Red flags help hospitalists spot human trafficking

Hospitalization presents an opportunity to intervene and stop exploitation.


A form of modern slavery, human trafficking is a lucrative crime involving the exploitation of people, typically for forced labor or commercial sex. In addition to being a political and legal issue, trafficking becomes a medical concern when hospitalization offers an opportunity to intervene.

“These patients are indeed being seen in health care settings, exiting our doors as quickly and as inconspicuously as they came in,” said Wendy Macias-Konstantopoulos, MD, MPH, an emergency physician and executive director of the Human Trafficking Initiative at Massachusetts General Hospital in Boston.

Photo by Thinkstock
Photo by Thinkstock

When the issue first started to come into social consciousness, it was initially thought of as a labor trafficking issue affecting immigrants, she said. Now, more attention focuses on sex trafficking, but both forms exist in the U.S.

Despite increased awareness, hospital clinicians may often treat and release victims without identifying them as such. In a survey of 98 female survivors of domestic sex trafficking who were 14 to 60 years of age, about 88% reported having contact with a clinician while they were being trafficked. About 63% of survivors reported being treated in a hospital or emergency department, according to the study, published last year in Annals of Health Law.

Some hospitals are taking action by training clinicians to spot human trafficking victims and developing response protocols. But these efforts have only started within the last couple of years, said Holly Atkinson, MD, FACP, assistant professor of medicine and preventive medicine at the Icahn School of Medicine at Mount Sinai in New York. “There may be some early adopters, but it really is a very recent trend,” she said.

Hospitalists can help combat human trafficking by learning the signs to recognize and the steps to take in order to help turn victims into survivors.

The problem

Almost 21 million people worldwide are victims of human trafficking, according to the International Labour Organization. In North America, the organization estimates that the prevalence of victims is 1.5 per 1,000 population. Extrapolating from 2010 census data, that means the U.S. is home to roughly 471,000 victims of trafficking.

“With that high prevalence rate, any time you've got a large hospital serving a significant population, you're going to have victims of trafficking within that area,” said Jeffrey Barrows, DO, director of U.S. training for Hope for Justice, a nonprofit that helps human trafficking victims and trains professionals in identifying and referring them.

Specific data on the prevalence of human trafficking in the U.S. are limited because of the hidden nature of the crime, he said. Trafficking likely takes place within cities with populations greater than 30,000, but it also exists in certain rural areas, and types of trafficking vary by location, Dr. Barrows said.

Victims could be of any gender, race, ethnicity, or socioeconomic status. “The commonality is the vulnerability that they found themselves in at the time when they were exploited, and that can be for many different reasons,” Dr. Macias-Konstantopoulos said. Runaways, those with a history of sexual abuse, and lesbian, gay, bisexual, and transgender individuals are all at higher risk of being trafficked, said Dr. Atkinson, who co-chairs the American Medical Women's Association's Physicians Against the Trafficking of Humans initiative.

Victims face both physical and mental health consequences. In a study of 192 sexually trafficked women ages 15 to 45, nearly two-thirds reported 10 or more concurrent physical health problems, and 39% reported having suicidal thoughts within the past week, according to results published in 2008 in the American Journal of Public Health.

Despite the connection between human trafficking and health, medical schools rarely cover the subject, said Dr. Barrows, who retired from practice as an obstetrician/gynecologist to focus full-time on human trafficking. “They may touch on it very briefly if they're discussing things like child abuse and domestic violence within the curriculum in medical school, but I think, even in most schools, those topics aren't covered all that well,” he said.

Identifying victims

Even though hospitalists may lack formal training on the issue, they are in a position to help patients who might be victims of trafficking. “Just like anybody else, these victims can get very sick and require hospitalization. And when they do, they may come under the care of a hospitalist, and therefore the hospitalist would need to be trained to recognize them,” Dr. Barrows said.

Currently, there are no screening tools for human trafficking that are validated in the health care setting, but there are a number of red flags, which fit into 3 basic categories: physical indicators, behavioral indicators, and control indicators.

Physical signs include physical trauma, such as bruises, lacerations, and fractures, and indicators in the medical history include multiple sexually transmitted infections, multiple pregnancies, and abortions. Physical indicators could even include branding, as many people who are sex trafficked by pimps may have tattoos on them, perhaps of the pimp's name, according to Dr. Atkinson. “This often is indicative that these individuals are someone's property,” she said.

On the behavioral side, victims may be unable or unwilling to give their address, may not know which city they're in, or may give an inconsistent or scripted history. A victim could come in with a delayed presentation of a medical problem, carry large amounts of money, or appear younger than her stated age, Dr. Atkinson said. Victims often appear anxious, fearful, or hyperalert.

Finally, and of importance, control indicators would include the patient being accompanied by a controlling person who might not allow the patient to answer or might consistently interrupt the patient. The patient might also be anxiously tethered to her phone, frequently receiving calls or texts during an exam. One of the biggest red flags is a younger woman being accompanied by an older man who refuses to leave during the exam, experts said.

Usually, a constellation of red flags will present to a clinician, who may get the sense that things just don't seem to add up, Dr. Atkinson said. “And that's a sense worth paying attention to when that happens,” she added.

Getting help

Before deciding to call an interviewer, physicians may first want to support their suspicions. “There's a number of screening questions, and it really depends on who you have sitting in front of you,” Dr. Atkinson said. For instance, physicians could ask a foreign-born individual if someone is controlling his passport, she said. And a point-blank question, when appropriate given the trust built, would be to ask a suspected sex trafficking victim if she's ever exchanged sex for anything of value, such as money, food, or a place to sleep, Dr. Atkinson said.

Hospitals should have a protocol for what to do when a possible trafficking victim is identified, Dr. Macias-Konstantopoulos said. Protocols should outline which trained staff members, such as a social worker or sexual assault nurse examiner, will interview possible victims once they're identified, said Dr. Barrows.

One advantage of identifying patients in the hospital is that it's a secure environment. A protocol should also specify the proper authorities to notify, whether it's local law enforcement, the FBI, or Homeland Security, and these specifics will vary by location.

Hospitals need not worry about violating privacy laws when contacting authorities. “I've heard of some hospitals that are purposely not identifying victims of trafficking because they're afraid of running afoul of HIPAA…. HIPAA specifically has language that says it is not meant in any way to get in the way of reporting any form of abuse,” Dr. Barrows said. Additional advice for developing a protocol is available online (see sidebar).

Having a protocol in place saves time for clinicians when a possible victim is identified. “It would just be simply writing an order on the chart for a hospitalist: ‘Have social work see the patient and interview about possible human trafficking.’ That would be the length of time that they would need to have to be involved,” Dr. Barrows said.

Since trafficking victims have broad needs and hospital resources vary, physicians should adjust patient care on a case-by-case basis and realize that the right care likely involves a multidisciplinary team of clinicians, Dr. Macias-Konstantopoulos said. “Their needs are multifaceted. They have myriad short-term, mid-term, and long-term needs that need to be addressed, from immediate, emergency shelter or protective assistance to food and legal assistance or long-term housing,” she said.

From presenting grand rounds on human trafficking across the country, Dr. Barrows has learned just how many opportunities to identify human trafficking have been missed. “When I get done [with my presentations], it's not at all uncommon that I will have physicians come up to me afterward and say, ‘I know I've seen victims of trafficking from what you described, but I had no idea what they were,’” he said.

Educating oneself and others can remedy that problem, according to Dr. Macias-Konstantopoulos, who also speaks on the issue. “Our training is not only an eye-opener, but it also inspires health care providers to … make those links within their institution and start thinking about how to respond, should they identify a victim,” she said.