SPONSORED BY The MOUNT SINAI EMERGENCY MEDICine DEPARTMENT, the AMERICAN OSLER SOCIETY, the AMERICAN MEDICAL STUDENT ASSOCIATION, & the BROWN alpert MEDICAL SCHOOL

Information

Labor and sex trafficking is a “hot topic” in the media, but it is not a new issue to those surviving their situations, and clinicians have been—usually unknowingly—serving this population for decades or longer. Healthcare practitioners are among the professionals most likely to interact with trafficked persons, especially those in emergency departments (EDs). Emergency healthcare clinicians often miss or mistake the signs of human trafficking, and are uncommonly aware of how to best serve this patient population. We can do better.

Emergency care practitioners must recognize possible trafficking presentations to offer patients opportunities for relevant treatment. This website contains information specifically aimed at clinicians; it is a basic introduction to labor and sex trafficking, the clinical presentation of patients in a trafficking situation, and the sometimes unique treatment needs of this patient population. Click on the "Educational Tools" tab for helpful instruments in educating practitioners at your institution.

The recruitment, transportation, harboring, obtaining, and/or provision of a person;
by the threat or use of force, fraud, and/or coercion;
for the purpose of sexual exploitation or forced labor.
Source: Trafficking Victims Protection Act of 2000

• The recruitment, transportation, harboring of a person:

Trafficking does not require transnational movement, or any other movement, of persons; anyone can be victimized for the purpose of trafficking: documented and undocumented immigrants, migrant workers, US citizens and residents.

• or the obtaining or provision of a person:

This means that the trafficker has given another person payment, of some kind, for the use of the person trafficked. For example, a legal guardian with a substance use disorder may offer their child’s labor or body to someone else, in exchange for access to a drug.

• By the threat or use of force, fraud, and/or coercion:

Trafficking can result from a real or a perceived threat; an individual only has to believe that they or loved ones are in danger, they do not actually have to be in danger. The person trafficked believes that if they do not do what the trafficker demands (regardless of the trafficker’s actual ability to follow through with said threat(s)) there will be dire (physical, financial, legal, or other) consequences. Traffickers use a variety of techniques to manipulate people. They often use of psychological, financial, and/or legal control mechanisms, often minimizing or precluding the need for physical violence or confinement.

Or the trafficker actually does a harmful thing, causing the person trafficked to reasonably believe they have no other choice but to do as they are told.

• For the purpose of sexual exploitation or forced labor:

The trafficker uses the trafficked person for monetary or other commercial gain.

An important caveat, is that for people under the age of 18 years, any kind of commercial sexual exploitation qualifies as sex trafficking, regardless of third-party involvement. This means that a minor that receives anything of value (e.g., shelter, medication, clothes, food, phone, drugs) in exchange for a sexual act is legally considered a victim of human trafficking. This caveat does not (yet) exist for labor trafficking of minors. That is to say, a legal determination of labor trafficking of minor requires the use of force, fraud, and/or coercion.

• Trafficking affects people from the US and not from the US. Sometimes the person came, of their own accord, to the country and was then trafficked; sometimes people are duped from the very beginning; sometimes they are from the US. People with a trafficking experience do not speak a particular language or have a particular race; a trafficked person can look like anyone.
  

• Women and girls are more likely to be recognized as trafficking survivors. Men and boys are under-recognized as experiencing labor and sex trafficking. People with a transgender experience and nonbinary people may be at higher risk of being trafficked, given systematic oppression and marginalization that makes safe employment and housing hard to come by.

The most common form of human trafficking is labor trafficking. People can be trafficked in legal and illegal industries. Examples of ways in which people are trafficked include: being made to shoplift or steal; selling drugs; doing domestic service; working as a home health aide; working in construction; working in agriculture; working in restaurants; working in a strip club; performing sex acts for things of commercial value.

Who is a trafficker?

They may operate as individuals, families, or more organized groups of criminals, and may be facilitated by other indirect beneficiaries, such as advertising, distribution, or retail companies, and consumers. People of any gender can act as a labor or sex trafficker.

Traffickers may be professional or non-professional criminals because of the low start-up cost of trafficking. Trafficking is appealing because it is so lucrative: people can be used repeatedly. Traffickers often have socially acceptable relationships to patients; they may be patients’ parents or legal guardians, partners, or family members. They may be introduced as a patient’s boss or supervisor. This is why it is so important to speak with all patients, at least once during a visit, without their visitor. It is poor clinical practice to use visitors to interpret when the clinician and patient do not share a common language; practitioners should always use a certified medical interpreter.

Statistics that are reliable are often hard to come by in this field; offered statistics should always be interpreted cautiously. Labor and sex trafficking is a crime so finding out just how many are victimized has been difficult. Finding local statistics may also be difficult, but local organizations are better equipped to tell you about what kinds of trafficking they are seeing. Ideally, we need to know the number of persons trafficked locally, the number of people presenting as patients, and the number of survivors recognized and served because of hospital intervention. It is useful for clinical facilities to know from which social service facilities the referrals are coming. The National Human Trafficking Hotline collects data on how many calls and texts it receives about trafficking, but this is convenience sample data. That is to say, just because a call is not made does not mean trafficking is not a problem there. Many organizations serve people with a labor and/or sex trafficking experience; this directory is a useful place to start learning about anti-trafficking services in your area. Talk with your local anti-trafficking community-based organizations before you need them for a patient; they can connect you with other service organizations, to help you develop a more robust resource list specific to your clinical site.

• As with statistics, laws also vary state to state, but the federal law protects trafficking victims, as does international law, and prosecutes traffickers. The Trafficking Victims Protection Reauthorization Act of 2005 is an important document with which trafficking educators should be familiar.

• State and federal law are very clear that minors are a special population that requires special protection. The trafficking of an adult can only be reported to law enforcement if the adult consents or request. If a person under the age of 18 years (regardless of emancipation status) presents to a healthcare facility and a clinician is concerned for trafficking, the clinician is a mandated reporter; the Childhood Abuse and Prevention Treatment Act, reauthorized in 2015 requires that for concerns of “severe forms of trafficking” (labor and/or sex) of a minor, clinicians should report to their relevant state institutions (e.g., Central Registry of Child Abuse and Maltreatment). The requirement to report is a federal mandate, and may not align with state mandating reporting laws or capacities to intervene. No mandated report should be made in secret from the patient. 

After a patient is recognized as possibly experiencing labor and/or sex trafficking a few things can happen, all of which depend on what the adult survivor wants. Clinicians and/or social workers should have honest and respectful conversations with patients. The patient may not be ready to leave their situation; just as in intimate partner violence situations, this decision should be trusted and respected. The practitioner and/or social worker should use harm reduction and patient-centered approaches to work with all patients to determine the safest course of action. Patients can choose some services (e.g., mental health help) and not others.

Examples of services that patients may ultimately need or want (this list is NOT exhaustive, nor applicable to all patients):

·      Child Nutrition Program

·      Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

·      Substance Use Disorder Support

·      Victims of Crime Act (VOCA) Victim Compensation

·      Federal Victim-Witness Coordination

·      Emergency Witness Assistance

·      Witness Security Program

·      T- or U-Visa

·      Continuing Presence

·      Public Housing Program

·      Medicaid

·      Temporary Assistance for Needy Families

·      Supplemental Security Income

·      Job Corp

·      Title IV Federal Student Financial Aid

Clinicians in the ED do not need to assess patients for interest in and eligibility for all programs. Rather, clinicians should address healthcare first and then (with a multidisciplinary team when possible) develop an overall understanding of the patient’s immediate needs and goals to connect patients to appropriate local anti-trafficking organizations. To successfully do this, clinicians should work with their institutions to develop a robust anti-trafficking recognition and response protocol.  

Corruption is especially unfortunate in circumstances like those that surround human trafficking because trafficked persons cannot always count on the very people who ought to be helping them. Sometimes patients have already had prior negative experience(s) with law enforcement, which makes them scared of police and, more generally, mistrustful of institutions and people that are supposed to help. Practitioners are not always aware of who can be trusted in their local police departments. In developing institutional protocols, institutions to should learn which law enforcement numbers should be used, if the patient requests (or if state law requires clinicians report concerns of trafficking to law enforcement). Local anti-trafficking organizations are great resources and know when to contact which teams in law enforcement. Clinicians should ensure law enforcement is not called unless there is an active police emergency, they are mandated reporters to law enforcement, or the patient requests.

Note that this does not mean all law enforcement are corrupt, but that some have tainted the reputation of the institution and the result is that trafficked persons often do not trust law enforcement officials. It takes a great deal of time and effort to rebuild that trust and local anti-trafficking advocates are better positioned than the ED clinician to help rebuild that trust. Many law enforcement officials are receiving some training about working with trafficked persons, but because of previous bad experiences and sometimes misconceptions about police, service organizations are often a better next point of communication and connection for patients.

The general standards that apply to a survivor of sexual assault can be applied to a labor and/or sex trafficked person. Documentation can be useful in the event that the patient decides to involve the justice system. That said, if clinicians are not trained in forensic interviewing and documentation, it is best practice to document only what is medically relevant to their care for that visit. Details, such as “who, where, when” are not necessarily helpful to include and can actually be harmful. More instruction can be found here.

Presumptive treatment for sexually transmitted infection (for sexually exploited patients) is best clinical practice. A 2005 Doctors of the World document (above) describes empiric therapy, but as bacterial resistance and required antibiotic doses change, please use institutional antibiograms and/or Centers for Disease Control and Prevention (CDC) guidelines for dosing. Otherwise, clinicians should take care of the patient in front of them, using the best available evidence and highest standards of care. Patients who need to be admitted should be offered admission; patients that require transfer for specialty care should be offered transfer; patients that can be discharged (or decline admission) should be offered follow up (e.g., return to ED and/or outpatient service connections).

Anti-trafficking non-governmental organizations (NGO) offer trafficking survivors a safe space and the support of other survivors and advocates. Temporary housing, clothing, food, healthcare, counseling, food assistance, and legal aid may be available (depending on the organization), and educational (ESL classes, for example) and job opportunities may be offered. Anti-trafficking NGOs can also help some international survivors apply for T-, U-, or continued presence visas.

Local anti-trafficking NGOs are often the best resources from which to get information for trafficked patients. Note that all NGOs are not familiar with the needs of trafficking survivors. Anti-trafficking NGOs are experts in helping trafficked persons survive and thrive after (and in some cases during) their trafficking situation but clinicians should not make promises to patients.

Whatever causes the patient to present, may only be a symptom of a disease. Just as clinicians understand that fatigue, confusion, shortness of breath, and pruritis may be symptoms of kidney disease, we must also recognize that cigarette burns, ligature marks, depression, malnutrition, and docile or hostile demeanors may be symptoms of human trafficking. Merely treating the symptoms of kidney disease does not serve the best interests of the patient, nor does treating the symptoms of human trafficking without respectful, caring probing into underlying causes. Human trafficking should be considered in the differential when a patient presents to the ED with certain symptoms or signs (see the “In the ED” tab for more).

Clinicians should note, however, that making the “diagnosis” is NOT the goal of the clinical encounter. EM practitioners should focus on the provision of high quality healthcare. In doing this, using CLAS Standards, and patient-centered and harm reduction principles, patients can recognize the ED a safe place to receive care and connect to services. Attempting to force a trafficking disclosure disrupts the patient-practitioner relationship and is counterproductive to healthcare provision.

Read or listen to the stories of Jill Leighton, Ashek Hamid, and Ricardo Veisaga. There are many different ways in which people are trafficked and these stories only illustrate three. All three of these people could (or did) present as trafficking patients in an ED and all of them might demonstrate signs or symptoms of trafficking; think about who would present how. The stories of Leighton, Hamid, and Veisaga are true and give names to the millions that are counted as nameless. Emergency healthcare practitioners have a significant role to play in learning the names of these people but first practitioners must be made aware of the issue. 

National Human Trafficking Hotline

1-888-373-7888