We may live under the illusion that the issue of human trafficking is something that doesn't readily touch our daily lives. Despite serving the medical needs of those in our communities, we often fail to recognize the plight of those caught within the grips of this horrendous crime. It is a growing public health threat. While the awareness of international trafficking has become more prominent in mainstream media, sadly, the recognition of domestic trafficking—specifically domestic minor sex trafficking—is trailing behind. Furthermore, the powerful role the health care professional (HCP) has in identification and the critical responsibility we have for intervention is often overlooked by the media.
Through our medical education programs, we are taught the importance of identifying elder abuse, domestic violence and child abuse. This education enables us to hone our skills for identification and to develop almost a sixth sense when suspicious cases are before us. In all of my years of training—with a heavy emphasis in pediatrics and specifically, pediatric trauma and abuse—the issue of sexually exploited young women and children was never discussed. Children being sold for sex or “prostituted” need to be recognized and identified as victims of child abuse.
Clinical Pearl: Victims have an average of nine HCP encounters while in captivity.
They are rarely identified as victims of sex trafficking.
The physically traumatized are mistakenly believed to be experiencing common domestic violence.
I was similar to most providers who believe that trafficking is an overseas international issue; however, it was through my “day” job as a nurse that the gross reality of sex slavery and the exploitation of young women and children collided with my daily routine and practice. I began recognizing the abuse and searched for a label and answers to the crime presented in front of me. The sexual exploitation of women and young girls has forever changed my world, my practice and my discussions both with patients and my colleagues.
Case Study (based on a true patient encounter)
“17 year old female” presented to the ER for complaints of arm pain and upper leg pain. Patient reports that she was climbing over a railing when she twisted her arm and must have strained her leg. States she was trying to get back into her apartment because she locked herself out of the house. Complaining of pain to the right shoulder. Her boyfriend continues to interject and states that she is clumsy, forgetful and forgets her keys all the time. He is busy texting on his phone. Patient provides short answers. She is wearing a tank top, sweater and jeans. On physical exam- she has full range of motion of the arm, no focal deficits. No problem with ambulating. Good rom of her hip and lower leg. She is ambulating with a slight limp, but overall she looks fine. She is slightly reserved and seems distant in the conversation and keeps looking at the clock on the wall. You are paged overhead and must attend to another patient. She was given Motrin per the orders. The boyfriend insists on providing the ID and necessary paperwork to registration. Patient was seen ambulating to the bathroom, appeared to be walking better. Her boyfriend tells the nurse they want to leave. You write up the paperwork, and she is discharged.
Backstory: This 17 year old female was really a 16 year old with a fake ID. The boyfriend with her was not a boyfriend but actually her pimp. He was around 25 years old. The story of climbing over the railing because she was locked out was false and a coached story. Earlier in the evening the patient was in the middle of a “date” with a John, and he wanted her to go out on the balcony of the hotel room on the third floor. He had ropes around her as this was his desire for this date. When she didn't want to go out there he pushed her up against the railing, and she began to fall over the side. He then held her by her right leg and upper torso with the rope and began screaming at her. He shook her, called her a stupid whore and told her he would kill her if she didn't do what he wanted. She had almost nothing on. She continued to struggle, and he finally pulled her over the railing. In the midst of the struggle, she twisted her arm. When the date ended, she had a lot of leg and arm pain. The pimp decided to take her to the ER. He coached her before going into the ER on exactly what she could and couldn't say. He held a gun to her stomach, saying he would blow her away if she talked, and she would be “timbed” (to stomp on a victim as punishment; based on the word timberlands boots).
The physical exam of the upper extremities occurred while clothed. But had her upper back and right scapula skin been evaluated, it would have been noted that she had rope burns. Her lower back was tattooed with the name “Slim Jones.” The upper right thigh had a second degree burn, which was actually several cigarette burns from the day before when she was trying to get away from another client.
This child was a reported missing runaway and had been missing for six months.
For the past five years, I have worked not only in education and training on the symptomatology of trafficking but also the intervention and aftercare responsibilities on behalf of providers. There are common questions I am asked in the area of screening tools and questionnaires, protocols and intervention.
Identification, Risk Factors and Symptomatology
Residents, nurses, social workers and other service providers often ask me if there is a “three question” screening tool that can be used to screen for trafficking. After all, screening for alcoholism, as well as domestic violence, is usually a short screening tool with a few yes or no answers. The answer to the above question isn’t a simple yes or no. The complexities surrounding the identification of a trafficking victim are layered, especially with children and young women. There are tools that can be utilized to help in identification; however, if the clinical suspicion is not on the forefront of one’s mind, a trafficking situation will frequently be missed. The index of suspicion will only be raised if there is a keen understanding of the psycho-social and physical red flags surrounding the presentation of the victim. Awareness of the fact that human trafficking is an issue inherent in an HCP’s practice is the first step towards identification.
Although a one-size-fits-all approach to identification is not reality, there are common trends, risk factors and red flags that are helpful in heightening the index of suspicion. Victims rarely self-identify or report their abuse while seeking care. A key factor to remember is that most victims will not present for care with a chief complaint of “sexual assault.” For successful identification, a thorough physical exam coupled with a complete and comprehensive social history cannot be stressed enough.
It is often assumed that children and young women who are exploited for sex are from a specific socio-economic background. This is far from the truth. This crime knows no socio-economic, age or racial boundaries. Being female, young and vulnerable are risk factors that apply across the spectrum. Sex trafficking happens to males as well. It is not well documented and is very often underreported
The following tables discuss some of the risk factors, psychosocial red flags and physical indicators.
Runaways - “throwaways” (1/3 teens are lured into prostitution within 48 hours of leaving home)
History of violence and abuse (28x more likely to enter into prostitution)
Younger girls are more vulnerable
Mental health issues
Increasing sexualization of girls and young women
Access to technology
Children in the juvenile justice and child welfare systems
Psycho-social Red Flags
Lying about age
Older boyfriend, dominating boyfriend
Hotel room keys
Won’t make eye contact
Large amounts of cash, jewelry, new clothes
Multiple foster/group home placements, runaway attempts
Anxiety, s/s of PTSD, changes in habits
Avoidance and dissociative type behaviors
Suicide gestures or attempts
Presents for care with law enforcement needing clearance for placement in juvenile detention or jail
Physical Red Flags
Tattoos on neck, lower back with man’s name or initials/branding
Multiple health care visits
Pelvic complaints, multiple pregnancy, STIs
Untreated medical problems such as asthma, skin infections, diabetes
Signs of assault such as perioral or intraoral injuries from forced oral sex, neck bruising or hickies, burns, impact bruises, traumatic alopecia from forceful hair pulling, ligature marks, abrasion and friction injuries
Identification requires a comprehensive evaluation of the above indicators with an active piecing together of each component in profiling a trafficking victim. Evaluating trends, especially a comprehensive review of their electronic medical record, can be a key indicator to a complex situation.
When the index of suspicion is high, the manner in which a patient is approached about the current situation is a delicate process. The key to beginning the conversation requires setting the groundwork, and building trust and rapport cannot be rushed. Just because one wears a white coat or scrubs doesn't warrant immediate trust. Unfortunately, trafficked people have often been abused and used by those who wear uniforms – such as law enforcement, HCPs and trusted authorities. Trust has to be earned. In doing so, meeting the most immediate physical needs is essential. Providing nourishment and a safe space are also priorities. If possible, if the trafficker or perpetrator is present, have him leave the room. Building rapport entails sitting down with the patient, maintaining eye contact, beginning with surface talk and focusing on their health care concern first. This is a great stepping stone for diving in deeper to the social situation surrounding presentation. The story often begins as a socially acceptable story; however, if the index of suspicion is high, navigating through the story and re-clarifying can often lead to better understanding and the ability to read between the lines. Remember, she has been groomed by her trafficker to tell you what you want to hear. She will often use street slang, and providers should become familiar with the “lingo” utilized in the “game.” I cannot overemphasize the need for a thorough physical exam. In the case discussed above, a good physical exam may have caused the provider to further question the potential for a case of exploitation. Their mouths may lie, but their bodies speak of the abuse.
Many of the girls I have worked with consistently say the same thing, “I presented for health care needs many times within my trafficking experience, and I was hoping and praying someone would ask me about my situation.”
As a HCP, don't be afraid to ask questions.
Some sample questions can include the following:
Where do you live, and who do you live with?
Who takes care of you?
How did you meet your boyfriend?
Do you feel like you are in danger?
Are you being threatened in any way?
What does your boyfriend do when he is angry?
Do you feel trapped in your living situation?
Tell me about your tattoo.
Has your body ever been used for money?
Has anyone ever taken photos of you and put them on the internet?
Is there anything happening in your life that you want to stop?
Are you being asked to have sex with men you don’t want to have sex with?
The Children’s Hospital of Atlanta has recently developed a screening tool as well as an emergency room protocol that can provide guidance for identification and appropriate responses to child victims.
In September 2013, the Institute of Medicine and the National Research Council released a report addressing the commercial sexual exploitation and trafficking of minors in the United States.
Once I have identified, now what? Nationally, there is a lack of response protocols in place within health care settings and clinics in regards to intervention. Slowly, the models and protocols are being developed; however, the conversation needs to be initiated in every health center. This is crucial because as identification increases, the legalities around intervention and confidentiality will come into question and need clarification. Clinically validated screening tools and protocols in ERs across the country are lacking. Protocol development requires a multi-disciplinary response with service provider and law enforcement involvement. I challenge HCPs who attend my trainings to begin the conversation within their health system and respected work places and instigate protocol development. Waiting until the victim is in front of you will only lead to frustration and a likely failed or missed intervention opportunity. Awareness of the issue is only the tip of the iceberg. As HCPs, our work doesn't end simply with awareness of an issue or a problem. We took an oath to ameliorate suffering and contribute to people’s well-being. This entails educating the public and polity about present and future threats to the health of humanity and advocating for social, economic, educational and political changes.
Awareness of the atrocity of human trafficking has forever changed my world. I now view all of my patients through a different lens. My heart breaks when I think about the number of girls that have been under my care over the past decade who were not identified… An opportunity to intervene was missed… No more and not again.
Jessica Munoz is the lead nurse practioner for Emergency Medicine Physicians Inc. at Pali Momi Medical Center on Oahu. She has been a resident of Hawaii for 8 years. During the past 8 years she has been a mentor to high-risk youth and a leading advocate for holistic services to this vulnerable youth population. In addition to her full time job, she is currently the president of Ho ‘ola Na Pua whose goal is to establish the first licensed special treatment facility specific for children who have been affected by this crime in Hawaii and has spent the last four years helping lead the anti-trafficking movement on the islands.