With the socio-economic impact of COVID-19, the effects of human trafficking are predicted to increase. Victims of human trafficking typically seek initial medical care through acute care facilities such as EMS, urgent care or the emergency room. The recognition and intervention of human trafficking in these settings is essential for victims to be offered services and care. EMS receives limited access education into the recognition and intervention of human trafficking and this manuscript addresses those needs.
You are working your basic life support (BLS) ambulance in the overnight hours of your suburban community. Dispatch sends you to a local motel for a patient with an altered mental status. This motel is in a high-foot traffic area along the border of the city. A young female is inside the motel room who appears to be under the influence of drugs and/or alcohol. She cannot keep her eyes open and is slumped against the headboard of the bed. The motel room appears to be in disarray, has several trash bags which appear to have clothing in them as well as two other females and two other males. One male claimed that he is friends with the female and that she may have “partied too hard.” No one in the motel room knew the victim’s name other than “Broadway.”
As you transport the female to a local hospital, you administer Narcan as the patient begins to wake and is immediately scared and nervous. The victim had no identification on her. The patient then tries to get out of the ambulance, “I have to get back, now! Please take me back!” Attempts of reassuring her do not work as you pull into the local emergency room (ER). Inside the ER, nurses are familiar with your victim as a frequent flyer who always asks to be discharged with pain medication. They identified her as a 16-year-old female that has had multiple encounters with social services. She usually signs out against medical advice (AMA) and a group of males picks her up from the ER. Your EMS crew cleared the ER and continued your shift. As you drive home in the morning, something continued to eat at you about that patient from the hotel. It did not seem right, but you did not know whom to call. Should you get involved?
Human trafficking is the second-largest criminal industry in the United States involving the victims as children. The Polaris Project defines human trafficking as the “business of stealing freedom for profit.1 The majority of human trafficking victims access health care, often at an emergency department, at some point during their servitude.2 EMS is often involved in transporting these victims to the ER, yet prehospital personnel often do not receive suitable training in the recognition and intervention of human trafficking.
There is a lack of research on the identification and intervention of human trafficking victims in EMS. The latest study in 2018 shows that less than half of the prehospital providers surveyed in the research have received human trafficking training. EMS workers who received training were much less likely to believe common myths about human trafficking, such as trafficking is always or usually a violent crime or that all human trafficking involves sex.3
The National Registry of Emergency Medical Technicians (NREMT) recently updated (2016) the National Continued Competency Program (NCCP) curriculum for all levels of providers to discuss “at-risk” populations, including domestic abuse, human trafficking, and non-accidental trauma. The expected duration of this training is one hour every two years and is based on the United States Department of Homeland Security Blue Campaign, Human Trafficking Awareness Training.4
Other than this training, all remaining education on the identification and intervention of human trafficking remains self-initiated between the states (in-house, conferences, distance learning, etc.). Although it is a low-volume call for service, often, we don’t know what to do after we suspect human trafficking. Checklists, posters, stickers with contact numbers affixed to your clipboards, “badge buddies,” or even speed dial in your cell phone or department phone would be a step in the right direction.
Continuing education in human trafficking should be encouraged at all levels of healthcare. Training should be conducted from a valid source or subject matter expert (SME). The National Human Trafficking Training and Technical Assistance Center provides the SOAR to Health and Wellness Training Program and is designed to help you identify and respond to those who are at risk of, are currently experiencing, or have experienced trafficking and connect them with the resources they need.
The Department of Homeland Security also offers awareness training. Polaris and the United States National Human Trafficking Hotline offer online trainings as well. These trainings include what happens after you call the hotline, public outreach campaigns, responding to trafficking in a healthcare setting and awareness for social workers. Contact your local law enforcement and fire department to jointly conduct these trainings as often multiple prehospital resources may have contact with trafficked victims.
Organizations Combatting Human Trafficking
The Polaris Project is the organization that operates the United States National Human Trafficking Hotline. Founded in 2002, Polaris was named for the Northern Star which people held in slavery used as a guide to navigate their way to freedom. The organization provides research into illicit massage parlors, criminal record relief for victims, is the data hub for research and data collection, partners with financial institutions and provides training for the recognition of migrant workers.
In some cases, traffickers’ trick, defraud or physically force victims into selling sex. In others, victims are lied to, assailed, threatened, or manipulated into working under inhumane, illegal or otherwise unacceptable conditions. It is a multi-billion-dollar criminal industry that denies freedom to 24.9 million people around the world. In 2017, Polaris began analyzing more than 32,000 cases of human trafficking cases into one of the following business models in order of the most frequent encounters to the least frequent encounters: Escort services, illicit massage, health and beauty, outdoor solicitation, residential sex trafficking, domestic Work, bars, strip clubs, cantinas, traveling sales crews, restaurants and food service, peddling and begging, agriculture and animal husbandry, personal sexual servitude, construction, hotels and hospitality, landscaping, illicit activities, arts and entertainment, commercial cleaning services, factories and manufacturing, remote interactive sexual acts, carnivals, forestry and logging health care and recreational facilities.1
Unseen is a non-profit organization that collaborates with several organizations to provide global aid in proactive strategies such as root causes and prevention, the assistance of trafficking victims, and reactive strategies such as protection/aftercare, prosecution, and advocacy for stronger laws for human trafficking. They support this mission through private and corporate donations. The majority of people impacted through Unseen’s work have been in Africa and East Asia and Pacific regions. Victims are provided resources to start new businesses, access to credit, counseling, medical services, spiritual care, and shelter.5
Types of Human Trafficking
Labor trafficking is believed to be larger than sex trafficking, but there is a much wider awareness of sex trafficking. Labor trafficking occurs in the United States and other developed countries but is reported at lower rates than sex trafficking. You can recognize labor trafficking if your patient feels pressured to stay at their job if they want to leave for treatment. Victims can be confined at the restaurant around the clock or be isolated in a nearby home provided by the traffickers. A victim of labor trafficking may also not have any identification, including their passports.
Traffickers commonly secure these documents to keep them isolated and forbid the victims to travel. Labor trafficking may be present if you respond to a local farm where several workers are sleeping in an overcrowded room, isolated conditions without basic human needs such as bathrooms, water, food and communication. A boss may also threaten your victim of labor trafficking with deportation if they are seen at the hospital. Victims of labor trafficking may not want to be transported or evaluated by EMS as they already owe money to an employer or recruiter for being brought to the United States, and do not have insurance or means of paying the bill.1
Child sex trafficking is also highly relevant in escort and outdoor solicitation encounters. Females tend to make up the largest percentage of victimizations. The rate of male victimization in pornography is four times the rate in other types of sex trafficking. Children are often recruited through people they are familiar with, including members of their own family. Traffickers will build on trust, manipulating them into sexual exploitation. This manipulation typically happens via online recruitment and grooming through mobile social media and texting applications. Child sex trafficking victims almost always virtually know their traffickers by a street name or an online username.
Despite a teenager voicing the fact they are making their own choices, anyone involved in selling sexual services who is under the age of 18 is a victim of sex trafficking under United States law. Children who have been abused or faced trauma, runaways, children in unstable living situations, and children in families battling addiction are all increased risk factors of child sex trafficking (analogous to the adult risk factors).1
Children are paid low-wages, and with illicit drugs such as ecstasy and cocaine. In low-income countries, children make up half of the victims detected and are mainly trafficked for forced labor. It is easy to exploit young children in those countries when people are accustomed to sending their children to work away from home. Children are also exploited for begging and forced criminal activities, such as drug trafficking, among other crimes.6
Assessment of Potential Victims
When you arrive on a scene, you may see that rooms may have numerous beds on the floor and/or small rooms throughout the house that have locks on the outside of the doors. Locks may also be present on the windows to keep people from coming and getting out. If you are assessing a potential victim of human trafficking and have established rapport and trust, you may ask the following questions if you feel comfortable. Speak to the victim away from anyone attempting to communicate for the victim as well as patient belongings, as cell phones may be used to record the conversation:
- How did you get here?
- Where do you live, eat and sleep?
- What type of labor/services do you do?
- How long have you been working here?
- What are your hours of work?
- Have you been paid? If so, what were you paid?
- Describe the conditions of your workplace.
- Has your family been threatened?
- Is someone keeping your legal/travel documents?
- Have you or anyone you work with been abused at the workplace?
- Whom are you afraid of?
- Does your boss take anything out of your pay? If so, for what?
- Do you owe someone money? If so, what do you owe them for?
- Are you allowed to come and go freely? Are you afraid to leave? What would happen if you tried to leave?
The answers to these questions can be documented on your patient care report (PCR) and may be used in the future by law enforcement when investigating these crimes. Victims are likely to be very distrustful of public safety. Therefore, victims may not admit that they are victims and may not ask for help. Communication with victims may seem scripted and/or vague, inconsistent – this is how they have been told to answer.
The conversation can be normalized by starting with, “The questions that I am going to ask you are questions that I ask all my patients. You do not have to answer any questions that you are not comfortable with answering.” The victim should not be asked to repeat his or her story to multiple people, as detailed or unnecessary further discussion can be traumatizing. Provide a detailed report to the receiving emergency room staff to limit these further discussions, as further probing may cause the victim to shut down and not want to speak at all.
Victims may exhibit signs of physical and/or sexual abuse such as: bruises, burns, scars, broken bones, black eyes, poor hygiene and/or malnourishment. They may not make eye contact with you as a sign of depression or fear.7 Some additional general indicators of trafficking victims that may be present:
- Be fearful of the police or authorities.
- Be fearful of the traffickers, believing their lives or family members’ lives are at risk if they escape.
- Exhibit signs of physical and psychological trauma e.g., anxiety, lack of memory of recent events, bruising, untreated, conditions.
- Be fearful of telling others about their situation.
- Be unaware they have been trafficked and believe they are simply in a bad job.
- Unaware of where they are as they have been moved multiple times, often times EMS may recognize this as an altered mental status versus an indicator of human trafficking.
- Have limited freedom of movement.
- Be unpaid, or paid very little.
- Have sparse access to medical care.
- Seem to be in debt to someone.
- Have no passport or mention that someone else is holding their passport.
- Be regularly moved to avoid detection.
- Believe they are being controlled by the use of witchcraft.5
Victims may constantly try to text their trafficker to let him/her know where he/she is. Be aware that a trafficker may be a family member and/or identified as a significant other. This trafficker may only have one trafficked victim or may have several. Ensure patient care is the priority, continue to advocate for the victim throughout your care, and if the victim does not want to provide answers, document accordingly and follow-up with law enforcement or one of the resources listed below.
Despite how the victim answers your questions or admits to being a victim, continue to build rapport and trust so that the victim will feel that EMS and healthcare is an environment to which they can safely return in the future. Many victims will not be interested in leaving their current situation due to fear and mistrust, but may be willing to accept resources or return later if they are assured that calling for EMS and entering the healthcare system is safe for them. The number of the United States National Human Trafficking Hotline can be provided to the victim on a small piece of paper, privacy paperwork, survey or any generic paperwork during the encounter. In situations of immediate, life threatening danger, follow your organizations policy for contacting law enforcement. Whenever possible, make an effort with the patient in that decision to contact law enforcement as to not lose trust or rapport.
Effects of COVID-19 on Human Trafficking
On March 13, 2020, a national emergency was declared in the United States of America in response to COVID-19. Children nationwide were told to remain at home and conduct virtual learning, which meant unprecedented time in front of the computer and on the Internet. The National Center for Missing & Exploited Children has experienced a 28% increase in CyberTipline reports between January – December 2020 versus the same period in 2019 for child exploitation.8 The availability of smartphones, messaging applications and the growth of escort websites has shown technology is the primary means of recruiting and managing trafficking victims.
COVID-19’s impact also implicated many of the risk factors for human trafficking. It left many seeking an alternative means of income. When an already struggling family loses a source of income, it can leave the vulnerable population at a heightened risk of trafficking. Given the inequitable distribution of COVID-19’s impact, trafficked individuals may also live-in neighborhoods with higher rates of infection.9 With many adults working remotely or unemployed along with the youth population being nearly all online learners in this past year, the identification of possible human trafficking victims has been difficult. Labor trafficking victims have poor and condensed living situations, limited access to healthcare, and reduced compliance with preventative measures.10
When trafficked victims do access healthcare through EMS or the hospital, COVID-19 has presented its barriers to building relationships with victims/patients. Personal protective equipment, distancing, and the abhorrent difficulties of being in a hectic environment limit the trust that needs to be present to recognize trafficking victims. As the United States begins to open up again, aggressive, adaptive strategies must be put into place for comprehensive, integrated services trafficking victims need and deserve.9
United Nations Office on Drugs and Crime (UNODC) Global Report on Trafficking in Persons 2020 reports that female victims continue to be particularly affected by trafficking in persons. About one-third of the detected victims were children, both girls (19 %) and boys (15 %), while 20 % were adult men. Those countries who have been impacted by the COVID-19 pandemic the hardest with the highest unemployment rates are showing those job seekers more likely to take high risks to continue to provide support for their families. These job seekers are part of those likely to be trafficked to parts of the world where the economy is stabilizing.6
If you ever find yourself needing to report incidents of suspected human trafficking, there are several reporting methods. The United States National Human Trafficking Hotline can be reached 24/7 and has access to over 200 languages through a tele-interpreting service at 1-888-373-7888 or by texting “BeFree” to 233733. Every report to the United States National Human Trafficking Hotline is referred to the appropriate law enforcement agencies for investigation.
The U.S. Department of Homeland Security at 1-866-347-2423 24 hours a day, 7 days a week, every day of the year, or submit a tip online at www.ice.gov/tips. The Tip Line is accessible internationally by calling +1-802-872-6199. You may also submit a tip online to the FBI at https://tips.fbi.gov/. If you suspect a child is being trafficked, you may also contact your local child abuse hotline and/or The National Center for Missing & Exploited Children, at 1-800-THE-LOST or www.cybertipline.com.
The Congressionally-authorized CyberTipline is operated by a nongovernmental organization and provides a means for reporting crimes against children and is staffed 24 hours a day, 7 days a week. All reports to any of these organizations can be made confidentially to the extent permitted by law and the callers do not need to provide personal information. Many times, a tip from a third-party such as healthcare or EMS is the only report of trafficking and the only chance a victim has to survive. Be someone’s only chance.
The author certifies that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
- Polaris. Human Trafficking [Internet] Washington (D.C) [cited 2021 May 22]. Available from https://polarisproject.org/human-trafficking/.
- Roney L. Villano C. Recognizing Victims of a Hidden Crime: Human Trafficking Victims in Your Pediatric Trauma Bay. Journal of Trauma Nursing. [Internet] 2020 January/February [cited 2021 May 11]; 27(1)37-41. Available from https://pubmed.ncbi.nlm.nih.gov/31895318/.
- Donnelly, E., Oehme, K., Barris, D., Melvin, R. What do EMS professionals know about human trafficking? An exploratory study. Journal of Human Trafficking. [Internet]. 2018 Aug 13 Available from https://www.tandfonline.com/doi/full/10.1080/23322705.2018.1501258.
- National Registry of Emergency Medical Technicians. National Continued Competency Program [Internet]. Columbus (OH); [cited Jun 3, 2021]. Available from https://www.nremt.org/Document/nccp.
- Unseen. How We Fight Human Trafficking [Internet] Fargo (ND); [cited 2 May 2021]. Available from https://www.weareunseen.org/our-plan.
- United Nations Office on Drug and Crime. Trafficking in Persons [Internet] New York (NY); [cited 28 May 2021] Available from https://www.unodc.org/unodc/data-and-analysis/glotip.html.
- New Jersey Office of the Attorney General, Division of Criminal Justice, NJ Human Trafficking Task Force. New Jersey Human Trafficking Guide Card [Internet] Trenton (NJ); [cited 11 May 2021]. Available from https://www.nj.gov/oag/dcj/humantrafficking/downloads/NJHTTF_FS_Law-Enforcement.pdf.
- National Center for Missing & Exploited Children. COVID-19 and Missing & Exploited Children [Internet] Alexandria (VA); [cited 9 May 2021] Available from https://www.missingkids.org/blog/2020/covid-19-and-missing-and-exploited-children.
- Todres J. Diaz, A. COVID-19 and human trafficking—the amplified impact on vulnerable populations. JAMA Pediatrics. [Internet]. 2021 [cited 2021 May 24]; 175.2 (2021): 123-124. Available from https://pubmed.ncbi.nlm.nih.gov/32955557/.
- Baum T. Nguyen T. Hospitality, tourism, human rights and the impact of COVID-19. International Journal of Contemporary Hospitality Management. 2020 [Internet]. 32(7): 2397-2407. Available from https://strathprints.strath.ac.uk/72219/.