I Think My Patient Is Being Trafficked

Roxanne Nelson, RN, BSN

Disclosures

September 24, 2019

Christine was 16 years old and showed up in the emergency department (ED) late on Saturday night with vaginal bleeding. She was accompanied by her older brother, Jason, who told the staff that he became Christine's caregiver after their parents were killed in a car accident. Since then, he said, she has been suffering from schizophrenia and various delusions.

He told the triage nurse that the bleeding "hasn't been much" but was unsure as to when it started. Christine was very pale and appeared to have trouble standing on her own. They were both brought into an exam room, where Jason answered all questions while Christine lay quietly in bed. He said that the bleeding started out of the blue. He brought her to the ED immediately when it looked like she was losing a lot of blood.

Doctors noted scars on Christine's neck, wrists, and ankles, as well as trauma to her cervix, but they didn't ask her about it because the ED was extremely busy and short-staffed. Her labs revealed that she was pregnant. Christine received several units of packed cells and was taken to the operating room for a dilation and curettage; she was admitted overnight, and then discharged to home with Jason.

Two months later, Christine was back in the ED, but at a different hospital so as not to arouse suspicion. She again had vaginal bleeding, but this time accompanied by discharge, abdominal pain, and fever. Christine winced when her abdomen was touched. The physician noticed fresh welts on her wrist that resembled a rope burn. She became increasingly suspicious, especially when Jason explained that Christine had accidently cut herself and while he spoke, the girl turned her head away.

The physician asked Jason to leave the room, citing patient privacy, and after resisting, he finally complied. The physician then asked Christine if she was in any sort of trouble, but she didn't respond.

Christine was admitted with a diagnosis of pelvic inflammatory disease. The ED physician passed along her concerns to the staff in Christine's unit, and a medical resident visited her when Jason stepped out of the room. He asked how she got the welts on her wrist as well as the older scars, but Christine didn't answer. He spoke with her a little longer and assured her that this was a safe place, and they could help her. Their eyes finally met and Christine nodded, ever so slightly, when again asked if she was in trouble.

Because Christine was a minor, the resident reported the patient’s acknowledgement of trouble immediately to local authorities. It turned out that Christine was a runaway and Jason was not her brother but a trafficker who had tricked her into coming home with him 2 years ago, and now forced her to work as a prostitute in his basement. She had become pregnant and a botched abortion was performed, which had brought her to the ED.

Where Human Trafficking and Healthcare Meet

Slavery is often considered something that existed long ago, but unfortunately, it is alive and well in a modern-day form known as "human trafficking." In fact, it is a $150 billion global industry in which individuals are forced or coerced by traffickers into engaging in commercial sex acts or labor services against their will.

Many trafficked persons will seek medical care at some point during the time they're being exploited. A hospital or clinic may be the only place where they will have the opportunity to interact with a professional who can help them.

But even though studies estimate that anywhere from 30% to 88% of trafficked persons report having had contact with a healthcare system at some point during their exploitation, many physicians are not equipped to identify the signs of trafficking or address the needs of these patients. They may also be unaware of how prevalent trafficking is and what steps to take even if they do suspect something.

"There is also a lot of unconscious bias that shapes our perception of what a trafficking victim looks like," said Hanni Stoklosa, MD, MPH, an emergency physician at Brigham and Women's Hospital in Boston, Massachusetts. "Doctors are human too, so we are shaped by what media tells us a trafficking victim looks like."

In one survey sent to clinicians working in specialties that would be most likely to encounter victims of sexual exploitation, nearly two thirds (63%) reported that they had never received any training in identifying trafficked patients. Another study found that only 16% of practicing physicians surveyed could correctly estimate the number of children who are trafficked, and most reported that they would not know where to turn if they encountered a trafficking victim.

Many clinicians may think that trafficking is something that only happens in other countries and not in the United States. "And if we get past that, the narrative that the media focuses on in the United States is sex trafficking, and also tends to focus on white females," said Stoklosa, who is also the executive director of HEAL Trafficking, an organization dedicated to ending human trafficking.

"So if a trafficking victim is a Mexican migrant laborer working in construction, and he comes into the ED with bruises and a broken arm, that is the antithesis of what a trafficking victim is supposed to look like. No red flags may be raised at all because this person doesn't fit the bill of someone who is trafficked," says Stoklosa.

Although identifying trafficked individuals can be complicated, it is only one piece of the puzzle. More challenging is figuring out what to do next.

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