When Jill was 14, she was forced to run away from home to escape repeated physical and sexual abuse. She ended up in the home of Bruce who found her alone at a local mall and promised her a job in his home “business.” Unfortunately for Jill, Bruce’s home business involved prostitution. Jill initially refused to be used in this way, but was tortured to the point that she ended up having scars on both her wrists, ankles, and across her neck and larynx from being hung from the ceiling rafters.

Over the course of the next several months, Jill was forced to have sex with many different clients brought into the house by Bruce. Eventually, Jill became pregnant. When Bruce found out, he attempted to abort the pregnancy, but was only successful in causing Jill to bleed profusely to the point that Bruce was forced to take Jill to the emergency room to prevent her from bleeding to death.

Upon arriving in the emergency room, Bruce told the staff that Jill was his sister and also suffered from schizophrenia due to the recent death of their parents in an automobile accident. Because of the schizophrenia, Jill was prone to delusions and erratic behavior that forced Bruce to tie her up to keep her from running away. Without investigating any further, the emergency department personnel accepted the story without hesitation. Jill was admitted to the hospital after having a D&C to control her bleeding and was sent home after three days during which time Bruce was rarely out of her presence. No psychiatric consult was ordered and no further investigation of the obvious bondage scars on Jill was ever undertaken. Jill was freed eighteen months later when the police arrested Bruce on separate drug charges.

What to include in a proper protocol on intervening with a potential victim of trafficking: • Measures to separate the patient from the accompanying party • Identification and training of personnel to do the interview • Established criteria regarding when to contact law enforcement • Contact information for local law enforcement agencies • Contact information on local service organizations that specialize in helping human trafficking victims

This true story illustrates not only the horrors of modern day slavery (now known as human trafficking), but also the important role that healthcare professionals play in identifying and freeing victims caught in the web of human trafficking. There are several reasons that Jill was not recognized as a victim of trafficking in this busy ER setting, but prominent among those reasons is lack of proper training of healthcare professionals regarding human trafficking, as documented in a study done of two emergency departments in Los Angeles in 2007.¹ If the emergency room personnel in Jill’s case had been trained on the existence of human trafficking and how to recognize victims, they could have potentially intervened and saved Jill from experiencing an additional eighteen months of trauma. One study of women coming out of sex trafficking in Eastern Europe found that 28 percent of victims had encountered a healthcare professional at some point during their trafficking experience, yet unfortunately, none of those encounters had resulted in their release, due to the failure of the healthcare professional to recognize the situation as trafficking.² If healthcare professionals are going to be involved in providing justice to victims of human trafficking, they must first learn to recognize the victims that may be within their own patient population.

The US State Department estimates that between 14,500 and 17,500 victims of human trafficking are brought into the United States every year, and between 600,000 to 800,000 victims are transported across international borders around the world every year.³ In terms of the total number of people in the world living in slavery today, the International Labor Organization estimated that number in 2005 as 12.3 million⁴ while two other researchers put that number closer to 28 million.^5,6 The type of slavery illustrated so graphically in Jill’s story is known as domestic minor sex trafficking (DMST). A university study estimated that over 300,000 American youth are either actively involved in DMST, or are at high risk of becoming involved.⁷ The conclusion is that there are literally millions of people across the world enslaved today, with the US itself containing hundreds of thousands of these victims who need to be found, freed, and cared for.

Caring for Trafficked Persons: Guidance for Health Providers CMDA members Drs. Clydette Powell and Katherine Welch participated in the development of a handbook entitled Caring for Trafficked Persons: Guidance for Health Providers, with the International Organization for Migration Expert Group on Health and Human Trafficking and the London School of Hygiene and Tropical Medicine. The handbook, funded by the United Nations Global Initiative to Fight Human Trafficking and bringing together a broad range of experts working on the issue, provides practical, non-clinical advice to help a health provider understand the phenomenon of human trafficking, recognize some of the associated health problems, and consider safe and appropriate approaches to providing healthcare for victims.

We in healthcare can learn to recognize these victims in part through their clinical presentation. Depending on the type of trafficking scenario the victim may be trapped within, they may present with findings of repetitive chronic and acute physical trauma that may be the result of a labor trafficking situation. A victim of sex trafficking may present with multiple sexually transmitted infections in association with signs of physical or sexual trauma. They may also present, as Jill did, with the complications of an attempted or illegal abortion. It is also important to remember that victims are not brought to the attention of healthcare until their problem or complaint is severe enough to threaten their well-being. In other words, these victims tend to present late in the course of an illness or injury, often at times when the ER is busiest to reduce the risk of discovery.

Keep in mind that your first response as a healthcare professional will not be to immediately recognize the person as a victim of trafficking. In fact, your first response may be a form of revulsion to a person who smells bad from having not bathed in several days, who is dressed shabbily, and acting very strangely. They will typically be accompanied by someone claiming to be a relative or spouse and very controlling of the person and the encounter. That person will answer most, if not all, of your questions and will give some good reason for the appearance of the patient. You will most likely walk out of the initial encounter with the thought that something very strange is going on, but will have no category in which to initially fit the situation.

If, however, because of learning more about human trafficking, you decide that possibly a particular patient may be a victim, you are in a unique position of being able to free that patient, but only if you have made the proper arrangements in advance. Without prior critical preparations, you may in fact do more harm than good to this patient by alerting the trafficker so that he/she takes the patient out of the clinic before medical therapy and proper intervention can be undertaken.

What does the proper preparation to handle a victim of human trafficking entail? The first step is setting up a protocol within your office, clinic, or hospital that specifically lays out steps to undertake when you suspect a patient may be a victim of human trafficking. A good protocol will include how to separate the patient from the accompanying party, proper training on how to interview a patient to see if they are a victim of trafficking, and who to contact in regards to law enforcement and other service provider organizations specializing in the care of human trafficking victims. Secondly, someone from your office, clinic or hospital should meet personally with representatives from those service organizations who specialize in the investigation and care of victims of human trafficking. They can help you as you design your protocol, and be specific in regards to the types of trafficking you will encounter in your area, local law enforcement officials you should contact, and how to specifically contact their own organization when needed. With the proper preparations in place, you can activate your protocol when you have a suspicious patient or client, and more efficiently and safely investigate and help this potential victim.

These victims deserve justice and freedom to live their lives to their full potential. Physicians and dentists are among the few groups who are likely to encounter them while they are still in captivity. Therefore, it is incumbent on us within the healthcare profession to learn what we can about this issue and be prepared to the best of our ability to identify and intervene when the Lord should allow our paths to cross with these modern day slaves.

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Resources to help investigate organizations that specialize in helping human trafficking victims: International: • US State Department TIP report http://www.state.gov/g/tip/ • International Justice Mission http://www.ijm.org • Shared Hope International http://www.sharedhope.org Domestic: • HHS Rescue and Restore Coalition http://www.rescueandrestore.org • Salvation Army http://www.salvationarmyusa.org • Polaris Project http://www.polarisproject.org

Bibliography

¹ Chisolm-Strike, M. and Richardson, L. “Assessment of Emergency Department Provider Knowledge about Human Trafficking Victims in the ED.” Acad Emerg Med 2007;14(5), Supplement 1: 134.

² Turning Pain into Power: Trafficking Survivors’ Perspectives on Early Intervention Strategies. Family Violence Prevention Fund in Partnership with the World Childhood Foundation, March 2005.

³ United States Department of State. Trafficking in Persons Report: June 2004.

⁴ Belser P., de Cock, M. and Mehran, F. ILO Minimum Estimate of Forced Labour in the World. ILO, Geneva. April 2005. Available online at: http://www.ilo.org/dyn/declaris/DECLARATIONWEB.DOWNLOAD_BLOB?Var_DocumentID=5073.

⁵ Bales, Kevin, Disposable People, New Slavery in the Global Economy, University of California Press, Berkeley and Los Angeles, California, 1999.

⁶ Siddharth, Kara. Sex Trafficking: Inside the Business of Modern Slavery. Columbia University Press: New York, 2009.

⁷ Estes, R.J. and Weiner, N.A. The Commercial Sexual Exploittion of Children In the US, Canada and Mexico. University of Pennsylvania, 2001. Available online at: http://www.sp2.upenn.edu/~restes/CSEC_Files/Complete_CSEC_020220.pdf.