Confronting Human Trafficking

Human trafficking generates an estimated $33.9 billion worldwide and is the 3rd largest source of income for organized crime. According to the 2017 US Department of State Trafficking in Persons Report, there were 100,409 victims identified across the globe in 2017, which has more than doubled since 2014.3 In the United States there were 8,524 confirmed cases of human trafficking in 2017, and the numbers are climbing every year.

Despite these growing numbers, it is estimated that less than 1% of victims have been identified due to difficulty obtaining accurate surveillance data. Human trafficking can be further categorized into sex trafficking and labor trafficking. Sex trafficking is the recruitment, harboring, transportation, provision, or obtaining of a person for a commercial sex act, in which commercial sex is induced by force, fraud, or coercion, or in which the person induced to perform such an act is below 18 years of age. Labor trafficking is any means of obtaining a person for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.The majority of human trafficking victims are women who are subjected to sex trafficking and domestic work.

Risk factors for human trafficking include poverty, lack of education, undocumented immigrant status, marginalized populations such as LGBTQ, personal history of abuse, and an unstable family home. The states with the highest reported cases of human trafficking are California, followed by Texas and Florida.

According to a study, 87% of sex trafficking survivors received medical care at some point during their trafficking. Of these, the most common healthcare setting was the emergency department.

Unfortunately only 10% of physicians recognize human trafficking victims and a mere 3% of emergency physicians receive training on human trafficking.
Trafficking can also be confused with overlapping crimes like domestic violence, drug addiction, sexual assault, and prostitution.
It is imperative that healthcare professionals receive training on the identification and treatment of victims of human trafficking, along with how to provide a trauma-informed approach to care.

BARRIERS TO DISCLOSURE

There are numerous barriers that prevent victims from disclosing their situation. Fear of arrest or deportation, fear of retaliation by the trafficker, distrust of authority figures, prior negative experiences with seeking for help, and re-traumatization when asked repeatedly to disclose the details of their abuse are just a few. Many victims are being tracked via GPS on their phone by the trafficker and simply don’t feel safe. Others truly believe that they are willingly complying with the abuse (referred to as trauma bonding) and don’t realize they are being trafficked, that safe alternatives exist, or that they have legal rights. Illegal immigrants in particular are at increased risk due to multiple risk factors.

PROVIDING TRAUMA INFORMED CARE

Understanding the trauma patients have experienced is fundamental to providing a victimcentered approach to care. Providers need to understand that by the time they encounter survivors they have already been threatened with violence from traffickers, buyers, and/or employers. They have suffered the consequences of prior attempts at seeking help. They have been subjugated to repeated victimization on a daily basis and doing nothing may have been self-protective. As one victim shares, “It is important for anyone working with victims of commercial sexual exploitation to realize that this population is very reluctant to reveal anything personal…to adults, especially in professional positions…Many victims have been in circumstances where adults have consistently let them down.” After understanding their trauma experience and barriers to disclosure, providers may provide the emotional safety needed to offer help. The first step of providing trauma informed care is attending to the basic needs of the patient. If they are cold or wet, offer a change of clothes and a warm blanket. If they’re hungry, offer them food. Reassure the potential survivor and build trust and rapport. It is of utmost importance that the provider be conscious of his/her language. For example, asking “what happened to you?” as opposed to “what’s wrong with you?” Do not act shocked or disgusted when the patient discloses information. These patients are the most sensitive to power dynamics. Sit at their level and do not force disclosure of their situation. Victims are known to “test” the healthcare setting by making several visits before deciding if it would be safe to ask for help. In addition, be sensitive if patients do not want to file a police report as many have a warrant out for their arrest. Above all, avoid re-traumatization caused by recounting their abuse experiences.

GENERAL INDICATORS OF HUMAN TRAFFICKING

If you’re not looking for human trafficking, you’re going to miss it!

Patients will often provide a scripted or inconsistent history. It is not uncommon for the paramedics to provide a concerning history and the patient deny it altogether. This behavior grants the patient control over the process. Patients are often fearful, avoid eye contact, or may come off as hostile. It is safer to get angry at the advocate than the abuser. They may not know their home address, nor the current date or time. Victims often do not have possession of their personal identification and are not in control of their own money.

INDICATORS OF SEX TRAFFICKING

Victims of sex trafficking frequent the emergency department. They come in Baker Acted for overdose attempt, have a history of multiple STIs, or come in with vague abdominal pain and depression. They may be accompanied by an older, controlling individual who speaks for them, claiming to be their “boyfriend,” “cousin,” etc. They may have tattoos or branding that say “Daddy,” “Property of…,” etc. History of multiple abortions is not uncommon. Patients often have somatization symptoms such as recurring headaches or pelvic pain.
Pay attention to signs of trauma that are inconsistent with the patient’s explanation. Unfortunately most victims of sex trafficking at some point suffer from drug abuse, depression, and suicidal ideations, which often cloud the clinical picture. Traffickers are known to recruit in drug addiction clinics.

INDICATORS OF LABOR TRAFFICKING

Patients will often appear malnourished or extremely dehydrated. Most will have poor dental hygiene, untreated skin infections, or serious injuries from exposure to harmful chemicals. Some patients will have ophthalmologic complaints due to lack of protective eye equipment. They may claim to work in “mom-and-pop” businesses, farms, factories, construction, or oil/gas extraction. Victims may carry high debt, live in crowded sleeping quarters, and sleep only in shifts.

DOCUMENTATION IN THE CHART

According to the Assistant State Attorney of the Anti-Trafficking Unit, physicians should document the following in order be pro-active:

• State who the patient is with, e.g. “Male who seems to be answering all the questions for patient, very defensive about leaving patient alone in the room with the doctor.”
• Document if the patient appears intoxicated, fearful, or disheveled.
• Include tattoos, bruising, and clothing in the documentation, as well as the scene on EMS arrival.
• It is appropriate to document statements by the patient or others around her/him

RESPONDING TO VICTIMS OF HUMAN TRAFFICKING

Institutions are encouraged to implement a human trafficking protocol in the emergency department. The National Human Trafficking Resource Center has examples of algorithms that may be used, as well as specific resources for patients. The first step is to carefully separate the victim from the trafficker. A reasonable example is to ask the patient to provide a urine sample. Next, attend to the medical, psychological, and basic (clothing, food, etc.) needs of the patient. Sit at eye level and perform a safety check by asking “Is it safe for you to talk to me right now?” Next, determine if the patient is working or has a means of income. Ask questions pertaining to their work environment. Examples include “What are your work hours? Can you come and go as you please? Do you owe money to your employer or anyone else? Do you feel safe? Where do you eat and sleep? Is anyone hurting you or threatening you? Did someone tell you what to say today?”

Questions helpful when assessing for sex trafficking:

• Do you feel safe at home? At school? With your boyfriend or spouse? With your peers?
• Is anyone hurting you, threatening you, or pressuring you to do anything you don’t want to do? Is anyone hurting or threatening your family, children, or friends?
• Is anyone forcing you to have sex with others or to perform sex acts for money, food, clothes, drugs, or a place to sleep?
• Has anyone ever taken a photo of you that made you feel uncomfortable? Was it posted on a website for classified ads?

OFFER RESCUE

Educate the patient on their rights and resources available to them. Offer assistance, but if the patient declines then respect their decision. Call the Human Trafficking Hotline at 888-3737-888 to report a possible case. Offer to place the human trafficking phone number in the patient’s shoe. It may also be provided in the follow up instructions disguised as the primary care physician office number to follow-up with. Alternatively,the patient may memorize the number.
Tell the patient that, if their “no” turns into a “yes” at any time, they can always return to the ER. If the patient needs an excuse to come back, place a follow up appointment in their discharge instructions. The goal should not be “rescuing” or gaining disclosure from the patient. The goal is to create a safe, non-judgmental space to educate the patient on their rights, options, and offer assistance.

PROTOCOL ATAVENTURA HOSPITAL

At Aventura Hospital, we developed a human trafficking protocol with three screening tools. The first screening method is based on indicators or “red flags” of trafficking. The second screening method is a question at triage that asks “Were you (or anyone you work with) ever beaten, hit, yelled at, raped, threatened, or made to feel physical pain for working slowly or for trying to leave?” The third screening method is also referred to as the “urine cup method.” Posters with educational material about human trafficking are placed in the restrooms and if patients believe they may be a potential survivor of human trafficking, they are asked to place a blue sticker on the bottom of their urine cup.

CONCLUSION

Human trafficking is an egregious criminal act and human rights violation. A majority of survivors of human trafficking access medical services at some point during their captivity. Providers everywhere, in particular those in primary care, reproductive health, mental health, and pediatrics, must be cognizant of the indicators of human trafficking, barriers to disclosure, and how to provide trauma-informed care. Emergency medicine providers are in a unique position to be a fundamental part of the solution to this global epidemic.