Human Trafficking: Definition, Risk Factors, and Indicators

Human trafficking is a broad and complex issue that can take many forms, including commercial sexual exploitation, forced labor, bonded labor, and organ trafficking. ^{Reference Hachey and Phillippi7} The United Nations’ Palermo Protocol contains the first internationally recognized definition of human trafficking. ⁸ Federal law in the United States is modeled after international law and specifically defines sex and labor trafficking as the use of force, fraud, or coercion for the purpose of exploitation in commercial sex and labor, respectively. ⁹ Force can include physical assault or confinement, fraud can include deception or extortion, and coercion can include intimidation or emotional manipulation. ^{9,Reference Roe-Sepowitz, Hinckle, Bayless, Christensen, Garuba, Sabella and Tate10}

Several factors make individuals more vulnerable to human trafficking. Broad structural factors include poverty, corruption, isolation, and societal and oppressive cultural norms. ^{Reference Logan, Walker and Hunt11,Reference Macias Konstantopoulos, Ahn and Alpert12} Specific individual factors include childhood trauma, substance use, early exposure to violence, limited livelihood options, LGBTQ+ sexual/gender identities, family dysfunction, and housing insecurity. ^{Reference Hachey and Phillippi7,Reference Logan, Walker and Hunt11–13}

Traffickers may use addictive substances as tools for recruiting and maintaining control over victims. In a cohort of sex trafficking survivors, 84% reporting using substances while trafficked, 28% reported being forced to use addictive substances, and 26% experienced overdoses. ^{Reference Lederer and Wetzel14} Human trafficking, additionally, may result in significant negative psychological outcomes, including depression, posttraumatic stress disorder (PTSD), and complex PTSD. ^{Reference Hopper and Gonzalez15,Reference Stevens, Acker and Green16}

In their role, EMS providers can survey the scene where a potential victim of human trafficking may be found. There are several on-scene indicators that indicate a patient is a victim of sex trafficking, including drug or sexual paraphernalia, buildings with many rooms that lock from the outside, and restraint devices. ^{Reference Roe-Sepowitz, Hinckle, Bayless, Christensen, Garuba, Sabella and Tate10} Furthermore, consider lack of identification documents, inadequate or provocative clothing, and evidence of potential physical assault – especially if wounds are at different healing stages and may have been caused by a repeated pattern of abuse. ^{Reference Roe-Sepowitz, Hinckle, Bayless, Christensen, Garuba, Sabella and Tate10} Additionally, victims of human trafficking may have multiple concurrent sexually transmitted infections (STIs), pelvic inflammatory disease, and evidence of genitourinary trauma (eg, traumatic fistula or vaginal wall tears). ^{Reference Roe-Sepowitz, Hinckle, Bayless, Christensen, Garuba, Sabella and Tate10} In the case of labor trafficking, on-scene indicators include a lack of identification documents, poorly-ventilated or unsanitary working conditions, residence at place of work or with their declared employer, an alleged employer insisting on acting as a translator in the case of low English language proficiency or accompanying the patient, lack of access to personal protective equipment, performance of hazardous work without proper training, long work hours, and prolonged exposure to extreme heat or cold. ^{Reference Oram and Zimmerman17,Reference Macias-Konstantopoulos and Brown18} A combination of these on-scene indicators may be present when individuals are exploited for both sex and labor in domestic housework, massage parlors, and nail salons. ^{Reference Dank, Khan and Downey19,20}

Tiller and Reynolds in 2020 developed a list of potential indicators of human trafficking specifically for emergency providers. They include: (1) poor mental health or abnormal behavior; (2) poor physical health; and (3) lack of control. Each of these categories can be further broken down into various components. For instance, poor mental health or abnormal behavior includes fearful or anxious demeanor (eg, hyper-startle reflex) or avoiding eye contact. Poor physical health includes a lack of health care access for chronic conditions or signs and symptoms of physical or sexual abuse. Finally, a lack of control includes the victim having few personal possessions, as well as limited financial or interpersonal autonomy. ^{Reference Tiller and Reynolds21} Victims of human trafficking may present alone or accompanied by traffickers. ^{Reference Patel, Ahn and Burke22} When they present alone, providers have a unique opportunity to promote a safe space for them. Providers need to be extra vigilant when victims of trafficking present with traffickers. Creating opportunities for potential victims to have privacy and comfort within the health care setting can be incredibly helpful in fostering provider-patient rapport. ^{Reference Patel, Ahn and Burke22,Reference Bacchus, Mezey and Bewley23} When language barriers exist, employing professional interpreters is highly recommended to avoid inquiring about abuse or violence in the presence of a trafficker and inadvertently undermining survivors’ autonomy. ^{13,Reference Shandro, Chisolm-Straker and Duber24,Reference Macias-Konstantopoulos25}

Providers aware of these specific risk factors and indicators may be able to assess patients for potential links to human trafficking. Social history questions may be especially helpful in identifying victims of human trafficking and should be broached in conversational fashion rather than checklist question format. A number of things should be considered when a victim of human trafficking discloses their status to a provider. For example, it may be important to determine if the patient is in immediate danger. ^{Reference Macias-Konstantopoulos and Brown18} Providers should assess the needs and priorities of the patient in such a way that the patient maintains autonomy and control to the greatest extent possible. ^{Reference Macias-Konstantopoulos and Brown18} Depending on community protocols, providers can refer patients to local agencies or resources who may be able to help.

Human Trafficking and Emergency Care: The Role of Providers

Human trafficking is associated with negative physical and psychological health outcomes. ^{Reference Hachey and Phillippi7,Reference Greenbaum26,Reference Macias-Konstantopoulos and Ma27} Victims of human trafficking frequently encounter the emergency care system. ^{Reference Lederer and Wetzel14,Reference Baldwin, Eisenman, Sayles, Ryan and Chuang28,Reference Chisolm-Straker, Baldwin, Gaïgbé-Togbé, Ndukwe, Johnson and Richardson29} One study reported 63% of female victims of sex trafficking visited an emergency department while being trafficked. ^{Reference Lederer and Wetzel14} Both the American Board of Emergency Medicine (ABEM; East Lansing, Michigan USA) and American College of Emergency Physicians (ACEP; Irving, Texas USA) specifically highlight the role of emergency care in responding to human trafficking. ^{Reference Shandro, Chisolm-Straker and Duber24,Reference Macias-Konstantopoulos and Raja30–Reference Pourmand and Marcinkowski34}

Despite this proximity, research suggests emergency providers often lack the knowledge, skills, and confidence to identify potential victims of human trafficking. ^{Reference Chisolm-Straker, Richardson and Cossio35,Reference Todres36} This is concerning when considering the vulnerability of trafficked individuals and the potential for providers to have positive and negative impacts on trafficked individuals.

Improving Provider Awareness of Human Trafficking

There is wide-spread variation in provider awareness and formal training for human trafficking. ^{Reference Chisolm-Straker, Richardson and Cossio35} A review of 23 studies examining emergency department providers found a wide-spread lack of formal training about human trafficking, leading to differences in providers’ abilities to recognize human trafficking and provide the best possible care. ^{Reference Marcinkowski, Caggiula, Tran, Tran and Pourmand37} There is also variation among training within EMS – one study reports under one-half of EMS providers had formal training in human trafficking, and formal training was associated with increased ability to recognize indicators of trafficking. ^{Reference Donnelly, Oehme, Barris and Melvin38}

Training programs aimed at educating emergency care providers increase providers’ ability to recognize human trafficking victims and provide trauma-informed care. ^{Reference Marcinkowski, Caggiula, Tran, Tran and Pourmand37–Reference Bloem, Morris and Chisolm-Straker39} For instance, one study of the 20 largest emergency departments in the San Francisco Bay Area (California USA) found providers who received training on human trafficking reported improved knowledge about human trafficking and available resources. ^{Reference Grace, Lippert and Collins40} Similar studies report providers who participate in training programs may be better able to recognize and care for victims of human trafficking. ^{Reference Marcinkowski, Caggiula, Tran, Tran and Pourmand37} Specific training programs for EMS providers can improve their likelihood of suspecting human trafficking based on indicators as well as confidence in managing potential victims. ^{Reference Harlow, Rothman, Dyer and Stoklosa41,Reference Charron, Valenzuela, Donnelly and Oehme42}

Using validated techniques – as well as the experiences of subject-matter experts – represents an ideal starting point. The goals of these training programs should be multifold: (1) raise awareness about human trafficking; (2) teach providers how to recognize potential victims of human trafficking; and (3) familiarize providers with trauma-informed care. The core tenets of trauma-informed care can also be cross-applied to other circumstances, such as child maltreatment and domestic violence. ^{Reference Bacchus, Mezey and Bewley23,Reference Bath43} Once acceptable awareness has been developed, the focus can pivot towards developing protocols and interventions that reflect the unique needs and circumstances of specific communities. ^{Reference Shandro, Chisolm-Straker and Duber24}