Human Trafficking & Health Professionals: Questions and Answers
Question: As a healthcare provider responding to a disaster, what should I know about the relationship between trafficking and disasters?
Answer: Disasters increase the risk that persons will become victims of human trafficking for several reasons. First, because disasters create chaos and disrupt systems that are in place to protect people, perpetrators of human trafficking are able to exploit these conditions to their benefit. Another factor that increases risk is that disasters may cause survivors to engage in survival strategies in order to meet their basic needs. For example, individuals may voluntarily go somewhere with a stranger if that stranger promises them goods such as food, water, shelter, or transportation. Also, children may become separated from their parents or other adults during a disaster, making them vulnerable to being taken advantage of. Others may lose their means of making a living due to a disaster destroying their place of work, and may begin to engage in activities, such as entering the commercial sex market, in order to “make ends meet.” After the immediate crisis, needs for cleanup and re-building in the area affected by the disaster also create new markets for free and cheap labor. Desperation may cause individuals to be susceptible to exploitation, as they might overlook dangerous working conditions, accept work without a formal contract or benefits, and/or fail to do adequate research into the legitimacy of the workplace.
Question: How likely am I, a healthcare professional, to encounter a trafficked person?
Answer: Health care providers are among the few professionals likely to encounter human trafficking victims. Healthcare providers are a key element in the identification of human trafficking victims. These individuals commonly enter the health care system during periods of transportation, detainment, or exploitation.1 Studies have shown that approximately 50% of trafficking victims saw a health professional while in captivity. However, healthcare workers, and particularly physicians, are rarely engaged or trained to recognize these patients, despite their potential opportunity to intervene.1 For example, a recent study with Emergency Department personnel indicated that only 3% of Emergency Department personnel received training specific to human trafficking victims.2 Thus, many human trafficking victims who encounter a health professional are not identified, recognized, and referred to appropriate resources.
Question: What training resources are available to help me become better at recognizing human trafficking?
Answer: The SOAR to Health And Wellness Training for Health Professionals, available through the National Human Trafficking Technical Assistance Center, is an excellent source of training on this subject that is specifically tailored for health professionals. You can access information about the training here.
Question: What are some of the signs of human trafficking that I may encounter in a health care setting?
Answer: First, it is important to recognize while human trafficking is believed to disproportionately affect women and girls, human trafficking crosses all racial, gender, class, sexual orientation, age, ability, and socio-economic boundaries. Acute medical complaints seen in these patients are varied and multifactorial.1 Lack of nutrition, sleep deprivation, physical violence and injury, and mental health complaints due to extreme stresses are commonly seen.1 As with many of our disadvantaged members of society, they may also present with chronic diseases at advanced stages as they are systematically denied access to medical care by traffickers.1 While many of these patients can present with vague, minor, and nonspecific complaints, there are common secondary complaints of which emergency medicine practitioners should be aware. These are:
- Trauma/Musculoskeletal Pain: A very high number of trafficking survivors report physical injuries, injuries caused by weapons or instruments, and nearly all report either sexual assault or physical violence.1 Repeated physical abuse and torture resulting in fractures, contusions, and burns are common. Injuries around the head, mouth, or genital area, as well as wounds that appeared self-inflicted are warning signs. Wounds or burns caused by tools of myriad kinds leaving a pattern, injuries of varying ages, and on separate areas of the body are red flags, just as in evaluating possible abuse or domestic violence cases.
- Gynecologic: Gynecologic complaints, including genital pain, vaginal bleeding, and complications of pregnancy, are common among victims of sex trafficking. Sexually transmitted infections (STIs) are also common, presenting as vaginal discharge and pelvic pain.1 HIV, in particular, has been linked to trafficking victims, both globally and domestically.1 Pregnancy is a major risk for sex trafficking victims, and multiple elective abortions are common.1 Repeated visits to providers, previous treatment of STIs, pelvic inflammatory disease, and signs of trauma to the genitourinary area from sexual assault are all potential warning signs of sexual exploitation.
- Psychologic: Poor mental health is widely reported among all trafficking victims.1 Anxiety disorder, depression, suicidal ideation, and posttraumatic stress disorder (PTSD) have all been described in these patients. Symptoms of hostility, paranoia, and hopelessness are common.1 These may be the presenting symptoms to an emergency department setting and may also be offered as secondary after a somatic complaint of headache, back pain, dizziness, and generalized weakness.1
- Substance Abuse: Substance use and addiction make victims vulnerable to traffickers, and can be negative coping strategies during a stressful experience.1 Forced or coerced use of drugs and alcohol can also be used to isolate a victim and integrate them into their exploitation.1 Patients may present to the emergency department with overdose, intoxication, or withdrawal symptoms.1
- Dental: Victims may present with dental trauma and loss of teeth from violent acts.1 Injuries to the face and mouth area are common in abuse cases, and the potential for tooth involvement is high.1 Other dental problems arise as well, including infectious complications due to HIV, and even oral cancers or gingival disease due to substance use or poor access to dental care.
- Skin: Bruises and contusions in potential victims of human trafficking should not be dismissed as minor injuries. Bruising in areas that are unusual for accidental injury include the cheek, neck, trunk, and buttocks.1 Any repeated symmetrical injuries, patterns that may have been made with tools, and linear or circular burns are cause to investigate abusive injury.1 Multiple ecchymoses of varying ages, scarring, and signs of poorly cared for previous wounds should raise the concern for repeated inflicted injury.1 Tattoos are also of particular interest, as they have been reported in human trafficking to be used to designate property as humans are traded and sold.1
These red flags are not exhaustive, and no single issue is indicative of human trafficking but the presence of a combination of these red flags should increase your level of suspicion and prompt further assessment.
Question: What should I do if I think one of my patients is a victim of human trafficking?
Answer: Call the National Human Trafficking Hotline (NHTH) at 1-888-373-7888. When you call the hotline, you will be connected with a specialist who has had 60-80 hours of rigorous training on human trafficking. The hotline specialist you are connected with will help provide you with appropriate advice about next steps, referrals and resources for your patient’s needs, including transportation, shelter, food, and housing. After calling the hotline, you should prepare to assist your patient in determining their next steps. These steps could include providing them with a warm handoff to a social worker or caseworker, scheduling them for a follow-up, and/or providing them with the hotline phone number.
Question: Does calling the Hotline satisfy my state’s mandatory reporting requirements?
Answer: First, it is important to note that all states require you to report child trafficking to law enforcement. Whether calling the hotline satisfies your state’s mandatory reporting requirements depends on whether it is mandatory in that state to report adult human trafficking. Not all states require you to report instances of adult human trafficking as part of your mandatory reporting requirements. However, if you live in a state that does require you to report adult human trafficking, calling the Hotline would not satisfy that requirement. To satisfy that requirement, you would also need to contact your local law enforcement agency. If you are not sure whether or not you are required to report, one of the trained specialists at the Hotline will be able to answer that question for you and can help connect you to law enforcement if necessary.
Question: Does calling the hotline violate HIPAA?
Answer: HIPAA was written to protect patient confidentiality, but was never designed to prevent the reporting of trauma and crimes. The HIPPA Privacy Rule permits the reporting of injury or abuse if certain conditions are met. Further, even where specific permission to report injury or abuse does not apply, if an adult patient authorizes a particular disclosure of information, HIPAA requires only that the disclosure be limited to the terms of the authorization. Finally, if unsure about whether HIPAA permits the reporting of patient information in a specific situation, human trafficking can still be reporting without divulging individually identifiable patient health information. For example, a provider could report the gender, age of patient, and type of trafficking to the Hotline and obtain relevant referrals and resources. Additional information can be found here.
Question: My patient does not want me to call the Hotline. Can I give my patient the Hotline number and encourage them to call when they are ready?
Answer: Yes! One of the main goals of the Hotline is to receive calls (e.g., phone calls, texts, or emails) directly from victims and survivors of human trafficking. The Hotline received 166 calls from victims and survivors in 2008 and 3,487 calls in 2015. The Hotline will enhance services in the future by creating a chat feature for victims and survivors.3
Question: I think my patient may be a victim of human trafficking, but I am not sure. What should I do?
Answer: Call the Hotline! The Hotline stresses that you, as a provider, should know that your role is to be vigilant for human trafficking red flags and to know their resources. You are not responsible for investigating or confirming cases of human trafficking. You should call the hotline if you notice red flags, even if you are not sure that your patient is a victim of human trafficking. While it is not a health care or social service provider’s responsibility to decide whether or not an individual has actually been trafficked, it is important to understand and recognized the red flags as you are uniquely positioned on the front lines and might be the first person that a victim encounters.
Mukherji, Pinaki. “Recognizing Human Trafficking Victims in the Emergency Department.” AHC Media, March 8, 2015. https://www.ahcmedia.com/articles/134799-recognizing-human-trafficking-victims-in-the-emergency-department.
Barrows, J., & Finger, R. (2008). Human trafficking and the health care professional. Southern medical journal, 101(5), 521-524.
National Human Trafficking Hotline Statistics 2012-2016, https://humantraffickinghotline.org/states