Human Trafficking and Emergency Medical Services (EMS)

Abstract

Human trafficking is associated with wide-ranging mental and physical morbidity, as well as mortality, in the United States and globally. Emergency Medical Services (EMS) providers are often first responders to victims of human trafficking. Given their proximity to patients’ social and environmental circumstances, these clinicians need to be familiar with the signs and symptoms of human trafficking, as well understand how to best provide care for suspected or confirmed trafficked patients. Evidence from multiple studies indicates that providers who have received formal training may be better able to recognize the signs and symptoms of human trafficking, and thus, can provide better care to potential victims of human trafficking. This review will summarize the relevance of human trafficking to prehospital emergency care, touch on best practices for the care of patients with suspected or confirmed ties to human trafficking, and outline future directions for education and research.

Introduction

Human trafficking is a significant concern in the United States and around the world. Unfortunately, because of the furtive and illicit nature of the industry, it is difficult to estimate the true magnitude of human trafficking with any degree of precision. ^1–4 There is, however, an international consensus that human trafficking likely generates tens of billions of dollars per year through the victimization of tens of millions of individuals. ^5,6 Human trafficking has specific relevance to Emergency Medical Services (EMS) providers and prehospital care providers, because they have significant potential to encounter victims of human trafficking during their work.

Human Trafficking: Definition, Risk Factors, and Indicators

Human trafficking is a broad and complex issue that can take many forms, including commercial sexual exploitation, forced labor, bonded labor, and organ trafficking. ⁷ The United Nations’ Palermo Protocol contains the first internationally recognized definition of human trafficking. ⁸ Federal law in the United States is modeled after international law and specifically defines sex and labor trafficking as the use of force, fraud, or coercion for the purpose of exploitation in commercial sex and labor, respectively. ⁹ Force can include physical assault or confinement, fraud can include deception or extortion, and coercion can include intimidation or emotional manipulation. ^9,10

Several factors make individuals more vulnerable to human trafficking. Broad structural factors include poverty, corruption, isolation, and societal and oppressive cultural norms. ^11,12 Specific individual factors include childhood trauma, substance use, early exposure to violence, limited livelihood options, LGBTQ+ sexual/gender identities, family dysfunction, and housing insecurity. ^7,11–13

Traffickers may use addictive substances as tools for recruiting and maintaining control over victims. In a cohort of sex trafficking survivors, 84% reporting using substances while trafficked, 28% reported being forced to use addictive substances, and 26% experienced overdoses. ¹⁴ Human trafficking, additionally, may result in significant negative psychological outcomes, including depression, posttraumatic stress disorder (PTSD), and complex PTSD. ^15,16

In their role, EMS providers can survey the scene where a potential victim of human trafficking may be found. There are several on-scene indicators that indicate a patient is a victim of sex trafficking, including drug or sexual paraphernalia, buildings with many rooms that lock from the outside, and restraint devices. ¹⁰ Furthermore, consider lack of identification documents, inadequate or provocative clothing, and evidence of potential physical assault – especially if wounds are at different healing stages and may have been caused by a repeated pattern of abuse. ¹⁰ Additionally, victims of human trafficking may have multiple concurrent sexually transmitted infections (STIs), pelvic inflammatory disease, and evidence of genitourinary trauma (eg, traumatic fistula or vaginal wall tears). ¹⁰ In the case of labor trafficking, on-scene indicators include a lack of identification documents, poorly-ventilated or unsanitary working conditions, residence at place of work or with their declared employer, an alleged employer insisting on acting as a translator in the case of low English language proficiency or accompanying the patient, lack of access to personal protective equipment, performance of hazardous work without proper training, long work hours, and prolonged exposure to extreme heat or cold. ^17,18 A combination of these on-scene indicators may be present when individuals are exploited for both sex and labor in domestic housework, massage parlors, and nail salons. ^19,20

Tiller and Reynolds in 2020 developed a list of potential indicators of human trafficking specifically for emergency providers. They include: (1) poor mental health or abnormal behavior; (2) poor physical health; and (3) lack of control. Each of these categories can be further broken down into various components. For instance, poor mental health or abnormal behavior includes fearful or anxious demeanor (eg, hyper-startle reflex) or avoiding eye contact. Poor physical health includes a lack of health care access for chronic conditions or signs and symptoms of physical or sexual abuse. Finally, a lack of control includes the victim having few personal possessions, as well as limited financial or interpersonal autonomy. ²¹ Victims of human trafficking may present alone or accompanied by traffickers. ²² When they present alone, providers have a unique opportunity to promote a safe space for them. Providers need to be extra vigilant when victims of trafficking present with traffickers. Creating opportunities for potential victims to have privacy and comfort within the health care setting can be incredibly helpful in fostering provider-patient rapport. ^22,23 When language barriers exist, employing professional interpreters is highly recommended to avoid inquiring about abuse or violence in the presence of a trafficker and inadvertently undermining survivors’ autonomy. ^13,24,25

Providers aware of these specific risk factors and indicators may be able to assess patients for potential links to human trafficking. Social history questions may be especially helpful in identifying victims of human trafficking and should be broached in conversational fashion rather than checklist question format. A number of things should be considered when a victim of human trafficking discloses their status to a provider. For example, it may be important to determine if the patient is in immediate danger. ¹⁸ Providers should assess the needs and priorities of the patient in such a way that the patient maintains autonomy and control to the greatest extent possible. ¹⁸ Depending on community protocols, providers can refer patients to local agencies or resources who may be able to help.

Human Trafficking and Emergency Care: The Role of Providers

Human trafficking is associated with negative physical and psychological health outcomes. ^7,26,27 Victims of human trafficking frequently encounter the emergency care system. ^14,28,29 One study reported 63% of female victims of sex trafficking visited an emergency department while being trafficked. ¹⁴ Both the American Board of Emergency Medicine (ABEM; East Lansing, Michigan USA) and American College of Emergency Physicians (ACEP; Irving, Texas USA) specifically highlight the role of emergency care in responding to human trafficking. ^24,30–34

Despite this proximity, research suggests emergency providers often lack the knowledge, skills, and confidence to identify potential victims of human trafficking. ^35,36 This is concerning when considering the vulnerability of trafficked individuals and the potential for providers to have positive and negative impacts on trafficked individuals.

Improving Provider Awareness of Human Trafficking

There is wide-spread variation in provider awareness and formal training for human trafficking. ³⁵ A review of 23 studies examining emergency department providers found a wide-spread lack of formal training about human trafficking, leading to differences in providers’ abilities to recognize human trafficking and provide the best possible care. ³⁷ There is also variation among training within EMS – one study reports under one-half of EMS providers had formal training in human trafficking, and formal training was associated with increased ability to recognize indicators of trafficking. ³⁸

Training programs aimed at educating emergency care providers increase providers’ ability to recognize human trafficking victims and provide trauma-informed care. ^37–39 For instance, one study of the 20 largest emergency departments in the San Francisco Bay Area (California USA) found providers who received training on human trafficking reported improved knowledge about human trafficking and available resources. ⁴⁰ Similar studies report providers who participate in training programs may be better able to recognize and care for victims of human trafficking. ³⁷ Specific training programs for EMS providers can improve their likelihood of suspecting human trafficking based on indicators as well as confidence in managing potential victims. ^41,42

Using validated techniques – as well as the experiences of subject-matter experts – represents an ideal starting point. The goals of these training programs should be multifold: (1) raise awareness about human trafficking; (2) teach providers how to recognize potential victims of human trafficking; and (3) familiarize providers with trauma-informed care. The core tenets of trauma-informed care can also be cross-applied to other circumstances, such as child maltreatment and domestic violence. ^23,43 Once acceptable awareness has been developed, the focus can pivot towards developing protocols and interventions that reflect the unique needs and circumstances of specific communities. ²⁴

Conclusions and Future Directions

Victims of human trafficking have a high likelihood of interacting with EMS providers. A number of risk factors result in increased vulnerability to human trafficking, and there are several indicators that EMS providers can use to identify potential victims of human trafficking. A trauma-informed approach that involves ensuring safety, building connections, and managing emotions can be especially helpful when caring for potential or confirmed victims of human trafficking. Educational programs can improve providers’ abilities to identify and care for victims of human trafficking, although there needs to be expanded access to these programs.

There are a number of opportunities for future research examining the links between human trafficking and prehospital care. For instance, there might be interest in comparative-effectiveness studies assessing what types of training programs are most effective. Furthermore, there is a need for more research to better understand human trafficking globally. Finally, trends in human trafficking may have changed during the coronavirus disease 2019/COVID-19 pandemic. ⁴⁴ Pandemic-attributable changes in human trafficking should be assessed with the intention of updating knowledge of risk factors and indicators and developing public health solutions. Regardless, EMS providers should be aware of the possibility that they may encounter victims of human trafficking and be equipped with the knowledge and skills to be able to provide the best quality of care for them.