Human Trafficking: Identification and Treatment Tools for the Emergency Physician

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Authors: Maryam Hockley, MD MPH, Erin Hartnett, BS BA, Gregory Jasani, MD

Human trafficking (HT) affects over 21 million people worldwide¹, with 600,000-800,000 persons being trafficked annually across international borders, approximately half of whom are younger than 18 years old.² Closer to home, roughly 18,000-20,000 trafficking victims are brought into the United States every year, and this number does not count victims already within our borders.³ Its victims are not confined to a certain age, race, gender, sexual orientation, or socioeconomic level, and it is this level of pervasiveness that makes signs of HT difficult to identify. Vulnerable populations include those in the child welfare and juvenile justice systems, runaway and homeless youth, unaccompanied children, American Indians/Alaska Natives, migrant laborers including undocumented workers and temporary workers on visas, foreign national domestic workers in diplomatic homes, those with limited English proficiency and low literacy, disabled peoples, LGBTI, and those in court-ordered substance use programs.⁴ The International Labor Office estimates that 44% of all HT victims worldwide had migrated either within or across international borders prior to being put into forced labor.¹ The nature of human trafficking often leads to both physical and emotional harm for the victims, as it relies upon the coercion of a person into such an exploited role. As a result, an article by emDocs estimates that as many as 88% of victims will seek medical care during the time that they are being trafficked, oftentimes in an emergency department. However, their studies have also shown that as few as 5% of emergency medicine providers feel comfortable identifying and treating victims of HT.⁵ This unique encounter, however, offers emergency medicine physicians an invaluable opportunity to intervene in these victims’ lives. Improving this statistic represents a crucial opportunity to increase awareness and understanding of the potential role we can play in these patients’ lives.

As one of the primary contact persons for their health care, it is vitally important for emergency medicine physicians to identify those at a high risk for trafficking and understand the appropriate steps to take to intervene. Physicians Against the Trafficking of Humans (PATH), an organization within the American Medical Women’s Association (AMWA), offers a structured approach to identifying and caring for victims of trafficking called Stand Up to Sex Trafficking: Awareness, Implementation, and Networking (SUSTAIN).⁶ From this training, we learn that the first step is to pick up on subtle cues victims may give. Red flags during the history taking can include: high numbers of sexual partners, multiple sexually transmitted infections, prior abuse or self-harm, homelessness, or repeated ER visits with lack of follow-up. Physical exam findings can include: tattoos such as barcodes or other symbols of one’s ownership, scars, gynecologic injuries that seem out of proportion for age or medical history, and lack of prenatal care.² When in the room with your patient, be aware of their social history, including an unclear living situation as well as those that are in the room at the time of the encounter. Never assume an elder is their parent. Ask how they are related to the patient, and if a clear answer is not given, be on alert. Always ask everyone besides the patient to step out so you can speak to your patient privately. This can be a difficult part of the overall encounter, as this individual may insist on staying. Remind yourself that you are the physician and you can control the situation and realize that the patient should not be asked if they would like this person to stay as they will likely say yes out of fear of retribution. Once in a private setting, it is paramount to this conversation to allow the patient to feel like they have control and that their hospital room is a non-judgmental space. Questions to ask at this stage would be where they live and if they feel safe, and do they work and sleep in the same place. Administering a domestic violence screen would be appropriate, as well as asking outright if they have ever been forced to have sex in return for necessities for living. A crucial aspect to this very sensitive conversation is giving them the space to share as much or as little as they wish, and that includes asking probing questions like “Do you feel up to telling me what happened?” or “It would be helpful to us if you are willing to tell us what happened, but it is up to you and we understand if it is too difficult to talk about it,” as these statements shift the control back to the patient and reaffirms their autonomy.

A 12-step approach provided by SUSTAIN⁶ for when you suspect a patient is being trafficked:

1. Get the patient alone and comfortable. Tell other parties that they need to step out of the room for your examination.
2. Disclose mandated reporting obligations. Let them know that what is discussed is subject to confidentiality, unless they disclose thoughts of self-harm or harming others, in which you legally must report this to law enforcement for both their safety and the safety of others.
3. Inquire about immediate needs and safety. Ask where they live and if they feel safe there. Assess if living and sleeping occur in the same place.
4. Ask only for need-to-know information without judgement. Ask probing questions only when necessary to understand their situation, but maintain their control and let them know they only have to share if they feel comfortable doing so.
5. Listen to body language, especially during the physical exam. Stop when they don’t feel comfortable, especially during a GYN exam. During a GYN exam, consider standing to the side of the patient when possible instead of between their legs, as this may make the exam less traumatizing for victims.
6. Ask the patient if they feel safe during the encounter.
7. Ask direct questions sensitively. Remind them that they have control.
8. Provide resources:
1. HELP line: 888-3737-888. Tell them ways they can memorize this number or write it down/save it somewhere discreet, such as in the sole of their shoe or save it in their phone under a different name.
9. Obtain follow-up information. How can you reach them with test results? Ask for an email or two phone numbers for people important in their lives that both you and the patient can trust.
1. Often, they will have phone numbers that change constantly, so a phone may or may not be the best method for contact.
10. Give them a follow-up appointment in written form. They can show this to their pimp or whoever is trafficking them as proof that they will need to return for a legitimate medical reason. Traffickers know that in order to be profitable this person needs to be in good health, so this will make face-to-face follow-up more likely.
11. Involve Social Work services. They can assist with providing resources and are invaluable to the holistic care of these patients.
12. For all patients under 18-years-old, disclosure and notification of law enforcement is mandatory. For adult victims, disclosure is their choice. Should they choose to report, ask them about how they would prefer to disclose their situation to the proper resources and authorities. Actively empowering victims in the process gives them back some control. Victims often lack control in their lives, so they may be more likely to choose to disclose if they feel they have some autonomy. Additionally, involving them in decisions important to them is a positive way to begin their journey out of “the life” should they choose to pursue that.

Understanding what to look for in a patient encounter and how to address the situation with tact and careful assessment can help connect these patients to the proper resources necessary for their unique needs. Paramount to this approach is meeting them where they’re at and allowing them to have control of their lives when, for so long, they had none. Walking this path with them at their own pace and comfort level is one of the first steps to empowering them and ourselves to address this often-ignored epidemic.

To learn more about what impact you can have on human trafficking, visit https://www.amwa-doc.org/path-events/ for upcoming SUSTAIN training events.

References

1. Profits and poverty: The economics of forced labor. Special Action Program to Combat Forced Labor. Fundamental Principles and Rights at Work Branch. International Labor Office. http://www.ilo.org/wcmsp5/groups/public/—ed_norm/—declaration/documents/publication/wcms_243027.pdfhttp://www.ilo.org/wcmsp5/groups/public/—ed_norm/—declaration/documents/publication/wcms_243027.pdf
2. Clawson, H.J., Dutch, N., Solomon, A., Grace, L.G. (2009). Human Trafficking Into and Within the United States: A Review of the Literature. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation.
   a. https://aspe.hhs.gov/system/files/pdf/75891/index.pdf 
3. U.S. Department of State. (2003). Trafficking Victims Protection Act of 2000: Trafficking in persons report. Washington, D.C. Office of the Under Secretary for Global Affairs. https://www.state.gov/documents/organization/21555.pdf 
4. U.S. Department of State. (2018). Trafficking Victims Protection Act of 2000: Trafficking in persons report. Washington, D.C. Office of the Under Secretary for Civilian Security, Democracy, and Human Rights. https://www.state.gov/documents/organization/282798.pdf
5. Findlay S, Runde D, Buresh C. Human Trafficking in ED: Pearls and Pitfalls. Dec 2016. http://www.emdocs.net/human-trafficking-ed-pearls-pitfalls/
6. Stand Up to Sex Trafficking: Awareness, Implementation, and Networking (SUSTAIN) training provided by AMWA-PATH.