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.

Discussion
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?”

  AND

• “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.”