Welcome, and thanks for choosing this online learning session, Child Labor Trafficking, Essentials for the Pediatric Forensic Nurse. In this session, we will discuss child labor trafficking in terms of definitions, epidemiology, history, risk factors, consequences, identification of child labor trafficking and implications for practice. The session will conclude with an interactive case study. My name is Gail Horner. I'm a forensic nursing specialist with the International Association of Forensic Nurses, where I get to support the practice of forensic nursing nationally and also on a global basis. Prior to joining IFN, I worked as a pediatric nurse practitioner in a hospital-based child advocacy center, and also coordinated a team of pediatric sexual assault nurse examiners in a pediatric emergency department. Welcome to this session. I have no conflicts of interest to disclose. Here are our learning outcomes for this session. We will be defining child labor trafficking, describing limitations to the ability to quantify child labor trafficking victims in the United States. We will describe risk factors for entry into child labor trafficking. We will also discuss potential consequences from child labor trafficking victimization, and finally, explore practice implications related to the identification of an intervention for child labor trafficking victims in the clinical setting. Sex trafficking, especially child sex trafficking, has received significant lay and professional attention. However, few efforts have focused on learning more about youth experiencing labor trafficking in the United States. We know that human trafficking is a form of modern-day slavery and it is a significant pediatric healthcare problem. Although the exact number of child labor trafficking victims in the United States is difficult to quantify, we do have some numbers of youth affected. According to the International Labor Organization, globally, there are over five million child victims of labor trafficking. Forensic nurses will likely encounter victims in their practice. Having a basic understanding of child labor trafficking will aid in the timely identification and appropriate intervention for victims. The basic understanding of terms is necessary to further understand child labor trafficking. Let's explore this a bit more. The Trafficking Victims Protection Act of 2000 was the first federal legislation to address human trafficking, both sex and labor trafficking in a comprehensive manner. One important distinction to understand, so the Trafficking Victims Protection Act defines both labor trafficking and child labor trafficking, and child sex trafficking. One important distinction to understand is that when considering child sex trafficking, the use of force, fraud, or coercion is not required. However, with child labor trafficking, you see that the definition involves the trafficking of persons who are 18 years of age or younger, but it requires force, fraud, and or coercion. The difference between child sex trafficking and labor trafficking may be because children can legally work in the United States under certain stipulations, yet they cannot consent to involvement in a commercial sex act. It's important to note that a child can be a victim of labor trafficking and sex trafficking simultaneously, such as working in a nail salon to pay off a debt with job duties requiring having sex with clients. Some further definitions that are important to understand. What's force, fraud, and coercion? Force is the use of physical restraint or harming a victim. Fraud can be defined as intentionally deceiving victims regarding certain aspects of their employment such as their work hours, their pay, their job tasks, or their work conditions. Coercion involves threatening physical or mental harm to victims or their loved ones. It can be threats of abuse of the legal system such as deportation. Question 1. Which of the acts described is an example of the use of force? A, stating that a teen will be given protective equipment to protect from injury on the job, when in fact they are not given the equipment. B, physically shoving a youth into a truck, driving them to a job site and not letting them leave. Or C, stating that if the teen does not complete the job tasks, his family will be deported. B is the correct answer. B is an example of the use of force. A is an example of fraud, and C is an example of coercion. So voluntary servitude is defined as an individual forced through some sort of coercion to work for another person. Peonage or debt bondage involves the pledge of a person's labor or services to pay off a debt. Traffickers set the amount to be repaid, and often the amount is high and changes quite frequently. An individual can pledge the labor of another person under their control, such as a parent can pledge the labor of a child. Victims are never able to pay their way out of debt. The assessment of the monetary value of the labor is not reasonable, nor is it applied toward the payment of the debt. Question number two. What is not an example of debt bondage? A, 13-year-old female takes a job cleaning at a massage parlor and then discovers job duties include having sex with patrons. B, 14-year-old male is working at an egg farm 14 hours a day, six days a week to repay his transport to the United States. C, father of a 12-year-old girl arranges to have her work in the nail salon 16 hours a day, seven days a week to pay off his gambling debt. The correct answer is A. A is not an example of debt bondage. A is an example of labor trafficking and sex trafficking occurring simultaneously. The 13-year-old was not aware that job duties included sex with patrons. She was deceived. And examples B and C are examples of debt bondage. So state law defines legal child employment. State law defines the legal age of a child to work, the hours and specifics for child employment in that state. Now let's take a look at child labor, child labor exploitation, and child labor trafficking. Child labor can involve a child under the legal working age working or can involve a child engaging in illegal work and or work that causes potential harm to their health, development, or education. Child labor exploitation occurs when a child is working legally yet denied basic legal rights such as fair pay. There is no force, fraud, or coercion in child labor or child labor exploitation. Child labor trafficking, on the other hand, involves many aspects of child labor and child labor exploitation but is only child labor trafficking if force, fraud, or coercion is involved. Question number three, a 13-year-old male is working at a construction site alongside his father. He works 12 hours a day, six days a week for one year. Housing and food for the workers are provided at the site. Earnings are placed toward their debt. The debt is often high and often changing. And the debt is for the family's transportation to this country. Father and son agreed with this arrangement prior to transportation to this country. They were told that they would not be able to come to the U.S. without this arrangement. Is this child labor trafficking? Yes or no? The correct answer is yes. This is a classic example of adult and child labor trafficking. Child labor trafficking occurs in a variety of settings in the United States, especially in informal employment settings. Small businesses, organized crime, gangs, and even families may exploit victims. Although many child labor trafficking victims in the United States are foreign nationals, American-born youth are also at risk. American-born youth are primarily exploited in two industries, door-to-door sales and drug trafficking. In a study of American-born homeless youth in 10 cities, the most common form of child labor trafficking was that of forced drug trafficking with 81% of the youth reporting involvement in child labor trafficking via forced drug trafficking. And when talking about drug trafficking as a form of child labor trafficking, consider this. Youth reported feeling psychologically coerced into drug dealing and physically threatened to continue dealing. They may have been coerced by their families or experienced cultural coercion, 38% reported that. 50% reported gang involvement, and that is how they got involved with drug trafficking. The following factors related to gang involvement describe force and coercion equivalent to meeting the definition for child labor trafficking. Gang initiation is typically at a very young age. There was threat of violence involved with exiting the gang. When talking about commission-based sales, which is also a venue by which American-born youth are targeted for child labor trafficking, in commission-based sales, traffickers running the sales crews target economically disadvantaged youth. They promised them a fun job, travel, and high pay. In reality, the youth are working very long hours, oftentimes from early morning into the evening. They're in a new city, new neighborhood. They do not know where they are. They are experiencing unreasonable sales quotas, so that high pay isn't occurring. There's confiscation of their pay due to not meeting the unreasonably high sales quotas, and there may be verbal or physical abuse. Two, the youth are helpless and dependent because they're separated from their families and familiar surroundings. Other industries target foreign-born children. Children work in agriculture to harvest crops and care for livestock as part of the migrant and seasonal workforce. They work for long hours for little to no pay, most often alongside their parents. Work is seasonal, and families live very transient lives. Children also work as domestic workers, providing services in the home. They may work for one or more families, and they may live in the home with their employer. They work very long hours with little to no pay and no opportunity for schooling. Foreign-born children in the U.S. also may be exploited within the health and beauty industry. Undocumented immigrants and foreign-born nationals on temporary work visas are very vulnerable to these forms of child labor trafficking, and oftentimes force, fraud, and coercion are involved. Now let's take a look at the epidemiology of child labor trafficking. So over 5 million victims of child labor trafficking exist globally, and this map kind of denotes countries, divides countries into kind of three categories. Recruitment countries. These are the orange and red shades on the map that supply the victims for child labor trafficking. These are third-world countries where there's corruption and political arrest and poverty. And then there are destination countries, and these are the green countries on the map. These are first-world countries, and there's a demand for victims, countries like the United States, Japan, and Germany. And then there are bidirectional countries, which both supply and demand victims of child labor trafficking. There are many reasons that contribute to making a single estimate of child labor trafficking victims difficult. Trafficking is a covert business. Traffickers tend to guard their victims closely and or isolate them to the workplace. Victims are reluctant to disclose. They may fear physical harm or even deportation, and this makes the victim reluctant to disclose to healthcare providers, law enforcement, or child protective services. And oftentimes the victim does not think of themselves as a victim. They feel like they are responsible for their choices. There also is a discrepancy in definitions and beliefs regarding child labor trafficking, and this makes the scope of the problem difficult to define. Migrant child labor trafficking victims may be labeled as illegal immigrants instead of child trafficking victims. For its deficits in healthcare, child protective services, and law enforcement, identification of victims. However, data does exist that may provide some insight into the scope of the problem of child labor trafficking. In 2015, 16% of the calls to the National Human Trafficking Hotline involved child labor trafficking. And then Cochlear in 2019 conducted a study regarding 2013 tips and 82 potential victims in a Midwestern city. These calls were made to a social service agency in the city. And you'll see that labor trafficking victims, 7% were less than 18 years of age. And the majority, the vast majority, 95% of those victims were foreign born. When looking at sex trafficking victims, 23% were less than 18 years of age. And over half, 59% were U.S. born. Then when we look at the Bureau of Justice statistics report, we see that there are many more cases of child sex trafficking compared to child labor trafficking. And then there was a study of homeless youth in New Orleans. So 99 homeless youth in New Orleans were interviewed regarding their human trafficking experiences. 11% reported sex trafficking, 5% reported labor trafficking. Four of the five youth who reported labor trafficking had been forced to sell drugs. All reported entry into drug trafficking by their teens, with nine being the youngest age at which they were recruited into drug trafficking. Numbers suggest that child sex trafficking is more prevalent than child labor trafficking. However, the extent of child labor trafficking may be masked by current deficits in identification. The United States has a long history of exploiting children for labor. Child labor trafficking is not only a modern day American problem. Indentured servitude was a system of bonded labor where a worker was under contract to an employer for a fixed period of time in exchange for their transportation to the United States, food, clothing, and other necessities once they arrived. From the early 1600s to the early 1900s, a large number of people, both adults and children from Europe, came to the United States under a system of indentured servitude. The atrocity of slavery began in the mid-1600s. Black Africans were brought to the United States to work in fields and homes, first as indentured servants, and then that evolved into slavery. Children and their families were property of their owners. Children or their parents could be sold, resulting in separation from each other. Children could be beaten, starved, raped, and they were generally not allowed to be educated. This atrocity continued until 1865. The early 18th century brought along another example of the exploitation of children for labor, the practice of padrones in the United States, and this involved men, typically immigrants or first-generation Americans, lured young boys mostly from Italy, but also from Greece, China, Japan, and Mexico with promises of a good life in America. So these boys worked for the profit of the padrone. They had no education, no life skills training. They were stranded in a foreign country with no family, and they risked physical harm if they did not work. The early 20th century brought about legislation to address the child labor problem in the United States. This was in the form of the Keating-Owen Child Labor Act. It, however, was quickly repealed. However, this act did ban the interstate sale of products of child labor and said that factories shouldn't employ children less than 14 years of age. Mines children should not employ children less than 16 years of age. However, as I stated, this act was repealed quickly. So it really wasn't until 1938 that in the United States, we began to address the problem of child labor. So the Fair Labor Standards Act was passed in 1938, which was a federal law defining minimum wage, record keeping, overtime pay, and child labor in the United States. This law stated that children must be 14 years of age to work in nearly all industries except agriculture. It defined the number of hours per week a child could work. And in agriculture, a child could be less than 14 years of age. There was no limit to the number of hours. However, the work had to be performed outside of school hours. The 2000s have brought about increased prosecution of child labor trafficking perpetrators. The following cases are illustrations of this. U.S. v. Botella involved over 40 Mexican nationals, including children, recruited to work on a farm in New York State. They were forced into debt bondage with deplorable work and living conditions. And then the U.S. v. Ibram occurred in California, where a man and his wife were prosecuted due to the fact that they purchased a 10-year-old Egyptian girl for housework. She cooked, cleaned, provided child care without pay, experienced verbal and physical abuse. She was denied access to school and to religion. And then U.S. v. Afalabi in 2009. 20 girls between the ages of 10 to 19 years of age were forced to work at a hair braiding and nail salons in New Jersey, 14 hours a day, seven days a week for no pay. Child labor trafficking victims come from diverse ethnic and demographic backgrounds, and a shared profile of a labor trafficking victim is not existent. However, certain populations have increased vulnerability. Although most children and youth trafficked for sex within the United States are American-born, depending on the industry and circumstance, both U.S.-born and foreign-born youth are vulnerable to child labor trafficking. Both boys and girls are at risk for labor trafficking, but boys may be more likely to experience labor trafficking than sex trafficking. Children from impoverished backgrounds are also at increased risk for child labor trafficking. LGBTQ youth are at increased risk because they are at increased risk to have conflict and strife at home with their parents and to face being not accepted by their parents and perhaps to be also thrown out of the home by their parents, making them homeless. Homeless runaway youth are at increased risk due to needing money to meet their basic needs. Childhood trauma exposure also increases vulnerability for entry into child labor trafficking, really any form of child trauma exposure, including child maltreatment, but also factors that decrease a parent's ability to parent, such as domestic violence, drug and alcohol concerns for the parent, parent mental health issues. Hopper and Gonzalez in 2018, in a sample of human trafficking survivors, found that 65% of child sex trafficking victims endorsed a history of child maltreatment versus 18% of child labor trafficking victims. A thorough psychosocial assessment is important when concerns for child labor trafficking arise. Youth who are not United States citizens can be especially vulnerable to labor trafficking. Foreign children traveling to the U.S. alone or with parents are at increased risk, as well as undocumented migrant youth and other children of foreigners. These youth come to America to escape poverty or violence in their countries of origin. They have a strong desire to support themselves and their families, and this makes them vulnerable to child labor trafficking. They have this dream, this love of their family. They're coming to the U.S. escaping poverty and violence. They're going to work hard, but in reality, they experience manipulation, debt, fear, and they're trapped in the cycle of child labor trafficking. These youth are far from home, often do not speak the language, and have no understanding of basic human rights, making them extremely vulnerable to labor trafficking. Their dream of America is much different than their reality. Similar circumstances contribute to gang-associated youth. The gang is like a family. They are loyal. A trauma bond is formed, but these youth also experience fears, including abuse at home, violence by the gang, shame, and isolation. Child labor trafficking victims experience significant physical and psychological trauma. The trauma these youth experience is complex. Child labor trafficking victims are dependent on the trafficker for food, shelter, and basic existence, and despite inhumane treatment at the hands of their trafficker, cognitive distortions form where victims develop positive, thankful feelings for their trafficker. Victims are simultaneously fearful of and grateful to their trafficker for their survival. Trauma bonding is defined as the invisible, strong, emotional tie that develops between two individuals despite one person frequently beating, threatening, abusing, harassing, or intimidating the other. So victims are emotionally and physically dependent on their traffickers, making it difficult to leave, and leaving the situation is often times non-linear. The victim will leave and come back and then leave again. Child labor trafficking can result in a variety of negative physical and psychological health consequences. They can experience physical assault, physical injuries, work-related injuries. They may be sexually assaulted or also this victim of sex trafficking while being a victim of labor trafficking. Chronic malnutrition. There's a chronic lack of health care and so often times when child labor trafficking victims present for care, their injuries or their symptoms have progressed. They often work in unsafe environments which place them at increased risk for preventable work-related injuries. There are also mental health consequences that can occur from being a victim of child labor trafficking. What does this mean for us as forensic nurses? Forensic nurses are uniquely positioned to both identify potential victims of child labor trafficking and intervene appropriately. The goal of the health care encounter is not to force the individual into disclosing and then rescuing them. Rather, the goal is to provide health care, assess risk, educate, and offer resources. Being there for the patient and meeting their most immediate needs. Trauma-informed care is a method of caring for trauma-exposed individuals that acknowledge the presence of trauma symptoms and its effects on the lives of victims. Trauma-informed care emphasizes the need for all pediatric health care providers to recognize the effects of violence and trauma on an individual's health, behavior, and development. Safety is paramount to trauma-informed care. Create a safe place to discuss trafficking concerns. As the patient may be accompanied by the trafficker or an associate of the trafficker and threatened with harm if they disclose information about their situation, find a place to talk with the patient privately. If language barrier exists, obtain a professional interpreter. Assess potential safety risks of asking sensitive questions. Be transparent. Let the individual know that if they disclose information that is concerning for their safety that you may need to involve other community agencies and empower the individual. Allow them the choice to talk about what they feel comfortable talking about. Understanding possible physical and mental health consequences and red flags are crucial in identifying potential victims. Here you see some child labor trafficking red flags. These are some examples of screening questions for child labor trafficking. Rapport building is crucial and how you ask something is probably more important than what you ask. However, knowledge of basic screening questions to ask when concerns arise for possible child labor trafficking can assist the forensic nurse to decide when it is appropriate to involve other members of the healthcare team and multidisciplinary team. Always utilize principles of trauma-informed care. Here's some examples of some screening questions. Here are some examples of screening questions for child sex trafficking. Regardless of the answer to the screening questions, a thorough history and physical exam is indicated. Child labor trafficking victims may experience physical trauma as a result of physical assault or abuse or work-related injuries. Forensic nurses should be particularly concerned if the physical injury is inconsistent with the history provided by the patient. So thorough history and physical is crucial. Care of potential child labor trafficking victims requires thorough assessment of their safety. If screening interview and or physical exam reveals concerns for child labor trafficking, trafficking, physical abuse or assault, or sexual abuse or assault, or if the screening questions or history and physical raises safety concerns for a minor, a report to child protective services and law enforcement is crucial. Child protective services and law enforcement investigations result in protective measures for youth at risk for labor trafficking as well as prosecution of traffickers. The Child Trafficking Resource Center, and the number in the hotline website is listed there, can provide immediate information regarding local resources available to victims within the United States. So what can we do as forensic nurses? Spearhead efforts in your institutions to develop human trafficking protocols that are comprehensive, trauma-informed, and multidisciplinary to assist in the identification and management of child labor trafficking and child sex trafficking victims within your institution. A multidisciplinary healthcare team working seamlessly with a multidisciplinary community team involving child protective services, law enforcement, local advocacy agencies, legal and judicial services is necessary to meet the complex needs of child labor trafficking victims. Forensic nurses possess the passion, knowledge, and skills to play a pivotal role in the elimination of child labor trafficking. We can make a difference. Now let's work through a case study. Jose presents with burns to the palmar surface of both hands. Jose is 14 years old. He is Spanish speaking. He is accompanied by a middle-aged man who is fluent in Spanish and English. The man identifies himself as Jose's sponsor. He states his church, The Way of Jesus, sponsors Hispanic youth in America and provides them with on-the-job training and a place to live. The sponsor has Jose's passport and also hands you Jose's passport. Sponsor states that they were having a bonfire at the job site this evening to celebrate and Jose accidentally burned his hands. Is Jose a victim of child labor trafficking? A, yes. B, no. C, we're not sure. What do you think? The correct answer is C. We're not really sure yet if Jose is a victim of child labor trafficking. We know that the scenario is curious and we have some concerns regarding Jose's welfare, but we are not quite sure exactly what is going on yet. The burns appear to be non-acute. Remember, the history given was that the burns occurred this evening and they're infected. Jose's sponsor is resistant to leaving the bedside when asked to do so. The sponsor is resistant to the use of a professional interpreter, states that Jose will be more comfortable with him. Jose is reluctant to engage in conversation even with the interpreter assisting. What do you think now? Should we be more concerned about the possibility of child labor trafficking? What raises concerns for possible labor trafficking? A, delay in seeking healthcare. B, accompanied by a controlling co-worker. C, co-worker insists on staying at the bedside. D, Jose's reluctance to engage. E, all of the above. The correct answer is E, all of the above. All of these are concerning for child labor trafficking. Is Jose a victim of child labor trafficking? A, yes. B, no. C, not sure. Correct answer is C. We are still not sure about Jose, but we are definitely concerned. What is the ultimate goal of the healthcare encounter? A, obtain a disclosure of child labor trafficking and rescue Jose. B, provide healthcare, assess risk for trafficking, and provide education and resources. Correct answer is B. Our goal is to provide healthcare for Jose and assess for his safety and welfare. You separate Jose from his sponsor. You alert hospital security and other MDT members of your concerns. You ask Jose, would he rather talk with you or the social worker about what is going on with him? You use the interpreter. Jose is reluctant to engage in conversation. However, you let Jose know that he is the boss of his life, and it is his choice if he answers your questions or not. You inform Jose that you are concerned about his safety and you just want to make sure that he is okay. You let him know that if he tells you things that make you think he is not safe, that you will need to let others know about your concerns, such as child protective services and law enforcement, and that these other agencies can help make sure that he is safe. What element or elements of trauma-informed care did you utilize? Choose all that apply. A, safety, B, choice, C, empowerment, D, transparency, trustworthiness, F, all of the above. The correct answer is F, all of the above. You demonstrated concern for Jose's safety. You provided him the choice of whether or not he felt comfortable talking about his situation. You gave him the power in his life. You were transparent with Jose, letting him know that if he shared information that raised concerns for his safety, you would need to involve other agencies that could ensure his safety. So Jose states regarding the burns to his hands that they happened about a week ago while he was on the job. He was roofing a house. He was using hot tar on the roof and he lost his gloves and he was denied another pair of gloves. Think of the promises that Jose was made. He and his father signed a contract in Guatemala for Jose to work at the construction company for six months in exchange for transportation and official papers to the United States. After six months, he would be paid enough money to pay for his family to come to the United States. He was told he would work five days a week for eight hours a day. He was also told he would go to school the other two days a week. He was told he would get a nice place to live and good food to eat. He was told money would be sent every week to his family in Guatemala. However, Jose's reality was much different. He worked six days a week, 12 hours a day. He lives in a tumbledown shed. He now has to work for the company for one year to pay back his transportation. His family has not received any money. His employer has his passport. He is afraid his employer will kill him or his family if he does not do what he is told. Is Jose a victim of child labor trafficking? A, yes. B, no. C, not sure. The answer is A, yes. Jose is indeed a victim of child labor trafficking. Is a report to Child Protective Services and law enforcement indicated? A, yes. B, no. The correct answer is A, yes. Jose is a minor. He's only 14 years old and being exploited and neglected by his caregiver, his sponsor slash trafficker. A report to Child Protective Services and law enforcement is indeed indicated. Well, if you have any questions about this presentation regarding child labor trafficking, please shoot me an email and I will be more than glad to answer your questions. Here are the partial list of references and a complete list is available upon request. And I just want to say thank you for choosing this online learning session.

child labor trafficking

definitions

epidemiology

risk factors

identification

trauma-informed care

forensic nurses

case study

history

implications for practice

forensic nursing specialist