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Human trafficking is a worldwide problem. Often, victims are invisible to the public, including healthcare providers, who could help rescue victims if the public knew more about the issue.
Modern slavery, also called human trafficking, harms an estimated 21 million people around the globe. Victims include immigrants, young adults, and adolescents in the United States. They come from the suburbs, as well as the cities, and they work in brothels, farms, factories, beauty parlors, private homes, construction, and other places, according to Human Rights First (Learn more at: ).
Sixty-eight percent of these victims might be hiding in plain sight. They visit EDs, urgent care clinics, and see nurses, primary care doctors, obstetricians/gynecologists, and other healthcare practitioners.1
Ambulatory surgery centers (ASCs) also see but rarely recognize these victims. “A number of studies show us that the majority of trafficking victims in the United States access healthcare at some point during their exploitation,” says Hanni Stoklosa, MD, MPH, emergency physician, Brigham and Women’s Hospital, director of the Global Women’s Health Fellowship, Mary Horrigan Connors Center for Women’s Health & Gender Biology, and executive director of HEAL Trafficking, all in Boston.
“They’re accessing healthcare at every single point in the health system, and they all represent opportunities for healthcare professionals to interrupt that victim’s cycle of violence and set them on a path toward safety and freedom,” Stoklosa says.
Human trafficking is the subject of a new advisory by The Joint Commission, which calls human trafficking the fastest-growing criminal industry in the world. The advisory alerts healthcare professionals to recognize the signs of trafficking and to provide trafficking victims with information and options, while supporting victims as they connect with service providers (Available online at: ).
Traffickers are skilled at evading the law and will select healthcare settings where they are less likely to be caught, according to Mellissa Withers, PhD, MHS, associate professor of clinical preventive medicine, department of preventive medicine, at the Keck School of Medicine at the University of Southern California.
“[Traffickers] won’t go to a place where people are well-trained in identifying trafficking victims, so they’ll go to smaller places where they won’t be questioned about it,” Withers says. “And they won’t use insurance. They will pay in cash.”
Traffickers might even select a surgery center that is accustomed to treating out-of-state patients. For instance, when Jasmine Marino was a teenager, she was manipulated into a sex trafficking nightmare, sometimes beaten, always threatened, and for years unable to seek help. But she saw healthcare providers during this time, and mostly they didn’t notice anything unusual about her.
At one point her trafficker, also a young man, flew her to Florida from Massachusetts for breast implant surgery. “My trafficker thought I would look better with the implants,” Marino says. Marino’s traffickers had been using the services of a surgeon whose cost was about half the price of local surgery centers, so the traffickers made Marino schedule an appointment by phone.
In a labor trafficking case, another young woman had worked for four years in domestic servitude. She was not paid for her work, and suffered from ingrown toenails that became so severe she could not wear shoes. When the traffickers allowed her to see a doctor, she had to have surgery to remove the toenails or she would have lost her toes, according to a report by the Human Trafficking Legal Center of Los Angeles (Learn more at: ).
Physicians and healthcare providers do not put trafficking victims on their radar unless they’ve been trained to look for signs. Even then, it can be difficult to spot because the traffickers are so skilled at manipulation and not getting caught, Withers says.
“They’re good at not putting injuries on victims that are obvious that there’s a problem,” Withers says. “You don’t actually see a lot of visible injuries in sex trafficking cases, while with labor, you’d probably see more of that because of the nature of the work.”
Victims see healthcare providers under several different circumstances. For some victims, they see healthcare providers after they’ve been taken to the hospital by the trafficker or discarded by the trafficker because they’re so sick. Other times, the trafficker might be trying to make the victim more profitable in sex trade by paying for plastic surgery. In labor trafficking cases, the victim might have sustained injuries that need treatment, Stoklosa says.
“We’ve seen horrible cases where the person was tortured by tooth extraction — the molars in the back, where they’re not visible,” she says. The extractions could lead to infection, which could lead to a doctor visit.
In another example, the victim might have been punched and kicked, leading to wounds or even orthopedic injuries.
“One pattern I’ve heard from providers is how when victims get to such a point of desperation that they will jump off the second floor of a building or jump from a moving car,” Stoklosa says. “This clearly is a sign of desperation where they think, ‘Maybe I can escape by dying.’”
At some healthcare facilities, staff members are trained to watch for fall injuries and screen these patients for trafficking. Premier Health in Dayton, OH, collaborates with other organizations to offer seminars for nurses about human trafficking, says Patricia O’Malley, PhD, APRN-CNS, nurse researcher for Premier Health.
“It was amazing to listen to the feedback from people speaking at the seminar,” she says. “People involved in trafficking clinics and attorneys shared information about debt bondage, when people are terrified of the person holding them hostage.”
The bondage situation usually begins when people from other countries are baited into traveling to the United States for friendship and financial reward via a work permit, O’Malley explains. “Once they’re in that relationship, they can’t get out because of the threats.”
Healthcare workers should be aware that labor trafficking victims can come from several fields, including construction, farming, domestic service, restaurants, nail and hair salons, elder care, child care, forestry, and more.
“Healthcare has not figured out how to identify labor trafficking,” Stoklosa says. “When you look at the studies, so many are focused on sex trafficking, which does disservice to labor trafficking cases because those numbers are so much higher.”
When healthcare professionals see a patient whom they suspect might be a labor trafficking victim, there are some easy ways to question them to find out the truth. (Editor’s Note: See the story later in this issue for more information.)
“One of my strategies for labor trafficking is that if I suspect I’m seeing a victim, I ask the person if I can give them a work note to take time off and if they would be able to use it,” Stoklosa says. “I’ve had patients who say, ‘Of course, give me a work note,’ and others say, ‘No, I have to work.’”
When a patient declines the work note, this is an opportunity to follow-up, saying, “Tell me about your job,” Stoklosa adds. “From there, explore whether there’s any exploitation going on. Ask follow-up questions.”
Some examples of questions to ask include:
“Then, I say I care about the medical reasons they’re there, but also about how they’re doing in the rest of their life,” Stoklosa says.
Unconscious bias can affect how the public, including healthcare providers, view sex trafficking victims. When sex workers are adults, providers often assume they chose this occupation and might not ask any questions to see if the person is a trafficking victim. For example, a patient who uses heroin might be a victim of exploitation. Some traffickers recruit people outside of methadone clinics, realizing that addiction is a vulnerability they can exploit, Stoklosa says. (Editor’s Note: See story later in this issue for more information about trafficking myths.)
“We need to address the myths and stereotypes about what a trafficking victim and trafficker look like,” Withers says. “We have a Hollywood version of beaten and drugged and chained to a bed in a room and never having a day off or having a cellphone or being able to go to a grocery store or church.”
This version of trafficking is not what healthcare providers will see. Instead, they might see a young person who has a cellphone and appears to have the freedom to escape. What the healthcare professional does not see is how this person has been psychologically manipulated, beaten down, and threatened until they live in terror. Traffickers do not need physical chains to hold them, Withers explains.
Marino believes it might have been obvious to her breast augmentation surgeon that she was in the sex trade because she was very thin, wore expensive jewelry, owned a designer pocketbook, and was with a young man. Her trafficker paid for the surgery in cash. No one at the surgery center asked her any questions or showed any suspicion about her circumstance. She saw other healthcare providers while she was a trafficking victim, and none of them asked questions. “I saw my primary care physician the entire time I was in the trafficking situation, from age 19 to 25,” Marino says. “My primary care doctor was just so interested in clicking his boxes on his check list and going through the motions of quick, rush, rush, appointment, and get me out.”
Eventually, Marino rescued herself from trafficking with the assistance of a business owner who helped Marino demonstrate a work record, making it possible for Marino to secure her own apartment. Since then, Marino became the founder and director of Bags of Hope Ministries in Boston, an outreach organization that provides trafficking victims with socks and toiletries.
Financial Disclosure: Editor Jonathan Springston, Editor Jill Drachenberg, Editorial Group Manager Terrey L. Hatcher, Author Melinda Young, Physician Editor Steven A. Gunderson, DO, FACA, DABA, CASC, Consulting Editor Mark Mayo, MS, Nurse Planner Kay Ball, RN, PhD, CNOR, FAAN, and Author Stephen W. Earnhart, RN, CRNA, MA, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.