ASSESSMENT AND INDICATORS OF HUMAN TRAFFICKING IN CLINICAL SETTINGS

The goals of healthcare providers who wish to intervene and assist victims of human trafficking are in direct conflict with those of exploiters. Exploiters hope for the continued vulnerability of their victims and see their victims as merchandise. Exploiters use concealment and misdirection to confuse anyone who they view as a threat to their profits and manipulation, power, and control to discourage victims from disclosing their circumstances.

In order to develop a capacity to listen to patients who have a history of violence, healthcare workers must be willing to extend themselves into areas of malfeasance and human fallibility. Healthcare professionals’ best resource is knowledge. Being aware of warning signs and indicators of human trafficking can alert the clinician to possible victims.

Setting and Presentation

The media often portrays trafficking victims as women who are in chains or have a sign written on their hands that says, “Help Me.” However, this is not what most trafficking victims look like. When victims of human trafficking present in healthcare settings, it is uncommon for them to self-disclose that they are victims. They have significant trust issues, and even when asked directly, they are not likely to disclose that they are victims. The exploiter may also accompany victims, and as with victims of domestic violence, that presence will discourage victims from making any disclosures to a clinician.

A healthcare professional may encounter victims of sex trafficking in a clinic or emergency department setting who are requesting treatment or testing for pregnancy, abortion, sexually transmitted infections, and contraception. They may request a sexual assault forensic exam or treatment for substance abuse. Victims may suffer from broken bones or nonaccidental injury at the hands of exploiters or buyers.

Victims of labor trafficking may have physical injuries, pesticide poisoning, or salmonella from unclean water sources. If their illness or injury is severe, these patients may present in outpatient clinics or in the emergency department.

Behavioral health providers may encounter victims of trafficking who are depressed, cannot sleep, have anxiety, or are suicidal. Dentists may see these victims when dental problems become severe.

DOCUMENTATION

When conducting an exam of a patient who may be a victim of human trafficking, documentation should carefully record a written description of any findings, photographs, diagrams, and forensic evidence. It is important that documentation reflect the patient’s perspective and not the suppositions or biases of the clinician (HEALTrafficking.org, 2018).

Potential Indicators

Human trafficking may be indicated by numerous possible signs. Clinicians may note one or more of the following “red flags” in a healthcare setting.

PHYSICAL SIGNS

  • Signs or a history of deprivation of food, water, sleep, or medical care
  • Physical injuries typical of abuse, such as bruises, burns, cuts, scars, prolonged lack of health or dental care, or other signs of physical abuse
  • Brands, scars, clothing, jewelry, or tattoos indicating someone else’s “ownership”
  • Presence of sexually transmitted infections
  • Pregnancy
  • Possession of cell phones, jewelry, large amounts of cash, or other expensive items that appear inconsistent with the patient’s stated situation
  • Substance abuse or dependence signs and symptoms
  • Clothing that is inappropriate for the weather or emblematic of commercial sex
INDICATORS IN A VICTIM’S APPEARANCE

The patient’s appearance may include unusual tattoos that signify “branding,” such as “I belong to John,” “Team Zodiac,” “I cum for $,” or barcodes. The patient may dress incongruently for the weather, such as wearing long sleeves to cover bruises or other marks when it is warm, or clothing that is sometimes emblematic of commercial sex, such as skimpy skirts and low-cut tops regardless of when the weather is cool. It is important to remember that the victim may also be dressed as a school child, appear to be very well-dressed, or may be male or transgender.

PSYCHOLOGICAL/EMOTIONAL SIGNS

  • Fear, anxiety, depression, nervousness, hostility, flashbacks, avoidance of eye contact
  • Restricted or controlled communication, or use of a third party to translate, with no indicator of inability to understand English
  • Inconsistencies in the history of the illness or injury
  • Denial of victimization
  • Attempted suicide, submissiveness, fearfulness, self-harm, or other signs of psychological abuse
  • Appearing to be controlled by a third party (e.g., looking for permission to speak, not being left alone)
  • Isolation from family or former friends
  • Fear of employer
  • Described or implied threats to self or family/friends
  • History of running away

ENVIRONMENTAL/SITUATIONAL SIGNS

  • Working and living in the same place
  • Lacking the freedom to leave their working or living conditions
  • Being escorted or kept under surveillance when they are taken somewhere
  • Not being in control of their own money
  • Having no, or few, personal possessions
  • Frequently lacking identifying documents, such as a driver’s license or passport
  • Indicators of being a minor in a relationship with a significantly older adult
  • Not knowing their own address
  • Being in possession of hotel keys
BARRIERS TO RECOGNIZING MALE VICTIMS

Evidence has shown that even those providers who are trained to identify human trafficking victims often miss identifying male victims when they encounter them (U.S. DOS, 2017). Research identifies multiple contributing factors to the lack of recognition of male commercially sexually exploited children, even though half of children who are involved in commercial sex may be male, and why they are not offered services:

  • Boys are not likely to self-identify as sexually exploited due to feeling shame, stigmatization from their family or community, and in some cases concerns about being gay.
  • Western culture promotes the image of males as strong and self-reliant persons who actively pursue sex.
  • Anti-trafficking organizations offer limited outreach to areas that are known for male prostitution.
  • There is a general belief that boys are not trafficked but are willing participants, and this fallacy obscures the need for services for male victims.
    (Youth Collaboratory, 2018)

INDICATORS AMONG MINORS

Minor victims may present with the same physical findings as adult victims, but it is important to also take note of a youth’s belongings. Trafficked youth generally have a cell phone and may also have in their possession items that seem too costly for their age and occupation, such as expensive jewelry, purses, and large amounts of cash.

A careful social history may elicit that the child is “couch surfing” or “staying with a friend” and not attending school. Homeless youth may engage in “survival sex,” which is sexual exploitation in exchange for food, a place to stay, or cash. Trafficked youth may have a chronic illness such as asthma or diabetes that is neglected. They may be accompanied by an older person whom they call “Daddy” or “Uncle” or refer to as their “boyfriend.”

Screening

Screening should take place in a quiet environment free from interruptions. Food, drink, and tissues should be available during the interview, and the interviewer should be prepared to offer clothing and referrals to medical care and other services as indicated. The screener should be sensitive to the fact that formal dress, suits, and uniforms may be emblematic of immigration or enforcement agencies and are not conducive to open communication.

(See also “Trauma-Informed Care” below.)

USE OF INTERPRETERS

If interpreters are needed, in-person services through accredited agencies are preferred. Interpreters should be screened for any conflict of interest, and they should utilize trauma-informed care practices. Patients should be given the option to request a different interpreter if they are uncomfortable. Some patients may prefer the anonymity of using a translator on the phone instead of in person. Trained interviewers are available in 200 languages through the National Human Trafficking Hotline (see “Resources” at the end of this course) (HEALTrafficking.org, 2017).

STRATEGIES TO INTERVIEW THE PATIENT ALONE

In order to provide an opportunity for the patient to communicate freely, the healthcare professional may need to implement a strategy to create privacy when the patient is accompanied by someone else. Strategies include: requesting that patient leave the room with a clinician and without any accompanying person to undergo a procedure such as an X-ray, requesting that any accompanying person step out of the room due to hospital privacy policies, or asking an accompanying party to leave the room in order to provide assistance with registering the patient.

If the person who is accompanying the patient refuses to leave or to allow the patient to be separated, it may not be in the patient’s best interest to insist. If the trafficker feels threatened, there is a risk that the patient will not be allowed to receive treatment or be harmed after leaving the facility. The same is true for involving law enforcement or security. If the trafficker becomes suspicious, it may jeopardize the ability of the patient to return for needed treatment (HEALTrafficking.org, 2017).

SAFETY MEASURES

When working with human trafficking survivors, safety is a primary concern. Although many emergency departments have metal detectors to screen for weapons, it is important that all healthcare institutions have a response protocol in the event of violence. It is equally important that healthcare professionals are aware of how to keep their patients and themselves safe at work.

When working with crime victims and suspects in particular, the healthcare professional should pay attention to the environment and be prepared to act quickly. Because of the criminal nature of human trafficking, security should be alerted when a patient is suspected of being a human trafficking victim. Personnel should also be cognizant of prevention measures such as registering a high-risk patient under an alias, flagging their chart not to give information to the public, or placing the unit under lockdown if a direct threat occurs (Titler, 2020).

OVERCOMING SURVIVOR BARRIERS TO DISCLOSURE

The goal of the healthcare professional should not be to elicit a disclosure but to create a safe space where patients feel that they can be treated, learn more about their options, and receive support to make informed decisions (HEALTrafficking.org, 2017). There are many barriers to disclosure by human trafficking survivors to healthcare workers:

  • Patients who are trafficked are frequently in the presence of their trafficker or another person who is watching what they say and are not free to discuss their situation.
  • They may be unable to communicate due to linguistic issues, illness, or trauma.
  • Patients do not have any reason to trust healthcare professionals, are fearful of their trafficker, and are concerned that they will not be believed or might be arrested.

Assessment Tools

Several assessment tools have been developed to assist professionals in identifying victims of trafficking. These tools require training and are available online at no cost.

Florida’s Human Trafficking Screening Tool (HTST) is associated with a protocol that is specific to the Florida Department of Juvenile Justice and is designed to screen for indicators of human trafficking. (See “Resources” at the end of this course for a link to the Florida HTST screening tool.)

Another screening tool used for minors is the Commercial Sexual Exploitation Identification Tool (CSE-IT). The CSE-IT was developed by West Coast Children’s Clinic for social workers to screen at-risk youth who are 10 years of age and up for commercial sexual exploitation. The evidence-based and validated CSE-IT tool uses a weighted scoring system to evaluate observations made by the professional rather than answers given on a questionnaire to the youth (WCCC, 2017a & 2017b).

A more recent tool, Quick Youth Indicators for Trafficking (QYIT), evaluates for both labor and sex trafficking among homeless young adults. The QYIT is validated, brief to administer, and does not require a human trafficking expert to evaluate the results (Chisolm-Straker et al., 2020).