Quick Safety 42: Identifying human trafficking victims

Issue:

The United States is one of the largest markets and destinations for human trafficking victims in the world.¹ If staff at your health care organization have not yet encountered a human trafficking victim, very likely they will. Knowing how to identify victims of human trafficking, when to involve law enforcement, and what community resources are available to help the individual is important information for all health care professionals.

Over a 10-year period (2007-2017), the National Human Trafficking Resource Center (NHTRC) received 40,200 reports of human trafficking cases in the U.S., with the greatest number of reports coming from California (1,305), Texas (792), Florida (604), Ohio (365) and New York (333).² Human trafficking is the fastest growing criminal industry in the world and is the second-largest source of income for organized crime.¹

Identifying and helping victims of human trafficking can be difficult and can further endanger the victim. Most human trafficking victims or their families have been threatened with harm if the victim reveals their exploitation. In some cases, victims from different countries or cultures don’t realize that their exploitation is unusual or criminal. Also, some human trafficking victims have bonded with their exploiter, a condition called trauma bonding that is similar to Stockholm syndrome. Victims may keep silent about their exploitation from shame or fear of being humiliated. Since medical care is occasionally necessary for trafficking victims, health care professionals are in a unique position to help these unfortunate victims.¹

What is human trafficking and who is victimized?

Human trafficking is modern-day slavery.³ The United Nations Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Article 3, defines human trafficking as: The recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs.⁴

The U.S. Victims of Trafficking and Violence Prevention Act of 2000 (TVPA) defines and classifies human trafficking into two categories: sex trafficking and labor trafficking.⁵

According to the Office on Trafficking in Persons, human trafficking is a public health issue that impacts individuals, families and communities.

Traffickers disproportionately target at-risk individuals, including those who have experienced or been exposed to other forms of violence, and individuals disconnected from stable support networks.⁶

Recognizing signs of human trafficking

The NHTRC and other sources provide the following signs of human trafficking that can be used to recognize potential victims:²

Poor mental health or abnormal behavior:

• Appears fearful, anxious, depressed, submissive, tense, nervous or paranoid
• Avoids eye contact
• Refuses to change into a gown and/or to cooperate with physical exam
• Behavior or demeanor does not align with injury or complaint (i.e., acts like it is “no big deal,” even with concerning injuries)
• Refuses treatment that does not take place during that visit (i.e., refuses to go to specialist)

Poor physical health:

• Appears malnourished
• Signs of repeated exposure to harmful chemicals
• Signs of physical and/or sexual abuse, physical restraint, confinement or torture

Other:

• Is not in control of identification (ID or passport)
• Is not allowed or able to speak for themselves (a third party may insist on being present and/or interpreting)
• Claims of just visiting
• Unable to clarify address or where he/she is staying
• Unsure of whereabouts and/or of what city he/she is in
• Loss of sense of time
• Inconsistencies in his/her story
• Tattoo(s), brand(s) or other marking(s)¹

When human trafficking is suspected

Every situation of human trafficking is unique; it is important to use a victim-centered response. Not all victims of trafficking will be ready to seek assistance, and health care professionals cannot force an adult victim to report the crime of human trafficking. However, if the victim is a minor (under 18 years of age), the provider is legally obligated to contact Child Protective Services.

Medical providers can provide trafficking victims with information and options, while supporting them through the process of connecting with service providers if they are ready to report their situation.⁷

If human trafficking is suspected:

• Remain nonjudgmental
• Observe the body language and communication style of the patient and those who accompany him/her³
• Use plain language; try to use words the patient uses.
• Try to interview and/or examine the patient privately at some point during the visit.3 Ensure the patient is alone when you discuss sensitive issues.
• If you are able to interview the patient alone, use simple screening questions (see sidebar box for sample questions to screen a patient who may be a victim of human trafficking).¹
• Find an interpreter if necessary¹ 
• Build a trusting rapport with the patient¹ 
• Document your concern in your notes to ensure it is not overlooked if the victim returns for care or assistance

Safety actions to consider:

If a patient has disclosed that they have been trafficked, the health care professional should take the following actions to support and help keep the victim safe:⁷

• In situations of immediate, life-threatening danger, follow your institutional policies for reporting to law enforcement. Make an effort to partner with the patient in the decision to contact law enforcement.
• Provide the patient with the NHTRC hotline number. If the patient feels it is dangerous to have something with the number on it, have them memorize it.
• Provide the patient with options for services, reporting and resources. Ensure that safety planning is included in the discharge planning process.
• If the patient is a minor, follow mandatory state reporting laws and institutional policies for child abuse or serving unaccompanied youth.
• Accurately document the patient’s injuries and treatment in the patient’s records. Keep in mind that while documentation of abuse may be helpful in building a case against a trafficker, information about the victim also can be used against them in a court proceeding. Be careful with paraphrasing or summarizing; use patient quotes as much as possible, and stick to the facts.
• Gain permission and consent from adult patients who have been trafficked before disclosing any personal information about the patient to others, including service providers.
• If your institution has a social worker, utilize them. They can be instrumental in getting the support and resources your patient needs.

Health care organizations can take the following safety actions to help prepare staff to be on alert and prepared to identify and help patients who may be victims of human trafficking:

• Mitigate language barriers; provide professional interpreters.³
• Incorporate social, work, home history and domestic violence screening questions into routine intake.³
• Ensure that staff know when and how they should alert security and/or local law enforcement.
• Train frontline staff on how to identify, refer and report human trafficking victims, and how to connect victims to services and support systems to meet their immediate and longer-term needs.¹
• Provide staff with the following information to facilitate this:
• Local resources to help with suspected trafficking cases (many U.S. metropolitan areas have a Human Trafficking Task Force).³
• Local or state requirements regarding mandatory reporting of human trafficking.
• How HIPAA regulations impact reporting of potential trafficking situations on behalf of a patient.
• Confidentiality obligations when contacting the NHTRC or local service providers.
• NHTRC resources and services. These can include developing a safety plan that is acceptable to the patient and facilitating a report to specialized law enforcement trained to handle human trafficking cases.³

Resources:

1. Isaac R, et al. Health care providers’ training needs related to human trafficking: Maximizing the opportunity to effectively screen and intervene. Journal of Applied Research on Children: Informing Policy for Children at Risk, Human Trafficking, 2011; Vol. 2: Issue 1, Article 8.

2. National Human Trafficking Hotline, https://humantraffickinghotline.org/.
3. Baldwin SB, et al. Identification of human trafficking victims in health care settings. Health and Human Rights, 2011; Vol 13: Issue 1.
4. United Nations Office on Drugs & Crime, Human Trafficking webpage.
5. National Human Trafficking Resource Center, https://humantraffickinghotline.org/.
6. Office on Trafficking in Persons, an Office of the Administration for Children & Families, U.S. Department of Health & Human Services, Fact Sheet: Human Trafficking, Nov. 21, 2017.
7. National Human Trafficking Resource Center. Identifying victims of human trafficking: What to look for in a healthcare setting. February 2016.

Other resources:

1. Adult Human Trafficking Screening Tool and Guide, National Human Trafficking Training and Technical Assistance Center, January 2018. Includes relationship-building tips and adult human trafficking screening tool.

Note: This is not an all-inclusive list.