Human Trafficking in the ED – Part 1

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July 18, 2017 by dailybolusoflr

Seeing the Unseen Patients

By: Katie O’Conor



Jessica only wanted heroin detox, told us not to worry about her arm wounds. She was in police custody, and the officer who escorted her told us she’d been sleeping on the streets, picked up for an old warrant. We hospitalized her for osteomyelitis that was likely to result in amputations of both forearms. Despite a constant police presence during her stay, her trafficker made numerous attempts to visit her.  She was ultimately lost back to the streets, and presumably back to her trafficker, during an unsupervised transport between facilities.


Olivia was in the ED for pelvic pain, diagnosed to be a tubo-ovarian abscess after an untreated sexually transmitted infection. She previously had abusive partners and was fearful of a new man in her life. She lived with her friend or sister or boss or landlord – the answer changed during the conversation. Her “roommate” upstairs found work for her when she needed money. She said she was safe, but saved the human trafficking hotline number in her phone under “Katie from Baltimore.”

What Is Human Trafficking?

Human trafficking is an emerging criminal, social, and public health problem in the U.S. and abroad.  Human trafficking encompasses any activity related to the coercive or deceptive exploitation of individuals, most commonly sexual or labor exploitation, for the gain of the trafficker(s). Human trafficking does NOT require physical transport. Human trafficking cases in the healthcare system, like the cases above, are upsetting, unsatisfying, and incomplete. There is incomplete information, as trafficked patients often leave before completing their care. There is uncertainty in identifying whether someone is being trafficked, even when there is strong suspicion or clear evidence. The visits may be distressing to providers, who want to help but must ultimately allow the patient the freedom to decline social services or other interventions, even after patients have disclosed they are being trafficked.

  • 4.5 million estimated victims of forced sexual exploitation globally
  • 63% of trafficked persons had an ED visit during their captivity

Human Trafficking in the ED

Human trafficking poses a unique challenge for EM clinicians, who are often the only providers who see these patients while they are being trafficked. We have limited time to build the rapport and trust necessary to overcome patient’s fear and apprehension. We lack effective screening tools and guidelines that are specific enough to accurately identify trafficked persons, and sensitive enough not to miss those with more experienced and system-savvy traffickers. We have limited resources for adequately exploring the cases we identify as likely trafficking. We also know that pursuing trafficking cases or even identifying a person as a victim of trafficking may actually be more harmful than beneficial, and as such requires individualized responses for each patient. Premature identification of a trafficked patient, without a multidisciplinary team, may cause psychological harms like anxiety and retraumatization as well as critical safety risks as patients may be subject to physical, emotional, and sexual retaliation if they return to a trafficker.

In a 2016 Annals of Emergency Medicine article, Shandro et al. proposed a list of red flags for human trafficking screening in the emergency department:

  1. Patient accompanied by individual who is reluctant to leave patient alone with care team
  2. Vague or inconsistent history of present illness or injury
  3. Unexpected demeanor: irritable, anxious, flat affect, poor eye contact
  4. Apprehensive or hostile when law enforcement is referenced
  5. Unaware of home address or how to get home from ED
  6. No identification card and/or few personal items

While this is a helpful start, many of us working in urban or safety net emergency departments recognize that a significant majority of our patients would meet at least one, if not many, of these criteria.


  1. Banks D, Kyckelhahn T. Characteristics of suspected human trafficking incidents, 2008-2010 (NCJ 233732). Capital News Service. The Brothel Next Door – Human Trafficking in Maryland. Accessed June 20, 2017.
  2. Cassie, R. Children of the Night: Sex trafficking is Maryland’s dirty open secret. Baltimore Magazine. Mar 2017.
  3. Coppola JS, Cantwell R. Health professional role in identifying and assessing victims of human
  4. labor trafficking. J Nurs Pract. 2016 May;12(5):e193-200.
  5. Gibbons P, Stoklosa H. Identification and treatment of human trafficking victims in the emergency department: a case report. J Emerg Med. 2016 May;50(5):715-9.
  6. Hachey LM, Phillippi JC. Identification and management of human trafficking victims in the emergency department. Adv Emerg Nurs 2017 Jan/Mar;39(1):31-51.
  7. International Labour Organization. Summary of the International Labour Organization 2012 Global Estimate of Forced Labour. 01 Jun 2012.
  8. Lederer L, Wetzel C. The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Ann Health Law. 2014;23(1):61-91.
  9. Macias-Konstantopoulos WL. Caring for the trafficked patient: ethical challenges and recommendations for health care professionals. AMA J Ethics. 2017 Jan 1;19(1):80-90.
  10. Macias-Konstantopoulos WL. Human trafficking: the role of medicine in interrupting the cycle of abuse and violence. Ann Intern Med. 2016 Oct 18;165(8):582-588.
  11. Ottisova L, Hemmings S, Howard LM. Prevalence and risk of violence and the mental, physical and sexual health problems associated with human trafficking: an updated systematic review. Epidemiol Psychiatr Sci. 2016 Aug;25(4):317-41.
  12. Polaris Project. Accessed June 20, 2017.
  13. Powell C, Dickins K, Stoklosa H. Training US health care professionals on human trafficking: where do we go from here? Med Educ Online. 2017;22(1):1267980.
  14. Rollins R, Gribble A, Barrett SE, Powell C. Who is in your waiting room? Health care professionals as culturally responsive and trauma-informed first responders to human trafficking. AMA J Ethics. 2017 Jan 1;19(1):63-71.
  15. Salvation Army of Central Maryland. Combat Human Trafficking. Accessed June 20, 2017.
  16. Shandro J, Chisolm-Straker M, Duber HC, et al. Human trafficking: a guide to identification and approach for the emergency physician. Ann Emerg Med. 2016 Oct;68(4):501-508.e1.
  17. Stoklosa H, MacGibbon M, Stoklosa J. Human trafficking, mental illness, and addiction: avoiding diagnostic overshadowing. AMA J Ethics. 2017 Jan 1;19(1):23-34.
  18. Tahirih Justice Center. Human Trafficking Press Kit. Accessed June 20, 2017.
  19. Todres J. Physician encounters with human trafficking: legal consequences and ethical considerations. AMA J Ethics. 2017 Jan 1;19(1):16-22.
  20. United Nations General Assembly. Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention against Transnational Organized Crime, 15 Nov 2000.
  21. United States Department of Homeland Security. Accessed June 20, 2017.
  22. United States Department of Justice, Bureau of Justice Statistics. Apr 2011.
  23. United States Department of State. Trafficking in persons report. June 2016.

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