II. Definition
- Human Trafficking
- Persons forced or coerced into exploitation (e.g. Forced Labor, Sexual Slavery, Organ Trafficking)
III. Epidemiology
- Affects more than 27 Million persons annually worldwide ($10-30 Billion global industry)
- U.N. estimates up to 20% of Kidney donors were coerced into organ donation via black market
- Affects at least 17,000 Immigrants brought to the United States annually
- Affects U.S. residents who are coerced into Forced Labor or Sexual Slavery (87% are <25 years old)
- Adult women: 46%
- Minor Girls: 21%
- Adult Males: 21%
- Minor Boys: 12%
- Shandro (2016) Ann Emerg Med 68(4): 501-8 [PubMed]
IV. Risk Factors
- Highest risk
- Physical, sexual or emotional abuse
- Runaway, Homelessness or living in shelter
- From 10-50% report survival sex to obtain food, shelter, drugs or money
- Other risk factors
- Foster Care children
- Juvenile justice system offenders
- Disabled patients
- American Indian and Alaskan Native
- Decreased english proficiency
- LGBT patients (Lesbian, gay, bisexual, Transgender)
- Poverty
- Low education
- Substance Abuse or Chemical Dependency
- Delayed presentations for Prenatal Care
V. Precautions
- Victims of Human Trafficking are most likely to be seen in health care, especially emergency departments
- Emergency Departments offer a unique opportunity for identifying and assisting Human Trafficking victims
- From 30 to 80% of Human Trafficking victims are seen at medical facilities
- Red Flags
- Companion (trafficker, may be male or female, and may truly be a close relative)
- Speaks on behalf of the patient (may be dominant, controlling)
- Does not wish to be separated from the patient
- Acts as Interpreter for patient
- Completes medical paperwork for the patient
- Patient
- Does not have identification (often confiscated by traffickers)
- History may be vague or inconsistent
- Language barriers may be present (use an official Medical Interpreter)
- May have multiple sex partners or prior arrests for prostitution
- Mental illness and Substance Abuse may be comorbid
- Depressed mood
- Anxiety Disorder
- Low self esteem
- Does not know local area, their home address, directions home
- May claim they just moved to area or just visiting
- Companion (trafficker, may be male or female, and may truly be a close relative)
VI. History
- See HEADSS Screening (for adolescent and young adult history)
- Approach (Trauma informed care, with pearls from WHO)
- Build rapport with the patient and establish trust
- Treat in honest and nonjudgemental manner (empathy, not pity)
- Patient may not see themselves as a victim (and may resent the implication)
- Help patient feel that they are in a safe environment
- Recognize that patients may have coping mechanisms with maladaptive behaviors and difficult encounters
- Sit at eye level with patient
- Be aware of body language
- Avoid interrupting patient
- Avoid making un-keepable promises
- Avoid playing the role of friend or surrigate parent
- Avoid using technical words or derogatory terms (e.g. hooker)
- Disclose any mandatory reporting requirements when conducting interview
- Interview the patient without companions present (most important single measure)
- Obtain an independent, official Medical Interpreter
- May separate patient from companion during exam or diagnostics, or while companion completes forms
- Start with open ended questions and avoid leading questions
- Establish true age of patient (under age 16 or under age 18?)
- Crowded living and sleeping conditions?
- Adequate nutrition?
- Who are companions and do you trust them?
- Forced to work or have sex?
- Common presentations
- Vague presenting complaints
- Inconsistent medical history
- Recurrent Sexually Transmitted Infections or Pelvic Inflammatory Disease
- Recurrent Urinary Tract Infections
- Unwanted Pregnancy
- Dyspareunia
- Mental health conditions
- Other associated conditions
VII. Signs
-
General
- See Nonaccidental Trauma for signs of abuse (e.g. ligatures, Bruising, burns, bites, scars)
- Signs of injury not consistent with history
- Malnourished or dehydrated
- Poor Dentition
- Growth retardation or Developmental Delay in children
- Tattoos that function as a traffickers brand of ownership (may include numbers, letters)
- Retained material in vagina such as cotton sponges (used to hide Menses)
- Vaginal Trauma
- Inappropriate Dress
- Signs of drug use, Substance Abuse or Intoxication
- Affect and behavior
- May be irritable, anxious, aggressive
- May have flat affect, detached or make poor eye contact
- May fear involving law enforcement
- May have self-inflicted injuries (e.g. cutting)
VIII. Management
- Stabilize acute medical conditions and address the chief compliant
- Patient must give permission to proceed with each step of the evaluation
- Evaluation of Child Abuse or Child Sexual Abuse should follow local protocols (including reporting)
- Staff chaperone or victim advocate should acompany the patient
-
Sexual Assault (see SANE Nurse below)
- Perform Sexually Transmitted Infection testing (HIV, Hepatitis B, Syphilis)
- Offer Emergency Contraception
- Offer Post-exposure Prophylaxis (GC, Chlamydia, Trichomonas, HIV PEP, Hepatitis B)
-
Consultation
- National Human Trafficking Hotline (see below)
- Clinicians should consider calling for practical advice in suspected trafficking cases
- Hospital Security
- Notify early regarding concerns for safety of both the patient and staff
- Forensic nurses (SANE nurses) Indications (urgent evaluation in Emergency Department)
- See Sexual Assault
- Acute Sexual Assault within prior 120 hours
- Sexually Transmitted Infection symptoms or other medically urgent complaints
- Anogenital Trauma or other suspicious injuries requiring forensic documentation
- Child with mental health or safety concerns
-
Medical Interpreter
- Allows a detailed, reliable careful history
- Avoid translation by companions
- Survivor-centered protocols
- Social workers
- Crisis organizations
- Shelters
- Law enforcement
- Mental health and Chemical Dependency treatment
- National Human Trafficking Hotline (see below)
- Legal concerns
- Follow mandatory reporting protocols (e.g. Child Abuse)
- If not mandated by law, patient has the right to refuse law enforcement and other notification
- Undocumented Immigrants may obtain T Visa (trafficking Visa) in some cases
- Allows trafficking victims to safely remain in U.S. legally
- Several laws protect victims of Human Trafficking
- https://polarisproject.org/current-federal-laws
- Trafficking Victims Protection Act (TVPA)
- Justice for Victims of Trafficking Act (JVTA)
- Child Abuse Prevention and Treatment Act (CAPTA)
- Preventing Sex Trafficking and Strengthening Families Act
- Follow mandatory reporting protocols (e.g. Child Abuse)
- Documentation
- Document suspected Human Trafficking and related findings
- Follow-up
- Often difficult if continues under control of human trafficker
- Scheduling follow-up will increase contact and build rapport
- Consider hospital admission for serious illness or injury that requires close follow-up
- Reevaluate in 2 weeks for pregnancy, Sexually Transmitted Infection, injuries
IX. Resources
- National Human Trafficking Hotline
- https://humantraffickinghotline.org/
- Phone: 1-888-373-7888
- Text "HELP" to 233733 (BeFree)
- Online website also has a chat
- Polaris Project
- Wikipedia
- TraffickFree
- U.S. Laws on Human Trafficking (U.S. State Department)
X. References
- Jhun, Weinstock and Flores in Herbert (2015) EM:Rap 15(7): 7
- Roszcynialski, Irvine and Walter (2018) Crit Dec Emerg Med 32(12): 3-10
- Swadron, Weinstock, Downing and Kaiser in Herbert (2015) EM:Rap 15(7): 8-9
- Becker (2015) Pediatr Emerg Care 31(2): 144-7 [PubMed]
- Patel (2010) West J Emerg Med 11(5): 402-4 [PubMed]
- Suniega (2022) Am Fam Physician 105(5): 521-8 [PubMed]