Human Trafficking in the ED – Part 2

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July 20, 2017 by dailybolusoflr

Seeing the Unseen Patients

By: Katie O’Conor

What Can We Do?

Despite the absence of validated tools and guidelines, there are still many steps that ED providers can take to recognize and assist patients affected by human trafficking:

  1. Awareness of medical conditions found in trafficked persons
  • Injury & trauma: facial, rib, & extremity fractures, head injuries, injuries with different stages of healing
  • Behavioral health: anxiety, depression, PTSD, schizophrenia, dissociative disorders, eating disorders
  • Substance use: dependence, overdose, withdrawal; opioids prevalent
  • Obstetrics: frequent pregnancies, poor prenatal care, IUGR, septic/unsafe abortion, spontaneous abortion
  • Sexual health/gynecology: recurrent sexually transmitted infections with complications from non-treatment, vaginal trauma, dyspareunia, vaginismus
  • Sequelae of poor living conditions: malnutrition, dehydration, skin infections, insect bites and colonization
  • Trafficking stigmata: branding, bar codes, cigarette burns, scars, mutilation, ligature marks, alopecia
  1. Adoption of a trauma-informed approach

A trauma-informed approach means having sensitivity to the many ways patients may manifest the psychological trauma they have experienced. In a human trafficking context, the expectation might be that a patient would be timid, subdued, hesitant to provide details. However, a patient may have been trained to smile and be reassuring when asked if she feels safe. Away from her trafficker, a patient may also demonstrate emotional lability or hostility. During a physical exam, one might expect that trafficked persons would be hypersensitive and avoidant of touch, particularly during pelvic exam. This is often true. However a patient may appear unaffected due to self-training for toleration of unwanted touch and penetration. A patient may even appear inappropriately hypersexual, if she has associated this behavior with less violence or quicker resolution of unwanted touch. In these instances, compassionate and ethical conduct is paramount, as well as recognizing that trafficked persons may present in a variety of different ways, and their behavior cannot rule in or rule out their trafficking status.

  1. Awareness of what you can do as an ED provider

You may not identify many of the trafficked patients who cross your path as a provider. Of those you have concerns about, most will not self-identify or disclose to you. There are still many ways to facilitate a survivor’s journey on her or his own terms.

  • Privacy/confidentiality: clear the room to interview and examine the patient alone, and learn to do it in a manner that does not alert the trafficker’s suspicion.
  • Documentation: ensure excellent EMR documentation of injuries, symptoms, and other features of physical exam. This may be valuable evidence in any legal proceedings or social services applications.
  • Resources and compassion: even if the patient is not ready to disclose or seek help, simply stating that help is available can give a patient hope, and plant the seed that may empower her to seek help in the future.
  • Respect for autonomy: acknowledge the agency these individuals do have, within their trafficking context. Respect their rights to decide what medical and social evaluations and interventions they want to receive, and their autonomy regarding if, when, and how to disclose information.
  • Safely distributed resources: any resources/information should be provided in a way that does not endanger the patient. Traffickers review phone logs, text messages, contacts, and browsing history. Information may be hidden or encoded – shoe cards, numbers stored under alternate name, easily memorized facts.
  • Multidisciplinary collaboration: any exploration of possible human trafficking cases should involve consultation and coordination of law enforcement, social work, case management, behavioral health services, substance use services, safe houses, and social services.

The National Human Trafficking Resource Center has a framework for approaching human trafficking in the healthcare setting that may help ED providers and administrators in developing ED-specific protocols:


Maryland Human Trafficking Task Force                   

National Human Trafficking Resource Center     

National Human Trafficking Hotline                      

Department of Homeland Security: Blue Campaign    

Polaris Project                                                                                 


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  20. United Nations General Assembly. Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention against Transnational Organized Crime, 15 Nov 2000.
  21. United States Department of Homeland Security. Accessed June 20, 2017.
  22. United States Department of Justice, Bureau of Justice Statistics. Apr 2011.

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