Human Trafficking

Aka: Human Trafficking, Human Sex Trafficking, Sex Trafficking, Forced Labor, Sexual Slavery, Slavery, Organ Trafficking

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II. Definition

  1. Human Trafficking
    1. Persons forced or coerced into exploitation (e.g. Forced Labor, Sexual Slavery, Organ Trafficking)
  2. Sex Trafficking (U.S. Law definition)
    1. Recruitment, harboring, transportation, provision, obtaining, patronizing or soliciting a person
    2. Purpose of commercial sex in which the act is induced by force, fraud or coercion, or age <18

III. Epidemiology

  1. Affects more than 27 Million persons annually worldwide ($10-30 Billion global industry)
  2. U.N. estimates up to 20% of Kidney donors were coerced into organ donation via black market
  3. Affects at least 17,000 Immigrants brought to the United States annually
  4. Affects U.S. residents who are coerced into Forced Labor or Sexual Slavery (87% are <25 years old)
    1. Adult women: 46%
    2. Minor Girls: 21%
    3. Adult Males: 21%
    4. Minor Boys: 12%
    5. Shandro (2016) Ann Emerg Med 68(4): 501-8 [PubMed]
  5. Human Sex Trafficking
    1. Worldwide: 4.8 Million in 2016
    2. Women or girls account for 84% of sex traffickining victims
    3. Age <18 years in 79% of cases

IV. Risk Factors

  1. Highest risk
    1. Physical, sexual or emotional abuse
    2. Runaway, Homelessness or living in shelter
      1. From 10-50% report survival sex to obtain food, shelter, drugs or money
  2. Other risk factors
    1. Foster Care children
    2. Juvenile justice system offenders
    3. Disabled patients
    4. American Indian and Alaskan Native
    5. Decreased english proficiency
    6. LGBT patients (Lesbian, gay, bisexual, Transgender)
    7. Poverty
    8. Low education
    9. Substance Abuse
    10. HIstory physical, sexual or emotional abuse
    11. Substance Abuse or Chemical Dependency
    12. Delayed presentations for Prenatal Care

V. Precautions

  1. Victims of Human Trafficking are most likely to be seen in health care, especially emergency departments
  2. Emergency Departments offer a unique opportunity for identifying and assisting Human Trafficking victims
    1. From 30 to 80% of Human Trafficking victims are seen at medical facilities
  3. Red Flags
    1. Companion (trafficker, may be male or female, and may truly be a close relative)
      1. Speaks on behalf of the patient (may be dominant, controlling)
      2. Does not wish to be separated from the patient
      3. Acts as Interpreter for patient
      4. Completes medical paperwork for the patient
    2. Patient
      1. Does not have identification (often confiscated by traffickers)
      2. History may be vague or inconsistent
      3. Language barriers may be present (use an official Medical Interpreter)
      4. May have multiple sex partners or prior arrests for prostitution
      5. Mental illness and Substance Abuse may be comorbid
        1. Depressed mood
        2. Anxiety Disorder
        3. Low self esteem
      6. Does not know local area, their home address, directions home
        1. May claim they just moved to area or just visiting

VI. History: General

  1. See HEADSS Screening (for adolescent and young adult history)
  2. Approach (Trauma informed care, with pearls from WHO)
    1. Build rapport with the patient and establish trust
    2. Treat in honest and nonjudgemental manner (empathy, not pity)
    3. Patient may not see themselves as a victim (and may resent the implication)
    4. Help patient feel that they are in a safe environment
    5. Recognize that patients may have coping mechanisms with maladaptive behaviors and difficult encounters
    6. Sit at eye level with patient
    7. Be aware of body language
    8. Avoid interrupting patient
    9. Avoid making un-keepable promises
    10. Avoid playing the role of friend or surrigate parent
    11. Avoid using technical words or derogatory terms (e.g. hooker)
    12. Disclose any mandatory reporting requirements when conducting interview
  3. Common presentations
    1. Vague presenting complaints
    2. Inconsistent medical history
    3. Recurrent Sexually Transmitted Infections or Pelvic Inflammatory Disease
    4. Recurrent Urinary Tract Infections
    5. Unwanted Pregnancy
    6. Dyspareunia
    7. Multiple Somatic Complaints (e.g. Headache, Abdominal Pain)
  4. Mental health conditions
    1. Anxiety Disorder
    2. Major Depression
    3. Post-Traumatic Stress Disorder
    4. Self Injury
    5. Substance Use Disorder
  5. Other associated conditions
    1. HIV Infection
    2. Hepatitis B
    3. Hepatitis C

VII. History: Specific Interview

  1. General
    1. Interview the patient without companions present (most important single measure)
    2. Obtain an independent, official Medical Interpreter
    3. May separate patient from companion during exam or diagnostics, or while companion completes forms
    4. Establish true age of patient (under age 16 or under age 18?)
  2. Start with open ended questions and avoid leading questions
    1. Tell me about a typical work day and what you do?
    2. Are you able to keep your whole paycheck?
    3. Would anything or anyone prevent you from changing jobs?
    4. Crowded living and sleeping conditions?
    5. Do you sleep in a bed, a cot or on the floor?
    6. Who do you live with?
    7. Can you come and go from your home as you wish?
    8. Do you have enough to eat?
    9. Where do your parents live and how often do you see or speak with them?
  3. Later, more direct questions
    1. Who are companions and do you trust them?
    2. Does anyone deprive you of food or water?
    3. Are you allowed to eat, sleep or use the bathroom without asking permission?
    4. Are there locks on the doors and windows that prevent you from exiting your home?
    5. Is anyone forcing you to do something that you do not want to do?
    6. Does anyone harm you (e.g. yell, hit or force sex)?
    7. Are you forced to work or have sex?

VIII. Signs

  1. General
    1. See Nonaccidental Trauma for signs of abuse (e.g. ligatures, Bruising, burns, bites, scars)
    2. Signs of injury not consistent with history
    3. Malnourished or dehydrated
    4. Poor Dentition
    5. Growth retardation or Developmental Delay in children
    6. Tattoos that function as a traffickers brand of ownership
      1. May include numbers and letters
      2. May be located in atypical sites (e.g. within hair line, underarm or inner thigh)
    7. Retained material in vagina such as cotton sponges (used to hide Menses)
    8. Vaginal Trauma
    9. Inappropriate Dress
    10. Signs of drug use, Substance Abuse or Intoxication
    11. Exposure-related (e.g. sex, IV drugs) chronic disease (e.g. HIV Infection, endocarditis)
    12. Poorly controlled chronic disease (e.g. Asthma, Diabetes Mellitus)
  2. Affect and behavior
    1. Patient is often seen as "difficult"
    2. May be irritable, anxious, aggressive
    3. May have flat affect, detached or make poor eye contact
    4. May fear involving law enforcement
    5. May have self-inflicted injuries (e.g. cutting)

IX. Management

  1. Stabilize acute medical conditions and address the chief compliant
    1. Consider hospital observation or admission for more serious illnesses or injuries and concerns for unreliable follow-up
  2. Involve the healthcare team when suspicious for Human Trafficking
    1. Maintain confidentiality
    2. Alert others caring for the patient (nurses, ERTs), to be alert for unusual companion interactions or abuse signs
    3. Safety of the patient and staff are paramount
      1. Situation can escalate dangerously if companion or patient becomes uncomfortable with the evaluation
  3. Patient must give permission to proceed with each step of the evaluation
    1. Evaluation of Child Abuse or Child Sexual Abuse should follow local protocols (including reporting)
    2. Law enforcement cannot be contacted without an adult victims consent unless there is imminent danger
      1. Exceptions include vulnerable adults and those without decision making capacity
      2. Calling 911 is not the correct approach when managing a suspected trafficking victim outside imminent danger
        1. Best early guidance may be obtained with National Human Trafficking Hotline (see below)
  4. Staff chaperone or victim advocate should acompany the patient
  5. Sexual Assault (see SANE Nurse below)
    1. Perform Sexually Transmitted Infection testing (HIV, Hepatitis B, Syphilis)
    2. Offer Emergency Contraception
    3. Offer Post-exposure Prophylaxis (GC, Chlamydia, Trichomonas, HIV PEP, Hepatitis B)
  6. Emergency behavioral health assessment (Emergency Department)
    1. Evaluate patients with Suicidality or severe uncontrolled mental health (Psychosis, Mood Disorders, PTSD, chemical use)
    2. Extended, nuanced interview by a mental health provider may help confirm a suspected case of trafficking
  7. Consultation
    1. National Human Trafficking Hotline (see below)
      1. Clinicians should consider calling for practical advice in suspected trafficking cases
    2. Hospital Security
      1. Notify early regarding concerns for safety of both the patient and staff
    3. Forensic nurses (SANE nurses) Indications (urgent evaluation in Emergency Department)
      1. See Sexual Assault
      2. Acute Sexual Assault within prior 120 hours
      3. Sexually Transmitted Infection symptoms or other medically urgent complaints
      4. Anogenital Trauma or other suspicious injuries requiring forensic documentation
      5. Child with mental health or safety concerns
    4. Medical Interpreter
      1. Allows a detailed, reliable careful history
      2. Avoid translation by companions
    5. Survivor-centered protocols and Safety Plans
      1. Social workers
      2. Crisis organizations
      3. Shelters
      4. Law enforcement
      5. Mental health and Chemical Dependency treatment
  8. Legal concerns
    1. Patients should be made aware of U.S. and local laws
      1. Mandatory reporting criteria (e.g. Child Abuse, vulnerable adult)
      2. Local laws regarding prostitution (some states offer safe harbor laws, others may even arrest minors)
    2. Follow mandatory reporting protocols (e.g. Child Abuse)
      1. If not mandated by law, patient has the right to refuse law enforcement and other notification
    3. Undocumented Immigrants may obtain T Visa (trafficking Visa) in some cases
      1. Allows trafficking victims to safely remain in U.S. legally
    4. Several laws protect victims of Human Trafficking
      1. https://polarisproject.org/current-federal-laws
      2. Trafficking Victims Protection Act (TVPA)
      3. Justice for Victims of Trafficking Act (JVTA)
      4. Child Abuse Prevention and Treatment Act (CAPTA)
      5. Preventing Sex Trafficking and Strengthening Families Act
  9. Medical Documentation
    1. Document suspected Human Trafficking and related findings
  10. Follow-up
    1. Often difficult if continues under control of human trafficker
    2. Scheduling follow-up will increase contact and build rapport
    3. Consider hospital admission for serious illness or injury that requires close follow-up
    4. Reevaluate in 2 weeks for pregnancy, Sexually Transmitted Infection, injuries

X. Resources

  1. National Human Trafficking Hotline
    1. https://humantraffickinghotline.org/
    2. Phone: 1-888-373-7888
    3. Text "HELP" to 233733 (BeFree)
    4. Online website also has a chat
    5. Excellent first point of contact (and available 24/7)
  2. Stop, Observe, Ask, and Respond (SOAR) to Health and Wellness training program
    1. https://www.acf.hhs.gov/otip/training/soar-health-and-wellness-training
  3. Polaris Project
    1. http://www.polarisproject.org
  4. Wikipedia
    1. https://en.wikipedia.org/wiki/Human_trafficking
  5. TraffickFree
    1. https://www.traffickfree.com/
  6. U.S. Laws on Human Trafficking (U.S. State Department)
    1. https://www.state.gov/j/tip/laws/
  7. Toolkit to Combat Trafficking in Persons (UN Office Drugs and Crime, 2006)
    1. https://www.unodc.org/documents/human-trafficking/HT-toolkit-en.pdf
  8. Interviewing Labor Trafficking Victims (U.S. DOJ)
    1. https://portal.cops.usdoj.gov/resourcecenter/content.ashx/cops-w0922-pub.pdf

XI. References

  1. Jhun, Weinstock and Flores in Herbert (2015) EM:Rap 15(7): 7
  2. Roszcynialski, Irvine and Walter (2018) Crit Dec Emerg Med 32(12): 3-10
  3. Roszcynialski and Brown (2024) Crit Dec Emerg Med 38(2): 24-31
  4. Swadron, Weinstock, Downing and Kaiser in Herbert (2015) EM:Rap 15(7): 8-9
  5. Becker (2015) Pediatr Emerg Care 31(2): 144-7 [PubMed]
  6. Patel (2010) West J Emerg Med 11(5): 402-4 [PubMed]
  7. Suniega (2022) Am Fam Physician 105(5): 521-8 [PubMed]

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