RECOGNIZING TRAFFICKING

The media often portrays trafficking victims as women or girls 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 other forms of child abuse, 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.

Being aware of warning signs and indicators of human trafficking can alert healthcare professionals to possible victims. They may note one or more of the following “red flags” in a child who is a victim of trafficking.

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

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
SCREENING FOR COMMERCIAL SEXUAL EXPLOITATION OF CHILDREN

There are several validated screening tools for CSEC and a variety of known risk factors for victimization. Greenbaum and colleagues (2018) developed a short, six-question screening tool for CSEC that can be used effectively for youth in the healthcare setting. This short questionnaire also differentiates between victims of sex trafficking and youth who may have experienced sexual assault or abuse without sex trafficking. Each positive response is given a 1-point score. A cut-off score of 2 indicates a patient suspected for CSEC and indicates further questioning by someone trained in a trauma-informed approach.

  1. Is there a previous history of drug and/or alcohol use?
  2. Has the youth ever run away from home?
  3. Has the youth ever been involved with law enforcement?
  4. Has the youth ever broken a bone, had a traumatic loss of consciousness, or sustained a significant wound?
  5. Has the youth ever had a sexually transmitted infection?
  6. Does the youth have a history of sexual activity with more than five partners?
CASE

Haley is 14 years old and has always wanted to be a dancer or a chef when she grows up. One day she met a young man at the mall who told her she was beautiful. They exchanged phone numbers and began talking on a regular basis. He gave her gifts, and Haley thought she was in love. Haley was being “groomed,” one of the ways that exploiters gain trust and control over victims.

Haley’s new “boyfriend” soon asked her to have sex with other men, something she said she did not want to do but did anyway because she wanted to please him. Haley also had a history of physical, emotional, and sexual abuse in the home, which made her particularly vulnerable to the methods of exploiters because the cycle of abuse was familiar to her. Because Haley had endured years of sexual abuse in her home, she already felt dirty and ashamed in relation to sex.

Haley’s situation progressed to being sold to another exploiter, who beat her if she did not make any money and took all of her money when she was paid. She lived in a locked basement and slept on a mattress on the floor, with only a bucket to use as a toilet. Devoid of job skills, money, and fearing further abuse if she returned to her home, Haley felt trapped and that she had no way out.

Haley’s exploiter took her for frequent STI testing at various free clinics to avoid suspicion. Chandra, a nurse practitioner who volunteered at several of the clinics, began to recognize Haley. At the insistence of her exploiter, Haley always registered as an 18-year-old whenever she requested services, but Chandra suspected that Haley was probably younger. Before asking Haley her true age, Chandra made an effort to gain Haley’s trust, and Haley confided in her that she was only 14. This confirmed Chandra’s suspicions that Haley was probably a minor victim of trafficking, and so she followed the state protocol to report suspected child abuse.

Haley was taken to an emergency receiving center, and because her parents had never filed a missing person report or made an attempt to find her, she was placed in protective custody. Later, Haley was placed in a residential recovery facility for trafficking survivors. Haley was given a safe place to live, extensive treatment for her trauma, and enrolled in high school.