topic often barely addressed in pre-licensure nursing programs.
According to research Bono-Neri co-authored with Toney-Butler, fewer than 1% of nurses report full confidence in identifying human trafficking victims, and more than 91% of nursing students said they had received little to no education on the topic during their programs.
"We’re an army waiting to be deployed,” she said. “But we're going into this battle defenseless because we don’t have this information.”
Although human trafficking was defined federally in the Trafficking Victims Protection Act (TVPA) of 2000, only about 15 states mandate continuing education on the issue for nurses and healthcare professionals, according to Bono-Neri. Even then, these trainings are often just an hour or two long and barely scratch the surface.
Recognizing the warning signs
Trafficking victims aren’t always what you expect, said Bono-Neri.
"People think it's a white van, the abductions at Walmart, or the ropes and chains," she said. "No, it's psychological manipulation. It’s the exploitation of vulnerabilities with promises of a better life or substance use.”
It’s hidden in plain sight. In fact, studies have found that up to 88% of victims had come into contact with the healthcare system while being trafficked.
According to the International Council of Nurses, nurses can watch for some of the following warning signs:
- Frequent visits to healthcare settings, especially for cases of substance use or non-fatal suicide attempts
- Unexplained injuries, black eyes, broken teeth, STIs, or signs of physical abuse
- Lack of identification or personal documentation
- Controlling companions who insist on speaking for the patient
- Tattoo designs used as branding, such as crowns, dollar signs, or certain phrases
- Patients without control over their phones, transportation, or finances
Challenging our biases
Some healthcare professionals may unintentionally overlook victims due to bias.
"I think we're trained to identify certain things like abuse or potentially neglect, but we're not trained to see the warning signs of human trafficking,” said Lunsford, who shared her own experiences with trafficking. “And I would venture to say that people could fall into implicit bias.”
Bono-Neri shared an example of seeing a young woman and assuming she has a substance use problem, or if a young woman is with an older man, they assume she is a sex worker.
It’s also essential to avoid judgmental language when speaking with potential victims.
This means not speaking negatively about the victim’s companion because there is trauma and coercive bonding, she said.
“If we speak in a negative way, that person is shutting down, and no more conversation is happening,” she added.
How to safely intervene
If you suspect a trafficking situation, safety is the first priority. Bono-Neri outlined several key interventions:
- Separate the patient from their companion, using neutral excuses like collecting another urine sample or asking the companion to return to admitting.
- Disable and remove the patient’s phone during private questioning to prevent trafficker monitoring or eavesdropping.
- Avoid using the word “trafficking” or “trafficker,” especially if the patient doesn’t self-identify.
- Use open-ended questions, such as:
- Do you feel threatened?
- Are you afraid?
- Is there something that is worrying you?
If there is imminent danger, always call 911. For non-emergencies, contact:
- National Human Trafficking Hotline: 888-373-7888 or text HELP to 233733
Hospitals and clinics should have internal protocols to respond and refer victims. Without clear policies, even educated nurses may feel helpless.
“It is imperative that the facilities have the policies and protocols in place,” said Bono-Neri. “So once someone is identified, ‘OK, I need to activate this,’ you have the multidisciplinary teams responding because it's not a siloed approach. We all need to be on the same page, and every single department or discipline has [its] own roles.”
The road ahead for nursing education
Bono-Neri and Toney-Butler continue to push for national reforms. Their NUAHT training is now recognized by the Department of Homeland Security Blue Campaign and is used by professionals under the Indian Health Service (IHS).
“Our curriculum in total is nine hours in length,” she said. “It is delivered in an asynchronous manner so the learning can occur on your own time and schedule.”
She added that it has been approved to award nine nursing contact hours or nine CMEs.
And as of recently, there is now an Anti-Human Trafficking Certificate available through the University of Florida’s (UF) College of Nursing. UF’s College of Nursing is the first in the nation to offer this Anti-Human Trafficking Certificate through a partnership with NUAHT.
Bono-Neri shared that one thing that sets their program apart is that they have a “lived experience expert.” Toney-Butler is a survivor of sex trafficking.
She said that not only is our education coming from subject matter experts in the healthcare profession, but you also have the lived experience of Toney-Butler, whose voice is threaded throughout the training.
Speaking from her own experience, Bono-Neri said, “There was a fire that was lit inside of me that I said, ‘I am going to do everything in my power to never have an individual who is being exploited and trafficked be failed by another healthcare professional again, because it's a matter of being properly educated.”
