e6-09: Human Trafficking

General Considerations

Human trafficking is a criminal human rights violation that occurs in nearly all nations and impacts persons in both rural and urban centers. The United Nations defines trafficking as "the recruitment, transportation, transfer, harboring, or receipt of persons, by means of the threat or use of force or other forms of coercion of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation." While exact numbers are difficult to obtain due to the illegal nature of trafficking, the International Labour Organization estimates that 25 million people worldwide are actively engaged in forced labor, with women accounting for 71% of those impacted. Labor trafficking involves the illegal trade of persons for exploitation or commercial gain; labor trafficking practices occur in several industries, including agriculture, construction, elder care, janitorial work, beauty services, and domestic labor. The United Nations specifically defines sex trafficking as the recruitment, transportation, transfer, or harboring of an individual by means of threat, force, coercion, or deception for the purpose of sexual exploitation. In the United States, it is estimated that 400,000 persons experience trafficking at any given time point.

Trafficking may impact persons of any age or social group. However, poverty and young age (particularly girls) are particular risk factors. Additionally, migrant workers; persons experiencing homelessness; youth who have left their homes; lesbian, gay, bisexual, transgender, or questioning youth; and indigenous people (eg, American Indian or Alaska Native people); or those with a history childhood sexual abuse are at increased risk for exploitation.

Clinicians are likely to encounter patients who are actively experiencing forced labor or commercial sex work. Survivors of trafficking report being evaluated by health providers in a number of settings, including emergency departments, public health clinics, private practice clinics, and hospitals of all types. Several signs, symptoms, and red flags may help clinicians identify patients who are experiencing exploitation and provide resources to impact their health. Clinicians should use trauma-informed care principles with all patients to facilitate trust and increase the possibility of identifying those impacted by trafficking and providing resources for further assistance.

Persons who are trafficked may experience physical threats against themselves or loved ones, lack control over their identification documents, and be subject to manipulation and abusive behaviors by those who are exploiting them; these factors serve as barriers to disclosing trafficking to health care providers. As a result, providers and health care teams need to be aware of signs and behaviors that serve as indicators of human trafficking.

Health care team members may note that patients are accompanied by an individual who takes control of the visit, does not leave the visit, or who insists on serving as an interpreter for the patient. The patient may not have their identification documents or their own money and may be unaware of their location or their own address. During the visit, the patient's history may seem scripted or inconsistent; the patient may be hesitant to answer questions related to an injury or trauma. He or she may appear nervous with poor eye contact.

Patients experiencing forced labor may present with physical symptoms related to occupational exposures or injuries, such as chronic back pain, bruising, or head trauma. Survivors of sex trafficking report interacting with health care workers for contraception, STI evaluation, pregnancy, or evaluation of unremitting infections. Survivors of trafficking often experience headaches, fatigue, dizziness, back pain, and memory problems.

On physical examination, there may be examination findings that are inconsistent with the history obtained. Patients may have visible signs of abuse that require follow-up questioning regarding the patient's safety. Patients may appear malnourished. Testing may reveal uncontrolled chronic illness, such as diabetes, hypertension, or autoimmune disease.

When patients exhibit signs or symptoms that are concerning for trafficking, follow-up questions should only be asked when the patient is alone. Raising suspicion when the trafficker is present could result in increased harm to the patient.

Barriers to disclosure of human trafficking include threats to the patient and his/her family by the traffickers, distrust, fear, shame, and hopelessness. A patient may not disclose ongoing exploitation despite multiple visits and may not return to care despite appearing interested in care. However, several practices may facilitate trust building between the patient and health care provider. For patients with limited English language proficiency, professional interpreters should always be used who can converse in the patient's language of proficiency. When patients are accompanied by others, clinicians should interview or examine patients alone for at least some portion of an encounter. Additionally, open-ended questions, empathic statements, and eye contact can help build trust while the universal inclusion of an open-ended social history with questions about home, work, and screening for intimate partner violence may provide patients with an opportunity to disclose trafficking.

Once medical concerns are assessed and treated as needed, for patients who are alone, additional questions can be asked to elicit further history concerning for trafficking. The American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women suggests several questions, including:

• Sometimes individuals do unfair, unsafe, or even dangerous work or stay in a dangerous situation because if they don't, someone might hurt them or someone they love. Have you ever experienced this, or do you think this could happen to you?

• Sometimes individuals live where they work or where the individual in charge tells them to live. Have you ever experienced, or are you in a situation in which this could happen?

Additional questions may include:

• "Have you ever been forced to do work you did not wish to do?"

• "Have you ever been forced to work to pay off debt?"

• "Has anyone lied to you about the type of work you would be doing?"

Any patient who discloses a history concerning for either labor or sex trafficking can be referred to the National Human Trafficking Resource Center at 1-888-373-7888. The national toll-free hotline is available in the United States at all times and, in addition to providing resources directly to individuals experiencing trafficking, can assist clinicians in assessing the level of danger to the patient, additional questions to ask, and resources available. Clinicians should also familiarize themselves with location-specific resources, such as social workers, specialty clinics to care for patients experiencing trafficking, and local organizations who provide patients with additional social services. When caring for adult patients, health care providers should not involve law enforcement or social service providers without the patient's consent; because laws vary by state, providers must be familiar with the laws in their own state. For minors, providers must be aware of and follow mandatory reporting requirements for child abuse.