Annals of B-Pod: Human Trafficking
/THE CASE
The patient is a female in her early thirties presenting via EMS after an unintentional opiate overdose. She received 2 mg of intranasal narcan approximately 10 minutes prior to presentation in the emergency department (ED). On arrival, she endorses nausea and dizziness but denies any other complaints.
Vital Signs: T 98.0° HR 88 RR 14 BP 106/70 SaO2 98% on room air
Physical Exam: She is generally well-appearing, non-toxic, and in no acute distress. Cardiovascular, pulmonary, and abdominal exams are within normal limits. Musculoskeletal and neurologic exams are also within normal limits. Skin exam is notable for ecchymosis of the bilateral lower extremities and multiple tattoos.
Hospital course
The patient is given oral ondansetron with improvement of her nausea. She is monitored in the ED and maintains adequate oxygen saturations without any respiratory distress. An HIV test is performed and negative. The social worker is involved to assist in disposition, and her assessment reveals that she is both jobless and homeless. The patient is noted to have bruises on her bilateral lower extremities from an unknown source, and she is unwilling to disclose how she received them. She states that she is from the Southwest U.S. and is involved with a younger man she met through a family friend. She recently moved in with this younger man, and reports that her family friend has videotaped her without her permission during intimacy with her significant other. The patient reports that she paid for a vehicle that this family friend is now withholding from her because she pressed charges against him. She also reports that this family friend secretly listens to her private conversations and will not allow the patient to leave her home independently. Based on this discussion, the patient is ultimately dispositioned to the Salvation Army’s End Slavery Cincinnati program.
Discussion
Human trafficking (HT) is simultaneously complex and simple. While there is no “typical” human trafficking victim, repeated abuse, physical and sexual trauma, and addiction are the rule, not the exception, in the lives of victims of trafficking. Traffickers routinely and systematically destroy their victims’ identities so that the men and women they traffic feel devoid of protection and can therefore be maximally exploited. For many victims, the process of de-identification starts long before they cross the threshold of any emergency department.
Simply put, trafficking is slavery. There are more slaves today than any other time in human history, with an estimated 40.3 million victims of human trafficking globally and 24.9 million people trapped in forced labor.[1] HT is also a very complex legal, ethical, social, and economic issue. It is the second largest and fastest growing organized crime trade in the world, recently surpassing the illegal arms trade, and anticipated to surpass the illegal sale of drugs in the next few years.[2,3] This growth surge is likely explained by the fact that HT is an unfortunately profitable industry, earning $150 billion in profit annually for traffickers, tripling the 2016 yearly profit of the first ranking Fortune 500 company.[9,13]
The United Nations defines trafficking as “recruitment, transportation, transfer, harboring, or receipt of persons by improper means (such as force, abduction, fraud, or coercion) for an improper purpose including forced labor or sexual exploitation.”[10,11] The U.S. government differentiates between those trafficked for sex and those trafficked for labor or services, dividing victims of HT into three groups.[11] The first group includes minors under the age of 18 years that have been persuaded into commercial sex. The second group is adult sex workers who are forced into commercial sex work via threat of bodily harm, coercion, or fraud. The third group includes those who are forced to perform labor against their will. Recent data shows that forced labor exploitation (64% of the total) and commercial sexual trafficking (19%) are the most common forms of human trafficking. However, the majority of trafficking profits (estimated at $99 billion) come from commercial sex work. The average annual profit generated by each woman in sexual servitude is $100,000, yielding profit margins between 100% to 1,000%. Additional forms of human trafficking include the illegal sale of human organs as well as the trafficking of children, primarily boys, for armed combat.[9,12]
An estimated one million persons are trafficked across international borders on an annual basis with 14,500 to 17,500 persons trafficked within and across the US.[6] Human trafficking has been reported in all 50 U.S. states and the District of Columbia.3 Women and girls are disproportionately affected, as three quarters of trafficking victims are female. The average age of entrance into the commercial sex trade is 12 to 14.[8] Despite an estimated 2 million children entering the global human trafficking market per year, only a fraction of traffickers are prosecuted with just over 9,000 convictions for trafficking globally in 2016.[9]
Although there is no “typical” victim, marginalized populations such as homeless youth and those in extreme poverty are at especially high risk.[10,11] Traffickers prey on vulnerable groups such as adolescents and young adults with a history of child abuse, involvement in child protection and welfare systems, and those who identify as lesbian, gay, bisexual, transgender, or queer. Runaway youths are particularly vulnerable, and some experts suggest that adolescents are likely to be approached to participate in the commercial sex industry within 48 hours of being on the street.[8] Other at-risk populations are persons with disabilities, immigrants, migrant workers, ethnic minorities, and financially insecure persons with limited education or prospects for formal employment.[11] In the United States, American Indian and Alaskan Native women are frequently trafficked and disproportionately represented in prostitution arrests.
Although there has been much discussion of HT within national and international law enforcement, it is only recently that the health care community has joined the discussion. As many as 87.7% of victims of human trafficking have come into contact with the health care community, and the ED was identified as the most frequent setting where victims seek medical care.[4,5] Emergency providers have the unique opportunity to identify victims and intervene on their behalf.
Identifying those at risk can prove to be difficult since victims of human trafficking often have a wide array of physical, reproductive, and mental health problems. Acute traumatic injuries are common chief complaints. These injuries are often secondary to physical abuse, lack of protective equipment, or hazardous work conditions. Workplace injuries, exposure to chemicals, environmental exposure, and communicable diseases from poor living conditions are common in victims of labor trafficking. Common complaints in victims of sex trafficking include vaginal or perineal injury, recurrent sexually transmitted infections, unintended pregnancy, lack of prenatal care, and unsafe or forced abortion. Untreated chronic disease and mental health issues are also common. HT victims have exceedingly high rates of substance abuse, suicidal ideation, suicide attempts, and self-injurious behavior. Patients may present with sequelae of these behaviors rather than from injuries or illnesses directly related to trafficking. Another common finding, particularly for victims of sex trafficking, are tattoos or branding. The most common tattoos are barcodes and words like “property of...” or “daddy.”[12,15,19]
Exam findings include those typical of the injury patterns noted above. Additionally, victims may be malnourished, disheveled, dressed inappropriately, or present in the end stages of chronic disease processes such as HIV or other sexually transmitted diseases.[15]
Given the wide array of chief complaints and physical exam findings that may accompany HT victims, and the difficulty in correctly identifying those being abused, the American College of Emergency Physicians (ACEP) has issued a policy guideline on human trafficking. ACEP recommends that emergency clinicians be familiar with potential signs, symptoms, and indicators of human trafficking. Providers must maintain a high index of suspicion when evaluating patients who appear to be at risk for abuse and violence. Providers should assess for indicators of trafficking with a culturally sensitive and patient-centered approach. The policy encourages the creation of protocols to assure the medical, psychological, safety, and legal needs of these patients are met, and that providers familiarize themselves and receive regular training on these protocols.[17]
With the help of the entire ED staff, a patient-centered approach can be implemented to better treat victims of HT. Providers should actively seek to minimize retraumatization and foster physical, psychological, and emotional safety. Examples of this include ensuring appropriate verbal consent, the presence of chaperones before examinations of sensitive areas, and assisting patients to disrobe in a sensitive way to minimize retraumatization. Other important considerations include providing certified interpreters and/or interpreting services for non-English speaking patients and not relying on family members or friends to interpret.[12,15]
There is currently no externally validated screening tool for identifying persons at risk for HT to be specifically used in the emergency medical setting.[18] The Vera Institute of Justice developed an evidence-based screening tool that was validated in 2014. However, this tool is cumbersome, recommended for providers to use after rapport is established, and is not appropriate for use in the ED.[12] However, multiple proposed screening tools and lists of “red flag” indicators exist. One particular study implemented a HT screening tool and treatment algorithm at a level 2 trauma center in southwestern Pennsylvania. This screening tool included social screening by registration, medical screening by ED clinical staff, and a silent notification tool. Signs in the restroom instructed potential victims to identify their urine specimen cup using a blue dot sticker thus triggering additional investigation by the ED nurse. 38 patients were identified in five months: 20 via medical red flags and 18 via the silent notification system. All were offered intervention and five received help, including four adults who accepted assistance and one minor who received mandatory intervention as per state child abuse laws. After the intervention, staff members were surveyed. 97% of participants were committed to change their practice and most responded that receiving this education improved their perception of the problem.[20]
Currently in Cincinnati, a local task force comprised of social workers, forensic nurses, law enforcement, and a local hospital are working to develop and validate protocols both for EMS and emergency nurses. They have developed a tool for the electronic medical record used by nurses during the registration process that includes evaluation of visual and behavioral cues. A certain score on these cues prompts a second list of red flag indicators, similar to those provided below (Figures 1 and 2).[19]
Determining an appropriate disposition for these patients is often quite challenging. It is important to become familiar with available local resources and to involve social work, if available, early in the care of these patients. Reporting is mandatory for patients under the age of 18 and should be completed via the state’s child protective service agency.[8] With adult patients who do not appear to be in imminent danger, providers should inform the patient about their concerns before reporting a crime. Providers often lack the resources to protect patients outside of their clinical venue and reporting the patient’s trafficker may place the patient in imminent danger.[8,21] In some instances the appropriate intervention may be to disposition the patient to a shelter or protected setting. For others, the safest response may be to offer the patient educational and self-help resources prior to discharge.[15]
Human trafficking is a global and domestic problem that is vastly underestimated and often goes unrecognized in the health care setting. Emergency physicians are in a unique position to recognize and intervene early in these cases. The key to making a difference in this epidemic is having a high index of suspicion. Evidence-based protocols are currently being created, and screening tools are currently available, but the key to recognizing HT is to consider this as part of the differential. As part of a patient-centered approach to providing care, concerns about HT by any ED staff member should be addressed prior to disposition. By heightening awareness among staff and having protocols available to help victims of HT, emergency physicians can provide compassionate and life-changing care to this extremely vulnerable and under-represented patient population.
Authored by kelli jarrell, m.d.
posted by matthew scanlon, m.d.
references
International Labor Organization. Global Estimates of Modern Slavery: Forced Labour and Forced Marriage. Geneva, September 2017. <http://www.ilo.org/global/publications/books/WCMS_575479/lang--en/index.htm> , accessed 4 May 2018.
Federal Bureau of Investigation. Human Trafficking/Involuntary Servitude. <https://www.fbi.gov/investigate/civil-rights/human-trafficking>, accessed 4 May 2018.
Polaris Project. Human trafficking. <http://www.polarisproject.orga/human-trafficking/overview>, accessed 3 March 2018.
Lederer LJ and Wetzel CA. The Health Consequences of sex trafficking and their implications for identifying victims in health care facilities. Annals of Health Care Law, 23(1), 61-91.
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United Nations. UN Protocol to Prevent, Suppress, and Punish Trafficking in Persons, Especially Women and Children, <http://www.unodc.org/unodc/en/treaties/CTOC/index.html, accessed March 3, 2018.
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The Fortune 500’s 10 Most Profitable Companies. <http://fortune.com/2017/06/07/fortune-500-companies-profit-apple-berkshire-hathaway/>, accessed 4 May 2018.
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Kostantopoulos, WM. Human Trafficking: The Role of Medicine in Interrupting the Cycle of Abuse and Violence. Annals of Internal Medicine. 18 Oct 2016. 165 (8): 582-589.
Pierce A. American Indian Adolescent Girls: Vulnerability to Sex Trafficking, Intervention Strategies. American Indian and Alaska Native Mental Health Research: The Journal of the National Center. 2012. 19(1): 37-56.
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