Family and Sexual Violence
Family and Sexual Violence
C H A P T E R 8 6
1356
Family and Sexual Violence
Nursing and U.S. Policy
Kathryn Laughon, Angela Frederick Amar
“If the numbers we see in domestic violence were applied to terrorism or gang violence, the entire
country would be up in arms, and it would be the lead story on the news every night.”
Rep. Mark Green, Wisconsin
Our society is steeped in violence. In the most recent national statistics, more than 26 per 1000
people aged 12 years or older will be the victims of a violent crime (Truman, Langton, & Planty,
2013). Most of our violence prevention strategies prepare potential victims to ward off violent
attacks from strangers; yet, someone known to the victim perpetrates most violence against women,
children, and older adults. The intimate nature of this violence, often perpetrated behind closed
doors, has made these forms of violence less visible. However, the toll of violence on individuals
and societies is substantial. The World Health Organization has framed violence as a significant
public health problem (Truman, Langton, & Planty, 2013). A public health approach suggests an
interdisciplinary, science-based approach with an emphasis on prevention. Effective strategies draw
on resources in many fields, including nursing, medicine, criminal justice, epidemiology, and other
social scientists.
The purpose of this chapter is to provide an overview of state, federal, and health sector policies
regarding violence against women in the United States, briefly discuss policies related to violence
against children and older adults, and outline the resulting implications for nurses and directions
for future work.
1357
Intimate Partner and Sexual Violence Against Women
Intimate partner violence (IPV) is physical, sexual, or psychological harm inflicted by a current or
former partner (same sex or not) or a current or former spouse (Black et al., 2011). Almost one third
of American women experience being hit, slapped, or pushed by an intimate partner, and nearly a
quarter will experience serious forms of IPV during their lifetimes. Additionally, nearly one in five
women will experience a completed or attempted rape in their lifetimes. Men experience IPV and
rape as well, although at far lower rates than do women. About a quarter of men will experience
IPV (about 12% serious forms of violence) and nearly 1.5% a completed or attempted rape.
Although more than half of women reporting rape report that the assailant was an intimate partner
and 40% that the assailant was an acquaintance, men report that half of rapes were by
acquaintances and 15% by strangers; the number raped by an intimate partner was too small to
estimate.
The health effects of IPV and sexual violence are substantial and cost as much as $8.3 billion in
health care and mental health services for victims (Max et al., 2004). Violence is associated with a
wide range of health problems, including chronic pain recurring central nervous system symptoms,
vaginal and sexually transmitted infections and other gynecological symptoms, and diagnosed
gastrointestinal symptoms and disorders (Black et al., 2011). Mental health symptoms include
depression, anxiety, posttraumatic stress disorder, and alcohol and drug use (Black et al., 2011;
Campbell, 2002).
1358
State Laws Regarding Intimate Partner and Sexual
Violence
State laws address a number of issues important for nurses to understand. Most often, crime of IPV
and sexual violence are addressed through state laws. Most, although not all, states have laws
specifically providing enhanced penalties for assault and battery that occurs between intimate
partners. (It worth noting that most laws refer to domestic violence or family abuse rather than
IPV.) For example, at least 23 states have some form of mandatory arrest for IPV (Hirschel, 2008).
Research findings are mixed on whether mandatory arrest laws reduce reassault (Felson,
Ackerman, & Gallagher, 2005; Hirschel et al., 2007), although findings from at least one study
suggest that the overwhelming majority of victims support mandatory arrest laws (Barata &
Schneider, 2004). Additionally, states may have enhanced penalties, such as escalating third
offenses to felonies.
Until 1975, all states provided what is called the marital rape exemption under which it was
legally impossible to commit rape against one’s wife. Beginning in the mid-1970s, based in part on
nursing research, these laws began to change (Campbell & Alford, 1989). Although all states now
recognize marital rape as a crime, in some states it is still treated differently from rape by a
nonspouse (Prachar, 2010).
Nonlethal strangulation of women is a significant but often overlooked threat to public safety.
Most (80%) strangulations of women are committed by intimate partners (Shields et al., 2010). They
can result in significant physical health problems for victims (Taliaferro et al., 2009) and
substantially increase risk of later lethal violence (Glass et al., 2008). These cases can be difficult to
charge and prosecute commensurate with the severity of the crime (Laughon, Glass, & Worrell,
2009); therefore, a growing number of states have strengthened laws related to strangulation.
All states provide for civil protective orders in cases where victims have a reasonable fear of
violence from an assailant (Carroll, 2007). States vary widely, however, in who is eligible to obtain
an order and how the orders are obtained. For example, in some states minors or dating partners
may not be able to obtain orders of protection. Most states provide for civil protection orders
against assailants who are accused of sexual assault, but the procedures may be different from those
for protective orders against intimate partners. Studies of the effectiveness of these orders are mixed
(Logan & Walker, 2009; Prachar, 2010).
In addition to these criminal justice remedies, state laws may address other issues related to IPV
and sexual violence. As of 2010, 26 states had established intimate partner fatality review teams
(Durborow et al., 2010). Fatality review teams use a multidisciplinary, public health approach to
reviewing fatalities and identifying risk factors (Websdale, 1999). A handful of states require health
care providers to report domestic violence against competent adults. It is important to understand
that in most states, IPV and sexual assault are not mandatory reports unless there are other factors
present.
1359
Federal Laws Related to Intimate Partner and Sexual
Violence
There are two significant federal laws that address violence against women. The Family Violence
Prevention and Services Act was first authorized in 1984. It was most recently authorized through
2015 (Public Law [PL] 111-320 42 U.S.C. 10401, et seq.). It is the primary federal funding source for
domestic violence shelters and service programs in the United States. It also funds the work of state
coalitions on domestic violence, community-based violence prevention efforts, and a number of
smaller training and assistance programs.
The Violence against Women Act (VAWA) was first authorized in 1994 (Title IV, sec. 40001-40703
of the Violent Crime Control and Law Enforcement Act of 1994, HR 3355, signed as PL 103-322). As
states began creating the protective order and criminal statutes discussed earlier, the limitations of
this patchwork of remedies became apparent. The VAWA was therefore created to address the gaps
in state laws; create federal laws against domestic violence, including protection for immigrant
women and enhanced gun control provisions; and fund a variety of violence-related training and
other local programs (Valente et al., 2009). The law originally included a provision making crime
motivated by gender a civil rights offense. This provision was, however, found unconstitutional in
2000 (Brzonkala v. Morrison, 2000).
The VAWA represented a significant turning point in public policy related to violence against
women. Previously, women who received a protective order might find that violations that
occurred in other states could not be enforced. The full faith and credit provision of the VAWA
requires that protective orders be recognized and enforced across jurisdictional, state, and tribal
boundaries within the United States. Likewise, by creating federal crimes of domestic violence and
stalking, criminal acts that cross jurisdictional boundaries can now be more easily charged and
prosecuted. Under the VAWA, it is illegal for individuals subject to certain types of protective
orders or convicted of even misdemeanor domestic violence offenses to possess a firearm. Given
that risk of intimate partner homicide increases dramatically when firearms are available to the
assailant, this represents an important safeguard for women (Campbell et al., 2003). The VAWA
addressed the significant hardships faced by both legal and illegal immigrant women experiencing
abuse from their partners. The VAWA additionally funds a wide range of victim advocacy and
training programs, with the goal of ensuring that victims of violence receive consistent, competent
services in all communities.
Each subsequent renewal of the VAWA has strengthened these provisions. The latest renewal in
2013 expanded its definitions to explicitly include gay, lesbian, and transgender victims; expanded
the safeguards available to women assaulted in tribal territories; expanded housing provisions to
prohibit discrimination against victims of IPV in all forms of subsidized public housing;
strengthened protections for immigrant women; and, for the first time, specifically addressed
violence on college campuses (Violence against Women Act, 2013).
1360
Health Policies Related to Intimate Partner and Sexual
Violence
As discussed earlier, the health consequences of violence are significant for women. Additionally,
women who have experienced violence have significantly higher health care costs than women
without a victimization history (Bonomi et al., 2009; National Center for Injury Prevention and
Control, 2003). There is now a consensus that these health care settings offer a unique opportunity
to identify and support women living with the effects of violence (Family Violence Prevention
Fund, 2002; World Health Organization [WHO], 2013). The U.S. Preventative Services Taskforce
recommends “clinicians screen women of childbearing age for IPV such as domestic violence, and
provide or refer women who screen positive to intervention services.” The Institute of Medicine
identified screening and brief counseling for interpersonal violence as an essential and evidencebased
practice necessary to ensure the well-being of women (National Research Council, 2011). A
wide variety of medical and nursing professional organizations also recommend routine screening
for violence (Amar et al., 2013). Significant evidence now exists for safety planning strategies to
prevent homicide for women in abusive relationships. The Danger Assessment Instrument, for
example, has been shown to have good predictive value and can assist women with making a
realistic appraisal of their likelihood of experiencing lethal violence (Campbell, Webster, & Glass,
2008). Health care institutions should also have the appropriate capacity to provide care to women
in the acute period after a physical or sexual assault (WHO, 2013).
Nurses and other health professionals have a role to play in community responses to violence.
Many localities have created sexual assault response teams. These interdisciplinary teams work to
ensure consistent, trauma-informed, and effective care for victims of sexual assault. Despite scant
research on the effectiveness of these teams, they are a promising practice (Greeson & Campbell,
2013). Likewise, intimate partner/domestic violence fatality review teams review cases of intimate
partner homicide with a public health approach. As with sexual assault response teams, there are
little data on the effectiveness of these teams that have also been labeled a promising practice
(Wilson & Websdale, 2006).
1361
Child Maltreatment
Child maltreatment includes physical, sexual, and emotional abuse, as well as neglect. Actual
prevalence of maltreatment is unknown, but there are more than 3 million referrals for more than 6
million children to child protective agencies annually, with nearly a quarter of these cases
substantiated. An estimated 1570 children nationally died from abuse or neglect in 2011
(Administration on Children, Youth, and Families Children’s Bureau, 2011; U.S. Government
Accountability Office, 2011), a number that is believed to be undercounted. The estimated annual
cost of child abuse and neglect in the United States for 2008 was $124 billion (Fang et al. 2012). Child
maltreatment results in lifelong adverse physical and mental health consequences such as
posttraumatic stress disorder, increased risk of chronic disease, lasting impacts or disability from
physical injury, and reduced health-related quality of life (Corso et al. 2008).
1362
State and Federal Policies Related to Child Maltreatment
Because minors are considered to need additional protection as a result of their age, states not only
have laws making the acts of abuse and neglect criminal offenses but also have laws requiring that
certain adults must report suspected maltreatment to appropriate authorities. In some states, all
adults are mandated reporters. In most states, specific professionals, teachers, health care
professionals, social workers, law enforcement personnel, and others are mandated reporters (Child
Welfare Information Gateway, 2011). At the federal level, the Child Abuse Prevention and
Treatment Act (CAPTA) provides funding to states to support prevention, assessment,
investigation, prosecution, and treatment activities related to child maltreatment and funding for
research activities (Child Welfare Information Gateway, 2011, 2013).
1363
Health Policies Related to Child Maltreatment
Children’s Advocacy Centers coordinate investigation and intervention services for maltreated
children by bringing together social work, legal, health care, and other professionals and agencies in
a multidisciplinary team to create a child-focused approach to child abuse cases. Home visitation is
another strategy that shows promise for improving child health and preventing child maltreatment
(Avellar & Supplee, 2013).
1364
Older Adult Maltreatment
Best estimates indicate that 1 to 2 million Americans over the age of 65 years are abused, neglected,
or exploited, most often by caregivers (National Center on Elder Abuse, 2005). Precise numbers are
not available, attributable to differences in definitions of abuse, lack of a comprehensive national
data system, and different state system reporting and data collection. Further, only a small fraction
of abuse comes to the attention of Adult Protective Services (Dong & Simon, 2011). The U.S. aging
population is rapidly increasing with projections for individuals 65 years and older to increase from
40.2 million in 2010 to 54.8 million in 2020 and to 72.1 million in 2030 (Dong & Simon, 2011).
Legislation has been effective in bringing about reform.
1365
State and Federal Legislation Related to Older Adult
Maltreatment
As with child maltreatment, state laws provide for criminal charges related to the abuse of older
adults (the definition of which varies from state to state, but may be as young as 55 years of age).
Most (but not all) states define certain individuals as mandated reporters of abuse of older adults as
well. At the federal level, the Older American Act of 2006 developed and maintains the National
Center on Elder Abuse, which provides funding for prevention activities, research, data collection,
and long-term planning for elder justice. The Elder Justice Act (EJA) of 2010, which was part of the
Patient Protection and Affordable Care Act (2010), is the first comprehensive strategy to address
older adult abuse, neglect, and exploitation. It is important to note that the authorized funding has
not been appropriated at this time and that the EJA is set to expire in 2014. Funding for older adult
maltreatment is significantly less than for other types of violence and a national database has yet to
be established.
1366
Health Care Policies Related to Older Adult
Maltreatment
Recent efforts have focused on using the primary care setting to identify and respond to older adult
abuse (Perel-Levin, 2008). Case management strategies can be effective in providing consistency in
monitoring of adult patient and caregiver behavior (Choi & Mayer, 2000). Research on effective
intervention strategies in this area lags behind that of other areas of violence and is an area where
nursing can make an impact.
1367
Opportunity for Nursing
Nurses have the skills and education to take a leadership role in addressing violence and abuse on
multiple levels, as providers, researchers, policy analysts, educators, and advocates. Efforts to
address violence against children, women, and older adults have met with impressive successes
over the past decades. These forms of violence, seen as largely justifiable and perhaps even
necessary in the past, are now recognized as both crimes and important public health problems. The
evidence base for interventions to prevent these forms of violence, end them when they start, and
mitigate the related health consequences is growing. It is clear, however, that we still have
important gaps in our understanding of both effective violence interventions and policies. Although
we work to address these gaps in knowledge, we can continue to move forward on numerous
fronts. Educators should ensure that curriculums at all levels include content on violence and
abuse. Given the high rates and significant health effects of violence, all nurses should have basic
clinical knowledge of how to assess for, competently respond to, and appropriately refer all patients
with a history of violence or abuse. Nurses can serve as powerful advocates for victims of violence,
ensuring that state and federal laws meet the highest standards.
Violence and crime unite two powerful systems, health care and criminal justice, and involve
multiple professionals including physicians, nurses, social services, police, lawyers, and judges.
Prevention and intervention strategies require efforts at the individual, community, institutional,
and public policy levels. Nurses can have a significant voice in ensuring the best possible
prevention and advocacy services at the local, state, and federal levels. Nursing research and the
testimony of nurses has been foundational for federal and state laws and resulting public policy
related to violence.
1368
Discussion Questions
1. Consider the differences in the treatment of violence across states and what federal provisions
might be advantageous to address the discrepancies.
2. How might nursing research help to fill the gaps in the knowledge?
3. It is apparent in the chapter that different strategies exist for violence against women, child
maltreatment, and older adult abuse. Could the same strategies work across populations and abuse
types? What might be the advantages/disadvantages to having similar strategies?
1369
References
Administration on Children, Youth, and Families Children’s Bureau. Child abuse and neglect
fatalities 2011: Statistics and interventions. U.S. Department of Health and Human Services,
Administration for Children and Families: Washington, DC; 2011.
Amar A, Laughon K, Sharps P, Campbell J. Screening and counseling for violence against
women in primary care settings. Nursing Outlook. 2013;61(3):187–191.
Avellar SA, Supplee LH. Effectiveness of home visiting in improving child health and
reducing child maltreatment. Pediatrics. 2013;132(10, Suppl. 2):S90–S99.
Barata PC, Schneider F. Battered women add their voices to the debate about the merits of
mandatory arrest. Women’s Studies Quarterly. 2004;32(3–4):148.
Black MC, Basile KC, Breiding MJ, Smith SG, Walters ML, et al. The national intimate partner
and sexual violence survey (NISVS): 2010 summary report. National Center for Injury
Prevention and Control, Centers for Disease Control and Prevention: Atlanta, GA; 2011.
Bonomi AE, Anderson ML, Rivara FP, Thompson RS. Health care utilization and costs
associated with physical and nonphysical-only intimate partner violence. Health Services
Research. 2009;44(3):1052–1067.
Brzonkala v. Morrison, 529 U.S. 598, 627. 2000.
Campbell JC. Health consequences of intimate partner violence. Lancet. 2002;359(9314):1331–
1336.
Campbell JC, Alford P. The dark consequences of marital rape. American Journal of Nursing.
1989;89(7):946–949.
Campbell JC, Webster D, Koziol-McLain J, Block C, Campbell D, et al. Risk factors for
femicide in abusive relationships: Results from a multisite case control study. American
Journal of Public Health. 2003;93(7):1089–1097.
Campbell JC, Webster DW, Glass N. The danger assessment: Validation of a lethality risk
assessment instrument for intimate partner femicide. Journal of Interpersonal Violence.
2008;24(4):653–674.
Carroll CA. Sexual assault civil protection orders (CPOs) by state. American Bar Association
Commission on Domestic and Sexual Violence: Washington, DC; 2007.
Child Welfare Information Gateway. About CAPTA: A legislative history. U.S. Department of
Health and Human Services, Children’s Bureau: Washington, DC; 2011.
Child Welfare Information Gateway. Long-term consequences of child abuse and neglect. U.S.
Department of Health and Human Services.: Washington, DC; 2013 [Retrieved from]
www.childwelfare.gov/pubs/factsheets/long_term_consequences.cfm.
Choi NG, Mayer J. Elder abuse, neglect, and exploitation: Risk factors and prevention
strategies. Journal of Gerontological Social Work. 2000;33(2):5–25.
Corso PS, Edwards VJ, Fang X, Mercy JA. Health-related quality of life among adults who
experienced maltreatment during childhood. American Journal of Public. 2008;98(6):1094–
1100.
Dong XQ, Simon MA. Enhancing national policy and programs to address elder abuse. JAMA:
The Journal of the American Medical Association. 2011;305(23):2460–2461.
Durborow N, Lizdas KC, O’Flaherty A, Marjavi A. Compendium of state statutes and policies on
domestic violence and health care. Family Violence Prevention Fund: San Francisco, CA; 2010.
Family Violence Prevention Fund. National consensus guidelines on identifying and responding to
domestic violence victimization in health care settings. Author: San Francisco; 2002.
Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the
United States and implications for prevention. Child Abuse & Neglect. 2012;36(2):156–165.
Felson RB, Ackerman JM, Gallagher CA. Police intervention and the repeat of domestic
assault. Criminology. 2005;43(3):563–588.
Glass N, Laughon K, Campbell J, Block CR, Hanson G, et al. Non-fatal strangulation is an
important risk factor for homicide for women. Journal of Emergency Medicine. 2008;35(3):329–
335.
Greeson MR, Campbell R. Sexual assault response teams (SARTs): An empirical review of
their effectiveness and challenges to successful implementation. Trauma, Violence and Abuse.
2013;14(2):83–95.
1370
Hirschel D. Domestic violence cases: What research shows about arrest and dual arrest rates.
National Institute for Justice: Washington, DC; 2008.
Hirschel D, Buzawa E, Pattavina A, Faggiani D. Domestic violence and mandatory arrest laws:
To what extent do they influence police arrest decisions? Journal of Criminal Law &
Criminology. 2007;98(1):255–298.
Laughon K, Glass N, Worrell C. Review and analysis of laws related to strangulation in 50
states. Evaluation Review. 2009;33(4):358–369.
Logan T, Walker R. Civil protective order outcomes: Violations and perceptions of
effectiveness. Journal of Interpersonal Violence. 2009;24(4):675–692.
Max W, Rice DP, Finkelstein E, Bardwell RA, Leadbetter S. The economic toll of intimate
partner violence against women in the United States. Violence and Victims. 2004;19(3):259–
272.
National Center on Elder Abuse. Fact sheet: Elder abuse prevalence and incidence. National Center
on Elder Abuse: Washington, DC; 2005.
National Center for Injury Prevention and Control. Costs of intimate partner violence against
women in the United States. Centers for Disease Control and Prevention: Atlanta; 2003.
National Research Council. Clinical preventive services for women: Closing the gaps. The National
Academies Press: Washington, DC; 2011.
Patient Protection and Affordable Care Act, 42 U.S.C. § 18001. 2010.
Perel-Levin S. Discussing screening for elder abuse at primary health care level. World Health
Organization: Geneva; 2008.
Prachar M. The marital rape exemption: A violation of a woman’s right of privacy. Golden Gate
University Law Review. 2010;11:717.
Shields LB, Corey TS, Weakley-Jones B, Steward D. Living victims of strangulation: A 10-year
review of cases in a metropolitan community. American Journal of Forensic Medicine and
Pathology. 2010;31:320–325.
Taliaferro E, Hawley D, McClane G, Strack GB. Strangulation in intimate partner violence.
Mitchell C, Anglin D. Intimate partner violence: A health-based perspective. Oxford University
Press: New York; 2009.
Truman J, Langton L, Planty M. Criminal victimization, 2012 No. NCJ 243389. US Department of
Justice, Office of Justice Programs, Bureau of Justice Statistics: Washington, DC; 2013.
U.S. Government Accountability Office. Child maltreatment: Strengthening national data on child
fatalities could aid in prevention (GAO-11-599). U.S. Government Accountability Office:
Washington, DC; 2011.
Valente RL, Hart BJ, Zeya S, Malefyt M. The violence against women act of 1994: The federal
commitment to ending domestic violence, sexual assault, stalking, and gender-based crimes
of violence. Renzetti CM, Edelson JL, Bergen RL. Sourcebook on violence against women. 1st ed.
Sage: Thousand Oaks, CA; 2009.
Violence against Women Act, Public Law 113–4.
Violence Against Women Reauthorization Act of 2013. 2013.
Websdale N. Understanding domestic homicide. Northeastern University Press: Boston, MA;
1999.
Wilson JS, Websdale N. Domestic violence fatality review teams: an interprofessional model
to reduce deaths. Journal of Interprofessional Care. 2006;20(5):535–544.
World Health Organization [WHO]. Responding to intimate partner violence and sexual violence
against women: WHO clinical and policy guidelines. World Health Organization: Geneva; 2013.
1371
Online Resources
Child Welfare Information Gateway.
www.childwelfare.gov.
Futures without Violence.
www.futureswithoutviolence.org.
National Center of Elder Abuse.
www.ncea.aoa.gov.
Rape, Abuse, and Incest National Network.
www.rainn.org.
.
1372
C H A P T E R 8 7
1373
Human Trafficking
The Need for Nursing Advocacy
Barbara Glickstein
“I freed a thousand slaves. I could have freed a thousand more if only they knew they were slaves.”
Harriet Ross Tubman, nurse abolitionist
Human trafficking is a serious crime of forced labor or enslavement. As defined under U.S. federal
law, victims of human trafficking include children involved in the sex trade, adults age 18 years or
over who are coerced or deceived into commercial sex acts, and anyone forced into different forms
of labor or services, such as domestic workers held in a home or farm workers forced to labor
against their will. A victim does not have to be physically transported from one location to another
for the crime to fall under the definition of human trafficking (U.S. Department of State, 2013a).
Trafficking not only violates human rights but also contributes to harmful social, health, and
economic conditions for the persons who are trafficked. Persons who are trafficked can experience
intense psychological trauma, infectious disease (most notably HIV/AIDS), extensive physical
injury, drug addiction, unwanted pregnancy, and malnutrition. Human trafficking also poses a
significant public health problem.
Victim identification is the critical first step in stopping this crime. Nurses are well placed in
every community to identify trafficking victims. They also bring a public health lens to this human
rights issue, which contributes to their having a better understanding of the complexity of the issues
a survivor faces. Nurses can focus on developing and implementing a victim-centered approach.
The U.S. Department of Homeland Security Blue Campaign defines a victim-centered approach to
combating human trafficking as one that places equal value on the identification and stabilization of
victims, with the investigation and prosecution of traffickers (U.S. Department Homeland Security,
2013).
1374
Encountering the Victims of Human Trafficking
Many nurses have treated victims of human trafficking without realizing it. Encountering modernday
slavery can provoke a strong visceral response, often followed by the urge to distance oneself.
These feelings make it hard to imagine what you, one nurse, could possibly do to stop it. However,
nurses are uniquely situated to make a difference.
Nurses should ask themselves one question: “What role can nurses have in stopping human
trafficking?” (See Box 87-1.)
Box 87-1
What Can You Do About Human Trafficking?
• Be well informed. Start with investigating what policy and protocols are in place at your health
institution and if the issue of human trafficking is being addressed in the nursing curriculum in
courses at your university or college.
• If there are no policies in place, start an interdisciplinary task force to develop policies and pursue
a plan to implement them.
• Assess and educate community stakeholders, such as shelters, victim-assistance agencies,
advocacy groups, and law enforcement agencies, and collaborate with them.
• Become familiar with services and hotlines so that you can refer people who have been trafficked.
Build a resource list, and keep it current. Access to reporting at the national level includes the
National Human Trafficking Resource Center (NHTRC). The NHTRC is a national, toll-free
hotline that operates 24 hours a day, 7 days a week, 365 days a year. The NHTRC can be reached
by calling 1-888-3737-888 or text BeFree (233733).
• Bring the issue of human trafficking to the public’s attention in their local communities through
public speaking in schools, places of worship, and social action groups. Use both traditional
media and social media to launch campaigns and increase pressure on local authorities to act to
stop human trafficking.
1375
Advancing Policy in the Workplace
Does your place of employment have a policy on nursing’s role in human trafficking? Does it have
an action plan or protocol to follow when a person who is trafficked is identified? Networks of
health care providers, law enforcement, lawyers, and nongovernmental organizations are
developing evidence-based multisectored policies and protocols on how to proceed when a person
has been identified as being trafficked. If your place of work does not have a policy, you can take
the lead and get this process in motion to ensure that people who have been trafficked are given
proper care, treated with respect, protected from harm, and directed to social and legal services.
Resources that can provide support to develop a protocol are the Polaris Project (2014), which offers
training and technical assistance, and the International Organization for Migration handbook on
Caring for Trafficked Persons (International Organization on Migration, 2009).
1376
Role of Professional Nursing Associations
Historically, nursing organizations have played a critical role in developing and advancing policies
on human rights issues. The International Council of Nurses’ (ICN) Code of Ethics for Nurses
position statement, Nurses and Human Rights, requires nurses to safeguard and promote human
rights (ICN, 2006a, 2006b). This statement as well as other ICN advocacy and lobbying position
statements cover a wide range of health issues where nurses must act to enforce human rights and
to promote and protect health as a fundamental human right and a social goal (ICN, 2010).
In 2008, the New York State Nurses Association (NYSNA) invited me to deliver an address
entitled Nurses Working to Stop Human Trafficking at their annual convention. The NYSNA board’s
response was immediate. They drafted and submitted an action proposal on human trafficking to
the American Nurses Association (ANA), which was passed by the ANA House of Delegates in
2008. The resolution states that it will advocate legislation to reduce the incidence of human
trafficking and will work to ensure that nurses know how to identify and assist victims. This is a
commendable action by the ANA to educate nurses nationally and support stronger enforcement of
the federal laws (American Nurses Association [ANA], 2008).
Investigate to see whether your state nurses’ association and specialty nursing association has a
position statement on nurses’ role in human trafficking. You can be the person who takes the lead
on this initiative if nothing exists to date. A good place to start would be to identify one or two state
nurses’ associations that have already developed a policy and ask for guidance from them on
strategy and language for your state nurses’ association.
1377
Advocating for State Legislation and Policy on Human
Trafficking
Nurses can become part of a national network of health providers and advocacy groups challenging
the lack of services available to victims of human trafficking by advocating for the allocation of
resources on both the federal level and state level to address this void. They can also use their
influence and leadership to advocate for better enforcement of existing antitrafficking laws in their
state.
In 2000, the federal law Victims of Trafficking and Violence Protection Act (TVPA) was enacted,
making human trafficking a federal crime. The TVPA includes a provision that each state could
pass their own legislation to strengthen the work of the federal government and coordinate a
partnership with local and federal law enforcement. The Federal Bureau of Investigation (FBI) and
agents of Immigration and Customs Enforcement (ICE), a division under Homeland Security, are
the main federal agencies involved in investigating human trafficking cases. Because states are
enacting legislation and strengthening laws to prosecute traffickers and training law enforcement,
we have an increase in investigating human trafficking. To date, not every one of the 50 states has
done so. The website of the Center for Women Policy Studies (2014), an advocacy organization,
provides an interactive map to learn about individual states and their statutes on human trafficking.
If your state has legislation and an interagency antitrafficking task force working on a
comprehensive plan to provide services for persons who have been trafficked, ask if there is a nurse
on the task force. Once identified, ask how you can help. If there is no nurse on the task force, work
toward getting a nurse appointed, or nominate yourself. If your state is one of the remaining states
without antitrafficking laws, identify local and national advocacy organizations working toward
this goal and work with them to pass this legislation. Contact and engage your state nurses’
association to lobby to pass these comprehensive laws.
1378
Advancing Policy Through Media and Technology
The media, both traditional media and digital media, is the single most powerful tool to educate,
effect social change, and influence policies. Like most Americans, nurses’ knowledge about human
trafficking has been shaped by the media. A study by researchers Johnston, Friedman, and Scaefer
(2012) evaluated print and broadcast media reports on human trafficking beginning in 2008 through
2012. They found that stories on the crime of sex trafficking dominated the coverage, while stories
of survivors or the impact on public policy were less common. Dramatization of human trafficking
appears more frequently in story lines on popular crime series on television and in movie plots in
theaters. The news media have been the primary source of national policy and legislative issues
about human trafficking.
Coverage of the issue about the health of the victims and the public health implications of human
trafficking has been missing. A recent study on the dominant issues covered in the media on the
issue of sex trafficking reported that only 1% of the news coverage addressed the issue of public
health. When nurses become educated on the health implications of human trafficking they can
become resources for the media’s coverage on trafficking and shape the public’s understanding of
human trafficking beyond the issue that it is a crime. When the public is aware of the indicators of
human trafficking and whom to contact if they see such indicators, victims can more readily be
identified and helped.
Technologies are now being used for antitrafficking efforts. The Global Human Trafficking
Hotline Network shares and analyzes data from hotlines to find and help victims and identify
trafficking locations. One of them, the National Human Trafficking Resource Center (NHTRC) in
the United States, answers calls from anywhere in the country and has started accepting text
messages. Texting can be a safer form of connecting with victims and those seeking to report
suspected human trafficking activities. When a text is received, a live, trained specialist receives the
text and responds immediately. Texting provides secrecy that phone lines cannot provide if the
person reporting feels threatened by others near them (Polaris Project, 2014).
1379
Trafficking as a Global Public Health Issue
There are more than 13 million nurses worldwide providing up to 80% of the health services in
most countries (ICN, 2010). In every community where a nurse provides care, there are people who
are vulnerable and could be targeted by traffickers. For nurses, trafficking in persons can be best
understood as a very serious health risk, because trafficking, like other forms of violence, is
associated with physical and psychological harm (International Organization on Migration, 2009). It
has serious public health implications related to the spread of infectious diseases such as
tuberculosis, HIV, and other sexually transmitted infections. Victims of trafficking are highly prone
to social, economic, and legal issues that further put them at risk for a variety of mental health
issues, including substance abuse, addiction, posttraumatic stress disorder, anxiety, depression, and
even suicide (Hynes & Raymond, 2002). Common abuses experienced by trafficked persons include
rape, torture, and other forms of physical, sexual, and psychological violence (Zimmerman et al.,
2008). Paradoxically, these victims who desperately require health services are less likely to have
access as a result of discrimination, social stigma, fear of law enforcement, and other factors. Nurses
can contribute their expertise by conducting research on human trafficking as a global public health
issue.
Nurses are also at risk for being trafficked. As poorer nations prepare nurses for export to other
countries, questionable recruiting practices have led some migrating nurses to be threatened with
criminal charges and deportation when they object to exploitative working conditions. Raising
nurses’ awareness about human trafficking can lower their own risk.
1380
The World of the Victims
Without recruiters and criminals, human trafficking would not exist. Poverty, unemployment,
economic collapse, war, natural disasters, and the lack of a promising future are compelling factors
that facilitate the ease with which traffickers recruit people, but they are not the cause of trafficking.
Traffickers take advantage of poverty, unemployment, and the desire to emigrate to recruit people
and traffic them into dangerous situations. Tragically, recruiters often know their victims. A
common way that many victims are recruited is through a friend or acquaintance (e.g., a cousin,
neighbor, or boyfriend) or by an individual recommended to them by someone they trusted.
Finally, traffickers can be anyone. Traffickers brazenly operate in our neighborhoods. They
advertise in our newspapers and on Craigslist. They are men and women of all ages. They run legal
employment agencies. They are diplomats who often get diplomatic immunity when caught, and
they work in all types of professions (General Accounting Office [GAO], 2008). They act alone or
they may be members of international crime rings (Table 87-1).
TABLE 87-1
Myths and Facts of Human Trafficking
The U.S. Department of Homeland Security’s antitrafficking plan, called the Blue
Campaign, provides a list of six myths and misconceptions about human trafficking:
Myth #1
Human trafficking does not occur in the United States. It only happens in other
countries.
Fact
Human trafficking exists in every country, including the United States. It exists
nationwide, in cities, suburbs, and rural towns, and possibly in your own community.
Myth #2
Human trafficking victims are only foreign-born individuals and those who are poor.
Fact
Human trafficking victims can be any age, race, gender, or nationality: young children,
teenagers, women, men, runaways, U.S. citizens, and foreign-born individuals. They
may come from all socioeconomic groups.
Myth #3
Human trafficking is only sex trafficking.
Fact
You may have heard about sex trafficking, but forced labor is also a significant and
prevalent type of human trafficking. Victims are found in legitimate and illegitimate
labor industries, including sweatshops, massage parlors, agriculture, restaurants,
hotels, and domestic services. Note that sex trafficking and forced labor are both forms
of human trafficking, involving exploitation of a person.
Myth #4
Individuals must be forced or coerced into commercial sex acts to be a victim of human
trafficking.
Fact
According to U.S. federal law, any minor under the age of 18 years who is induced to
perform commercial sex acts is a victim of human trafficking, regardless of whether he
or she is forced or coerced.
Myth #5
Human trafficking and human smuggling are the same.
Fact
Human trafficking is not the same as smuggling. “Trafficking” is exploitation-based
and does not require movement across borders. “Smuggling” is movement-based and
involves moving a person across a country’s border with that person’s consent, in
violation of immigration laws.
Although human smuggling is very different from human trafficking, human
1381
smuggling can turn into trafficking if the smuggler uses force, fraud, or coercion to hold
people against their will for the purposes of labor or sexual exploitation. Under federal
law, every minor induced to engage in commercial sex is a victim of human trafficking.
Myth #6
All human trafficking victims attempt to seek help when in public.
Fact
Human trafficking is often a hidden crime. Victims may be afraid to come forward and
get help; they may be forced or coerced through threats or violence; they may fear
retribution from traffickers, including danger to their families; and they may not be in
possession or have control of their identification documents.
Retrieved from www.dhs.gov/blue-campaign/myths-misconceptions.
1382
International Policy
The first international statement to use the term human rights was the Universal Declaration of
Human Rights (UDHR), adopted by the United Nations General Assembly in Paris in 1948. The
UDHR states that human rights are rights inherent to all human beings, whatever our nationality,
place of residence, sex, national or ethnic origin, color, religion, language, or any other status.
Among several protections covered by the UDHR, Article 4 of the UDHR states: “No one shall be
held in slavery or servitude: slavery and the slave trade shall be prohibited in all their forms.” The
UDHR made history and is used by human rights activists globally (General Assembly of the
United Nations, 1948).
The first international legal instrument to address human trafficking as a crime and to define
trafficking was passed in 2000, when the United Nations Office on Drugs and Crime (2000) passed
the Protocol to Prevent, Suppress, and Punish Trafficking in Persons. As of 2009, 136 Member States
have signed the Protocol. It defines trafficking in persons as follows:
The recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or
use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or
of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the
consent of a person having control over another person, for the purpose of exploitation. Exploitation
shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual
exploitation, forced labor or services, slavery or practices similar to slavery, servitude or the removal
of organs. (United Nations, 2000)
This International Protocol established the standard approach for governments developing
policies on trafficking: the 3P Paradigm—prevention, prosecution, and protection of victims.
In 2007, the United Nations Global Initiative to Fight Human Trafficking (UN.GIFT) was
established to coordinate global efforts to adopt the Protocol. In addition to working with
governments, the UN.GIFT works with businesses, academia, civil society, and the media to
develop effective tools to fight human trafficking (United Nations Office on Drugs and Crime
[UNODC], 2009).
1383
U.S. Response to Human Trafficking
The U.S. Department of State began monitoring trafficking in persons in 1994, when the issue began
to be covered in the Department’s Annual Country Reports on Human Rights Practices. During the
Clinton administration, the United States passed the TVPA of 2000. This Act established the
standard for federal policy on trafficking, and responses to the Act were all based on the 3P
Paradigm.
More recently, advocacy organizations globally are launching campaigns that focus on the
demand side of slavery as a means of stopping this crime. These laws would take the focus off the
women and children in prostitution and put it on the end user or customer. Another demandreduction
strategy is an education and awareness campaign that is aimed at boys and young men
and focuses on the negative consequences of purchasing sex: from public and private health
problems such as the spread of HIV and other sexually transmitted infections to the grim facts
about who runs the sex trade and how customers are helping traffickers flourish and hurting those
who have been trafficked.
The 2013 Trafficking in Persons (TIP) report (U.S. Department of State, 2013b) outlines major
forms of human trafficking including forced labor, bonded labor, debt bondage among migrant
laborers, involuntary domestic servitude, forced child labor, child soldiers, sex trafficking, and child
sex trafficking and related abuses. The 2013 report focuses on victim identification as a top priority
in the global movement to combat trafficking in persons. It details training and techniques that
make identification efforts successful, and areas that need further focus such as culturally sensitive
health services for all victims and better understanding in identifying boys, men, and lesbian, gay,
bisexual, and transgender people who are trafficked. The 2013 TIP report stated that 47,000 victims
of human trafficking were identified globally in 2013, a small percentage of the estimated 27 million
women, men, and children being trafficked at any time. Global convictions of human traffickers
increased by almost 20% from 2012 with 4746 convictions in 2013.
In January 2014, the White House released the 5-year federal strategic action plan Coordination,
Collaboration, Capacity: Federal Strategic Action Plan on Services for Victims of Human Trafficking
in the United States, 2013-2017. The Plan is a collaborative project involving 15 agencies across the
federal government and nonprofits. This strategic plan includes significant input from survivors of
trafficking. Development of the Plan was a collaborative, multiphase effort across a number of
federal agencies, led by co-chairs from the U.S. Departments of Justice, Health and Human Services,
and Homeland Security.
The Plan outlines a strategic coordinated effort with specific goals, objectives, and action items to
better identify and provide services to victims of trafficking in the United States.
1384
Conclusion
Although there is much work that needs to be done to understand and end human trafficking, great
progress has been made since 2000. The international community has taken decisive action to end
human trafficking. Greater research related to trafficking is a prerequisite for ending the abuse.
Lack of data and failure to grasp the complexities that underlie human trafficking worldwide must
be addressed. The media treatment of trafficking does not present the true dimensions of the
problem, and we should work toward better reporting to help shatter the myths about human
trafficking. Nongovernment agencies and advocacy groups dedicated to creating public awareness
campaigns and developing victim services programs should be supported by volunteering your
nursing expertise, time, and resources. Whether nurses are engaged in clinical care, advocacy,
policy, or program activities, they can monitor human trafficking and have an impact on preventing
it. Most activists agree that to stop human trafficking, global awareness of the problem must
increase. Nurses can add their voices through advocacy and help build the global capacity needed
to stop human trafficking.
1385
Discussion Questions
1. There is a clear need to develop, implement, and evaluate high-quality education and training
programs that focus on human trafficking for nurses and other health care providers. How can you
contribute to this unmet need?
2. What skills do you already have as a nurse when it comes to working with a patient who has
experienced violence and trauma that can inform your work going forward advancing the health
care needs of people who have been victims of human trafficking?
3. Consider researching a current news item on human trafficking and conduct a media analysis of
how human trafficking is reported. Is this news item a blame narrative? Is the language sensitive to
the victim or exploitive? Does it provide a health lens or public health lens? If not, consider a
response pointing these issues out with a letter to the editor. Be sure to identify yourself as a
registered nurse.
1386
References
American Nurses Association [ANA]. RN delegates to ANA biennial meeting take action to work
toward greater nurse retention, address public health issues. [Retrieved from]
www.nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/2010-
PR/ANAs-Delegates-Take-Action.pdf; 2008.
Center for Women Policy Studies. U.S. policy advocacy to combat trafficking (US PACT). Center
for Women Policy Studies: Washington, DC; 2014 [Retrieved from]
www.centerwomenpolicy.org/programs/trafficking/default.asp.
General Accounting Office [GAO]. Human rights: U.S. government’s efforts to address alleged
abuse of household workers by foreign diplomats with immunity could be strengthened. [Retrieved
from] www.gao.gov/new.items/d08892.pdf; 2008.
General Assembly of the United Nations. Universal declaration of human rights. [Retrieved from]
www.un.org/en/documents/udhr; 1948.
Hynes P, Raymond JG. Put in harm’s way: The neglected health consequences of sex
trafficking in the United States. Stillman J, Bhattacharjee A. Policing the national body: Sex,
race and criminalization. South End Press: Cambridge, MA; 2002.
International Council of Nurses [ICN]. ICN code of ethics for nurses. [Retrieved from]
www.icn.ch/images/stories/documents/about/icncode_english.pdf; 2006.
International Council of Nurses [ICN]. Nurses and human rights. [Retrieved from]
www.icn.ch/images/stories/documents/publications/position_state
ments/C06_Nurse_Retention_Migration.pdf; 2006.
International Council of Nurses [ICN]. About ICN. [Retrieved from] www.icn.ch/abouticn/
about-icn; 2010.
International Organization on Migration. Caring for trafficked persons. International
Organization for Migration: Geneva, Switzerland; 2009 [Retrieved from]
http://publications.iom.int/bookstore/free/CT_Handbook.pdf.
Johnston A, Friedman B, Shafer A. News framing of the problem of sex trafficking: Whose
problem? What remedy? Feminist Media Studies. 2012 [Retrieved from]
dx.doi.org/10.1080/14680777.2012.740492.
Polaris Project. Tools for service providers and law enforcement. [Retrieved from]
www.polarisproject.org/resources/tools-for-service-providers-and-law-enforcement; 2014.
United Nations [UN]. Protocol to prevent, suppress, and punish trafficking in persons, especially
women and children, supplementing the United Nations Convention Against Transnational
Organized Crime. [Retrieved from]
www.uncjin.org/Documents/Conventions/dcatoc/final_documents_
2/convention_%20traff_eng.pdf; 2000.
United Nations Office on Drugs and Crime [UNODC]. Global report on trafficking in persons.
[Retrieved from] www.unodc.org/documents/human-trafficking/Global_Report_on_TIP.pdf; 2009.
U.S. Department Homeland Security. Blue campaign. [Retrieved from] www.dhs.gov/bluecampaign/
about-blue-campaign; 2013.
U.S. Department of State. Trafficking in persons report. [Retrieved from]
www.state.gov/documents/organization/210737.pdf; 2013.
U.S. Department of State. Federal strategic action plan on services for victims of human trafficking in
the United States 2013–2017. [Retrieved from]
www.state.gov/documents/organization/210737.pdf; 2013.
Victims of Trafficking and Violence Protection Act [TVPA] of 2000, 22 U.S.C. § 7102(8).
Zimmerman C, Hossain M, Yun K, Gajdadziev V, Guzun N. The health of trafficked women:
A survey of women entering post trafficking services in Europe. American Journal of Public
Health. 2008;98(1):55–59.
1387
Online Resources
General HEAL Trafficking Listserv.
HEAL Trafficking.
Health Professional Education, Advocacy, Linkage.
Because Human Trafficking is a Health Issue.
The purpose of the HEAL Trafficking Listserv is to discuss issues at the intersection of health
and human trafficking. Although we recognize the value of learning about the breadth of
antitrafficking efforts, please reserve nonhealth-related conversations for another forum.
Please do not solicit funding on this Listserv and at no time discuss any protected health
information, including identity, about any potential victim.
[To post to this group, send an e-mail to] human-trafficking-and-health-care@googlegroups.com.
[Visit this group at] groups.google.com/group/human-trafficking-and-health-care.
[For more options, visit] groups.google.com/d/optout.
ECPAT USA.
www.ecpatusa.org/home.
Polaris Project.
www.polarisproject.org.
U.S. Department of State Office to Monitor and Combat Human Trafficking.
www.state.gov/j/tip.
.
1388