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 experience 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 in 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.

SURVIVOR VOICE

“I was taken to the hospital about 80 times for injuries and sometimes to check for STIs, but I never told the truth about what happened. The nurse always just accepted what I said. For example, one time I said that I fell even though it was obvious I didn’t just fall. I had a broken nose so bad that I had to have reconstruction. I came in with sore ribs, and I had teeth knocked out from one side of my jaw. I didn’t go back to the same hospital because I was trafficked across several states.”

SURVIVOR VOICE

“We always dressed in nice clothes and wore heels. I carried a cell phone and a Louis Vuitton bag. Our nails and our hair were always done, and we only rode in a new SUV. We got food, so I didn’t have malnutrition or anything, but I know some girls who did. I had bad scars on my legs from being dragged from a car, but no one ever asked me about them.”

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

SURVIVOR VOICE

“There was a new girl, and I was taking her around. She was really young, and she couldn’t take it. She shot herself.”

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

SURVIVOR VOICE

“I couldn’t ever go to the hospital alone. One of the girls always came with me and never left the room. She was there to make sure I didn’t tell the hospital staff the truth. I think one nurse knew, but all she did was give me a phone number. I never could call it because as soon as we left, the girl who came with me took it away. I would have been too afraid to call it anyway because it would have been dangerous to do that. [The trafficker] controlled our phones.”

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. 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.”

It is important to note that 1 in 6 runaways is likely to be trafficked within 48 hours of leaving home and may become sexually exploited in exchange for food, a place to stay, or cash. This is sometimes referred to as “survival sex” and is another form of commercial sexual exploitation. The youth may also disclose a history of involvement in the foster care or juvenile justice system.

Although children who have run away and are on the street are particularly vulnerable to traffickers, youth who live at home with parents or who are in foster care homes or group homes are also vulnerable to exploiters and may become victims of trafficking or CSEC when approached at malls, schools, parks, youth groups, and online.

SAFE HARBOR LAWS PERTAINING TO MINORS

In 2000, the federal Victims of Violence and Trafficking Prevention Act redefined the commercial sexual activity of minors as victimization as opposed to criminal behavior regardless if the child’s activity appeared to be voluntary (Finklea et al., 2015). But this law proved to be ineffective over state child protection laws. A minor is defined as being under the age of 18 years, but the age for consent for lawful intercourse in some states is as low as 16, leaving youth between the ages of 16 and 18 vulnerable to arrest in those states.

Until 2014, any minors who were victims of sex trafficking in Michigan were arrested as criminals. The arrest and criminalization of trafficked youth only compounded their trauma and diminished their self-esteem. Placement in the juvenile justice system also exposed trafficking victims to other youth who were detained because they had committed crimes.

Although the law in Michigan technically only protects youth under the age of 16 completely from arrest for prostitution, a “Safe Harbor” law in Michigan, passed in 2014, provides protection from such an arrest for all minors under the age of 18. This law presumes that any minor under the age of 18 who is involved in commercial sex is a trafficking victim. Law enforcement officers are required to refer minors under the age of 18 who are engaged in sex trafficking to CPS for treatment services provided by the Michigan Department of Health and Human Services (Michigan Attorney General, 2023b).

CASE

Sex Trafficking

Haley was 14 years old and wanted to be a dancer or a chef when she grew 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 and phoned the Centralized Intake for Abuse and Neglect Hotline.

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, a high school education, and eventually, culinary training. Haley works as a cook now.

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, 2020).

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 the 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 for the healthcare professional 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, 2020).

SURVIVOR VOICE

“I knew a girl who went to the hospital with her trafficker. He was in the room, but she slipped the nurse a note by shaking her hand. The note said, “I am not okay, and I need help.” The nurse left the room. When she came back, she told the trafficker that she had to take the girl to get an X-ray. As soon as they were alone, the girl told the nurse that the trafficker had a gun on him, and she asked the nurse to call the police for her.”

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 & Reynolds, 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 (NHTTACenter, 2021). 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.

Survivors who have experienced human trafficking are experts on this topic and understand what healthcare providers need to know in order to create a safe space for disclosure. According to survivors, it is important that healthcare workers have a working knowledge or skills in these areas:

Resources for human trafficking survivors
Mandatory and nonmandatory reporting of human trafficking
Trust-building
Means of separation from the trafficker
Survivor empowerment, follow up, and monitoring
“Red flags” for human trafficking
Skilled collaboration and assessment
Compassion
Advocacy
Respect
Trust
Patience
Gentleness
Sensitivity
Safety
Nonjudgmental attitude

Survivors also recommend that healthcare professionals:

Obtain informed consent for all treatments
Share accurate timeframes
Avoid touching the patient and, when clinically necessary, only do so after asking permission
Provide opportunities for the patient to be in control when possible
Listen and respond to the needs that patients verbalize
Include other survivors in the care team to reduce the possibility of shame
(Chisolm-Straker et al., 2020)

SURVIVOR VOICE

“Nurses should look at the behavior of the patient and any person accompanying them. They should talk to the patient one to one. If just one nurse could have taken me somewhere private, I would have told them what was happening and asked them to call the police.”

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. Research identifies multiple contributing factors to the lack of recognition of male commercially sexually exploited children, even though an estimated 31%–71% of youth who are involved in commercial sex may be male:

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.
Boys may not disclose their status due to fear of criminalization for substance use or being undocumented.
Providers may defer to cultural norms that recognize girls as being vulnerable and needing protection but expecting boys to “tough it out.”
Providers may accept a social standard that assumes that boys who are involved with forced sex do so willingly in exchange for benefits, thereby believing they are not being trafficked but are willing participants.
If a girl has new clothes or a manicure from an unexplained source, providers may suspect it is because she has been sexually exploited. If a boy has new shoes, jewelry, etc., he may instead be suspected of theft or gang involvement.
If a girl is seen with an older man, providers will investigate, but if a boy is involved with an older man, providers might assume he is a willing participant in a same-sex relationship.
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.
(French Nafekh et al., 2023)

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.

Michigan’s Department of Health and Human Services (MDHHS) has developed two screening tools for the purpose of identifying minor victims of human trafficking: the MDHHS-5523 (for ongoing cases) and MDHHS-5524 (for closed cases). These tools were developed by child welfare professionals. The protocol for child trafficking published by MDHSS also allows the use of the TVIT from the Vera Institute of Justice or HTIAM-14 from New York State’s Covenant House (see below) in place of the 5523 or 5524 (MDHHS, 2017).

The Vera Institute of Justice’s (2014) Trafficking Victim Identification Tool (TVIT) is validated and continues to be used by health professionals, law enforcement officers, and other service providers to screen adult victims of trafficking. This tool consists of a 30-topic questionnaire and was developed over two years with a grant from the National Institute of Justice. The tool is available in both English and Spanish and comes in a full or abbreviated version. This tool requires about an hour to administer, and the results are evaluated by a human trafficking expert. The topics that are covered include background and demographics, migration into the United States, and working and living conditions. The total responses are evaluated, and needs such as safety, housing, social service, and employment are assessed. This tool works best with reliable referral networks so that victims can receive the services that they need from community partners (TX DHHS, 2023).

New York State’s Covenant House developed the Human Trafficking Interview and Assessment Measure (HTIAM-14) to assess youth for trafficking. It is similar to the other screening tools, with the child welfare professional scoring responses to quantify risk; it is brief to administer; and it does not require expertise in trafficking (TNOYS, 2023).

(See also “Resources” at the end of this course.)