EXECUTIVE SUMMARY

Victims of human trafficking often seek medical treatment while they are in captivity, but experts note that too often frontline providers miss the signs that these patients are in trouble as well as the opportunity to intervene. However, with education and training in this area, providers can learn to identify potential victims, approach them in a non-traumatizing way, and link them to appropriate resources.

  • Investigators note that 50-80% of the time, healthcare providers miss the identification of victims of human trafficking, and 68% of the time, these patients present to the ED.
  • Trafficking victims may have been to multiple hospitals giving different names. They may appear younger than the age they state because they are asked to lie. They may tell a vague or inconsistent story about their injury or history.
  • Other red flags include a suicide attempt, a drug overdose, or patients experiencing pseudo seizures, a condition whereby patients will fake uncontrollable seizures as a method of self-preservation.
  • Two of the biggest issues that EDs must address if they are going to identify victims of trafficking are substance use and safe housing.

The U.S. Department of Justice estimates that 14,500-17,500 people are trafficked into the country annually, and that does not include the thousands of trafficking cases involving U.S. citizens. Further, the Department of Health and Human Services (HHS) estimates 240,000-325,000 children are at risk for sexual exploitation annually.

Researchers note that most victims seek medical treatment while they are in captivity, making frontline providers ideally positioned to recognize the plight of these patients and connect them with appropriate help.

However, in too many instances these opportunities slip away, explains Amber Egyud, DNP, RN, the chief nursing officer and vice president of patient care services at Forbes Hospital, a level II trauma center in Monroeville, PA, and part of the Allegheny Health Network, a large health system serving western Pennsylvania. Egyud is the lead author of a new study that outlines a multidisciplinary approach aimed at helping healthcare professionals better recognize when a patient could be a trafficking victim, and how to intervene most effectively.1

In her own research on the subject, Egyud found that 50-80% of the time, healthcare providers miss the identification of victims of trafficking when they present for medical treatment, and roughly 68% of the time, these patients present to the ED. “We completely miss it,” she explains. This realization is what prompted Egyud to study the issue and determine what kinds of assessments and education could be provided to frontline providers to help them improve in this area. “I knew we weren’t doing anything specific to human trafficking,” she says. “We all do domestic abuse screening, but we really weren’t educating about trafficking in our health network.”

Learn the Signs

Typically, trafficking victims will seek care in the ED because they are unable to work or they have suffered a trauma or been the victim of a violent assault, Egyud notes. “Anything that would prompt them to need medical attention is when we would have the opportunity to intervene,” she says.

However, emergency personnel must be aware of the signs of trafficking. For instance, rape is one of the red flags. Also, these patients may present with sexually transmitted diseases (STDs) or they may report an unusually high number of sexual partners for their age, Egyud observes. “They may have been to multiple hospitals giving different names. They may appear younger than the age they state because they are asked to lie. They may have a vague or inconsistent story about their injury or history,” she shares. “What they are saying about their injury may not match [the clinical evaluation].”

Other red flags include a suicide attempt, a drug overdose, or what Egyud refers to as a pseudo seizure. “It’s a condition where people will have fake seizures, uncontrollably, as a method of self-preservation,” she explains. To help clinicians recognize the social signals, Egyud and colleagues incorporated assessment questions, suggested by HHS, into the hospital’s electronic medical record (http://bit.ly/2wG0jsp).

For instance, if clinicians suspect that a patient may be in some trouble, they may ask whether there is someone making the patient do something that he or she does not want to do or whether the patient can come and go as he or she pleases, Egyud explains. “Then, we use our clinical judgment for the medical red flags such as STDs, drug addiction, pseudo seizures, suicide attempts, traumas, and inconsistent injuries or stories,” she says. “We put that all together, and then if there is a suspicion of human trafficking, we have a treatment algorithm where we actually make sure that we separate the person who brought the patient [to the ED], who is often times a pimp or the person who is holding the patient captive.”

Clinicians will follow the treatment algorithm to make sure the patient is medically stable and isolated from danger. “We try not to tip off the handler of the patient because that could become a security issue,” Egyud observes. “We involve security, social services, the local police department, and the [FBI], and then we plan a rescue for the patient in conjunction with local authorities.”

If the patient is younger than 18 years of age, the hospital notifies children and youth services; for older patients, local police help provide a rescue, Egyud adds. However, Egyud emphasizes that the pathways for treatment and rescue must be established ahead of time and they need to be well-understood by care providers.

“We developed an algorithm for action, and we implemented the education and a screening tool,” Egyud observes. “We developed a treatment algorithm for the ED so that [emergency personnel] can follow the algorithm. Everybody knows their role in the algorithm and what to do.”

Facilitate Disclosure

Embedded within these policies and procedures is a process for what Egyud refers to as silent notification. This is a method that patients can use to notify staff that they are in trouble for cases in which their captors are with them or they are too afraid to voice their predicament.

“Some people can’t tell you what is going on or don’t want to disclose what is going on as far as trafficking because they have been coached that if they tell, they will be the ones who will get arrested for prostitution or for other crimes, and they will have no place to live,” Egyud explains. “They often live in fear that if they disclose what is happening, bad things will happen to them or there will be threats of violence against them or their families.”

To help such individuals communicate what is happening, the team at Forbes Hospital developed a process whereby if the staff suspects that a patient may be a victim of trafficking or any kind of abuse, the patient will be directed to use a patient-only restroom, where there is a sign telling patients to place a blue sticker on their urine specimen cup if they are in an unsafe situation or they need help. “If the patient puts a blue sticker on the cup, then we know that even if he or she can’t verbalize [the threat] or the handler won’t leave the patient alone long enough to verbalize, then they can just hand in the urine specimen with the blue dot on it and we know the patient needs rescue,” Egyud shares.

During a five-month period, investigators tracked the effect of the education, screening, and rescue protocols implemented in the ED. Clinicians identified 38 potential victims, with about 20% accepting rescue from their abusive environment. One of the identified patients was a trafficking victim, while the others were victims of other types of violence, Egyud explains. Among the ED personnel who participated in the project, 75% indicated that the education and training improved their competence level in recognizing trafficking victims.

One frustrating reality when dealing with this issue is that it often takes multiple encounters before a victim is ready for rescue, Egyud notes. “If the patient is over 18, there is nothing we can do unless the patient asks for help or is willing to disclose [that he or she is a trafficking victim],” she says. “We have identified people who were at risk for trafficking or even said they were trafficked, but they weren’t ready for rescue. They screened as potential victims, but declined intervention.”

Nevertheless, staff members have encountered few roadblocks while implementing these procedures. “We have sustained the program since its implementation in February 2016, so we are about 18 months into it,” Egyud shares. “We continue to have our screening tool available, we continue to do education at various points throughout the year, and our network hospitals have also almost all implemented [the program] in their facilities as well.” Although some health systems are taking steps to focus more attention on human trafficking, awareness among healthcare providers remains low, according to Wendy Macias-Konstantopoulos, MD, MPH, an attending physician in the ED at Massachusetts General Hospital (MGH) in Boston, and medical director of the hospital’s Human Trafficking Initiative, which launched in 2008. “There are groups across the country that are trying to increase the level of awareness and do some educational training for healthcare providers who are seeing patients in settings like EDs, but I think it is still an ongoing challenge that needs to be addressed,” she says.

Helping victims is complicated by the fact that so many of them are unwilling to self-identify, Macias-Konstantopoulos observes. “One of their main jobs when they come in is to not be identified [as a trafficking victim] for fear that they will be exposed to more physical harm by the trafficker,” she says. “Traffickers often coach victims and teach them to lie about their age or about their identity, and if they are being labor trafficked and they are in the United States without proper documentation, they may be even more frightened about the possibility of being identified and turned in to the authorities.”

Recognizing the signs that a patient may be a trafficking victim, and learning how to approach the individual, requires significant training, Macias-Konstantopoulos notes. “You need to [talk to them] in a way that is not re-traumatizing, and then if they do disclose, you need to know what the next steps are,” she explains. “In the same manner that we would be trained around how to react and respond to a family with children who might be experiencing child abuse or an elderly person who might be experiencing elder abuse, we need to learn how to respond to human trafficking.” There is a lot of crossover between the opioid epidemic and what healthcare providers see in trafficking patterns, Macias-Konstantopoulos notes. “If you have a patient who has been exposed to substances and has become addicted, and their trafficker is their supplier ... that can go way beyond anything the patient has control over,” she says. “These [patients] would rather be exposed again to the emotional and physical harm than bear the pain of the withdrawal that they are experiencing.”

Another issue that can be particularly difficult to tackle is finding safe housing for trafficking victims. “I think it is one of the most scarce and yet important resources needed for combatting trafficking and being able to assist these victims,” Macias-Konstantopoulos offers. “A shelter is not always the best place for these patients because many of them have been victimized or trafficked out of a shelter, so going back to a shelter is very traumatizing, and if that has been their experience, most of the time they would prefer to stay on the street.”

Safe housing and substance use treatment are key issues that emergency personnel should consider ahead of time if they are going to start identifying trafficking victims, Macias-Konstantopoulos stresses. “You have to be ready to respond to those resources,” she says.

Assemble Resources

The Human Trafficking Initiative at MGH is a center for research in this area, and it also provides education and training to hospitals on how to recognize and interact with trafficking victims who present to healthcare settings. In addition, the initiative has established the MGH Freedom Clinic, which is dedicated to providing long-term primary and mental healthcare to the victims and survivors of trafficking. “We see patients who are 13 years old and older who have had various experiences with trafficking,” Macias-Konstantopoulos says. “We also have case management to work with them to figure out what their social needs are ... and they are referred to community resources to make sure they are connected in a way that will be productive and help them to reintegrate in a safe manner into society.”

For more information about the Human Trafficking Initiative, visit: http://bit.ly/29ahO85. Another resource for healthcare providers interested in establishing programs or initiatives to address the issue is the Project to End Human Trafficking (http://bit.ly/2xJDelf).

REFERENCE

  1. Egyud A, Stephens K, Swanson-Bierman B, et al. Implementation of human trafficking education and treatment algorithm in the emergency department. J Emerg Nurs 2017 Apr 18. pii: S0099-1767(17)30041-7. doi: 10.1016/j.jen.2017.01.008. [Epub ahead of print].

SOURCES

  • Amber Egyud, DNP, RN, Chief Nursing Officer, Vice President of Patient Care Services, Forbes Hospital, Monroeville, PA. Email: Amber.Egyud@ahn.edu.
  • Wendy Macias-Konstantopoulos, MD, MPH, Emergency Physician, Medical Director, Human Trafficking Initiative, Massachusetts General Hospital, Boston. Email: wmacias@mgh.edu.