JR, 16, is brought in by her older brother for severe vaginal bleeding from a suspected self-induced abortion. She is agitated, and her brother notes she has a history of schizophrenia. She has emergency surgery, and then is evaluated by the psychiatry service, given anxiety medications, and discharged to her brother's custody. (http://stanford.io/25Y5mhk.)
Human trafficking is no less than modern-day slavery, the act of recruiting, harboring, transporting, providing, or obtaining a person for compelled labor or commercial sex acts through the use of force, fraud, or coercion. It is currently the second largest and fastest growing criminal industry worldwide, and the International Labour Office, an agency of the United Nations, estimates that traffickers profit to the tune of $32 billion annually. Traffickers coldly calculate the value in exploiting human beings: “You can sell a human 10, 20, even 30 times a day. You can't sell drugs or a firearm that many times,” said Holly Atkinson, MD, the director of the Human Rights Program at Mount Sinai in New York City and a chair of the AMA's Physicians Against the Trafficking of Humans initiative. (Yahoo Health, March 18, 2015; http://yhoo.it/1qmVoVK.)
The National Human Trafficking Resource Center, a national, toll-free hotline, receives 100 calls a day, and generated more than 5,000 cases of sex trafficking being investigated in 2015. (https://traffickingresourcecenter.org/states.) One misconception is that victims of human trafficking are always foreign nationals who have been smuggled across a border, but the most common victims of trafficking in the United States were born in this country.
Girls are generally first victimized in sex trafficking around ages 12 to 14. A sex trafficking charge requires a show of force, threat, fraud, or coercion for adult victims, but force, fraud, or coercion is not necessary for children. Victims and perpetrators can be male or female. Often there is overlap with labor trafficking, which exists when a person uses force or physical threats, psychological coercion, abuse of the legal process, fraud, debt bondage, or other coercive means to compel someone to work. Victims of labor trafficking are commonly identified in agriculture, domestic work, factories, the hospitality industry, and bars and clubs.
JR, the girl from earlier, was actually a 14-year-old runaway who met her trafficker at a mall. He promised her food, shelter, and a job. Her vaginal bleeding was caused by his using a broken bottle to try to induce an abortion.
Adolescent patients such as the one in this true story who are not identified as victims of trafficking during the ED visit are forced back into a criminal environment by their perpetrator, at risk for death from drug overdose or physical abuse.
The EP's Role
EPs have an opportunity to identify victims of trafficking. Likely imprisoned and kept from the public, any chance a victim is brought to the hospital for treatment may be the only opportunity for someone to intervene. Six of 12 human trafficker survivors interviewed in one study were brought into the medical system by their trafficker, who filled out paperwork and communicated with hospital workers. Sadly, none was identified by health care personnel as a victim of human trafficking. (Health Hum Rights 2011;13:E36.)
Some findings that raise suspicion for human trafficking can be found in the victim's demeanor (fearful, submissive, appears coached, avoids eye contact) or physical signs (bruises, tattoos that mark ownership, signs of drug abuse). EPs can utilize techniques to separate the victim from a suspected trafficker by walking the patient to the bathroom for a urine sample or to radiology for an x-ray so they can speak with the patient alone. Victims are often terrified to speak or flee from their trafficker. (See table.)
Some states have expressly identified by statute that human trafficking of under-age victims is child abuse, and mandates reporting by health professionals, educators, and police officers. (Maryland Human Trafficking Task Force; http://bit.ly/1N76uZA.) Although intuitively evident, EPs should retrain themselves to identify child abuse in the context of human trafficking, making it mandatory to report human trafficking of victims under 18. (Find child welfare statutes by state at http://1.usa.gov/1lAShaG.) If the identified victim is 18 or older, she should be given the autonomy to decide whether authorities should get involved.
Polaris, a top organization in the global fight to eradicate trafficking, launched the “BEFREE” text line (text HELP to 233733) in 2013, which affords victims a means to communicate with Polaris staff trained in assisting victims. As a measure of safety, Polaris advises victims to delete all texts after ending conversations, and promises that staff won't text back if the conversation is halted or share information about communication unless the victim discloses that a child is in danger of being abused. If an adult victim is not amenable to immediate assistance, whether by contacting law enforcement or placing a call to a trafficking hotline, resources can be discretely offered to patients when they are in the ED.
Red Flags for Identifying Human Trafficking Victims
Historical Red Flags
- Does the person lack knowledge about where she lives?
- Is the person in the company of someone, male or female, to which she defers? Or with someone who seems to be maintaining control of the situation?
- Is his history vague or inconsistent?
- Does the person work in the commercial sex industry?
- Is there a large age gap between spouses or partners? Do they speak the same language?
Behavioral Red Flags
- Is the person not free to come and go as they wish?
- Is the person fearful, submissive, or tearful?
- Does the person seem to be coached on what to say?
- Does the person avoid eye contact or show signs of physical or mental abuse?
Physical Red Flags
- Does the person show signs of being denied food, water, or basic medical care?
- If the person has tattoos, can she tell you about how she chose them? Are there names or signs of branding on the person?
- Do findings suggest the victim is addicted to drugs?