Healthcare providers are one of the few groups of professionals who interact with victims while they are still under the control of their abuser or the person profiting from their abuse.
Roe-Sepowitz, et al., 2015
Effective training for all healthcare personnel is necessary for the protection and identification of human trafficking victims. Without fully trained healthcare providers, many victims will fall through the cracks even as they are being seen by medical professionals. Victims are often reluctant to seek help at all because they have been taught by their abuser that if they attempt to escape or find help, no one will believe them or they will be treated like a criminal or prostitute (Roe-Sepowitz et al., 2015). However, one study showed 87.8% of trafficking survivors reported accessing healthcare services during their trafficking situation (68.3% in EDs), which suggests that there may be many opportunities to "see" trafficking victims and possibly do something to help them (NHTH, 2016a).
Many similarities are seen between domestic partner violence and sex trafficking. Victims may feel shame, self-blame, and feelings of unworthiness. Or they may not see themselves as a victim at all (Roe-Sepowitz et al., 2015). Effective communication is imperative when screening to identify possible trafficking victims. Because victims are fearful, providers must try to cultivate trust and a feeling of safety to encourage them to open up about their situation.
Employ a victim-centered approach that strives to:
- Meet basic needs
- Reassure the potential victim
- Build trust and rapport
- Be conscious of language
- Remain sensitive to power dynamics
- Avoid re-traumatization (NHTH, 2016a)
Medical professionals are on the front lines for human trafficking victims. Prioritize the prompt and private screening done away from the abuser or "family member." Safety of the staff, facility, and victim is essential before intervention can begin. When encountering a potential victim, also keep in mind that victims may not be comfortable coming forward and that their accompanying person may be dangerous, even armed.
Warning Signs for Human Trafficking
The National Human Trafficking Resource Center (NHTH, 2016) provides "Red Flags and Indicators" to watch for concerning trafficking in general and for labor and sex trafficking more specifically. It is important to remember that any individual indicator may not equate with human trafficking just as there will be victims who do not exhibit these signs.
General indicators of human trafficking can include:
- Shares a scripted or inconsistent history
- Is unwilling or hesitant to answer questions about the injury or illness
- Is accompanied by an individual who does not let the patient speak for themselves, refuses to let the patient have privacy, or who interprets for them
- Evidence of controlling or dominating relationships (excessive concerns about pleasing a family member, romantic partner, or employer)
- Demonstrates fearful or nervous behavior or avoids eye contact
- Is resistant to assistance or demonstrates hostile behavior
- Is unable to provide his/her address
- Is not aware of his/her location, the current date, or time
- Is not in possession of his/her identification documents
- Is not in control of his or her own money
- Is not being paid or wages are withheld
Indicators for labor trafficking include:
- Has been abused at work or threatened with harm by an employer or supervisor
- Is not allowed to take adequate breaks, food, or water while at work
- Is not provided with adequate personal protective equipment for hazardous work
- Was recruited for different work than he/she is currently doing
- Is required to live in housing provided by employer
- Has a debt to employer or recruiter that he/she cannot resolve
Indicators for sex trafficking include:
- Patient is under the age of 18 and is involved in the commercial sex industry
- Has tattoos or other forms of branding, such as tattoos that say, "Daddy," "Property of…," "For sale," etc.
- Reports an unusually high numbers of sexual partners
- Does not have appropriate clothing for the weather or venue
- Uses language common in the commercial sex industry (NHTH, 2016).
The most common healthcare areas that attract trafficking victims are EDs, urgent care or primary care clinics, obstetrician/gynecologist clinics, school nurses' offices, community health centers, mobile clinics, planned parenthood clinics, and dental clinics (Roe-Sepowitz et al., 2015).
Indicators and Consequences of Human Trafficking
Signs of Physical and Sexual Abuse
In a medical clinic you may be confronted with multiple signs of sexual and physical abuse. These include but are not limited to evidence of sexual trauma, fractures, cigarette burns, bruises or contusions, tattoos on the body that may serve as a "brand" of their trafficker, respiratory infections, dental issues, drug-related issues (hepatitis, skin infections), malnutrition, dehydration, unexplained scars, injuries to head and mouth, temporal mandibular joint (TMJ) problems from oral sex, bite marks, stab or gunshot wounds, hearing loss from head trauma, bald patches from having hair pulled, tension headaches, traumatic brain injury, bladder damage, other injury or infection (Roe-Sepowitz et al., 2015, NHTH, 2016).
Physical abuse of those in labor trafficking can include: musculoskeletal and ergonomic injuries, malnutrition/dehydration, lack of routine screening and preventative care, poor dental hygiene, untreated skin infections/inflammations, injuries or illness from exposure to harmful chemicals/unsafe water, ophthalmology issues or vision complaints, somatization NHTH, 2016a).
When assessing a patient in a medical setting, look for behavioral characteristics such an inconsistent medical history; no eye contact; an unwillingness to share answers; resistance to gynecologic exams; being accompanied by an individual who does not let the patient speak; inability to provide an address or unaware of location or date/time. Victims can often act fearful and nervous, especially if the abuser is present. Other mental health indicators can include depression, suicide attempts, anxiety, hostility, and numerous others. Social and developmental indicators might include trauma bonding with trafficker or other victims, delayed development, and impaired social skills (Roe-Sepowitz et al., 2015; NHTH, 2016).
Behavioral indicators of labor trafficking can include: anxiety/panic attacks (e.g., shortness of breath, chest pains), unexplained/conflicting stories, overly vigilant or paranoid behavior, inability/aversion to make decisions independent of employer, inability/aversion to speak without an interpreter, affect dysregulation/irritability (NHTH, 2016a).
Trafficking victims seldom disclose their situation in clinical settings. Healthcare practitioners need to be thoughtful about how they approach engagement, understand trauma-informed practices, and create a space in which the patient feels comfortable discussing human trafficking. The practitioner must assess the safety situation for everyone. For example, is the patient's abuser sitting in the waiting room and likely to react violently if the person does not return? Accept that the goal is not disclosure or rescue but to create a safe place to identify indicators of trafficking and assist the patient (NHTH, 2016).
When performing an assessment keep the following in mind:
- Allow the patient to decide if they are more comfortable speaking with a male or female
- If interpretation is needed, always use professionals not related to the patient or situation.
- Find a way to meet with the patient privately without anyone who may have accompanied them.
- Build rapport with the victim or find another staff member who can do that.
- Ensure patient clearly understands confidentiality policies and practices, including mandatory reporting laws.
- Employ multidisciplinary resources whenever possible (e.g., social workers).
- Utilize existing institutional protocols for victims of abuse/sexual abuse.
- Utilize your institution's protocols for assessments or reach out for assistance in doing so .(NHTH, 2016)
Questions should be as neutral as possible and never accusatory. Rather than asking questions such as "What's wrong with you?" or "Why are you doing this?" reframe it as "What has happened to you?" Questions should reduce the blame and shame that can come from feeling labeled. Questions that show interest in connecting the past to the present can lead to a future with healing and recovery (Roe-Sepowitz et al., 2015; NHTH, 2016, 2016a).
(National Human Trafficking Resource Center, 2016)
Maya, a young woman, comes to the ED with severe abdominal pain. A man identifies himself as her father-in-law and offers to translate for her. He explains she has had stomach problems recently, but she has not been to a doctor because she doesn't have insurance. The patient does not make eye contact with staff or her father-in-law.
A nurse explains to the father-in-law that she needs to examine each patient privately, and the father-in-law says something harsh to the patient, speaking in Spanish. A professional hospital interpreter is present and the patient informs the nurse she helps clean her father-in-law's house and provides child care for various family members. While she loves the children, she states she is very stressed because she works over 12 hours every day. Her father-in-law monitors all of her phone calls and conversations.
A physician diagnoses the patient with a stomach ulcer and gives her a prescription. Maya is visibly troubled. She tells the nurse she has been to another ED and given the same diagnosis. She stopped taking the medicine because she did not have enough money saved to pay for it and she cannot go to a pharmacy unless her father-in-law drives her there.
What questions could be asked to determine if this is a human trafficking situation? Consider the following.
- Maya, stress can make stomach ulcers worse and you seem to work a lot of hours. Do you have days off or get out of the house to do something for yourself? Why, or why not?
- Do you get adequate breaks during the day, eat all your meals or get enough sleep every day when you are working for your family?
- If you wanted to stop working for your father-in-law to get a different job, would you be able to leave?
- Is there someone else who can help you with your healthcare when needed?
- Your father-in-law seemed to speak harshly to you earlier. Does he speak to you like that often? Has he ever harmed or threatened to harm you?