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It was 2 a.m. on a typically hectic Friday overnight shift in the emergency department.
A young woman, Kelly, checked into triage, accompanied by her older boyfriend Jim, who explained that Kelly had abdominal pain and some vaginal bleeding. Jim wanted her checked out and maybe some pain medicine to help her rest at home.
Kelly had no identification. She appeared younger than her stated age of 18. I also noticed track marks punctuating both of her arms — a sign of IV drug use. She immediately looked to Jim after answering all my questions.
If this sounds suspicious, that’s because it is. While clinicians are trained to address Kelly’s medical ailment, many of us fail to recognize the larger social cues right in front of us. It appears that Jim is in control of the situation. Kelly is young, maybe very young. As a clinician I must consider Kelly’s living situation, and her relationship with Jim.
As emergency care providers, it is standard practice for us to separate patients from their visitors long enough to at least ask about domestic violence. And for most of us, that would likely be the first concern in this case. But Kelly is actually a victim of human trafficking.
By definition, human trafficking, sometimes referred to as modern day slavery, is the recruitment, transportation and harboring of persons by means of force, fraud, coercion or deception. And while many assume trafficking is the movement of people across international borders, in reality many victims never leave their hometowns.
Victims are found in domestic service, nail salons, massage parlors, restaurants, the sex trade, as well as farm and factory work. Few people realize the Northeast is one of the nation's human trafficking hot spots. We have seen the magnitude of the problem in our region further compounded by the opioid epidemic.
Several studies show that most trafficking victims receive medical care while being trafficked, with the majority showing up in the ER. We expect emergency providers to recognize and address many public health ills, and the time has come to add human trafficking to the list.
Identifying Cases, And The Physical Signs
Unfortunately, most of us on the front lines lack the training to even recognize the signs of trafficking -- let alone what to do when a case is confirmed.
Part of the challenge in identifying cases is that they all look different. On Monday, I could see a foreign-born woman or girl being sexually exploited. Tuesday, it could be a man working as a domestic servant who grew up in the area.
Force, fraud, coercion and deception obviously can take a variety of forms, and health care providers must learn to think more broadly than most of us do today. Going back to Kelly’s situation, there were several opportunities to ask questions to get a sense of her daily life.
It could have been something as simple as, "How do you pay for your drugs?" Working in emergency departments around Boston, we encounter patients struggling with heroin addiction often — sometimes several times in a shift. Finding out how they get their drugs may open up a broader conversation about whether this person in your exam room is trapped, forced to do something he or she doesn’t want to do.
We must train ourselves to notice the nuanced clues of exploitation on our patient’s bodies. Signs of trafficking can be subtle, such as track marks from heroin use, or more obvious, such as facial hematomas from being pistol whipped while raped.
In addition to signs of physical violence and STDs, trafficked patients may have chronic infections, dehydration, malnutrition and the stigmata of trauma and psychological stress.
I have never met a patient who called himself a victim of human trafficking. As with victims of domestic violence, many may not acknowledge the true nature of their situation. The sense of shame they feel is profound. And many decline intervention or services. The goal for us as health care providers is not rescue. First and foremost, we need to communicate that the health care setting is a safe place for them to seek help when they do want it, and to ensure — with the support of our hospitals and departments — that it actually is. Whenever possible, involving our social worker colleagues can help us navigate potential options for these complex patients.
The response to children, it should be noted, is unique. In Massachusetts, and in many other states, suspected child victims of human trafficking must be reported to the Department of Children and Families. In Massachusetts, that report will trigger a multidisciplinary team response to help meet the trafficked child’s needs.
Providers and victims should utilize the National Human Trafficking Resource Center Hotline. This hotline is meant as a resource to both victims themselves, and for health workers and others looking for support in helping potential victims. The hotline can advise providers and their patients on local resources such as shelter, and provide continued guidance through the process.
We encourage our colleagues in health care, particularly in emergency departments around the region, to be vigilant for the trafficking victims that come through our doors. Human trafficking is an egregious form of suffering that health care providers are only starting to grapple with recognizing and addressing. Clinicians should know that support is there, for their victims and for them, as they continue to serve the most vulnerable and exploited people in our society.
The National Human Trafficking Resource Center recently published three resources for health care professionals about human trafficking:
Or you can join others combating trafficking through HEAL Trafficking, a national network of professionals improving the public health response to trafficking.
Editor's Note: The names used in this story are not the real names of the individuals involved.
Laura Janneck is an emergency medicine physician at the Cambridge Health Alliance. Hanni Stoklosa is an emergency physician at Brigham and Women's Hospital, Harvard Medical School and executive director of HEAL Trafficking.