Editor’s note: The opinions expressed by the authors do not necessarily reflect the opinions of the AAMC or its members.
Amy was an 11-year-old girl who arrived at the pediatric emergency department where I work, accompanied by the police. Frightened and alone, she told me that she was dragged and physically restrained by family members to be transported to the home of her molester. Once she arrived at his house, she ran away and asked a stranger to call the police, who brought her to my hospital.
I learned more about Amy’s troubled life. The Department of Children and Families (DCF) had investigated this man twice for physical and sexual violence against her. At the tender, young age of 11, Amy had already had two inpatient psychiatric stays, multiple runaways, a suicide attempt, and various instances of DCF involvement in her family life. I now realize that many aspects of Amy’s story were “red flags” for human trafficking, but at the time did not have the training to recognize them and refer her to appropriate resources.
What exactly is human trafficking? It’s a form of modern slavery and occurs when someone exploits an individual with force, fraud, or coercion to make them perform work (labor trafficking) or commercial sex (sex trafficking). Notably, according to federal law, those under the age of 18 who are compelled to perform a commercial sex act are considered trafficked regardless of whether or not there is force, fraud, or coercion. Furthermore, according to U.S. law, trafficking does not require someone to be moved, and may occur in someone’s own home.
The definition of trafficking is broad, and yet when most people, including physicians, think about trafficking, the stereotypical images that emerge are of young woman being kidnapped, sold into slavery, and physically held captive against their will. The media reinforces this portrayal, yet labor and sex trafficking happen to those of any nationality, immigration status, gender, sexual orientation, and age.
In the United States, men and women are trafficked in a number of industries, including legal ones (e.g., construction and health care) and illegal ones (drug dealing and commercial sex). For instance, some carnival companies recruit young men and women from abroad, and when they arrive they are forced to work under abusive conditions without pay and threatened with deportation if they try to leave. American children may be targeted by gangs to sell drugs. If they do not comply, they face extreme threats of, and sometimes perpetration of, violence against themselves and family members. There is no “typical victim” of human trafficking. However, certain populations may be more vulnerable to trafficking. Risk factors for trafficking include poverty, history of abuse, hunger, substance use disorders, migrant status, homelessness, being LGBTQ+, and having a disability.
Despite the prevalence of trafficking and its infiltration into various industries, as physicians, we frequently miss this diagnosis. We know that the majority of individuals trafficked in the United States seek medical treatment at some time during their exploitation, but health care providers are ill-prepared to recognize trafficked persons even in our own exam rooms.
How do we as physicians improve our ability to recognize the red flags of our patients who have experienced trafficking? Like any other disease process, the first step is recognizing characteristic signs and symptoms. The patient may be with a person who is speaking for them, seem afraid to answer questions, unaware of where they live, not in control of their personal documents, not able to keep the money they earn, or have a cryptic story that does not match their clinical presentation. In particular, victims of child sex trafficking are more likely to have had previous experiences with violence, substance use, running away from home, involvement with child protective services and/or law enforcement, and a longer history of sexual activity.
As I think about children like Amy, vulnerable to horrific exploitation, I am reminded that our medical schools, residency, and fellowship programs need to rise to the challenge to train physicians to recognize people at risk for trafficking. Two free educational resources that have been helpful in teaching physicians and physicians-in-training include the Department of Health and Human Service’s online interactive training program called SOAR, which can be integrated into learning management systems, and the National Human Trafficking Resource Center’s brief webinar for health professionals. Furthermore, as physicians, we can and must champion the development of protocols in our own institutions to recognize at-risk individuals and refer patients to supportive programs. In my own hospital, we are currently implementing policies to better identify at-risk individuals such as Amy, including a list of resources physicians can tap into at any time.
In honor of National Slavery and Human Trafficking Prevention Month and the approximately 40.3 million victims of trafficking worldwide, let us take this moment to acknowledge this global crisis and bolster our health care systems to recognize and respond to the red flags before us.
Larissa Truschel, MD, MPH, is a pediatric emergency fellow at Boston Children’s Hospital.
Hanni Stoklosa, MD, MPH, is an emergency physician and director of the Global Women’s Health Fellowship at Brigham and Women’s Hospital. She is also executive director of HEAL Trafficking and an internationally recognized expert and researcher on the well-being of trafficking survivors in the United States and internationally.