“Most providers lack the training and ability to recognize victims of the sex-slave industry…victims frequently present to EDs, but are rarely detected as such.11”
Human trafficking victims often present to emergency departments and women’s health or family planning clinics. One retrospective survey of 173 US survivors of human trafficking, 68% were seen by a healthcare provider and 56% seeing emergency or urgent care providers while they were being trafficked. Healthcare providers have an opportunity to identify victims of human trafficking.3
Victims of human trafficking are hard to identify in a healthcare setting. Victims rarely self-report because of fear of the trafficker, distrust of authorities, feelings of shame and hopelessness, trauma bonds (i.e., Stockholm syndrome), and threats. Victims may not seek healthcare unless they have no other options.3 It is critical for healthcare providers to recognize that their role is not disclosure or rescue; but, to create a safe, non- judgmental place that will help you identify trafficking indicators and assist the patient.
The National Human Trafficking Resource Center (NHTRC) provides training and technical assistance on a wide range of human trafficking topics through the hotline and website. The NHTRC can also guide providers through an assessment of a potential victim.
If human trafficking is suspected or confirmed, assess acute healthcare needs and additionally perform a complete physical to identify medical conditions common in trafficked persons. Sex-trafficked and sexually abused labor-trafficked victims should be offered a forensic medical evaluation. Pregnancy testing and emergency contraception should be offered.3
Unfortunately, the healthcare professionals’ financial and time incentives are to treat the complaint and street the patient.
Calm, open-ended questioning helps build rapport.11
Avoid questions starting with “Have you ever…” because the answer will be “no,” and you will have lost an opportunity. You may ask the patient where she lives and who takes care of her, how she met her “boyfriend,” or whether she must contribute money to her family. You may suggest, “Tell me about your tattoo.”
Take time to answer questions the victim might have, and acknowledge and address their fears; Being sensitive to cultural differences, gender differences, and language barriers and using an interpreter when needed.12
More direct questions related to trafficking situations may be made later in the interview.
Most victims experience intense fear of their traffickers and of being deported. Therefore, it is important to reassure the victim that they are safe, so they can begin the process of getting protection and assistance to rebuild their lives.13
Gaining the trust of trafficking victims is important. Sample messages to help gain trust include13:
- We are here to help you.
- Our priority is your safety.
- Under the Trafficking Victims Protection Act of 2000, victims of trafficking can apply for special visas or could receive other forms of immigration relief.
- We will give you the medical care that you need.
- We can find you a safe place to stay.
- You have a right to live without being abused.
- You deserve the chance to become self-sufficient and independent.
- We can help get you what you need.
- We can help to protect your family.
- You can trust me.
- We want to make sure what happened to you doesn’t happen to anyone else.
- You have rights.
- You are entitled to assistance. We can help you get assistance.
- If you are a victim of trafficking, you can receive help to rebuild your life safely in this country.
The healthcare needs of human trafficking victims range from physical abuse to psychological trauma. Unlike other violent crime, trafficking usually involves prolonged and repeated trauma including8:
- physical, sexual, psychological abuse
- forced use of substances
- economic exploitation
- abusive working and living conditions
The health problems of trafficking victims relate to the type of trafficking. For instance6:
- a sex worker may have repeated sexually transmitted diseases
- a construction worker may have injuries due to unsafe working conditions
- a nail salon worker may have lung disease from inhaling chemicals
- an agricultural worker may have dehydration due to working without adequate rest and water.
The mental health repercussions of trafficking include6:
- complex forms of post-traumatic stress disorder
- struggle with addiction
Trafficked children and adolescents are at risk for physical, mental, and psychological repercussions. These victims should be screened for the following3:
- delayed physical and cognitive milestones
- impaired social skills
- stunted growth
- long-term effects of untreated common childhood diseases
The following is a list of health-related indicators and consequences of human trafficking published by the National Human Trafficking Resource Center and available at traffickingresourcecenter.org10
This list of physical and mental health indicators of human trafficking is not exhaustive. Trafficking survivors may experience one or more of these indicators, none of these indicators, or health indicators not on this list.
Health Indicators and Consequences of Human Trafficking
|Physical Health Indicators||Mental Health Indicators||Social or Developmental Indicators|
- Signs of physical abuse or unexplained injuries
- Cuts or wounds
- Blunt force trauma
- Broken teeth
- Signs of torture
- Neurological conditions
- Traumatic brain injury
- Headaches or migraines
- Unexplained memory loss
- Vertigo of unknown etiology
- Difficulty concentrating
- Cardiovascular/respiratory conditions that appear to be caused or worsened by stress, such as:
- High blood pressure
- Acute Respiratory Distress
- Gastrointestinal conditions that appear to be caused or worsened by stress, such as:
- Irritable bowel syndrome
- Dietary health issues
- Severe wight loss
- Loss of appetite
- Reproductive issues
- Sexually-transmitted infections
- Genitourinary issues
- Repeated unwanted pregnancies
- Forced or pressured abortions
- Genital trauma
- Sexual dysfunction
- Retained foreign body
- Substance use disorders
- Other health issues
- Effects of prolonged Exposure to extreme temperatures
- Effects of prolonged exposure to industrial or agricultural chemicals
- Somatic complaints
- Suicidal ideation
- Self-harming behaviors
- Post-traumatic stress disorder
- Lack of emotional responsiveness
- Feelings of shame or guilt
- Attachment disorders
- Lack of or difficulty in engaging in social interactions
- Signs of withdrawal, fear, sadness, or irritability
- Depersonalization or derealization
- Feeling like an outside observer of themselves, as if watching themselves in a movie
- Emotional or physical numbness or senses
- Feeling alienated from or unfamiliar with their surroundings
- Distortions in perception of time
- Dissociation disorders
- Memory loss
- A sense of being detached from themselves
- A lack of a sense of self-identity, or switching between alternate identities
- A perception of the people and things around them as distorted or unreal
- Increased engagement in high-risk behaviors, such as running away or early sexual initiation of a minor
- Trauma bonding with trafficker or other victims (e.g., Stockholm syndrome)
- Difficulty establishing or maintaining healthy relationships
- Delayed physical or cognitive development
- Impaired social skills
There is no consensus on the optimal screening questions for identifying victims of human trafficking. The clinician should start with indirect questions that touch upon aspects of the patient's life, job, and a general sense of safety.3 As with domestic violence cases, try to separate the patient from visitors and family before beginning any sensitive discussions.14
Interpreters should be screened to be sure they do not know the victim or the traffickers and do not otherwise have a conflict of interest.14
The following are sample questions health care providers can ask in screening an individual to determine if he/she is a potential victim of human trafficking. This list is published by United States Department of Health and Human Services, Administration for Children and Families. Screening tool for victims of human trafficking and available at acf.hhs.gov. 14
- Can you leave your job or situation if you want?
- Can you come and go as you please?
- Have you been threatened if you try to leave?
- Have you been physically harmed in any way?
- What are your working or living conditions like?
- Where do you sleep and eat?
- Do you sleep in a bed, on a cot or on the floor?
- Have you ever been deprived of food, water, sleep or medical care?
- Do you have to ask permission to eat, sleep or go to the bathroom?
- Are there locks on your doors and windows, so you cannot get out?
- Has anyone threatened your family?
- Has your identification or documentation been taken from you?
- • Is anyone forcing you to do anything that you do not want to do?