Concealed but Not Forgotten: Human Trafficking and the ED

Emergency physicians are in a unique position to recognize human trafficking, as the emergency department may be the first or only contact a victim has with the medical community. This is why it is important to quickly recognize signs of human trafficking, gain victims' trust, and respond appropriately to provide effective aid.

Editor's Note: Please see the companion article, Is Your Patient a Victim of Human Trafficking?

Human trafficking occurs across gender, race, age, and nationality, but primarily exploits those who are most at risk and vulnerable in our society. Due to being a world shrouded in secrecy, data collection on the magnitude and outcomes of human trafficking is scarce, however trafficking has proven to be robust in our society and should always be regarded as a possibility while working with patients in the emergency department.

Definitions

• Human trafficking: A violation of basic human rights in which an individual is controlled and forced to engage in sex work or labor by trafficker. The trafficker may coerce a victim into trafficking through physical force, fraud, threats, monetary incentives, and substance dependency.¹
• Sexual trafficking: A subset of human trafficking in which the trafficker moves and manages an individual to sell them for sex work. Commonly, the trafficker will procure and facilitate the meeting of individuals that will pay for sex work with their victims, and then benefit financially by taking some or all of the payment offered. This can occur in any setting; however, it is frequently seen in illegal brothels, escort services, massage parlors, adult clubs, and common venues with prostitution such as bars and specific intersections or roads.¹
• Labor trafficking: A subset of human trafficking in which the trafficker recruits and moves an individual to sell them into forced labor. This forced labor can include any form of domestic or commercial work, ranging from domestic work in a single household up to commercial work in large industries such as sweat shops and agricultural settings such as migrant farm work. Traffickers coerce victims into forced labor through physical punishment, fraud, debt bondage, false promises of a better life, and slavery.¹

Statistics
The prevalence of human trafficking is difficult to fully quantify, as many victims go unnoticed. In 2018, the National Human Trafficking Hotline received the most calls from California, followed by Texas and Florida. It is also estimated that 50,000 people are trafficked into the United States each year, most often from Mexico and the Philippines.¹ In 2018, 1,649 human trafficking victims were cited in criminal cases with approximately half being adult and half being children. Child-only sex trafficking encompasses 52% of cases and females make up 94% of all human trafficking victims identified. The internet was used to facilitate trafficking in 88% of the cases. It is estimated that only 0.04% of victims and survivors of human trafficking cases are identified.² Although there is no true profile of a human trafficking victim, individuals who were at one time homeless and runaway youth have been shown to make up greater than 50% of prostitutes. Foreign nationals and individuals who have experienced trauma and violence in the past are also noted to be at increased risk of exploitation through human trafficking.¹

Studies have shown that 50%-90% of human-trafficking victims have sought medical care while being trafficked.^3,4 This population suffers from increased morbidity and mortality, both while being trafficked and after surviving trafficking.³ Victims that are forced into prostitution have an increased rate of being murdered⁵ and increased overall mortality when compared to the general population.⁶ Mortality rates for victims of child- and labor-trafficking are more difficult to ascertain as these victims are often concealed by their perpetrators.

Patient Presentations
Patients may present with a wide variety of signs and symptoms that can have similarities with victims of other types of psychological and physical trauma. When considering whether a patient may be a victim of human trafficking consider the physical, behavioral and other features of their overall presentation to gain a clearer picture. If a provider observes suspicious injuries or injury patterns, overly involved companions, scripted stories, and conflicting information, it is important to consider trafficking. If a patient that is unaware of their location, city, or region, at the time of evaluation, despite being fully alert and oriented, this may be a sign that they are being trafficked between different areas against their will.⁷

Physical signs and symptoms that trafficking victims may present with can be broad and nonspecific. Reproductive health concerns, including multiple sexually transmitted infections, recurrent pregnancies, and multiple pregnancy terminations that may be against their wishes are common among human-trafficking victims.⁷ Somatization, such as headaches, abdominal pain, and pelvic pain are also signs that may be exhibited by those that are being trafficked as well as victims of sexual abuse.⁷ If a patient presents with physical injuries, it is important to consider signs of non-accidental trauma, which may include mechanisms inconsistent with the the type or degree of injury, broad and nonspecific injury patterns, multiple fractures with heterogeneous stages of healing, and cigarette burns or other burn patterns that appear intentional.⁷ Other important physical signs to evaluate are conspicuous tattoos (often used for branding), as well as signs of malnutrition and poor dentition.⁷

Behavioral signs and symptoms that victims of human trafficking may exhibit include depression or having a depressed or flat affect, anxiety, panic attacks, anger, and poor mental status.⁷ Victims may be chronically sleep-deprived or intoxicated by mind altering substances. If a patient presents in a seemingly altered mentation, it is important to further evaluate the patient’s circumstances, even if the people accompanying them claim that to be their baseline. Aggression towards the healthcare team or law enforcement, either by the patient or by someone accompanying them, may indicate a fear of repercussions or an attempt at concealment.⁷ People that are victims of human trafficking frequently experience a phenomena known as traumatic bonding, otherwise known as “Stockholm Syndrome,” through sustained abuse and infliction of trauma.¹ In these cases, with time the victim may believe their trafficker to be acting in their best interest, often identifying them as a friend or an ally. It will likely be difficult in these cases to gain the victim’s trust, as they may feel protective of their trafficker, and the trafficker might influence them to perceive those attempting to help them as threats.¹

How to Respond
Always be compassionate and empathetic. Ask yourself, "How can I create a situation in which the victim feels safe, makes his or her own choices, and feels understood?"⁸

• If possible, see the patient in a private room, and ask open-ended questions in a nonjudgmental tone and manner.
• Try to sit at or below the level of the patient; standing over them can be perceived as being threatening or intimidating.
• Use body language that can be interpreted as open and accepting.
• Offer to bring in a chaperone of the same gender as the victim for the entire interview and exam, as this may equalize any power differential the victim may perceive.

Health care should always be interdisciplinary and patient-centered, so make sure the patient is involved in every decision that is made and knows they are in control of their care. Use a medical interpreter if the patient does not speak English; this not only is the standard of care, but it also mitigates the possibility of details being lost in translation and helps the patient feel heard. Separate the victim from the trafficker if possible, but approach this cautiously as the trafficker may react with violence toward the patient or staff if they perceive a threat. It is important to remain calm and non-confrontational. Ask the suspected perpetrator to step out of the room to allow the patient to change and for the physical exam. Never confront the suspected perpetrator, regardless of their behavior. Involving your hospital’s security and law enforcement if the situation escalates is essential. Provide resources for patients, such as referrals to counseling services or social work. If your department has a domestic violence intervention team, it may be beneficial to involve them if the patient allows. Depending on the situation, offer to involve police, but do not force it as this may discourage the victim from seeking medical help in the future. Do not forget that if you suspect trafficking and your patient is a minor, mandated reporting laws likely apply; know and follow your hospital's reporting procedures and local laws.

Providers should consider asking the following questions to all patients, regardless of complaint or circumstance: "Do you feel safe at home?" "Can you leave your work if you wanted to? Have you ever been hurt or threatened?" "Do you know how to get help if you needed it?"⁷ Answers to these questions can help guide you in finding the right resources to help the patient. For the physical exam consider having a sexual assault nurse evaluation performed if indicated. Consider ordering a skeletal survey, especially in cases of non-accidental trauma. Follow evidence collection protocols for your jurisdiction and institution. If your hospital does not have these, consider developing them.

Contact the U.S. National Trafficking Hotline: 1-888-3737-888 or text 233733; this resource can help victims find the resources in their area to help them receive trauma-informed services.^{8, 9,10}

Considerations for the Emergency Physician
Learn how to identify potential victims of human trafficking and help them access the resources they need. Consider holding a departmental or residency training with social services and victim-resource agencies to learn about how they can assist in helping victims and obtaining the best patient outcomes. Learn the differences between mandatory reporting in adult and child victims in your jurisdiction. Mandated reporting laws and criteria vary somewhat by state but typically require all cases of abuse of children to be reported. Your local child and adult protective services agencies can be a resource on local mandating laws and resources. Even if the patient does not disclose they are a victim of trafficking, it is important that they feel able to return.

Take-Home Points

• Human trafficking is a human rights violation that exists on both a national and global scale. It is prevalent in every state and territory. Most trafficking victims have sought medical treatment; they can be of any socioeconomic status and any age.
• Establishing trust is of utmost importance. Every patient should be made to feel safe and heard. Even if the victim does not want to press charges or separate from their trafficker, it is important they know the ED is a safe place to turn.
• EM teams are mandatory reporters. If there is a suspected case involving the abuse or trafficking of a minor, it must be reported. Refer to your facility's protocols and local laws regarding the agencies and processes involved in reporting.

References

1. National Human Trafficking Hotline. Accessed May 7, 2020.
2. The Human Trafficking Institute. 2018 Federal Human Trafficking Report. Accessed May 9, 2020.
3. Lederer LJ, Wetzel CA. The health consequences of sex trafficking and their implications for identifying victims in healthcare settings. Ann Health Law. 2014;23:61-91.
4. Office on Trafficking in Persons. Administration for Children and Families. Accessed May 9, 2020.
5. Farley M. Risks of Prostitution: When the Person Is the Product. J Assoc Consumer Research. 2018;3(1):97-108. doi:10.1086/695670.
6. HG Legal Resources. Prostitution in the United States. Published 2020. Accessed May 19, 2020.
7. Jablow MM. Physicians Can Play a Crucial Role in Identifying Human-Trafficking Victims. AAMC. Published May 2, 2017. Accessed May 7, 2020.
8. Office for Victims of Crime Training and Technical Assistance Center. Human Trafficking Task Force e-Guide.  Accessed May 9, 2020.
9. Ahn R, Burke T, Patel RB. Human trafficking in the emergency department. West J Emerg Med. 2010;11(5):402-404. 
10. Love146. Published 2020. Accessed May 19, 2020.
11. Polaris. Published 2020. Accessed May 9, 2020.