EXECUTIVE SUMMARY

Healthcare professionals and others often are mistaken about what human trafficking is and what its victims are like. Professionals could identify and help trafficking victims by learning the truth about the crime.

  • Traffickers are women as often as they are men. Especially in healthcare settings, women are more likely to accompany female victims.
  • If a healthcare worker suspects or knows an underage patient is a sex worker, then this must be reported. Sex workers under age 18 are trafficking victims and this situation is subject to mandatory reporting laws.
  • Trafficking victims are not always poor. Some come from suburban middle class and affluent backgrounds.

One reason why too few healthcare workers identify and help trafficking victims is because their mental picture of what a victim looks like does not always match the kinds of victims they’ll see in their centers. There are several myths about trafficking. Experts dispel these myths and offer additional advice on how to identify and help victims.

Traffickers are men. People don’t think of female traffickers, yet an estimated half of all traffickers are women, says Mellissa Withers, PhD, MHS, at the Keck School of Medicine at the University of Southern California. “Often, when a healthcare professional sees another female, it doesn’t raise a red flag with people,” she says. “They assume that if the person’s a female, she’s not going to be a trafficker, and it’s not true.”

Women are more likely to accompany a female trafficking victim to the healthcare facility, particularly in cases of immigrant labor trafficking victims, Withers notes. “They send women to accompany the person who is being trafficked so no one will become suspicious.”

Immigrant victims do not speak English. “Traffickers will pretend the person being trafficked doesn’t speak English, and they’ll say, ‘I need to be with her. She’s my cousin from Thailand, and she doesn’t speak English,’” Withers explains.

Traffickers might say they need to be with the patient at all times to translate. “There’s never an opportunity for the victim to be alone with a provider because this person is watching over them,” Withers says.

Healthcare providers should enforce a policy of separating patients from the person who accompanied them. If a translator is needed, the provider can use a telephonic interpretation service. Healthcare organizations that receive federal funding are required to offer professional healthcare interpretation services. It is a requirement in Section 1557 of the Affordable Care Act.

“This requires a policy shift on the part of the clinic, but it seems like it would be worth it in the end,” Withers says. “In the clinics I work with, we say they need to institute a policy where at some point they can say, ‘Due to confidentiality, you need to wait in the waiting room,’ and they have interpreters available.”

Underage prostitutes choose to be sex workers. All sex workers under age 18 are trafficking victims. They are not legally capable of choosing to be sex workers. The mean age of U.S.-born trafficking victims is 16.5 years. More than half of the overall victims were under age 18 when they were first trafficked.1 Healthcare providers are mandated by law to report cases of underage sex workers.

“Most health professionals would not know that someone under age 18 involved in commercial sex is being trafficked,” says Hanni Stoklosa, MD, MPH, executive director of HEAL Trafficking in Boston. “But that’s the federal definition of trafficking, and just by knowing that definition, it opens a health professional’s eyes that the girl dressed weirdly in the middle of the night and who has a foreign body in her rectum or vagina is being trafficked. That’s reframing what one may have judged or noticed, but didn’t have a label for it.”

Healthcare professionals know how to look for the signs of abuse, and now it’s time to use the same skills to look for mismatches between the young patient’s story and their physical and medical problems, Stoklosa adds.

“Look for why they broke an arm a week ago,” she suggests. “Have the ability to ask questions, fill in gaps, and realize that some gaps might be caused by violence or abuse.”

Trafficking victims come from poverty. “Everyone thinks people who are trafficked come from poverty, and that’s not true,” says Patricia O’Malley, PhD, APRN-CNS, a nurse researcher with Premier Health. “Every economic stratum is subject to trafficking. Traffickers like to cruise malls in affluent communities, and they know how to identify children who are at risk.”

Traffickers start relationships with young people, buying them extravagant presents, and eventually manipulating them into a relationship that becomes a bondage situation. “They like the suburbs,” O’Malley adds.

One trafficking survivor’s experience is an example of this phenomenon. “I was raised in an upper middle class neighborhood,” says Theresa Flores, LLW, director and founder of the S.O.A.P. Project in Columbus, OH. Flores was 15 years old when a classmate drugged, raped, and photographed her. He blackmailed her with the pictures and threatened her life and her family’s lives if she didn’t do what he wanted. Flores was forced into prostitution, a stint that lasted two years.

Flores’ rescue came when her father’s work transferred him across the country. That was her escape, but she still never told her family what had happened to her until she was grown up and ready to share her story with the public to bring attention to trafficking.

“About five years after it, I told my family a little about it, but I didn’t tell them more until I went on the ‘Today’ show,” Flores says. “They thought that I was just going through teenage hormones or growing pains or being a rotten kid and having a hard time adjusting to where we were living. Who would have ever thought that was happening to your child when you live in a $200,000 home in a nice neighborhood?”

While Flores was a trafficking victim, she experienced migraines and gastrointestinal problems. Her parents took her to doctors for exams. “I believe those were directly related to the stress and trauma of being trafficked,” she says. No physician or nurse asked Flores whether she was sexually active or whether anyone was doing something to her that made her uncomfortable. If they had asked, while her mother was in the room, she wouldn’t have told the truth, Flores says.

“I know a lot of survivors that were trafficked by their fathers or a family member or a neighbor, and their mothers and the school had no idea,” Flores says. “Traffickers brainwash people — like a cult, and they use anything they can to threaten you with, holding something over you so you’re terrified to talk with anybody. You’re just wishing and hoping somebody will say something to you to get you out of that situation.”

If trafficking victims repeatedly visit doctors with obvious injuries of abuse, they’ll be identified. Unfortunately, this is not true.

“I’ve talked with some foreign-born victims, and one labor trafficking victim from Indonesia saw 17 healthcare providers, including in the ER, while she was being abused, and not one time did anyone ask her about the abuse,” Withers says. “Another woman from Indonesia would go with [the victim] to these visits. Sometimes, [the victim] had an odd physical injury because of beatings, and still no one suspected she was a trafficking victim. The woman was enslaved for years before she was rescued when a neighbor called in a tip on the trafficking hotline.”

Most trafficking victims will ask for help if they are alone with a healthcare professional. This almost never happens. The victims are brainwashed, manipulated, terrified, ashamed, and distrustful of everyone in authority, including healthcare staff.

“Do you believe you’ve never cared for a trafficked person? Think again. You have,” O’Malley says. “[Victims are] very good at hiding. They’re trafficked through fear and their relationship with the person trafficking them. It’s modern slavery.”

O’Malley explains that in addition to fear of personal harm or retaliation against loved ones, victims often feel shame for these relationships. Flores says healthcare providers should look these patients in the eyes and ask them whether someone is doing something to them that makes them uncomfortable or whether they’re in an uncomfortable situation they’d like to get out of.

When trafficking survivors talk about their past trauma and experiences, many say that their healthcare providers knew they were prostituted, but never asked them about their lives, Flores says.

“Nobody wants to be in that life,” she says. “No one chooses to have sex with 20 men every night. No one does it voluntarily. And there’s no such thing as a 14-year-old or 15-year-old prostitute — that’s trafficking.”

Since victims often do not leave the trafficker, there’s little point in healthcare providers trying to speak to them. It can take many visits to healthcare providers who reach out and build trust with a victim before the person decides to escape trafficking. Each time a healthcare provider tries to help a victim, it can help lay groundwork for the time when victims feel strong enough to ask for help.

“Even if they get a woman alone in the room and ask her if she’s being abused or trafficked, she may not want to say anything the first time around,” Withers says. “But you still have the opportunity to say, ‘If you are, this is a safe place where you could tell someone. I would be a good person to talk with, and I would keep everything confidential.”

This creates space for trust. “Victims have been threatened, beaten, and have been told the police will arrest them ... but [victims] often will go back to that clinic and provider at a follow-up visit. Planting that seed is really important, whether or not they decide right then to reveal,” Withers says.

O’Malley says healthcare providers can provide patients a trafficking hotline number to call for assistance after leaving the facility. Still, providers must report any time they suspect a person under age 18 is a trafficking victim.

“In clinics, provide information cards about trafficking,” O’Malley suggests. “Put cards about the National Center for Human Trafficking and the trafficking hotline in your waiting room.”

But providers should be cautious when they do identify a victim because the person lives under a constant threat. Providers should use discretion in assessment and referral, O’Malley counsels. Sometimes, providers use discretion for their own safety.

“I’ve gotten a call from a clinician in an outpatient clinic in a strip mall, and he says, ‘I know this guy is a trafficker, and he comes in here with them, and I’m scared and don’t know what to do,’” Stoklosa says. “I gave him a National Human Trafficking Hotline number so he could place it, stealthily, where the victim could find it.”

Another reason a trafficking victim might be reluctant to speak, even when alone with a healthcare provider, is because traffickers use spyware on victims’ cellphones to listen into their conversations, Stoklosa says.

“If they know spyware is on their phone, they might not be forthcoming,” she says. “But you could write a message and give them a chance to say something that’s not out loud.”

One way to get trafficking victims alone is to walk with them to obtain a urine sample, and ask victims to leave their phone with the traffickers, she suggests.

If the victim lacks residency documents, helping them might also hurt them. Foreign-born trafficking victims might have visas or passports that their perpetrators are guarding. Or, their legal status might be questionable. Either way, the government has the ability to process certain types of visas, specifically for trafficking victims, Withers says. “It can be connected to services — housing, job services, and they’re not forced to go home.”

Healthcare providers should help identify trafficking victims and get them help whenever possible, Withers adds. “Imagine how sad it would be as a healthcare provider to think I had the opportunity, and I had this weird feeling in my gut, but I didn’t say anything or pursue it. I didn’t do anything, and the person spent another five years in slavery.”

On the other hand, Withers asks healthcare providers to imagine helping someone get out of trafficking. “Think about how wonderful it would be to be the person who could save someone from that type of exploitation and abuse.”

REFERENCE

  1. Chisolm-Straker M, Baldwin S, Gaïgbé-Togbé B, et al. Health care and human trafficking: We are seeing the unseen. J Health Care Poor Underserved 2016;27:1220-1233.

More Educational Resources

  • The American Medical Association adopted a policy that calls for physician education to identify and report suspected cases of human trafficking to authorities and to ensure victims have the necessary medical, legal, and social resources (http://bit.ly/2uPiXuH).
  • The Institute of Medicine and National Research Council published a guide to confronting commercial sexual exploitation of minors for the healthcare sector (http://bit.ly/2Lsnqh8).
  • Healthcare facilities could list ways for victims to reach help. These include the National Human Trafficking Hotline at (888) 373-7888 or the BeFree Textline (Text “HELP” to 233733). More information about trafficking signs and facts are available at: https://bit.ly/2z4P0vT.