Most human trafficking victims (about 66%) interact with the healthcare system while being trafficked, yet healthcare providers often fail to recognize the signs of trafficking or are unsure how to help. Trafficked persons are unlikely to disclose their situation.

A healthcare provider’s ability to identify the presence of trafficking and their knowledge of support services can turn a very bad situation into a positive one. For this reason, all staff in all departments should be familiar with strategies used to identify signs of human trafficking, just as organization trains staff members to spot child and elder abuse.

2.1 Patient-Centered and Trauma-Informed Strategies

Identifying and engaging with a patient who might be the victim of human trafficking requires sensitivity and good judgment. It can be described as a thoughtful, patient-centered, trauma-informed,* and safety-focused approach. The goal should be to build trust and create a safe environment for the victim.

*Trauma-informed: focuses on the impact of trauma; promotes physical, psychological safety, and emotional safety; and provides opportunities to regain control.

Trauma-informed care focuses on:

1. Physical and psychological safety.
2. Trustworthy and transparent operations and decisions.
3. Peer support (survivors connecting with other survivors for help and support).
4. Collaboration (staff and clients work together).
5. Empowerment (recognizing individual strengths and experiences, shared decision-making).
6. Humility and responsiveness.

2.1.1 Establish Trust and Safety

Offering the opportunity to speak privately, away from a controlling companion, can be the first step in establishing trust. Frame the request neutrally:

“I need to ask a few routine health questions in private. May I ask your companion to wait in the hall for a few minutes?”

Let the person know that fear, hesitation, and mistrust are normal and understandable.

Inform the patient that you may be mandated to report potential abuse if the patient is a minor or is in imminent harm.* Reassure them that you will not share information with the person who accompanies them unless the patient explicitly asks you to.

*Imminent harm: an immediate, impending threat of serious physical injury, death, or significant damage that is about to occur at any moment.

2.1.2 Trauma-Informed Communication

Trauma-informed communication uses a nonjudgmental approach that focuses on a patient’s choices. Avoid the impulse to “rescue” the victim and be careful not to make promises that cannot be kept, such as over-promising services.

Trauma-informed communication is built around these four key practices:

1. Realize: understanding how trauma can affect a person.
2. Recognize: being able to recognize the signs of trauma.
3. Respond: adopting practices that take trauma into consideration.
4. Resist re-traumatization: understanding that some practices may re-traumatize patients.

Trauma-informed care gives the patient as much power and control as is possible. This can be accomplished by asking,

“Where would you like to sit.”
“You can stop this conversation at any time.”
“Would you prefer I examine you now, or would you like to talk first?”

The initial interview should focus on the person’s experience as a potential victim of trafficking. Avoid language that labels their experience as criminal activity. Try not to judge or demand details. Do not ask a victim to recount the details of their victimization, which can be particularly difficult for children.

Because trauma can affect memory, a person may struggle to recall certain events. You can reassure the patient by saying,

“Trauma often makes it hard to remember things clearly. It's alright if you don't recall all the details right now.”

2.1.4 Plan for Next Steps (Referral)

If a patient is identified as a survivor, or you have strong suspicion, a supported referral* should be made. Assess whether the patient is in immediate danger. If the trafficker is present or danger is high, follow your organization’s established protocols (calling on social work or security). Prioritize the patient's immediate safety.

* Supported referral: connecting a person with social services, housing, healthcare, or other specialized services.

Let the patient decide what to do next but, at the very least, provide a phone number for a national trafficking hotline or local advocacy group. If needed, you can write the number down on a piece of paper that looks like a casual note or appointment reminder.

Document all findings objectively in the medical record, focusing on injuries, inconsistent history, and patient statements, but avoid using the term trafficked unless the patient identifies that way or it is confirmed by law enforcement. This protects the person’s privacy and legal status.

2.2 Clinical Settings in Which Trafficked Persons Are Encountered

Most victims of human trafficking interact with the healthcare system at some point. Because of this, healthcare providers are often one of the few points of contact for victims outside the control of their trafficker. A controlling companion who refuses to leave the patient's side, speaks for them, or holds their identification documents are strong indicators of the presence of human trafficking.

The most common settings in which a person being trafficked interacts with the healthcare system include:

• emergency departments (acute injuries and illnesses)
• primary and urgent care clinics
• mental health and substance abuse facilities
• reproductive health and maternity services (pregnancies and sexually transmitted diseases)

For a patient seeking healthcare services, several points of contact exist. The “front line” includes the lobby, clerical staff, or enrollment specialist. The “mid-line” is where a patient meets doctors, nurses, therapists, lab techs, or case managers. The “finish line” is where the next appointment is scheduled, insurance or fees are paid, and the patient exits the building. Each employee, at each point of contact, has an opportunity to interact with a potential victim of human trafficking.

2.3 Clinical Indicators of Human Trafficking (Red Flags)

Although no single clinical indicator is proof of human trafficking, certain physical and behavioral indicators should raise suspicion—especially when they occur in combination. Indicators are broadly divided into acute injuries (recent trauma), chronic conditions (long-term neglect and abuse), and behavioral indicators.

2.3.1 Acute Injuries and Presentations

Treatment for an acute injury is often the reason a trafficked person is brought into an emergency department or clinic. Traumatic injuries are like those you might see in a victim of domestic abuse.

These can include:

• bruises, fractures, burns, or lacerations in various stages of healing
• head injuries or concussions resulting from blunt force trauma
• rope burns or ligature marks suggesting restraint or confinement
• oral health issues, including broken teeth
• unexplained memory loss
• signs of substance overdose or acute withdrawal symptoms

Injuries from sexual assault/genital trauma can include:

• unexplained or recurrent STIs
• unwanted or complicated pregnancies
• request for abortion

Injuries related to labor trafficking include:

• skin or respiratory issues related to exposure to unsafe chemicals
• workplace injuries
• overuse injuries
• hypothermia or heat related injuries

Injuries due to acute illness, communicable diseases, and infections can be severe if left untreated (neglected wounds, lack of hygiene).

2.3.2 Chronic Conditions and Subtle Physical Signs

Chronic conditions often reflect long-term deprivation, physical stress, and poor living conditions. Look for subtle physical signs of chronic malnourishment, dehydration, or exhaustion. Pay attention to non-specific complaints like severe headaches, back pain, or stomach pain with no clear physical cause (these are often due to trauma).

During the initial evaluation, be aware of:

• poor dental hygiene or untreated decay
• untreated chronic diseases
• tattoos or branding that may signify ownership or control (names, symbols, or phrases like “Daddy” or “For Sale”)
• musculoskeletal injuries resulting in chronic pain from forced strenuous labor or repetitive motions

2.3.3 Behavioral, Mental, and Contextual Red Flags

The most revealing indicators of human trafficking may be the patient's demeanor or behavior. The trafficked patient is likely accompanied by a controlling companion who refuses to leave the patient alone, speaks for them, or is aggressive toward staff.

Victims of human trafficking often appear fearful, timid, or anxious. They may avoid eye contact or be fearful of authority figures. The victim’s report of the history of the illness or injury may be inconsistent with the physical findings; likewise, the explanation may sound scripted or rehearsed.

The trafficked patient probably does not possess their own ID, passport, or money, and may not know their home address. Victims are often wearing clothing that is not appropriate for the weather, or they may show up wearing the same clothing over multiple visits.

These patients often exhibit severe, complex trauma symptoms, including dissociation, PTSD, or suicidal ideation. Signs that medical care has been delayed or limited is revealed by injuries that are old or illnesses that are advanced. It is not uncommon for victims of human trafficking to leave a clinic or emergency department against medical advice.

2.4 Challenges and Opportunities for Providers

A critical first step in combating human trafficking is for service providers to identify and respond to survivors with a trauma-informed, victim-centered approach. This involves navigating significant challenges while maximizing opportunities through best practices like ensuring privacy and utilizing professional interpreters.

2.4.1 Challenges for Providers

Providers face systemic, organizational, and victim-related challenges in identifying and assisting survivors of human trafficking. Trafficking is a hidden crime in which abusers intentionally conceal their actions through isolation, threats, and coercion. Victims are often unaware of their rights and are fearful of seeking help.

Many people, including healthcare providers, do not recognize the signs of human trafficking or believe it exists in their community. Because of a lack of awareness and training, most victims who interact with healthcare providers are not identified.

Fear of retaliation. Victims of human trafficking are understandably reluctant to share details about their situation due to real fears of retaliation and threats of violence from the trafficker. They may be concerned they will be arrested or deported.

Lack of services. A lack of funding for specialized services, long waitlists for housing, and few clinicians trained in trauma-informed care mean that victims of human trafficking may not receive the services they need.

Shame and stigma. Victims of human trafficking suffer from complex physical, psychological, and social needs, which often require unique and comprehensive interventions. They may feel a great deal of shame, stigma, and guilt for being in a situation where they have little control.

2.4.2 Opportunities for Providers

Because healthcare settings are one of the most common points of contact for trafficked persons, healthcare providers are in well-positioned to intervene. They can build trust and through a non-judgmental, compassionate approach. The healthcare setting can be a safe space that encourages disclosure over time. This can be especially effective when organizational policies provide a systematic, consistent response to potential victims.

Healthcare organizations can also collaborate with other agencies and specialists. This provides the opportunity to partner with law enforcement, anti-trafficking organizations, and social services to ensure comprehensive care.

2.4.3 Strategies for Private Conversations

Creating a safe, private, and non-coercive environment is crucial for disclosure. If a potential victim is accompanied by a third party (who may be the trafficker or their associate), find an excuse to speak with the patient alone. For example, you can say the patient needs an x-ray, a lab test, or a procedure in an area where visitors are not allowed. If the accompanying person is aggressive or refuses to leave, contact security and follow institutional safety protocols.

To ensure confidentiality and privacy, conduct the conversation in a private room with a closed door and make sure no one is within earshot. Explain the limits of confidentiality (e.g., mandatory reporting laws) to maintain transparency and trust. Inform the patient of privacy measures, such as concealing their name on whiteboards or making their documents private in the system.

Use non-judgmental language, express concern for a person’s well-being, and prioritize safety and comfort. Ask permission before touching, making referrals, or contacting law enforcement. Respect the person’s decisions, including if they decline assistance.

Avoid interrogating the patient. Start with general questions related to safety, living conditions, and freedom of movement. For example, “Are you comfortable? Do you feel safe at home?”

2.4.4 Importance of Using Professional Interpreters

Federal law requires healthcare providers who receive federal funding to offer interpretation services to patients with limited English proficiency and those who are deaf or hard of hearing. These services help all parties understand medical instructions and create a more comfortable, trusting environment for patients.

The use of professional, trained interpreters ensures that complex and sensitive topics are accurately conveyed, including cultural nuances, which is vital for informed consent and proper diagnosis. For suspected victims of human trafficking, never allow an accompanying individual to interpret. This is a critical safety measure, because the person accompanying the victim may be the trafficker, or someone who may not maintain confidentiality.

Ideally, interpreters should be trained in trauma-informed care and understand the complexities of human trafficking disclosure. Using a professional, impartial interpreter builds trust and reinforces the provider's commitment to victim safety and care.

2.5 Best Practices for Documentation and Operational Protocols

Navigating the response to human trafficking requires providers to adhere to meticulous best practices in documentation and operational protocols, ensuring a high standard of trauma-informed care while prioritizing the safety and autonomy of the patient.

2.5.1 Best Practices for Appropriate Documentation

Documentation serves a dual purpose: providing continuity of care and potentially providing evidence for future legal action. The patient's safety and confidentiality as the highest priority.

2.5.1.1 Informed Consent

Always discuss and obtain the patient's consent for documenting sensitive information. Explain the risks and benefits (e.g., potential for use in a legal case vs. risk if the trafficker gains access). This empowers the patient and builds trust, upholding autonomy within legal limitations (like mandatory reporting).

2.5.1.2 Safety Measures

Use coded language or abbreviations (e.g., HT for human trafficking) in the medical record rather than explicit terms and utilize “confidential” sections of the electronic health record where available. This protects the patient's privacy in case the trafficker gains access to common documents like “After Visit Summaries”.

2.5.1.3 Objective Detail

Document specific observations and non-clinical data objectively and factually, such as:

• Direct quotes from the patient.
• Physical signs (branding, tattoos, multiple injuries in different stages of healing.)
• Behavioral cues: (fearful, scripted answers, being constantly observed by an accompanying person.

Objective documentation is stronger evidence and less likely to be seen as judgmental.

Information related to a patient's injuries and treatment must be fully and accurately documented in the patient's records. If visible injuries are present, photographs are crucial for evidence and medical follow-up. Photos should be dated, include a ruler for scale, and be securely stored according to facility protocol. Photos also require explicit, informed consent.

2.5.2 Operational Protocols for Safety

Each organization must have in place victim-centered, trauma-informed protocols that fit the unique needs of the organization. This includes clear guidelines for reporting abuse.

A comprehensive protocol covers both patient and provider safety. The overall goal is to treat, educate, and empower patients and staff. Key elements are:

• Developing a screening tool for your organization
• Ensuring staff are trained to use the screening tool
• Establishing a network of referral partners
• Outlining reporting requirements
• Developing staff training

To keep patients safe, implement a clear procedure for separating the patient from any accompanying individuals (who may be the trafficker). This must be done discretely, often under the guise of medical necessity (e.g., “The patient needs to go for a lab draw/scan alone”).

If the patient discloses that they are a victim of human trafficking or you suspect this is the case, work with the patent and a social worker or victim advocate to develop a safety plan. This includes providing the National Human Trafficking Hotline number (1-888-373-7888) discreetly (e.g., written on a prescription slip for a follow-up appointment or simply memorized).

If the patient chooses to leave the trafficking situation, coordinate a referral to an anti-trafficking organization or shelter. Never discharge the patient back to the person who accompanied them if trafficking is suspected. An identified escort team (e.g., security, social worker) should accompany the patient to a safe location.

2.5.3 Measures to Keep Providers Safe

All staff involved should be discreetly made aware of any security concern. Have a specific, established security protocol or code word to alert security personnel if a suspected trafficker becomes aggressive or refuses to leave the patient's side.

Providers should never give out personal contact details or attempt to house a patient themselves. All assistance must be provided through approved institutional channels and resources. Providers should never Intervene directly: they are clinicians, not law enforcement. The role of a provider is to identify, stabilize, and link to specialized resources, not to attempt a "rescue" or confront a suspected trafficker.

2.5.4 Implications of Law Enforcement Involvement

The decision to involve law enforcement has profound and complex implications and should be driven by the victim-centered approach. Always partner with the patient on the decision to involve law enforcement, unless a mandated report for a child or person in immediate life-threatening danger overrides that autonomy.

2.6 Screening and Identification Strategies

If a healthcare provider suspects their patient is being trafficked, the provider should try to speak with the patient privately without anyone who is accompanying them. Safe, private conversations can establish trust and allow the patient to share information about their situation. Healthcare organizations should establish protocols on responding to human trafficking, including screening methods and questions to ask potential trafficked persons.

When screening for potential trafficking, ask patient-centered questions such as, “are you able to come and go as you please?” “Do you have control of your own money and identification documents?” “Do you receive pay for the work you are doing?”

Additional examples of patient-centered questions:

• Do you owe anyone a debt you must work off?
• Has anyone threatened you or your family if you try to leave?
• Have you been hurt by the person you work or live with?
• How did you get this job or meet this person?

The Michigan Department of Health and Human Services (MDHHS) offers comprehensive information about all aspects of trafficking for healthcare providers with its Human Trafficking Response Protocol: A Tool for Hospitals. Other screening tools include the Commercial Sexual Exploitation-Identification Tool (CSE-IT), the Short Child Sex Trafficking Screen for the Healthcare Setting, and the Adult Human Trafficking Screening Tool and Guide.