Human Trafficking in the ED: Pearls and Pitfalls

Authors: Shannon Findlay, MD (EM Resident, University of Iowa), Daniel Runde, MD (EM Attending, University of Iowa), and Christopher Buresh, MD (EM Attending, University of Iowa) // Edited by: Jamie Santistevan, MD (@Jamie_Rae_EMdoc, Admin and Quality Fellow at UW, Madison, WI) and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW Medical Center / Parkland Memorial Hospital)  

 Background Information

Human trafficking (HT) affects individuals of all ages, genders, races, sexual orientations, and socioeconomic levels. This pervasiveness makes it difficult to identify potential victims. Human trafficking is not limited to overseas’ brothels or the rough inner cities of America. Trafficking occurs every day throughout America and involves individuals manipulated and coerced into exploited roles.

screen-shot-2016-12-01-at-10-22-39-am

Image 1: Locations of potential human trafficking cases in 2015

Nearly 21 million people are affected worldwide.1,2 It is estimated that 18,000 victims of HT are brought into the US annually, a number that does not account for the numerous individuals already in the US who are victims of HT.3

HT has significant mental and physical health effects. Emergency Medicine (EM) physicians are in a unique position to identify, treat, and assist victims of HT with their medical needs and connect them to safe houses, counseling support, legal assistance, and additional resources as needed. Studies have shown that between 28-88% of victims of HT seek medical care during the time when they are being trafficked. Conversely, only 5% of EM physicians feel comfortable identifying and treating possible victims of HT. 4-8

Awareness and education about both labor and sex trafficking are critical in understanding the complex needs of this difficult to identify population.

 At Risk Populations

Being aware of populations and persons at risk is the first step in identifying potential victims of HT.

Marginalized Populations9 Psychosocial Risk Factors9
·      Child welfare or juvenile system

·      Runaway youth and homeless youth

·      Children working in agriculture

·      American Indians and Alaskan Natives

·      Migrant laborers

·      Foreign national domestic workers

·      Employees of business in ethnic communities

·      Populations with limited English

·      Person with disabilities

·      LGBT

·      Previous physical, sexual, or emotional abuse

·      Poverty

·      Limited education

·      Substance misuse

 

Concerning Signs

Emergency physicians should have heightened suspicion for HT when patients present with the following signs/symptoms.

Signs of Abuse/Exploitation9-13,15 Sex Trafficking9-15 Labor Trafficking9-13,15
·      Sleep deprivation

·      Bruises, lacerations

·      Malnutrition

·      Untreated chronic illness

·      Anxiety, depression, suicide attempts

·      Overbearing accompanying person

·      No self-identifying documents

·      Lack knowledge of surroundings

·      Substance abuse

·      Multiple STDs, urinary symptoms

·      Ob/Gyn Concerns

·      Unintended pregnancies

·      Trauma to the vaginal or rectal area

·      High number of sexual partners

·      Limited use or access to contraception

 

·      Heat related illness

·      Musculoskeletal injuries

·      Lack of appropriate protective clothing at work

·      Chemical exposures

·      Chronic respiratory Illness

·      Chronic skin conditions

 

Case 1:

Worried, Anxiety, Women.

A 17-year-old female with history of drug/alcohol abuse along with depression and previous suicide attempt presents to the ED with the complaint of urinary symptoms and nausea. She is not very cooperative during the examination. She states that she has been seen in the past for similar symptoms and just wants antibiotics so that she can get back to work. She works to support herself and cannot afford to miss work.

When asked if she could be pregnant, patient says that she has not been able to buy birth control the past few months. Her LMP was about 1 months ago and reports barrier protection is rarely used. The patient refuses a pelvic exam and to give a urine sample because she states it’s a waste of time since she has already answered your questions. On visual inspection, you notice a thin tired appearing female with several bruises along her extremities. She has poor eye contact and appears anxious. She refuses to be examined further.

Vitals: T: 37 HR: 70 BP: 110/60 RR: 12 spO2: 99%

SH: High school student. Currently in the Foster Care System, but reports living with a friend presently.

Case 2:

migrant-worker-kort-duce

A 40-year-old male who does not see doctors presents with syncope from work. He is Spanish speaking and accompanied by a co-worker. He is able to speak simple English and states he is seasonal worker. His co-worker speaks over the patient to answer questions about the event and work environment. Patient states that he fainted after working in the field all day. Prior to this, he felt very hot and thirsty.

He further explains that he has a cough with bloody sputum production and extremely irritated eyes. Blood sugar by EMS is 400. Patient does not have any identification with him and does not have insurance.

Vitals: T: 39 HR: 115 BP: 90/60 RR: 20 spO2: 98%

Physical Exam:

Constitutional: Appears fatigue. Strong chemical smell present

HEENT: Dry mucus membranes and cracked lips. Red, watery, irritated eyes

Heart: Tachycardic with regular rhythm

Lungs: Normal breath sounds bilaterally

Skin: Hot and dry. Dermatitis on hands

Abdomen: Soft and non-distend. Non-tender

Extremities: Atraumatic

Neuro: CN in tact, moves all extremities spontaneously

Review of the Cases

Many of us have seen cases similar as those described above. The important thing is to recognize potential victims of exploitation. Below are concerning signs of human trafficking from the cases. No single sign guarantees that a person is a victim of human trafficking. Instead, concerning signs should prompt you to ask patients about their well-being and offer assistance as appropriate.

CASE 1: Suspected Sex Trafficking CASE 2: Suspected Labor Trafficking
·      Unexpected demeanor

·      Foster care background

·      Mental health history

·      Previous history of urinary infection /STD

·      Potential concerning work history

·      Limited use/access to contraception

·      Multiple bruises

·      Poor eye contact

·      Language barrier

·      Overbearing accompanying individual

·      No self-identifying documents

·      Migrant worker

·      Untreated or poorly controlled health conditions

·      Heat-related illness

·      Possible chemical exposures

Approach to Suspected Cases of Human Trafficking

  1. Remember that human trafficking can affect anyone, anywhere, anytime. You need a high level of awareness to identify potential victims of human trafficking. Treat the patients immediate medical and basic needs first.15
  2. Use a well-informed and culturally sensitive approach when interviewing your patients. Ask open ended questions about safety, employment, living environment, documents, and youth-specific questions.11,12,15
  3. Use a multi-disciplinary approach that involves social workers, those trained in medical evidence collection, interpreters, community resources, and law enforcement only when appropriate and with the consent of the individual. Exceptions include mandatory reporting laws in your area.10-12,15
  4. Recognize that your patients may not be ready to leave their situation for a wide variety of reasons including fear for themselves and loved ones. It often takes several visits for an individual to disclose their situation to healthcare providers.11 Your responsibility is to build a trusting and safe environment where individuals feel comfortable returning. This also includes safety awareness for not only the patient during the encounter but also healthcare staff.
  5. Call the National Human Trafficking Hotline 24/7 for assistance and reporting of potential cases of HT. You may also Text BeFree from 3PM-11PM EST. 

Hotline number: 1-888-373-7888. Text: BeFree 233733

References / Further Reading

  1. United Nations Office on Drugs and Crime. Global Report on Trafficking in Persons 2014.
  2. International Labour Organization. Profits and Poverty: The Economics of Forced Labour. May 20, 2014.
  3. Department of Health and Human Services. Human trafficking into and within the United States: a review of the literature. 2009. Available at: https://aspe.hhs.gov/basic-report/human-trafficking-and-within- united-states-review-literature. Accessed January 4, 2016.
  4. Lederer L, Wetzel C. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law. 2014;23:61-91.
  5. Baldwin SB, Eisenman DP, Sayles JN, et al. Identification of human trafficking victims in health care settings. Health Hum Rights. 2011;13:e36-e49.
  6. Family Violence Prevention Fund; World Childhood Foundation. Turning Pain Into Power: Trafficking Survivors’ Perspectives on Early Intervention Strategies. San Francisco, CA: Family Violence Prevention Fund; 2005.
  7. Chisolm-Straker M, Baldwin S, Gaigbe-Togbe B, et al. Healthcare and human trafficking: we are seeing the unseen. J Health Care Poor Underserved. In press.
  8. Viergever R, West H, Borland R, et al. Heath 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 Health. 2015; http://dx.doi.org/10.3389/fpubh.2015.00006.
  9. United States Department of State. Trafficking in Persons report. July 2015. Available at: http//www.state.gov/j/tips/rls/tiprpt/
  10. Zimmerman C, Borland R. Caring for Trafficked Persons: Guidance for Health Providers. Geneva, Switzerland: International Organization for Migration; 2009.
  11. Alpert EJ, Ahn R, Albright E, et al. Human Trafficking: Guidebook on Identification, Assessment, and Response in the Health Care Setting. MGH Human Trafficking Initiative, Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA and Committee on Violence Intervention and Prevention, Massachusetts Medical Society, Waltham, MA. September 2014.
  12. Becker H, Bechtel K. Recognizing victims of human trafficking in the pediatric emergency department. Pediatric Emergency Care. 2015; 31: 144-150.
  13. Zimmerman C. Trafficking in Women. The Health of Women in Post-Trafficking Services in Europe Who Were Trafficked into Prostitution of Sexually Abused as Domestic Labourers.
  14. Raymond JG, Hughes DM. Sex Trafficking of Women in the United States: International and Domestic Trends. New York, NY: Coalition Against Trafficking in Women; 2001.
  15. Jamie Shandro, MD, MPH; Makini Chisolm-Straker, MD, MPH; Herbert C. Duber, MD, MPH; Shannon Lynn Findlay, MD; Jessica Munoz, MSN, FNP-BC; Gillian Schmitz, MD; Melanie Stanzer, DO; Hanni Stoklosa, MD, MPH; Dan E. Wiener, MD; Neil Wingkun, MD. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. Annals of Emergency Medicine. October 2016; 68. 4. 501-508.

 

Images Obtained from the following

  1. Image 1. Accessed Nov 13, 2016. Image available from: https://polarisproject.org/sites/default/files/2015-Statistics.pdf
  2. Case 1. Accessed Nov 13, 2016. Image available from: http://docorman.com/anxiety-and-telling-the-truth/
  3. Case 2. Accessed Nov. 13, 2016. Image available from: http://images.fineartamerica.com/images-medium-large/migrant-worker-kort-duce.jpg

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