Human trafficking

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Human trafficking is the recruitment, harboring, transportation, or provision of a person for the purpose of labor and/or sexual exploitation through the use of force, fraud, or coercion. Signs of human trafficking are often nonspecific and a high index of suspicion is required to identify affected individuals. Patients may appear fearful and present with injuries inconsistent with their medical history and signs of neglect, abuse, or malnutrition. Management includes treating acute injuries and medical conditions, provision of appropriate local human trafficking resources, and following local laws and institutional guidelines on reporting suspected cases.

The recruitment, harboring, transportation, or provision of a person for the purpose of labor and/or sexual exploitation through the use of force, fraud, or coercion ^[2][3]

• Anyone can be a victim of human trafficking, regardless of age, gender, sexual orientation, or socioeconomic status. ^[3]
• Individuals who have experienced or been exposed to violence or who are disconnected from stable support networks are disproportionately targeted by traffickers.
• Approximately 60% of victims of human trafficking will visit an emergency department at some point during their exploitation. ^[3][4]

Epidemiological data refers to the US, unless otherwise specified.

Suspect human trafficking if any of the following are present: ^[3][4]

• History
  • Medical history inconsistent with the injury
  • Delay between onset of illness or injury and seeking medical care
  • Frequent relocation
• Examination findings
  • Signs of neglect and/or malnutrition
  • Branding, e.g., a tattoo or intentional scarring
• Behavioral
  • Flat, fearful, and/or submissive affect
  • Difficulty answering simple personal questions
  • Answers controlled by an accompanying individual
• Other
  • Inappropriate clothing for the weather or reported activity at the time of injury
  • Patient appearing younger than their stated age
  • Missing or fraudulent personal identification documents

Clinical evaluation ^[4]

• Take a detailed medical history in a private setting.
• Consider using a screening tool, e.g., Rapid Appraisal for Trafficking.
• Physical examination
  • Evaluate for red flags for human trafficking.
  • Assess for red flags for sexual violence, red flags for intimate partner violence, and signs of strangulation.

Rapid Appraisal for Trafficking (RAFT) ^[2]

A four-question screening tool; an affirmative answer to any of the following questions warrants further investigation:

1. Have you ever worked or done things in a place that made you feel scared or unsafe?
2. Have you ever been tricked or forced into doing work you did not want to do?
3. Have you ever been afraid to leave or quit a work situation due to fears of violence or threats of harm to yourself or your family?
4. Have you ever received anything in exchange for sex (e.g., a place to stay, gifts, food)?

Diagnostics

• Diagnostics testing is based on the injury and clinical suspicion.
• Laboratory studies may include a pregnancy test and STI cultures.
• Imaging may include x-rays to assess for fractures and CT head to assess for brain injury.

General principles ^[3][4]

• Obtain informed consent for every diagnostic and management step.
• Attempt to speak to the patient in private with a chaperone.
• Maintain a low threshold for notifying hospital security about suspected human trafficking to ensure the safety of the patient and staff.
• Contact the National Human Trafficking Hotline for advice on the appropriate next steps. ^[3]
• Involve a multidisciplinary team early.
• Follow local protocols for preparing accurate medical documentation for potential criminal proceedings.

Treatment ^[3][4]

• Evaluate and treat acute injuries (e.g., fractures) and medical conditions.
• Offer treatment for other injuries and any undertreated medical conditions, e.g., STIs.

Reporting ^[3][4][5]

• Follow local laws and institutional guidelines on reporting suspected child abuse, older adult abuse, abuse of at-risk adults, and abuse involving a firearm. ^[4]
• Allow all other adults to choose whether and how to report abuse or seek help. ^[3][5]

Disposition ^[3][4]

• Admit patients if there are any clinical indications.
• Involve social workers, case managers, and/or advocates if the patient is returning to an exploitative situation.
• Provide patients with contact information for the National Human Trafficking Resource Center and local resources. ^[3]

In the United States, the National Human Trafficking Hotline can be accessed by calling 1-888-373-7888 or texting “INFO” or “HELP” to BEFREE (233733). ^[4][6]