For many victims of human trafficking, their only chance to find freedom comes when and if they see a healthcare provider. Otherwise, their captors often deliberately isolate them so no one can intervene. That’s why, if you’re a clinician or healthcare administrator, learning the signs of human trafficking can save lives.

Unfortunately, though, many healthcare professionals don’t understand the magnitude of the problem and believe it’s a niche issue outside their community, says Eileen Owen-Williams, DNP, Ph.D., APRN, CNM, FNP, AFN-BC, FAANP, who’s worked as a sexual assault examiner for 27 years in urban and remote locations in the US and Canada.

“The most important part of care for human trafficking victims is provider awareness,” Dr. Owen-Williams explains. “It goes beyond the sex trade. It includes so much of the labor force with undocumented immigrants and refugees.”

How Common Is Human Trafficking in the United States?

So, what’s the likelihood you’ll encounter a human trafficking victim in your practice? It depends on where you work, Owen-Williams says. Practitioners in urgent care or high-volume, high-risk practices in urban environments have the greatest chance.

That said, trafficking also happens in rural areas, where conditions are often more dangerous because victims are so isolated, she adds. Small towns by major highways may encounter victims being transported who get sick or injured along the way. Hubs for certain industries — such as fishing, mining, oil-developing, hospitality, and athletic events — create a demand for trafficking, as well.

Owen-Williams also advises practitioners to be aware of Human Trafficking Hotline statistics. The states with the highest rates of reported incidents in 2018 were:

• California (1,656)

• Texas (1,000)

• Florida (767)

• New York (492)

• Ohio (443)

How Can Healthcare Professionals Identify a Human Trafficking Victim?

Because trafficked patients may present with a range of symptoms, Owen-Williams recommends clinicians conduct thorough exams of the patient — and that administrators know the warning signs that might surface in the waiting room.

Know the At-Risk Groups for Trafficking in Your Community

“Marginalized populations” have the highest risk of being trafficked, Owen-Williams says. Examples include people whose primary language isn’t English, such as refugees, undocumented immigrants, and those with temporary visas; people with a disability or mental health condition; or people living in shelters or on the street.

Observe the Relationship Between the Patient and Any Accompanying Person

If a patient is indeed being trafficked, often it’s the pimp or person otherwise controlling that individual who brings them in. Owen-Williams explains that the accompanying party might introduce him or herself as a family member, significant other, or friend. “They will monopolize the conversation and attempt to control the questions and answers,” she adds. “They will also stay close to the patient and not let them out of sight.”

Notice the Patient’s Clothing

In Owen-Williams’ experience, trafficking victims often don clothing that hides their bodies, such as “sunglasses, hoodies and big sweatshirts.” In such an instance, try to get the patient into a gown so you can conduct a top-to-bottom search for any injuries or tattoos that may indicate ownership.

Thoroughly Examine All Injuries, Even if They Seem Unintentional

“Any kind of injury needs to be evaluated to determine if it’s intentional or unintentional,” Owen-Williams asserts. In addition, a single injury should serve as a reminder to look for concurrent and prior ones that may have begun to heal in case there’s a pattern of abuse.

When assessing for human trafficking, important areas to examine include:

• The hair (to see if any has been ripped out)

• Wrists and ankles (keep an eye out for patterned injuries that suggest the patient has been restrained with a cord or belt)

• The face (look for tenderness, bruising, and lacerations in various stages of healing)

• Genitalia (especially important if the individual presents with STIs)

• Inside the mouth (look for knocked-out teeth and condition of the tongue, frenulum, and gums)

• Eyes, ears, and neck (remove any turtlenecks or scarves; look for signs of attempted strangulation or restraints, hemorrhaging in the eyes, lacerations, swelling, and ruptured ear drums)

Assess Hydration, Nutrition, and Hygiene

Traffickers tend to control their victims’ food and water intake, so they often become dehydrated or malnourished. In addition, many trafficked individuals are not allowed to bathe when they want.

Get the Patient Alone and Conduct a Screen for Human Trafficking

Owen-Williams says it’s crucial to establish a system for getting a potential trafficking victim alone in “a non-obvious fashion” so the provider can ask questions. Consider diversions like: “We’re heading to the [lab, bathroom, x-ray room], and there’s a rule that no one besides patients can come in here.”

You can better assess their safety once you’re alone with the patient. Remember during the interview that many victims won’t reveal their histories or will only tell the story the trafficker has provided. They also may deny there’s a problem because they feel bonded to and compelled to protect the trafficker.

As far as screening processes for human trafficking go, Owen-Williams says there’s a lack of reliable instruments. But she has successfully asked the following questions (especially the first one) from the Department of Health and Human Services trafficking screening tool.

• “Can you come and go as you please?”

• “Can you leave your job if you want? Have you been threatened if you leave?”

• “Have you been physically harmed in any way?”

• “Is anyone forcing you to do anything you don’t want to?”

• “What are your work and living conditions like?”

• “Are you limited in food, water, sleep, or healthcare?”

• “Do you need permission to go to the bathroom or eat?”

• “Are there locks on your doors and windows?”

• For individuals from other countries: “Is someone else in possession of your documentation?”

• For children: “Where do you sleep?” (“A bed, cot, or on the floor?”)

Owen-Williams stresses that providers should never interview potential victims in front of their traffickers or give cards or pamphlets that someone might uncover. “The worst thing is to have that individual be taken back because you know they’ll be beaten and hurt,” she adds.

Don’t Rely on the Patient’s Interpreter

Occasionally, if a potential victim doesn’t speak English, the trafficker may send them to a healthcare facility with an interpreter. The problem with this, Owen-Williams says, is the multilingual individual may belong to the group controlling the patient. “Always follow the national standard of practice of use for interpreters when you’re talking with an interpreter,” she says.

What Can Healthcare Professionals Do if They Suspect Human Trafficking?

Gather As Much Information As Possible on the Patient

This is especially important for administrators or medical assistants dealing with patients’ private information and payment, Owen-Williams advises. Notice the vehicle’s make, model, and color the patient entered, and write down the license plate number. Ask about insurance and make any other information they hand over readily available. Also, keep in mind trafficking victims will often pay with cash.

Call Upon Resources Available in Your Community

Ideally, you should familiarize yourself with community resources before encountering a potential victim. That way, you’ll already know exactly whom to contact. For example, if other healthcare professionals nearby have worked with trafficking victims, ask them to see your patient under the guise of a specialty referral or another type of care, Owen-Williams says. You can also phone another emergency department or call a local or national hotline for the patient.

Contact Law Enforcement

You should try to construct a plan with law enforcement for responding to human trafficking beforehand, Owen-Williams says. But if you haven’t, you can feel comfortable calling the police if the person states they are being held and wants to get out. Otherwise, “it’s difficult with individuals who are scared and worry about getting themselves or their family hurt,” she adds.

Practice Trauma-Informed Care

The most effective way to protect patients and your staff from traffickers is to implement trauma-informed care, according to Owen-Williams. University of Buffalo’s School of Social Work defines it as care that “considers the pervasive nature of trauma and promotes environments of healing and recovery rather than practices and services that may inadvertently re-traumatize.”

To deal with human trafficking specifically, you should structure your practice so front-desk employees can recognize the signs and alert the provider, who can then contact law enforcement or a social worker, Owen Williams says. Ensuring each team member knows what to do during these events will keep everyone safe.

Thoroughly preparing to encounter a victim of human trafficking may seem like a daunting task, especially if it feels unlikely to happen. But remember, even if you only see one, you might be their only contact with the outside world for months.

“We have to make our interaction with potential victims count,” Owen-Williams says. “And we have to do it in a manner that keeps them safe.”