What Are Some Potential Indicators of Human Trafficking?

Patient Presentation
A pediatrician was travelling when she noted several public service advertisements encouraging the air traveling public to be aware of potential victims of human trafficking. One advertisement advocated just being aware of the problem, while others listed potential behavioral changes that might be noted in victims or traffickers. The pediatrician was disturbed by her own lack of knowledge and awareness, so when she returned home she decided to read more about the subject.

Human trafficking is estimated to be the second largest criminal activity in the world after illegal arms trafficking. It affects all nations with an estimated 27 million people of all ages worldwide but only a small number are identified. It is defined by the United Nations as “the recruitment, transfer, harboring, or receipt of persons by means of threat or use of force or other forms of coercions, abduction, fraud, deception, the abuse of power, or a position of vulnerability to achieve the consent of a person, having control over another person, for the purpose of exploitation.” It includes commercial sex and labor or services. Victims include adults and children of all genders and sexual orientations, including people who are foreign nationals or native citizens. Anyone can be a victim.

In the U.S. any child less than 18 years of age who is involved in prostitution is considered a victim of sex trafficking, regardless of the use of coercion, force or fraud by another person. The average age that children enter the commercial sex trade in the U.S. is 12-14 years and it is estimated that children who move to live on the streets are approached for sex trafficking within 2 days of living on the streets. Trafficking may involve individuals being transported across domestic or international borders but does not require crossing a border. Restraint, abuse and physical force may also be involved but again are not required to define human trafficking.

When interviewing patients whom trafficking is suspected, separate the patient from accompanying persons. This usually can be done while performing the physical examination, testing, or filling out paperwork (in a separate area). Try to build rapport and trust, with open, yet directed questions while sitting at eye level and maintaining eye contact. Use a trained interpreter if needed and provide the patient with immediate needs such as food and water.

Questions that 2 papers suggest to ask include:

  • “Where do you live?
  • Who takes care of you?
  • Do you feel trapped in your situation?
  • Is anyone forcing you to do things you do not want to do?
  • Has anyone threatened your family?
  • Tell me about your tattoo.
  • Has anyone at home or work ever physically harmed you?
  • Have you ever been denied food, water, sleep, or medical care?”


  • “Can you come and go from your home (or job) whenever you please?
  • Has anyone at home or work every physically harmed you?
  • Have you ever been threatened for trying to leave your job?
  • Is anyone forcing you to do things you do not want to do?
  • Do you have to ask permission to eat, sleep or use the bathroom?
  • Are there locks on your doors and windows that keep you from leaving?
  • Have you ever been denied food, water, sleep, or medical care?
  • Has anyone threatened your family?
  • Has anyone taken away your identification papers or cards?”

Avoid using words such as coercion, sex worker, trafficking victim, call girl, escort, or pimp.

National Human Trafficking Resource Center Hotline 888-373-7888, TEXT 233733, https://humantraffickinghotline.org is available to anyone including victims and healthcare providers.

Each situation is unique and victims should be offered protection and assistance for their situation. Children should have child protection services and/or law enforcement contacted. Adults should be offered services, but they cannot be compelled to utilize them. For future reference, unlabeled telephone and other resources contacts can be written on a small piece of paper that can be hidden or on discharge paperwork from the hospital or clinic. For victims who are not U.S. citizens there is a federal program “…that enables trafficking victims to obtain medical care, witness protection, and other social service assistance, including the ability to obtain legal immigration status.”

Learning Point
Health care providers may be unaware of the complexities and scope of human trafficking. One study found < 5% of emergency room clinicians were confident in their ability to recognize a victim.

Indicators that may arouse suspicion of human trafficking (many of which overlap categories):

  • Medical history
    • Not knowing basic information such as their location, or how to get home from current location
    • Vague or inconsistent history or injuries
    • Unexpected demeanor – hostile, aggressive, irritated, anxious, flat affect, poor eye contact, etc.
    • When law enforcement, social work, etc. are referenced, becomes apprehensive or hostile
    • Does not have personal documentation such as driver license, etc.
    • Does not have access or little access to money, food, clothing, housing, medical care or other
    • Person accompanying the patient is unwilling or very reluctant to leave the patient. “Traffickers may present themselves as a partner, family member, friend, or advocate. Traffickers may also actually be a partner or family member.”
    • History of running away from home or foster care placements
    • Truancy or attending school
    • Highly sexualized behavior or dress
    • Pregnancy at young age
    • Evidence of abortions at young age
    • Early sexual initiation
    • Abnormal number of sexual partners for young age
    • Unwilling pregnancy
  • Injuries
    • Genital trauma to vagina and/or rectum, retained foreign object
    • Sexually transmitted infection or urinary tract infection symptoms
    • Bruises, whip marks, ligature marks
    • Burns
    • Head trauma or loss of consciousness
    • Lacerations
    • Gunshot wounds
    • Hair pulled out
    • Injuries that do not match history or seem violent – hit by car, fell down stairs
  • Physical signs and symptoms
    • Acute or chronic disease
      • Untreated or undertreated problems – asthma, diabetes
      • Back pain
      • Dental disease
      • Dizziness
      • Fatigue
      • Gastrointestinal disorders including abdominal pain
      • Nausea and emesis
      • Malnutrition
      • Migraine
      • Poorly healed fractures and strains
      • Respiratory problems that are frequent
      • Skin disorders from close contact and poor environment
      • Substance abuse
      • Tuberculosis
    • Genitourinary
      • Sexually transmitted infection
      • Pelvic inflammatory disease
    • Tattoo – “especially of a male name or a nickname, in unusual locations such as the inner thigh, underarm, breast, or back of neck, may suggest branding.”
  • Mental health
    • Anxiety including panic attacks
    • Depression including suicidal ideation and attempts, flat affect
    • Agoraphobic
    • Dissociative reaction
    • Fear for family members’ safety
    • Memory loss
    • Poor self esteem
    • Shame and guilt
    • Substance abuse
  • Other
    • Poor hygiene
    • Repetitive yawning, being excessively tired

    School personnel can also see trafficked children. In its information for school professionals, the United States Department of Education notes the following:

    “However, once a student is victimized, identifying him or her can prove difficult for a variety of reasons: (1) the student’s reluctance to disclose the problem due to a sense of shame and fear; (2) the stigma associated with forced prostitution; (3) the power and control of the tracker’s seduction and manipulation; and (4) the student’s inability to recognize that he or she is a victim and, therefore, is unwilling to seek help.
    Possible behavioral indicators of a child sex trafficking victim include, but are not limited to, the following:

    • an inability to attend school on a regular basis and/or unexplained absences
    • frequently running away from home
    • references made to frequent travel to other cities
    • bruises or other signs of physical trauma, withdrawn behavior, depression, anxiety, or fear
    • lack of control over a personal schedule and/or identification or travel documents
    • hunger, malnourishment, or inappropriate dress (based on weather conditions or surroundings)
    • signs of drug addiction
    • coached or rehearsed responses to questions
    • a sudden change in attire, behavior, relationships, or material possessions (e.g., expensive items)
    • uncharacteristic promiscuity and/or references to sexual situations or terminology beyond age-specific norms
    • a “boyfriend” or “girlfriend” who is noticeably older and/or controlling
    • an attempt to conceal scars, tattoos, or bruises
    • a sudden change in attention to personal hygiene
    • tattoos (a form of branding) displaying the name or moniker of a tracker, such as “daddy”
    • hyperarousal or symptoms of anger, panic, phobia, irritability, hyperactivity, frequent crying, temper tantrums, regressive behavior, and/or clinging behavior
    • hypoarousal or symptoms of daydreaming, inability to bond with others, inattention, forgetfulness,
      and/or shyness

    Additional behavioral indicators for labor tracking include the following:

    • being unpaid, paid very little, or paid only through tips
    • being employed but not having a school-authorized work permit
    • being employed and having a work permit but clearly working outside the permitted hours for students
    • owing a large debt and being unable to pay it
    • not being allowed breaks at work or being subjected to excessively long work hours
    • being overly concerned with pleasing an employer and/or deferring personal or educational decisions to a boss
    • not being in control of his or her own money
    • living with an employer or having an employer listed as a student’s caregiver
    • a desire to quit a job but not being allowed to do so”

    Questions for Further Discussion
    1. What are your local policies if a child is identified as a victim of child abuse, neglect or trafficking?
    2. How might adolescents present differently than adults who are victims of human trafficking?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
    Information prescriptions for patients can be found at MedlinePlus for these topics: Sexual Assault and Homeless Health Concerns.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    U.S. Department of Education, Offce of Safe and Healthy Students, Human Tracking in America’s Schools, Washington, D.C., 2015.
    Available from the Internet at: http://safesupportivelearning.ed.gov/human-tra cking-americas-schools (cited 1/28/19)

    Becker HJ, Bechtel K. Recognizing victims of human trafficking in the pediatric emergency department. Pediatr Emerg Care. 2015 Feb;31(2):144-7; quiz 148-50.

    Viergever RF, West H, Borland R, Zimmerman C. Health care providers and human trafficking: what do they know, what do they need to know? Findings from the Middle East, the Caribbean, and Central America. Front Public Health. 2015 Jan 29;3:6.

    Shandro J, Chisolm-Straker M, Duber HC, Findlay SL, Munoz J, Schmitz G, Stanzer M, Stoklosa H, Wiener DE, Wingkun N. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. Ann Emerg Med. 2016 Oct;68(4):501-508.e1.

    Greenbaum J, Bodrick N; Committee on Child Abuse and Neglect; Section on International Child Health. Global Human Trafficking and Child Victimization. Pediatrics. 2017 Dec;140(6). pii: e20173138.

    United Nations Office on Drugs and Crime. Human Trafficking. Available from the Internet at https://www.unodc.org/unodc/en/human-trafficking/what-is-human-trafficking.html (rev. 2019 cited 1/28/19).

    National Human Trafficking Resource Center. Recognizing and Responding to Human Trafficking in a Healthcare Context.
    Available from the Internet at: https://humantraffickinghotline.org/resources (cited 1/28/19).

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa