I Think My Patient Is Being Trafficked

Roxanne Nelson, RN, BSN


September 24, 2019

Hard figures are difficult to come by, owing to the elusive nature of the crime. The International Labour Organization estimates that globally, there are nearly 25 million people in forced labor. Women and girls account for 99% of those in the commercial sex industry and 58% in other sectors.

In the United States, an estimated 44,000 trafficked persons were identified and assisted in 2014, but this may be a vast underestimate.

Speaking at TEDMED 2016, Susie Baldwin, MD, MPH, from the Department of Public Health in Los Angeles County and president of the board of directors of HEAL Trafficking, pointed out that according to estimates from the US State Department, "we've only managed to identify 1% of the people trafficked here. Human trafficking is a hidden crime, and we are not the best detectives."

In the United States, human trafficking is also big business and the fastest-growing criminal enterprise in the nation. A trafficker can earn up to $300,000 per victim, and the industry as a whole is valued at an estimated $32 billion each year. By comparison, the annual revenue of Starbucks is only $19 billion.

Human trafficking is an "equal opportunity" scourge, and victims come from diverse socioeconomic, education, ethnic, and cultural backgrounds, as well as all age groups and genders—including transgender persons. Trafficked individuals often need a complex and wide-ranging array of healthcare services, owing to the nature of the abuse.

In addition, many present with illnesses and problems that are beyond what would normally be expected given the person's age and gender, and the fact that they are living in the United States.

All healthcare providers should be aware of and educated about the signs of potential human trafficking, explained Jordan Greenbaum, MD, medical director of the Child Protection Center at Children's Healthcare of Atlanta, Georgia. "In general, the most likely places are the ED and outpatient clinics, but people are seen in all types of clinical settings."

Greenbaum pointed to a case where a minor was being sex trafficked by her father and was seeing her gynecologist in his office. "I've also worked with kids who have chronic diseases and are being seen by specialists," she said. "So everyone needs training."

When and How to Engage

Perhaps the most difficult step for a physician is figuring out what to do and where to turn if trafficking is suspected. How to approach the patient once abuse is suspected will depend on the specific circumstances.

Dignity Health, one of the largest healthcare systems in the nation and the largest hospital provider in California (recently merged with Catholic Health), rolled out an extensive protocol in 2017 to guide staff on how to respond to patients who may be victims/survivors of any type of abuse, neglect, or violence, including human trafficking.

"We have a policy on how to respond to any victim of abuse, including human trafficking," said Gibbs. "What we learned is that it doesn't make sense to have different procedures for different types of abusive situations."

Part of their protocol is the PEARR (privacy, educate, ask, respect and respond) tool, developed in conjunction with HEAL Trafficking and the Pacific Survivor Center and which clinicians can use as a guide for framing their encounters with patients. It offers key steps on how to provide education to a patient and how to offer assistance in a trauma-informed and victim-centered manner.

Privacy is the first step in the PEARR tool and is essential to moving forward with a suspected trafficking situation.

"We need to create conditions that make the patient feel safe, so that they will be comfortable disclosing," said Stoklosa. "But one of the first things is privacy, to speak with the patient alone."


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