Human Trafficking in the ED – What you need to know

Human trafficking is a devastating crime, where a human being’s labor is exploited through force, fraud, or coercion, for someone else’s profit (1). For survivors, connecting to support in the community can be incredibly difficult, and may come at the expense of their personal safety (1, 2).

The emergency department (ED) is a rare exception, with some studies estimating that over 60% of trafficked persons will present at some point during their exploitation to the ED (3). Unfortunately, less than 5% of emergency physicians report feeling confident in their ability to identify a trafficked person, citing confusion around patient characteristics and their role as a provider (4).

By learning more about human trafficking, ED providers can better prepare themselves to identify and provide appropriate support to those who experience human trafficking.

Just the Facts – Human Trafficking

What is Human Trafficking?

Human trafficking always involves 3 components –an act, a means, and a purpose.

• The “act” refers to the role a trafficker is playing in exploiting the person
• The “means” refers to the use of force, fraud, or coercion to exploit a person
• The “purpose” is what type of labor they are exploited for (1)

Often human trafficking will overlap with other crimes such as assault, domestic violence, rape, and child abuse (5). Of note, anyone under the age of 18 engaged in commercial sex is considered to be sex trafficked regardless of whether a means is present, as they cannot provide consent.

How many people are affected?

Human trafficking is widespread, but is often undetected, making true estimates of size difficult.

For example, human trafficking prevalence estimates may fail to account for survivors who do not recognize they are being exploited or are afraid to disclose (6, 7).

Who is trafficked?

While no identity is spared, there are certain populations that are at greater risk. These may include:

• People of color
• Children in welfare and juvenile justice systems
• Runaway and homeless youth
• Children working in agriculture
• Indigenous patients
• Migrant laborers
• Foreign national domestic workers
• Patients with limited English
• Patients with disabilities
• Members of the LGBTQ community
• Patients with limited education
• Patients who use substances (6,8)

Why are they targeted?

The only thing all trafficked persons have in common is their vulnerability (1). Trafficking determinants can be conceptualized as “push” and “pull” factors. Push factors lead people to away from their current situation to trafficking (e.g., abuse, poverty, family conflict). Pull factors, drive an individual to something new that increases the risk of trafficking (e.g., income, housing, access to substances) (9, 10).

Who are the traffickers?

In the same way that anyone can be trafficked, anyone can be a trafficker.

Traffickers may be well known in the community, recruiting victims from places of employment or education (1). They may be a family member. They may also lure at-risk individuals by acting as a romantic partner, or by providing emotional affirmation, financial assistance, and material goods (1).

How do traffickers coerce survivors?

A number of tactics can be employed by traffickers, each tailored to the individual survivor but can include any combination of the following (1).

• Physical violence
• Sexual violence
• Emotional violence
• Withholding basic needs (food, water, shelter)
• Intimidation
• Coercion and threats
• Economic coercion
• Social isolation

Specific situations to be wary of:

• Runaway or homeless youth – greater incidence of “survival sex,” where sexual acts are exchanged for basic necessities (1, 11)
• Recent immigrants – withholding documentation/ fear of deportation are used as powerful coercion tactic (1, 5, 6)

What are some of the health consequences of Human Trafficking (6)?

• Physical abuse (traumatic injury, chronic pain)
• Sexual abuse (sexually transmitted infections, pregnancy)
• Emotional abuse (post-traumatic stress disorder, suicide ideation)
• Poor living conditions (malnutrition, dehydration, exposure injuries)
• Substance use, overdose
• Death

10 Common Misconceptions of Human Trafficking

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Guide for Emergency Department Providers

What are the primary goals of an ED visit with a potentially trafficked patient?

1. Address the acute presenting illness or injury
2. Establish the ED as a haven from trauma or exploitation
3. Offer additional resources, if appropriate and available

The goal of the visit is NOT to elicit a disclosure.

Your role as a provider is not to investigate or confirm the presence of trafficking, but to respect the autonomy of the patient in front of you, meet their healthcare needs, and empower them to seek additional support on their terms.

What steps should I take during my encounter?

1. Capitalize on the same “trauma-informed” principles used to care for survivors of intimate partner violence and child maltreatment.
2. Encounter tips (1, 6, 12)
   • Separate the potential victim from accompanying persons
3. If difficult, ask the patient to move to another room for an x-ray or routine test.
   • Use a trained interpreter when required
   • Foster trust and establish rapport
   • Use education about rights and resources as an empowerment tool (12)
4. Providing nonjudgmental education around violence and safety can normalize the sharing of information and open discussion (12)
   • Be patient
   • Always get consent before proceeding with any next steps (physical exam, diagnostic tests, and involvement of other providers)

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Red flags For Human Trafficking (1, 13)

Red flags for pediatric patients (1, 14)

• Accompanied by unrelated, non-guardian adults
• Material possessions you reasonably doubt they would be able to afford
• Truancy or running away
• Multiple sexual “partners”

What are the next steps after my assessment?

Any next steps should always be determined by the patient

• Referrals (social work, case manager or discharge specialist, local advocacy services) (6, 15)
• Human Trafficking Hotline
  • USA – National Human Trafficking Hotline at 1-888-373-7888
  • Canada – Canadian Human Trafficking Hotline at 1-833-900-1010

• Consider offering admission if unsafe to discharge
• Clear and accurate documentation (may be relevant to future legal proceedings)
• Consider notifying security if appropriate (6)

Unless local criteria for mandatory reporting are met, Police should only be contacted at the explicit instruction of the patient (6, 16).

Interested in advocacy?

Consider implementing an ED and institutional protocol for human trafficking. A complete protocol guide is available through HEAL Trafficking.

References

1. Alpert EJ, Ahn R, Albright E et al. Human Trafficking: Guidebook on Identification, Assessment, and Response in a Healthcare Setting. Boston, MA: MGH Human Trafficking Initiative, Division of Global Health and Human Rights, Department of Emergency Medicine.
2. Human Trafficking. Public Safety Canada, Government of Canada. 2019.
3. Lederer L, Wetzel C. The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities. Ann Heal Law. 2013;23(1):61–91.
4. Viergever RF, West H, Borland R, Zimmerman C. Health care providers and human trafficking: What do they know, what do they need to know? Findings from the Middle East, the Caribbean, and Central America. Front Public Heal. 2015;3:1–9. PMID: 25688343
5. Canada’s Human Trafficking Laws. British Columbia Public Health Agency. 2014.
6. Shandro J, Chisolm-Straker M, Duber HC, Findlay SL, Munoz J, Schmitz G, et al. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. Ann Emerg Med. 2016;68(4):501-508.e1. PMID: 27130802
7. Global Report on Trafficking in Persons [Internet]. New York; 2014. Available from: https://www.unodc.org/res/cld/bibliography/global-report-on-trafficking-in-persons_html/GLOTIP_2014_full_report.pdf
8. 2021 Trafficking in Persons Report – United States Department of State [Internet]. U.S. Department of State; 2021. Available from: https://www.state.gov/reports/
9. Macias Konstantopoulos W, Ahn R, Alpert EJ, Cafferty E, McGahan A, Williams TP, et al. An international comparative public health analysis of sex trafficking of women and girls in eight cities: Achieving a more effective health sector response. J Urban Health. 2013. PMID: 24151086
10. Calhoun C. Push and pull factors. Oxford Dictionary. Soc Sci Oxford Univ Press. 2002;
11. Walls NE, Bell S. Correlates of engaging in survival sex among homeless youth and young adults. J Sex Res. 2011. PMID: 20799134
12. PEARR Tool Trauma-Informed Approach to Victim Assistance in Health Care Settings. Dignity Health, in partnership with HEAL Trafficking and Pacific Survivor Center. 2019.
13. Identifying Victims of Human Trafficking: What to look for in a healthcare setting. National Human Trafficking Resource Center. The Polaris Project.
14. Tracy EE, Konstantopoulos WMI. Human trafficking: A call for heightened awareness and advocacy by obstetrician-gynecologists. Obstet Gynecol. 2012. PMID: 22525917
15. Meshkovska B, Siegel M, Stutterheim SE, Bos AER. Female sex trafficking: Conceptual issues, current debates, and future directions. J Sex Res. 2015. PMID: 25897567
16. Zimmerman C BR. Caring for Trafficked Persons: Guidance for Health Providers. Health Providers. Geneva, Switzerland: International Organization for Migration. 2009.

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