Seeing the Unseen Patients
Jessica only wanted heroin detox, told us not to worry about her arm wounds. She was in police custody, and the officer who escorted her told us she’d been sleeping on the streets, picked up for an old warrant. We hospitalized her for osteomyelitis that was likely to result in amputations of both forearms. Despite a constant police presence during her stay, her pimp made numerous attempts to visit her. She was ultimately lost back to the streets during transport between facilities.
Olivia came to us unsure if she needed help. Her pregnancy was the outcome of rape while immigrating from El Salvador, committed by the man bringing her to the United States. She now lives with two other men, one of whom has taken her as his wife. She reflexively jumped off the table when we began the pelvic exam and broke down in tears. She began to tell us about her past assaults but trailed off and said she needed to leave.
Tanika either jumped or was thrown out of a car going 30 miles per hour. Her boyfriend said they were having a fight at the time. She did not remember what happened. She repeatedly insisted she was safe, as her boyfriend looked on. On the second day, he became aggressive with staff and was escorted off the premises by security. She declined a social work visit. She had three rib fractures, a scapula fracture, a sternum fracture, an iliac fracture, and a pubic ramus fracture, with pelvic hematoma and hemopneumothorax.
Marianela arrived with her older boyfriend for a pregnancy confirmation visit. He answered for her because he said her English isn’t so good when she is nervous. He did not want to leave her side, because he wants to make sure his baby gets good care. When we got her alone, with an interpreter, she cautiously asked questions about pregnancy and sexually transmitted infections and about surgery to prevent future pregnancy. She was 14 years old.
Xinyue came in for an unwitnessed injury, reportedly a motor vehicle collision. She had broken bones in her foot and bruising all over. She stared wide-eyed at the room full of gowned strangers in the trauma bay and said she is clumsy. She said she could not be pregnant and allowed us to do Xrays, while an older man who arrived with her watched from the hallway. After looking at her chart for medical history, we found repeated treatments for sexually transmitted infections and her report that she’d had sex with 30 to 40 men since her arrival to the United States two months ago.
Tala was in the ED for pelvic pain, diagnosed to be a tubo-ovarian abscess after an untreated sexually transmitted infection. She was incidentally found to have Hepatitis B. She shared with me her history of prior partners abusing her and her pride in putting that behind her. She was with a new man now who was angry that she had an infection and she was fearful of telling him more about her condition. She lived with her friend or sister or boss or landlord – the answer changed during the conversation. Her roommate upstairs found work for her when she needed money. She said she was safe and saved the human trafficking hotline number in her phone under “Katie from Baltimore.”
What Do These Cases Have in Common?
These case vignettes are unpleasant, unsatisfying, and incomplete. They are all real patients (names changed) who I have cared for in the last ten months either during or following an ED evaluation. They are all known or suspected victims of human trafficking.
Human trafficking is defined as the recruitment, transportation, transfer, harboring, or receipt of persons, by threat or use of force, coercion, abduction, fraud, deception, abuse of power or vulnerability, or payments, for the purpose of exploitation.(1) Human trafficking does NOT require physical transport – it may comprise any of the above acts for the purpose of exploitation of others. Human trafficking cases are always unpleasant, unsatisfying, and incomplete. There is incomplete information, as trafficked patients often leave before completing their care. There is uncertainty in identifying whether someone is being trafficked, even when you have a strong suspicion or clear evidence. The visits may be distressing to providers, who want to help but must ultimately allow the patient to decline social services or other interventions, even in the instances when patients have disclosed they are being trafficked. ED visits related to human trafficking are more common than many providers realize.
4.5 million estimated victims of forced sexual exploitation globally(2)
800,000 persons estimated to be transported across borders yearly(3)
83% of Department of Justice-confirmed trafficking victims were U.S. citizens(4)
87% of trafficked persons sought health care during their captivity5
63% of trafficked persons sought care in an emergency department during their captivity(5)
42% of trafficked persons attempted suicide during trafficking experience and 21% afterward(6)
Human trafficking may occur in isolation – by a single perpetrator subjugating a single victim. However, it is often an organized operation with a larger population of trafficked persons and multiple levels of management. In patterns of abuse and violence epidemiology, abused persons often go on to become abusers. In a human trafficking operation, this also provides a protective benefit – when the trafficked persons ascend to become recruiters, their daily coerced sex work requirements may decrease or even cease. This may also be a source of additional psychological trauma as survivors are forced into a decision to choose their own wellbeing at the expense of the victimization of others.
Maryland and particularly Baltimore are especially vulnerable to human trafficking activity due to a confluence of geographic and socioeconomic factors: 7-11
Proximity to major international airport(s)
Proximity to national thoroughfares with truck stops, motels, & gas stations
Prevalence of poverty in Baltimore City and zones within adjacent counties
Prevalence of substance use
Prominence and status of drug trade, sex work, gang activity, and crime intimidation culture
Scarcity of behavioral health resources, substance use treatment facilities, affordable housing, employment opportunities, and other safety nets
Human Trafficking in the ED
Human trafficking poses a unique challenge for EM clinicians, who are often the only providers who see these patients while they are in captivity or under the control of their trafficker. We have limited time to build the rapport and trust necessary to overcome patient’s fear and apprehension. We lack effective screening tools and guidelines that are specific enough to accurately identify trafficked persons, and sensitive enough not to miss those with more experienced and system-savvy traffickers. We have limited resources for adequately exploring the cases we identify as likely trafficking. We also know that pursuing trafficking cases or even identifying a person as a victim of trafficking may actually be more harmful than beneficial, and as such requires individualized responses for each patient.(5) Potential harms include the anxiety, fear, and unnecessary retraumatization provoked by interview domains that patients may not be ready to discuss and which are unnecessarily detailed for the needs of the interviewer. Furthermore, if a patient is not ready to attempt extrication, or if the extrication attempt is unsuccessful, the patient may be subject to physical, emotional, and sexual retaliation when she returns to the trafficker. An unsuccessful extrication attempt, e.g. without the planned and coordinated involvement of a multidisciplinary team, may result in psychological trauma, unsuccessful legal pursuit, and the alert to a trafficking operation that they have been identified and should relocate, thereby endangering not only the identified patient but any other trafficked persons harbored by the trafficking operation.
In a 2016 issue of Annals of Emergency Medicine, Shandro et al. proposed a list of red flags for human trafficking screening in the emergency department:
·patient accompanied by individual who is reluctant to leave patient alone with care team
Vague or inconsistent history of present illness or injury
Unexpected demeanor: irritable, anxious, flat affect, poor eye contact
Apprehensive or hostile when law enforcement is referenced
Unaware of home address or how to get home from ED
No identification card and/or few personal items (14)
While this is a helpful start, many of us working in urban or safety net emergency departments recognize that a significant majority of our patients would meet at least one, if not many, of these criteria.
So What Can We Do?
Despite the absence of validated tools and guidelines, there are still many steps that ED providers can take to recognize and assist patients affected by human trafficking: 15-23
1. Awareness of medical conditions found in trafficked persons
Injury & trauma: facial, rib, & extremity fractures, head injuries, injuries with different stages of healing
Behavioral health: anxiety, depression, PTSD, schizophrenia, dissociative disorders, eating disorders
Substance use: dependence, overdose, withdrawal; opioids prevalent
Obstetrics: frequent pregnancies, poor prenatal care, IUGR, septic/unsafe abortion, spontaneous abortion
Sexual health/gynecology: recurrent sexually transmitted infections with complications from non-treatment, vaginal trauma, dyspareunia, vaginismus
Sequelae of poor living conditions: malnutrition, dehydration, skin infections, insect bites and colonization
Trafficking stigmata: branding, bar codes, cigarette burns, bites, scars, mutilation, ligature marks, alopecia
2. Adoption of a trauma-informed approach
A trauma-informed approach involves sensitivity to the many ways patients may manifest the psychological trauma they have experienced. In a human trafficking context, the expectation might be that a patient would be timid, subdued, hesitant to provide details. However, a patient may have been trained to smile and be reassuring when asked if she feels safe. Away from her trafficker, a patient may also demonstrate emotional lability or hostility. During a physical exam, one might expect that trafficked persons would be hypersensitive and avoidant of touch, particularly during pelvic exam. This is often true. However a patient may appear unaffected due to self-training for toleration of unwanted touch and penetration. A patient may even appear inappropriately hypersexual, if she has associated this behavior with less violence or quicker resolution of unwanted touch. What is important in these instances, in addition to compassionate and ethical conduct, is recognizing that trafficked persons may present in a variety of different ways, and their behavior cannot rule in or rule out their trafficking status.
3. Respect for the autonomy of trafficked persons, within the context of local laws
Although the free will of trafficked persons is extremely restricted, it is important to acknowledge and honor the agency these individuals do have. That first and foremost includes their autonomy regarding the medical and social evaluations and interventions they wish to receive. This also extends to acknowledging that they have the right to assess their own situations and determine when, if, and how to disclose information. Maryland does not have mandatory reporting laws for intimate partner violence or human trafficking (other than acts involving minors or vulnerable adults), but local statutes may vary.
4. Awareness of what you can do as an ED provider
You may not identify many of the trafficked patients who cross your path as a provider. Of those you have concerns about, most will not self-identify or disclose to you. There are still countless ways to facilitate a survivor’s journey on her or his own terms.
Privacy: clear the room so you can interview and examine the patient alone, and learn to do it in a manner that does not alert the trafficker’s suspicion.
Documentation: ensure excellent EMR documentation of injuries, symptoms, and other features of physical exam. This may serve as valuable evidence in any legal proceedings or social services applications.
Initiate the discussion, offer resources, and provide compassion: even if the patient is not interested in disclosing or seeking help, simply stating that help is available can give a patient hope, and plant the seed that will empower her to seek assistance at a later time.
Safely distributed resources: for patients who are willing to receive information, it is imperative that the possession of the information does not endanger the patient. Traffickers are quite savvy and review phone logs, text messages, contacts, and browsing history. Make sure that information is “encoded” in a way that it will not be apparent to the trafficker – shoe cards, numbers stored under alternate name, easily memorized facts. Collaborate with the patient on what works for her.
Multidisciplinary collaboration: any exploration of possible human trafficking cases should involve consultation and coordination of law enforcement, social work, case management, behavioral health services, substance use services, safe houses, and social services
1. United Nations General Assembly. Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention against Transnational Organized Crime, 15 Nov 2000.
2. International Labour Organization. Summary of the International Labour Organization 2012 Global Estimate of Forced Labour. 01 Jun 2012.
3. United States Department of State. Trafficking in persons report. June 2016. http://www.state.gov/j/tip.
4. Banks D, Kyckelhahn T. Characteristics of suspected human trafficking incidents, 2008-2010 (NCJ 233732). United States Department of Justice, Bureau of Justice Statistics. Apr 2011.
5. Macias-Konstantopoulos WL. Caring for the trafficked patient: ethical challenges and recommendations for health care professionals. AMA J Ethics. 2017 Jan 1;19(1):80-90.
6. Lederer L, Wetzel C. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law. 2014;23(1):61-91.
7. Maryland Human Trafficking Task Force. www.mdhumantrafficking.org. Accessed June 20, 2017.
8. Tahirih Justice Center. Human Trafficking Press Kit. www.tahirih.org. Accessed June 20, 2017.
9. Salvation Army of Central Maryland. Combat Human Trafficking. salvationarmymwv.org/centralmaryland/help/human-trafficking/. Accessed June 20, 2017.
10. Capital News Service. The Brothel Next Door – Human Trafficking in Maryland. cnsmaryland.org/human-trafficking. Accessed June 20, 2017.
11. Cassie, R. Children of the Night: Sex trafficking is Maryland’s dirty open secret. Baltimore Magazine. Mar 2017.
12. Nine arrested in Ocean City prostitution, human trafficking bust. WBAL TV. www.wbaltv.com. Accessed June 20, 2017.
13. Two arrested in connection with human trafficking of teen. Baltimore Sun. June 6, 2017.
14. Shandro J, Chisolm-Straker M, Duber HC, et al. Human trafficking: a guide to identification and approach for the emergency physician. Ann Emerg Med. 2016 Oct;68(4):501-508.e1.
15. Coppola JS, Cantwell R. Health professional role in identifying and assessing victims of human
labor trafficking. J Nurs Pract. 2016 May;12(5):e193-200.
16. Gibbons P, Stoklosa H. Identification and treatment of human trafficking victims in the emergency department: a case report. J Emerg Med. 2016 May;50(5):715-9.
17. Hachey LM, Phillippi JC. Identification and management of human trafficking victims in the emergency department. Adv Emerg Nurs J. 2017 Jan/Mar;39(1):31-51.
18. Macias-Konstantopoulos W. Human trafficking: the role of medicine in interrupting the cycle of abuse and violence. Ann Intern Med. 2016 Oct 18;165(8):582-588.
19. Ottisova L, Hemmings S, Howard LM. Prevalence and risk of violence and the mental, physical and sexual health problems associated with human trafficking: an updated systematic review. Epidemiol Psychiatr Sci. 2016 Aug;25(4):317-41.
20. Powell C, Dickins K, Stoklosa H. Training US health care professionals on human trafficking: where do we go from here? Med Educ Online. 2017;22(1):1267980.
21. Rollins R, Gribble A, Barrett SE, Powell C. Who is in your waiting room? Health care professionals as culturally responsive and trauma-informed first responders to human trafficking. AMA J Ethics. 2017 Jan 1;19(1):63-71.
22. Stoklosa H, MacGibbon M, Stoklosa J. Human trafficking, mental illness, and addiction: avoiding diagnostic overshadowing. AMA J Ethics. 2017 Jan 1;19(1):23-34.
23. Todres J. Physician encounters with human trafficking: legal consequences and ethical considerations. AMA J Ethics. 2017 Jan 1;19(1):16-22.