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Recognize the signs of human trafficking, and be prepared to act
Knowledgeable ED providers can identify victims and connect them to help
While no one has precise numbers, the practice of human trafficking is hardly limited to third-world countries. In fact, experts maintain it is big business in the United States, with somewhere between 15,000 and 20,000 people trafficked into the country each year.1 And these people are in addition to the untold numbers of domestic victims who are forced into prostitution or some other type of labor. What is clear, however, is that ED personnel have a vital role to play in identifying victims who come to the ED seeking health care, but also need help in breaking away from their exploiters.
"Typically, they will present to the ED either because they have an acute injury or trauma that happened in the course of their exploitation, or as a consequence of a chronic illness that may need regular attention that they don't get, so it has become so bad that they need to come to the ED for care," explains Ronak Patel, MD, MPH, an attending physician in the Department of Emergency Medicine at Brigham and Women's Hospital in Boston, MA.
In either case, there is an opportunity to not only provide these victims with the health care they need, but also to connect them with help so that they can escape from their exploiters, but too often this opportunity is lost because ED personnel do not recognize the signs that these individuals may be trafficking victims, or they don't know how to handle this type of situation, explains Donna Sabella, PhD, RN, assistant clinical professor, College of Nursing and Health Professions, at Drexel University in Philadelphia, PA, and the founder and director of Project Phoenix, an organization that serves prostituted and trafficked women in the Philadelphia area.2 (Also, see Human Trafficking Resources for Health Care Providers, below.)
Indeed, while Patel recently reported on a patient he and a colleague recognized as being a victim of human trafficking in the ED at Massachusetts General Hospital, he acknowledges that there have probably been many other cases that have gone unnoticed.3 There are, however, steps that hospitals and ED managers can take to educate ED personnel about the issue, and establish protocols to ensure that a process is in place to connect victims with resources if they indicate that they want help.
Raise awareness with training
To identify a victim of human trafficking, you need to know what it is, so one of the initial steps that ED managers should consider is training, says Sabella. "People working in facilities should get some in-service training on site. That needs to be done first to at least explain what human trafficking is," she says, noting that it shouldn't take more than a couple of hours to get the basics. Sabella emphasizes that the training should include all the ED staff, not just clinicians, because sometimes registration staff, or even security guards, will be in a position to pick up on cues that the clinician may not see.
There are anti-trafficking coalitions in most areas that can provide training, says Sabella. Local universities and human rights organizations may also have experts on this issue. "Have the person who handles education at your facility look into who might be available locally who could come on site and do the training," she says.
Both staff and administrators need to be made aware of how diverse the victims of human trafficking can be, explains Wendy Macias Konstantopoulos, MD, MPH, an attending physician at Massachusetts General Hospital in Boston, MA, who has been researching this issue for several years as part of Harvard Medical School's Division of Global Health and Human Rights. "This is happening in the U.S. just as much as it is happening abroad," she says. "The faces of victims are different, and can vary across the races and across the economic strata, and there is no one definition of what a victim of human trafficking should look like."
Administrators also have a role to play in making sure that the ED personnel understand that there is support behind them if they come across a patient who needs added help in dealing with this issue. "Our environment is so chaotic, stressful, and fast-paced that clinicians may feel they do not have the resources to dedicate any extra time to these patients, so providing a milieu of support is important," says Konstantopoulos.
One way to provide this support is to allocate resources toward a multidisciplinary team charged with handling these cases within the ED, adds Konstantopoulos. Ideally, such a team should include a key clinician and social workers who can connect patients with local resources such as housing, mental health care, and legal aid, she says. "Having a multidisciplinary team in place with these connections makes it a little bit easier for clinicians [to take action]," she says.
Know the subtle cues
It can be difficult to pick up on human trafficking because it is well-hidden and the victims themselves often feel shame. Furthermore, while the ED setting offers an unparalleled opportunity to identify victims, there are also obstacles associated with emergency care. "You don't have the time to build up a rapport with patients over a period of time, so it is hard [to get patients to open up]," says Konstantopoulos.
Nonetheless, there are subtle tip-offs that should alert providers that a patient may be a victim of forced servitude. For example, if a patient comes into the ED with someone else, and the other person answers most of the questions, that should be a concern, explains Sabella.
Patients who carry no identification, or who don't know where they are or what their address is, are also cause for concern. Other red flags include inappropriate clothing, a lack of any spending money, and information that makes little sense, she explains.
"If you suspect the patient is a trafficking victim, the most important thing you can do is speak to this person alone," explains Makini Chisolm-Straker, MD, a resident in the ED at Mt. Sinai Medical Center in New York, NY. "This is pretty much true of all our patients. We should speak to them alone at some point just to make sure that we are not missing something that they don't want to say in front of the person they are with. There really is a provider-patient bond that you can build, if only briefly, so it is a matter of building that trust."
Chisolm-Straker began researching how health care providers can intervene in cases of human trafficking while she was in medical school, and she now regularly speaks to health care providers about this issue. Typically, you can ask patients whether they feel safe at home or at work, but Chisolm-Straker stresses that it is important to remain calm when patients reveal that they are in a forced-labor situation. "A surprised response suggests to patients that you may not believe them, which is the last thing you need because they're going to close down," she says.
Further, unless patients are minors, it is their decision on whether to leave their exploiter or not. "I can't make a 23-year-old leave a situation that I know is not safe. I can only say that this is a safe place and that I am a safe person," explains Chisolm-Straker. "I tell them if they want to leave in the future, we are here 24/7."
Build off of existing policies
For ED managers who have not yet taken up the issue of human trafficking, they should consider building a policy off of the procedures they have in place for intimate partner violence, suggests Konstantopoulos. "Trafficking is along the spectrum of other forms of interpersonal violence, and using what you already have in place, and just adding a little bit more so that your protocols include trafficking, would be feasible," she says. "Labor trafficking is not so much like domestic violence, but certainly sex trafficking can be like it, particularly here in the United States, where many of the victims are American-born."
Konstantopoulos says many of these victims describe what sounds like domestic violence, where they thought they were dating an older boyfriend, and then this person slowly started to groom them for the streets. "They don't really see themselves as victims of trafficking. Sometimes they don't see themselves as victims at all. In that sense, it is very similar to domestic violence," she says. "Certainly, using what is already in place [makes sense] rather than trying to reinvent a whole new field when it is another part of a spectrum that we have already addressed in the health care setting."
Human Trafficking Resources for Health Care Providers