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 old². 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 borders³. 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 programs⁴. 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 labor¹. 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 HT⁵. 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 healthcare, it is vitally important for emergency medicine physicians to identify those at a high risk for trafficking and understanding 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 care². 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:
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.
Approved January 2019